Evaluating emergency physicians' knowledge, attitudes, and experiences of FARC ex-combatants: A pilot study of Colombia's emergency medicine teaching hospitals

Impact of the armed conflict in Colombia: consequences in the health system, response and challenges

INTRODUCTION

In Colombia, research on health and conflict has focused on mental health, psychosocial care, displacement, morbidity, and mortality. Few scientific studies have assessed health system functioning during armed conflicts. In a new period characterized by the implementation of the peace agreement with the Revolutionary Armed Forces of Colombia (FARC) armed group, understanding the effects of armed conflict on the health system, the functions, and institutions shaped by the conflict is an opportunity to understand the pathways and scope of post-conflict health policy reforms. Therefore, this study was conducted to assess the effects of armed conflict on the health system, response, and mechanisms developed to protect medical missions during armed conflict in Colombia.

METHODS

This research was conducted using a qualitative approach with semi-structured interviews and focus group discussions. The qualitative guide collected information in four sections: (1) conflict and health system, effects and barriers in health service provision, (2) actions and coordination to cope with those barriers, (3) health policies and armed conflict, and (4) post-accord and current situation. Twenty-two people participated in the interviews, including eight policymakers at the national level and seven at the local level, including two NGOs and five members of international organizations. An academic project event in December 2019 and four focus groups were developed (World Cafe technique) to discuss with national and local stakeholders the effects of armed conflict on the health system and an analytical framework to analyze its consequences.

RESULTS

The conflict affected the health-seeking behavior of the population, limited access to healthcare provision, and affected health professionals, and was associated with inadequate medical supplies in conflict areas. The health system implemented mechanisms to protect the medical mission, regulate healthcare provision in conflict areas, and commit to healthcare provision (mental and physical health services) for the population displaced by conflict.

CONCLUSION

The state's presence, trust, and legitimacy have significantly reduced in recent years. However, it is crucial to restore them by ensuring that state and health services are physically present in all territories, including remote and rural areas.

Supporting healthcare workers caring for ex-combatants: incentives among Colombian providers with FARC ex-combatants

With the Peace Agreement between Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised healthcare to 13,000 'reincorporating' FARC ex-combatants. Shortages of healthcare workers in reincorporation camps means this promise is in danger of going unfulfilled. More information is needed to determine incentives, disincentives, and recruitment of healthcare providers to address this shortage. Semi-structured interviews were conducted with healthcare providers across FARC reincorporation camps, and a multidisciplinary team conducted analysis in NVivo12 using a team-based coding method. Twenty-four healthcare professionals from 15 camps participated, of which 75% were female. Incentives to work with FARC included improved clinical skills, professional advancement, increased comfort with FARC, and contributing to the peace process. Disincentives included poor living conditions, lack of support, biases, familial commitments, and sacrificing career opportunities. Three-fourths of the sample recommended working with FARC, and 92% reported a shortage of healthcare workers. Recruitment strategies included improved resources and specialised career development for healthcare workers, facilitating interactions between FARC and healthcare professionals outside clinical scenarios, and integrating medicine for vulnerable populations into health education. This study shows the impact that working with FARC ex-combatants can have on healthcare providers and tangible suggestions for increasing provider participation to address the healthcare worker shortage.

Healthcare access barriers for FARC ex-combatants in Colombia: qualitative perspectives from healthcare providers and FARC health promoters

Background

Following the 2016 Peace Agreement with the Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised to reincorporate more than 13,000 guerrilla fighters into its healthcare system. Despite a subsidized healthcare insurance program and the establishment of 24 Espacios Territoriales de Capacitación y Reincorporación (ETCRs—Territorial Spaces for Training and Reintegration) to facilitate this transition, data has shown that FARC ex-combatants access care at disproportionately lower rates, and face barriers to healthcare services.

Methods

Semi-structured interviews were conducted with FARC health promoters and healthcare providers working in ETCRs to determine healthcare access barriers for FARC ex-combatants. Analysis was completed with a qualitative team-based coding method and barriers were categorized according to Julio Frenk’s Domains of Healthcare Access framework.

Results

Among 32 participants, 25 were healthcare providers and 7 self-identified as FARC health promoters. The sample was majority female (71.9%) and worked with the FARC for an average of 12 months in hospital, health center, medical brigade, and ETCR settings. Our sample had experiences with FARC across 16 ETCRs in 13 Departments of Colombia. Participants identified a total of 141 healthcare access barriers affecting FARC ex-combatants, which affected healthcare needs, desires, seeking, initiation and continuation. Significant barriers were related to a lack of resources in rural areas, limited knowledge of the Colombian health system, the health insurance program, perceived stigma, and transition process from the FARC health system.

Conclusions

FARC ex-combatants face significant healthcare access barriers, some of which are unique from other low-resource populations in Colombia. Potential solutions to these barriers included health insurance provider partnerships with health centers close to ETCRs, and training and contracting FARC health promoters to be primary healthcare providers in ETCRs. Future studies are needed to quantify the healthcare barriers affecting FARC ex-combatants, in order to implement targeted interventions to improve healthcare access.