The findings of the study have been presented in two broad themes. First, factors that contributed to the implementation of actions in order to face the Zika outbreak, in terms of operations and functions. Secondly, gaps and critical barriers that emergedduring that implementation of health interventions and that needed to be addressed in order to improve the resilience of the health system in view of future health emergency crises.
Figure1 illustrates the main facilitators and gaps in the implementation of the ZIKA response plan in Colombia. This figure resulted from the most common answers and agreements among research participants during in-depth interviews and FGD.
Figure 1. Facilitators and gaps of the Colombian response to Zika.
Three major facilitators that promoted the implementation of actions to address the Zika epidemicwere: i) the role of health care providers; ii) inter-institutional coordination; and iii) capababilities and capacity building of technical teams
Health care provision
The first topic that emerged was associated with the role of health care providers, specifically at the primary health carelevel, building capacity among health care staff and theimplementation of follow-up systems of pregnant women at an individual level. Participants highlighted how health care providers promoted SRH through the adaptation of a gender-oriented approach and offeredinformation regarding abortion as an alternative, postponement of pregnancy and use of contraceptive barrier.
Campaigns were carried out even by the health care providers of the university. At that time, there was a campaign in a particular neighborhood, I do not remember very well where this was, in which Zika prevention campaigns were carried out…; it was Dengue and Zika and Sexual and Reproductive Health issues that were presented.
Public Health Officer, Health Service Provider, Barranquilla.
The second topic that emerged was associated with the need to share common objectives among government institutions, private health care providers and research institutes, which helped to increase the capacity of surveillance, diagnosis and response of the health system. There was an agreement among key participants that inter-institutional coordination played a key role during the outbreak. Many participants emphasized that the research on Zika Virus generated jointly by the National Health Institute (INS by its Spanish acronymous), the Center for Disease Control and Prevention (CDC) and the Ministry of Health and Social Protection (MSPS by its Spanish initials), helped the scientific community to identify the consequences of the virus in pregnant women, and the risk of microcephaly and early diagnosis of neurological disorders during conception, antenatal care and abortion.
The support of the National Health Institute was fundamental in this whole process and continues to be fundamental since, particularly in the Atlantic, they have been very vigilant, and we are still developing surveillance processes for pregnant women during the first trimester. They have not had Zika but they once had some contact [...].
Deputy Director of departmental public health.
In addition, this collaborative work was highlighted as the main facilitator of timely and effective control measures of the outbreak, as well as for the monitoring of the cases of pregnant women at greater risk of infection. Several participants noted that the inter-sectoral coordination was also fundamental to raise awareness among different government sectors.
We are coordinating with other health and social sectors, working hand in hand with the National Health Institute and the registered academic societies that are part of health; we work with other social actors as well, social leaders, such as the department for social prosperity.
Ministry of Health and Social Protection worker.
Capacity building of technical teams
The third topic that emerged as a facilitator was associated with building capacity and skills as a result of the inter-institutional coordination. Most of the participants highlighted the fact that technical teams were strengthened with the fieldwork experiences. They pointed out that the first cases reported allowed the identification and charaterization of the virus, the identification of potential health impacts, improvement of the epidemiological surveillance, and implementation of clinical protocols.
Apart from raising awareness, everyone was trained, they were all trained: the health assistants, technicians, doctors, nurses; everything was done with the entire interdisciplinary group in the surveillance area [...] So that was a pretty good job and well done, providing awareness to all the staff [...] sometimes, it was not easy because, you know, the individual responsibilities [that] everyone has, and it takes time, but it was a very very nice experience.
Secretary of departmental of public health.
Similarly, they emphasized that the role of the National Health Institute (INS) was key at all levels of the health system, particularly to facilitate the alignment of the response plan with the existing healthcare provision.
When we started to see the complications of what the Zika virus epidemic implied, and that it was not easy to managebecause, foreverytype of case we had surveillance protocols and clinical practice guidelines, but not for this specific health problem. An initial difficulty was the need to quickly issue guidelines considering that during a non-emergecncy period, clinical practice guide takes more than a year to be developed.
Director of epidemiology and demography. Ministry of Health and Social Protection.
