Why did I choose this country-policy?
Colombia implemented a radical reform of its health system in the early 1990s. The changes and process of implementation are at the heart of its main policy (Law 100, 1993). The policy has been perceived as a triumph by a rising number of commentators and institutions at the national and international level who consider it as one of the best in Latin-American, an “absolute success”, ranked 1 by the WHO (World Health report 2000, p.188 Annex Table 7) in terms of fairness in financial contribution, “the most responsive” the number 22 in the whole world (ibid). After looking at this particular policy this report will aim to investigate whether this particular policy has had negative or positive effects on outcomes and whether it serves the needs of users. I have chosen this country-policy case because many lessons might be learned from this particular experience. Colombia was the first country in the developing world to introduce market mechanisms in its health system, the reform was accompanied by a huge rise in public expenditure from its inception supported by international financial institutions, however, statistics and different evidence seem to suggest that despite its implementation health outcomes have not improved substantially in the country, rather it has brought many contradictions and new problems. When comparing it with similar experiences of other countries in the region such as Mexico or different such as the case of Cuba, Colombia health system until now has not been able to provide universal coverage, accessibility, equity and efficiency.
The following inclusion and exclusion criteria were applied to the literature search:
|Studies that describe the Colombian health system, its policies supported by original and secondary data|
|Studies evaluating Law 100 (Health sector reform) and the impact of this particular policy on health outcomes|
|Studies published during the period 1995-2008|
|Comparative data about socio-demographic and epidemiological profile of Colombia period 1993-2008|
|Personal opinions that are not supported by facts (from primary or secondary data).|
The literature search included the following databases:
|Databases (Electronic Journals)||Search Terms Used|
|Database journal Health policy||“Health sector reform”;Colombia|
|Oxford Journals. Oxford University Press. Health Policy and Planning.||“Health system; Colombia”|
|PUDMED (www.pubmed.com)||“Health system;Colombia”|
|Scielo (www.scielosp.org)||“Health sector reform”|
Additionally, some grey literature (local, regional, national, international), which was accessed during the search process was reviewed, however, as I have learned in this module and by my tutors I have many reasons not to believe, not to trust in many of these statistics, since they give the impression of being highly biased. Several searchers engines (i.e Google, Yahoo) were consulted with the same inclusion criteria and typing the same search terms outlined above in English and Spanish language. Quantitative data came from the Ministry of health documents, Departments Ministry, National Planning Department, Colombian Central Bank (Banco de la Republica) and Databases such as WHOSIS (WHO) PAHO (Pan American Health Organisation) Basic Indicators. Reports of the WHO (2000, 2003) were consulted as well as data from projects such as “The health system strengthening in Latin America” a 20 million regional agreement funded in 2004 by USAID, PAHO and WHO to improve the health systems in Latin-America.
Limitations of this report
It is important to note that a truly evaluation of this health system and its outcomes is beyond this paper. This is a small and modest attempt to evaluate the Colombian case since there are only a small number of evaluative studies on this issue. No information was held at King Fund’s library. Only one book was found at the LSE library, however, containing information about pre-reform issues in health in Colombia.
The review of grey literature (consulting reports or studies not published in international journals) was directed to those sources known to the author. They provided different conceptions and evaluations of the evolution of the policy. It is therefore possible that additional information may exist in other sources.
3. Analysis of Colombia Health System
3.1 Background of the Health system
Before 1993 and similarly to many Latin-American countries the Health system in Colombia used to be so simple to describe (figure 1). It was divided in three sectors: Private (for those who could afford), Compulsory social security (employees) and Public (for the poor). At the end of the 1980s, some 40% of the population was covered by the public sector and 18% by the social security, while 17% used private health services. This means that about 25% of the population remained without any coverage. (Hernandez 2002 quoted in De Vos P. 2006 p. 1606). This system has problems of low levels of insurance coverage, inequities in the access to services, low levels of solidarity, and high inefficiency in the public provision (Gaviria et al, 2006).
