Interview with Fernando de la Hoz, Director General, National Health Institute Colombia (INS)

You have an extensive background in the healthcare sector, with positions in Colciencias, the Department of Public Health, and the National University of Colombia. What can you bring from these experiences to the role of Director General of INS?

The INS is the head of the national surveillance system. It has a branch in charge of producing elements for lab diagnosis and also has production of pharmaceutical products like antiserum for snakebite. The Institute also has a branch for producing research in health. I have some experience in research and surveillance, but less with production. That being said, I think that my role is to improve the way in which the INS is doing surveillance and research as well as trying to help with the development of production. I worked here for thirteen years during my career, so I know more or less what areas need the most improvement, particularly with surveillance. I also think that I have solid awareness of the strengths and weaknesses of the Institute, and I can help improve the weaknesses. The INS is currently working on some very nice biomedical research in addition to many other priority health issues. This research is not being done from a population-based perspective and thus not very strong then another priority would be to strengthen the skills and abilities of those conducting this population-based research, such as cardiovascular disease which is prominent in Colombia. INS is historically known for its work in infectious diseases, epidemiology, biology and immunology and still maintains a strong background in these areas. The Institute is also working to develop wider access to resources in new key therapeutic areas as well. I also think that the INS needs to be more involved with evaluation of the interventions that the government has introduced within the healthcare system within the last few years, and in the future as well. For instance, the government is planning major health reforms and we know by experience that if we are not prepared to evaluate the changes and impact on people at an early stage, we risk perpetuating bad policy for many years before another decision is made to change the system again. For example, we reformed our health system twenty years ago, and there is still a lack of knowledge regarding how it has impacted the population. The government and the academic institutions have extensively evaluated the financial aspects of the system but not the impact on diseases and mortality.

What do you think is going to be the most important item on the health reform agenda that the INS will evaluate?

I think that we have to concentrate on evaluating health outcomes of people that use the system. As I mentioned, in the past we have been concentrating more on evaluating financial aspects, how the money is used, distributed, and spent but not on whether people are dying more or less, or if people are getting the right attention at hospitals. There are very few evaluations of that.

How do you prioritize one issue over another, given the many areas of interest that the INS observes?

We need to quickly exercise prioritization to identify areas to which INS will dedicate more effort in the next couple of years, as the organization still does not have a list of priorities. I would look at which areas of the INS deal with the issues most critical for the health of the people. One of the more critical areas that the INS is now covering is the surveillance of diseases with high epidemic potential. For example, the INS carried out surveillance on dengue and yellow fever outbreaks, and it also has to report every week whether these infectious diseases are increasing or decreasing, and generally the information we receive is reliable. However, there are several problems with the information system in terms of the way that people report, so we will have to work hard to ensure the capacity of the Institute in a more reliable way with more timely results, as well as improving the response time to health threats. Additionally, Colombia needs to again produce some vaccines that are critical also for our population. For instance, this institute used to produce yellow fever vaccines in the early 1960s, but ten years ago the production plant was closed because it was not fulfilling the requirements of quality. So quality and the effort to open an area to produce yellow fever vaccines should be priorities. We are receiving offers from several big players in the area of vaccine production to collaborate in order to again start the production of some critical vaccines.

The Director of Production at INS explained how important partnerships will be for the future of INS. What will be the importance of strategic partnerships with academia?

I think it will be very important. We cannot carry on all these tasks alone. INS will be looking to obtain support from universities not only in Bogota, but will be open to partnerships with other research groups in other areas of the country, especially in those areas that are not especially recognized for academia. For instance, we have a good relationship with Antioquia, Universidad Nacional, and Universidad del Valle, but we will also be looking for small universities where the information we receive is not very good, and try to work with such places to improve surveillance and other areas where the health situation is not fully clear. For this area of production we recognize that we need the expertise, skills and resources that the big industry has been developing for the last twenty or thirty years. In order to take advantage of that, I know that in Latin America there are several examples of good collaboration between private enterprise and government that has allowed, for instance, Brazil is starting a very strong industry of production of biological products. Cuba is not so associated with private enterprise, but it could also be a good partner.

