Colombia: Taking healthcare to cut-off communities in conflict-hit Pacific region

Twenty hours earlier, Yessica, in a state of alarm, had knocked on the door of her neighbour, María Daicy Mosquera, in Bocas de Apartadó, an Afro-descendant town on the Baudó River. Although her due date was still two months away, Yessica’s waters had broken and she had severe abdominal pains. María Daicy, an MSF-trained community health worker, urged her to head to the health centre, an hour upriver in Pie de Pató.

At Pie de Pató, Yessica was told she needed hospital care, so she travelled a further two hours by river to Puerto Meluk and then travelled four hours by ambulance towards Quibdó, the capital of Chocó department.

Yessica’s baby was born with extremely weak vital signs but was resuscitated by a nurse. Eighteen months later, he is a healthy toddler. “The child would have died if we hadn't referred Yessica,” says María Daisy, seated in a red chair at the door of her wooden house. Everyone in the Bocas de Apartadó community knows María Daisy for her work. She is one of 42 Afro-descendant and indigenous community health workers trained by MSF to support 133 communities where people struggle to access healthcare.

To see a doctor in the Baudó sub-region requires a certain degree of luck. It helps to get sick during the day, because at night people avoid travelling on the river – the main means of getting around in a region with few roads – on the perceived orders of armed groups (who nevertheless deny having issued such orders). Such movement restrictions are commonplace; according to figures from the Colombian Ombudsman's Office, in 2023 there were 124 events of ‘forced confinement’ – in which people were ordered not to leave their villages – across Chocó department, affecting more than 40,000 people.

Many residents of Chocó have also been victims of mass displacement – in which large numbers of people are forced to leave their homes and seek shelter elsewhere. In addition, local people live with the constant threat of forced disappearances, anti-personnel mines and unexploded ordnance, while healthcare providers have been targeted by violence.

To see a doctor, it also helps to fall sick when it is raining, so that the river contains enough water to be able to travel the three to 15 hours needed to reach the nearest sizeable town. It also helps to own a boat with a motor – or a friend who is prepared to lend theirs – because few villagers have a community boat and there is no river ambulance for the almost 100,000 people who live across the Alto, Medio and Bajo Baudó areas.

The multiple challenges of everyday life in this region have influenced the shape of MSF’s project, which takes healthcare to people living in the most remote and under-served communities and focuses on those ethnic groups who struggle most to get medical care.

“Because of the multiple effects of the armed conflict, the significant gaps in healthcare provision and the geographical conditions of the Baudó sub-region, MSF believes that its health model has to be community-based, decentralised and with an ethnic focus,” says MSF project coordinator Javier Mattos.

MSF’s model has three essential components. The first is the MSF team's knowledge of the perceptions and customs linked to health of the Afro-descendant and indigenous communities in the area. Using this knowledge, MSF has trained people within the community to help prevent and detect common diseases early, when they are still easy to treat.

“Most of the medical consultations we provide are linked to malaria, diarrhoea, respiratory syndromes and skin conditions,” says MSF medical advisor Dr Johana Vinasco. “All of these diseases are preventable or can be resolved with basic medical care.”

MSF trains community health promoters to give talks on topics such as hygienic food preparation and storage, the use of mosquito nets, and the how to use the water collection tanks installed by MSF to provide communities with clean, safe drinking water. MSF also trains them to provide basic treatment for common ailments and to identify warning signs so that they can refer patients to health centres for more specialised care.

The second component is a referral network that funds patients’ transport to health centres and pays for food for the days they have to be away from their community.

Lastly, MSF has helped reinforce services at the medical facilities to which patients are referred.

Over the past two years, the project has had a number of marked successes, including reducing serious medical complications among young children and bringing down mortality rates among under-twos.

“Our decentralised model has helped prevent serious complications in children under five, who make up the largest number of referrals, and has helped reduce mortality rates in children under two from diseases that are preventable or treatable, such as malaria,” says Vinasco.

From March 2022 to February 2024, MSF-trained community health workers provided 9,985 medical consultations and provided psychological first aid to 72 people. They also arranged 2,097 referrals to health centres, 1,388 of them urgent. Meanwhile, MSF-trained health promoters gave 5,172 talks about preventing health problems, reaching 46,915 participants.

Despite these successes, the difficulties of daily life in the region continue. Movement restrictions and landmines continue to prevent people from reaching health centres and from finding enough to eat. Many residents are unable to reach their vegetable plots and cannot go fishing or hunting, resulting in a risk of malnutrition, primarily in children.

The existing health system also has serious flaws. “For medical conditions that arise without warning – such as trauma injuries, accidents, and complications in childbirth – urgent referrals need to be made, but we're dealing with a system that is both unstable and inefficient,” says Vinasco.

The World Health Organization recommends a minimum of 23 doctors for every 10,000 population. The Colombian average is 24, but Alto Baudó has fewer than two doctors for every 10,000 people.

For people in the most remote areas, it can take a whole day to reach a doctor. If a higher level of care is required, patients have to go to the San Francisco de Asís hospital in Quibdó, which cannot guarantee care because it has been under investigation and placed in administration for four years. In addition, some indigenous patients report being discriminated against by health staff.

“We are calling for improvements to people’s access to healthcare in the Baudó sub-region, and to the development of decentralised models of care with an ethnic focus,” says Mattos.

Vinasco agrees, adding: “The community model is based on the actual conditions of patients’ lives. It helps them recover their dignity because it respects their life practices and strengthens their access to basic rights, such as healthcare.”