However, capacity building and training was completely focused on technical issues described aboveNo actions concerning how to better understandthe how and why sex and gender influence the acquisition of the Zika virus, the differential outcomes of the disease for women, particularly pregnant women, and the consequences of disability were developed. Nor were training processes identified in gender roles, human rights, SRH and its relationship with the Zika virus.
This study identified implementation gaps that had an impact to the response of the Zika epidemic in three categories: i) absence of a human rights and sexual and reproductive health approach; ii) focus on territorial actions centered exclusively on vector control management; and iii) limited attitudes, behaviors and knowledge of the Zika epidemic and its relation with SRH at the community level.
Lack of a human rights and sexual and reproductive health-oriented approach
The first topic that emerged was associated with the insufficient human rights and sexual and reproductive health-oriented approach in the response to the Zika epidemic. Thishighlighted that gender roles on SRH rights and access to health services were not fully managed by the governmentwithin the context of the Zika epidemic,
Prevention and education to the community. In what sense? the slogan is how to
reduce mosquitoes -less mosquitoes, less diseases- instead ofsexual and reproductive health issues.
Epidemiological surveillance coordinator
Many participants emphasized that the interconnection between the protocols to address the Zika outbreak and SRHmatterswere not constant or lacked completeness. They underlined therestrictedalignment of the Zika Response Planwith the National Policy of Sexuality and Sexual and Reproductive Rights, and the Ten-Year Public Health Plan 2012-2021. Participants highlighted that this lack of alignment was due to religions and stigma around abortion. Nevertheless, national health officials were able to carry out actions regardingSRHand gender among affected women. In addition, the government recommended postponing pregnancy, guaranteeing the right to voluntary interruptionofpregnancy and the use of condoms.
The issue of abortion induced due to congenital malformations was an issue that was strongly talked about; however, there was, andthere is here, a lot of reluctance [...].
Deputy Director of departmental public health
Conversely, these recommendations had limited acceptance at the local level with reluctance among health professionals. Most of the participants from communities and pregnant women at the local level said they had insufficient knowledge to understandtheimpact of a Zika outbreak on people's lives, in particular the impact for women’s SRH. They highlighted that the emphasis on health was focused only on the microcephaly risk of the newborns of mothers infected by Zika.
The Ministry of Health was one of the first health ministries in the world to say that women should postpone pregnancies because of this epidemic. I think that was very important and progressive in Colombia […].
Officer, Center for Disease Control and Prevention CDC
Approach of territorial actions focused mainly on mosquitoes
The second topic that emerged was associated with the problemoflimiting health interventions only to a mosquito-orientedcontrol approach during the Zika epidemic. There was an agreement among participants that capacity building and training need to be focused on intervention concerning reproduction mechanisms of mosquitoes: water, sewerageandenvironment. Only one participant at the local level was able to talk about the Zika virus as a health problem with an impact on womenand as a sexually transmitted infection.
We apply different types of strategies, but there is one implemented in Los Patioswhich is the "selling point" strategy; with it we have done different actions, among therm: days of waste collection, days of promotion and prevention, and environmental days. With this, we are not only talking about dengueorChicunguña, or Zika but infectious diseases
Departmental Health Secretary
Attitudes, behaviors and knowledge at the community level
The third topic that emerged is associated with problems related to gender normsin the communities. Many participants showed important misunderstanding of the impact of Zika on SRH of pregnant women and gender inequalities.
Is Zika also transmitted through sexual intercourse? I did not know that by having relationships you could also harm your partner, and all the negative consequences that could happen, because you do not have the information.
Participant of Focal Group in Los Patios, Norte de Santander.
In this regard, the attitudes and actions taken by the communities against the Zika virusand the practices assumed to prevent the outbreak, were that some people with Zika who did not have access to health services made thedecision to self-medicate with "home-mademedicines" such as beverages for symptoms such as fever. There are facilitating processes identified by this study which are relevant to the zika outbreak: implementation of the Zika response plan, knowledge transfer and management undertaken, and early preparedness at the government level. Gaps identified included lack of coordination between different levels of the health system, and insufficient alignment with the National Sexual and Reproductive Health Policy.