Different literature researched have illustrated how Colombia transformed its health system in 1993, “moving in a short time from a traditional model of providing health services in public hospitals to a managed competition model, in which the government buys health insurance from competing insurers for the poor” (Plaza B, Barona AB, Hearst N.2001 p.1). In line with the process of decentralisation, after 1993 the state is a regulator (Ministry of Social protection, MPS) rather than direct provider. Law 100, 1993 created a new system of social insurance which includes two regimes in order to increase accessibility: RC, Contributory regime (for workers, taxed 12% of income= 8% from employer plus 4% from employee, the insurance companies to which they get access are called EPS) and the other SR, Subsidised regime (for poor population, they get access to health from insurance companies called ARS).
SR is partly funded by the RC as well as supply or regional and national transfers. The contributions of the RC are collected by the EPS which takes the premium set by state and give the rest to a fund called FOSYGA. The latter send this to Local Governments which then send the risk adjusted premiums to the ARS, who then should pay for the hospitals according to the number of enrolees they have.
The beneficiaries are identified through surveys door to door through a system called SISBEN.
The ARS purchase health services for the poor from competing public and private insurance companies (IPS) as well as other institutions. Once enrolled in the SR the poor can choose the ARS they want. The services of the RC (workers) cover a substantial range of health services available in Colombia, while the services of the SR (poor) only cover a limited number such as prevention and primary care, beyond that is quite limited. The objective of the policy (implemented nationally without testing its feasibility) was to cover 70% of the entire population (employees-contributory regime) and the rest 30% (subsidized regime) by the end of 2000 as well as offering the same services offered to worker by the RC to the poor by the SR. Health insurance companies were created in both systems, and a basic benefit plan was provided to the users which includes: medical procedures, hospitalisation, and medicines that insurance must cover, what it was not covered in the plan should be bought in the market. No longer public hospitals would receive financial subsidies from the state, but instead they will have to compete for private contracts with the insurance companies.
Colombia’s pyramid population has taken another look:
Figure 4. Comparative Pyramid population Colombia 1973, 1983, 1993, 2008)
This means that people is living longer in comparison to the 1973, and after 1993 it is clearly perceived a increase in life expectancy, there are some gaps and is clearly because homicides is really affecting the young population and is a problem for the Colombian health system. The ongoing 43 year internal conflict is what differentiate Colombia from the rest of the Latin-American Countries.
Statistics suggest that there has been some increase in coverage, however, and according to the objectives of the policy it was supposed to enrolled around 30 million people by 2002. Critics suggest Plaza B, Barona AB, Hearst N (2001) that Law 100 came into effect in the entire country without testing its feasibility. as a result of that, people was not prepared for the changes. As this critic have observed, the implementation brought problems such as lack of managerial infrastructure, deficient flow of information, because of lack of knowledge, as a result of that substantial resources were wasted. The advice to countries willing to implement this type of policy is to test its feasibility first as well as establish better administrative capacity before the implementation process and have structures ready and in place before any reform or change might take place.
Several commentators seem to agree that there is a huge problem because of the lack of information to the users (Acosta-Ramírez, Naydú et al, 2005,)
In addition to it, the services provided for the poor (POSS) are only half when compared to the services received by the workers (POS) therefore the poor ends up paying out of pocket.
Pol de Vos (2006) argues the increase in public and private health expenditure is uncontested, however. Total expenditure for health care has increased from 7% of the gross domestic product (GDP) in 1990 to 10.5% in 1999. But the increasing of expenditure seem to have increased health inequities. A huge percentage of the budget goes to private profit and is not reinvested. Large amounts of public money are being deviated from its social objectives (Franco-Aguledo 1998 quoted in P. De Vos et al 2006 p. 1608). Public hospitals are closing down, private facilities are booming, and they take a big chunk of this public money as profits. As a consequence of this changes, and it has noted by De vos (2006 p.1608) this has clearly has an impact on outcomes “it have been observed an increase of the morbidity and mortality from malaria, dengue, tuberculosis, syphilis and other communicable diseases. Control of tuberculosis has lost quality. According to different studies, the ‘organizational chaos’ has led to a decrease in vector-control activity, which in turn has been associated with more malaria cases (Kroeger et al. 2002). An assessment of the tuberculosis control programme came to similar conclusions (Ayala-Cerna & Kroeger 2002). Immunization coverage has likewise decreased dramatically. Moreover, the increased participation that decentralization was supposed to bring about did not materialize (Mosquera et al. 2001).
My criticism unmistakably follows Navarro (2000) who suggest that the new identity given by different commentators and international institutions rather reflects the ideological bias of the report’s authors than the performance of the health system.