One of the main priorities of INS is to act for a reference point for all local laboratories throughout the country. What are the main challenges that these laboratories face and the opportunities that they can bring to Colombian health?

One of the main challenges that public health laboratories face now is the lack of political support. They are financed by local governments, and in many cases these governments see public health labs as expensive assets, and they do not recognize the importance they have for surveillance. Therefore, one of the main tasks is trying to improve the political support for local public health labs and we hope that with the new reform, Colombia will be able to introduce some specific incentives regarding the financial aspects of the public health labs. INS recognizes that the majority of them are underperforming their surveillance tasks, specifically for infectious diseases.

Might the government be able to provide an incentive for private companies to partner with such local businesses as a means of helping to fund them and “get back on their feet”?

I do not know if the government would be willing to do that. I am not completely sure if that should be the way forward for local public health labs because that is a national security problem. They are involved with the surveillance of health threats for the population, and I am not sure if the private sector would be an adequate ally for this specific task. I still think it would be better to see if the public sector is able to go ahead alone. Perhaps for some specific aspects the private sector could provide support. In any case, I am not convinced that the private sector should be too involved with public health surveillance.

INS is the only public health producer in Colombia and this involves with production and marketing of specific products for public health. Looking ahead to the future, what do you see as the main products or procedures or developments that INS is looking to strengthen in the coming months?

INS has been discussing on how to improve our share of the market for antiserum. The Institute has realized that it only has a small proportion of the potential market for this product. We have started thinking of how to take advantage of the potential benefits that our production has over competitors. I am not an expert in that area, but our head of production has mentioned that INS has some advantages over our competitors, which we will try to exploit.

You were appointed very recently to Director General by Minister Gaviria to strengthen the positioning of INS in the Colombian market. If we were to return to Colombia in the next three to four years, what is your vision for the future of INS in that time?

I hope that within five years we will be able to have a new plant of production for vaccines. I hope that that will be a concrete medium-term goal. I hope that we will be able to start new research on chronic diseases in Colombia. I hope that by that time we are able to quantify the impact of new intervention, the government will have financed prevention of problematic diseases. Recently, the government introduced the HPV vaccine, so I hope that we soon assemble a group devoted just to investigate the impact of this intervention and start the evaluation of risk factors for chronic diseases. We also want to have clearer partnerships with private enterprises with potential international partners, for instance how the Centers for Disease Control and Prevention (CDC) can help us to strengthen our surveillance system. I hope that by that time INS will have installed a new information system that is friendlier with local areas. I also hope that we have secured the financial state of the local public health laboratories.

What attracted you to come back to INS, having previously worked here for thirteen years?

This institute allowed me to start a career in epidemiology. Most of the things that I have learned during my career were because of the INS. I therefore have some kind of debt with the Institute and I also want to collaborate with these new efforts to try to unveil the full potential of the public health system. I understand that the government has to compromise to improve Colombia’s health system, and I want to collaborate with them. It would probably be a good collaboration, and this Institute has very specific tasks, which I mentioned earlier. I want to be part of that. It is more as if I have emotional leeway with the Institute – I have personal motivation to come back as Director General which is a challenge and responsibility. I also think that now the Institute has the potential to perform better than it has ever done previously. Given the increase in human and financial resources, the potential for the Institute is very good. It is a good moment to be the Director.

What is your final message to our readers who will be reading about the new report on Colombia?

I think that Colombia has much potential. I would say that people should come to Colombia but with the intention to collaborate with the development of the country and institutions because not all foreign industries necessarily bring hope or good things to the country. My invitation is to come but also be responsible with our development and our Institute and contribute to strengthen our institutionalism, not to weaken it.