Colombia enjoys the reputation of being a trendsetter in Latin America and is known throughout the developing world for innovations in reproductive health and family planning. The country has a 30-year-old private family planning program that serves thousands of people nationwide; a network of private clinics focusing on reproductive health and rights, which include treatment for complications of abortion; reproductive health clinics specifically for men; and a federal, obligatory national plan for sex education.

Most recently, the Colombian Ministry of Health (MOH) passed two new health laws that, while progressive in design and intent, have had a detrimental effect on access to family planning services. They have also dramatically affected AVSC's work in Colombia, demonstrating the interplay between politics, law, and programs that AVSC needs to consider as it carries out its work.

What the Laws Mean

One of the new laws, Ley 100, went into effect in 1993, after the Colombian government adapted key features of health care reform strategies from the United States, Canada, Chile, and other countries. The law has produced a fundamental transformation in the design, provision, and receipt of health care.

Universal Coverage

Ley 100 provides universal health care to the entire population, regardless of individuals' ability to pay, and allows individuals to choose between a public or private health facility. New agencies called Empresas Promotoras de Salud (EPSs) act as liaisons between individuals, employers, and hospitals or clinics--called Instituciones Prestadores de Servicios (IPSs)--to facilitate the purchase of health care packages.

A problem with the new system is that the law does not specify which family planning services are covered by the new health plan. Without legislative guidance, the EPSs have adopted a restrictive interpretation of what is covered. Thus, because the EPSs do not consider sterilization, oral contraceptives, IUDs, and hormonal implants to be preventive health measures, they have been unwilling to provide coverage for them.

In addition, individuals who want to use one of these contraceptive methods feel that they have already paid their insurance premium and do not want to pay an additional amount. This confusion about whether and how much individuals must pay for contraception has led those who had wanted these methods to choose other methods or no method at all.

Constraints on Anesthesiology

The other new law, Ley 6a, was enacted in 1991 and requires that only anesthesiologists can administer anesthesia. It was passed (with the support of a strong lobby of anesthesiologists) to protect patients and improve the quality of services. But in effect, it has prevented hospitals from performing a host of outpatient surgical procedures or routine procedures that might require surgery, such as normal delivery, postabortion care, and treatment of incomplete abortion.

Of concern to those trying to ensure full method choice in family planning is the fact that the law also prevents hospitals from performing female sterilization procedures with local anesthesia. Hospitals without full-time anesthesiologists have had to cancel such services, and hospitals with full-time anesthesiologists have reverted to doing the procedure with general anesthesia.

Shifting Strategy

Together, these two laws have had a significant impact on AVSC's work in Colombia.

In the early 1990s, AVSC shifted its focus in Colombia from the private sector to the public sector. To ensure full contraceptive method choice, AVSC conducted training in contraceptive methods and worked with medical and nursing schools to add reproductive health, including contraception, to the curricula. Counseling and informed choice has at all times been one of the pillars of AVSC's program.

AVSC also began to establish services for female sterilization with local anesthesia in public hospitals. The services gradually expanded to 18 states around the country.

But when these new laws took effect, much of AVSC's clinical work regarding female sterilization came to a halt. Faced with the challenge of continuing to advance family planning services in a constrained environment, AVSC has had to redesign its country strategy.

Re-examining the Laws

AVSC began working with the public and private sectors to help them understand and manage the changes wrought by Ley 100 and to market their services to the EPSs. In addition, AVSC supported Profamilia, Colombia's nongovernmental family planning organization, in analyzing the law, writing a public-information brochure about it, and conducting marketing workshops for its staff. AVSC also began to work with MOH officials to disseminate the law to service providers.

Regarding Ley 6a, AVSC began to include anesthesiologists in trainings so they would better understand the female sterilization procedure and try to promote rather than block its use.

AVSC's approach is paying off. In October 1996, a clarification of Ley 100 was passed stating that all individuals have the right to obtain information, education, and counseling about sexual and reproductive health and contraceptive methods (including hormonal implants, IUDs, condoms, and sterilization), as well as related services.

This is one more significant step toward ensuring that all Colombians have access to reproductive health services and one more innovation to make these services an integral part of the national program.

Andrea Eschen is assistant regional director for AVSC programs in Latin America and the Caribbean. She would like to thank Alcides Estrada, AVSC's regional director for Latin America, for his assistance in explaining the new laws and reviewing the draft of this article.