Despite the introduction of this policy, the Colombian health system has not been able to promote equity, efficiency and quality of services and this has influenced health outcomes in the country which are seem now to be worst. Colombia’s health system and its outcomes on users are totally different from another Latin-American countries such as Cuba. The latter has not implemented such Neoliberal policies, do not allow foreign capital and had a Gross Domestic Product (GDP) of US$ 1100 per person in 2000 (only half of that of Colombia, and a fifth of Mexico’s), but have achieved a life expectancy of 76 years (71 in Colombia and 73 in Mexico), an infant mortality rate of 7 per 1000 life births (25 in Colombia and Mexico) and a maternal mortality rate of 33 per 100 000 (80 in Colombia and 55 in Mexico) (Ministerio de Salud Pública 2002; UNDP 2002; World Bank 2002 quoted in Pol de Vos 2006, p1608)
After analysing the impact of this particular policy on health outcomes in Colombia I conclude that this particular policy has brought more negative than positive impact on health outcome in this country. The Subsidized system has established a new mechanism to include the poor through insurance coverage and there has been some increase, however, based on the evidence and literature gathered in this report, the optimum conditions of accessibility for the poor have not been achieved, because of severe problems within the implementation process, in addition to that the system seem weakly administrated. Therefore, all the inhabitants are not covered and do not have access. The lack of knowledge is leading users to make out of pocket payments, government reporting increases in public expenditure and lack of sustainability. The problems of implementing a system so fast has brought many consequences that have impacted on health outcomes in the country.
Colombia still have to face many challenges ahead, particularly because of the internal war that seems not to have an end and it has now more that 43 years, but which unfortunately, its one of the main factors in health issues in this country. The health system would have to be reformed if it is to achieve a better coverage and improve the efficiency, equity and accessibility.
Ayala Cerna C & Kroeger A (2002) La reforma del sector salud en Colombia y sus efectos en los programas de control de tuberculosis e inmunización [Health sector reform in Colombia and its effects on tuberculosis control and immunization programs]. Cadernos de Saude Publica 18, 1771–1781
Axel Kroeger, José Ordoñez-Gonzalez, Ana Isabel Aviña (2002) Malaria control reinvented: health sector reform and strategy development in Colombia Tropical Medicine & International Health
Acosta-Ramírez, Naydú et al, 2005,), 2005 Determinants of vaccination after the Colombian health system reform. Rev. Saúde Pública vol.39 no.3 São Paulo June 2005
Compensar, empleos, available at http://www.compensar.com/empleos/index.aspx. (Accessed on 9th April 2008)
Gaviria, A et al, 2006 Evaluating the impact of health care reform in Colombia: from theory to practice.
Hernández M (2002) Reforma sanitaria, equidad y derecho a la salud en Colombia. Cadernos de Saúde Pública 18, 991–1001.
Ministerio de Salud Pública (2002) Estadisticas de la Salud Cubana. La Habana,
Mosquera M, Zapata Y, Lee K, Arango C & Varela A (2001) Strengthening user participation through health sector reform in Colombia: a study of institutional change and social representation. Health Policy and Planning 16, 52–60.
National Health Service (2008). jobs. Available at http://www.jobs.nhs.uk/ (Accessed on 9th April 2008)
Navarro V (2000) Assessment of the World Health Report 2000. Lancet 356, 1598–1601.
Pol De Vos, Wim De Ceukelaire, Patrick Van der Stuyft (2006) Colombia and Cuba, contrasting models in Latin America’s health sector reform
Tropical Medicine & International Health
Plaza, Beatriz; Barona, Ana Beatriz; Hearst, Norman; “Managed Compeition for the poor or poorly managed competition? Lessons from the Colombia health reform experience” Health Policy and Planning, No. 16 p. 44-51, 2001.
United Nations Development Program (UNDP) (2002) Human Development Report 2002. Oxford University Press, New York
U.S. Census Bureau. International Database (IDB) (2008). available at: http://www.census.gov/ipc/www/idb/pyramids.html (Accessed on 7th April 2008)
World Bank (2002) World Development Report 2002. World Bank, New York
World Health Organization (2000) The World Health Report 2000. Health Systems: Improving Performance. WHO, Geneva, Switzerland