Universal coverage and increased accountability improve access to Colombia's health services

In recent decades Colombia’s health sector has gone through substantial changes and improvements, shifting from being underdeveloped to one of the highest ranked in the region. In a October 2018 review of 191 of the world’s health care systems, the World Health Organisation (WHO) ranked Colombia 22nd, ahead of Canada and the US. However, the system is under significant financial strain, with liquidity an issue for many public hospitals. During a press conference in November 2018 Juan Pablo Uribe, the minister of health and social protection, described the challenges facing the Colombian health care sector for 2019 and beyond. Of these challenges, the government is prioritising timely and quality services, the promotion of a healthy lifestyle and sector liquidity. The authorities are also giving the National Superintendence of Health (Superintendencia Nacional de Salud, SuperSalud) additional regulatory authority to increase accountability throughout the sector.

Structure & Oversight

The Ministry of Health and Social Protection (Ministerio de Salud y Protección Social, MinSalud) is responsible for overseeing the health care system, dictating policy and promoting health in the country. The system it oversees, the General System of Social Security in Health (Sistema General de Seguridad Social en Salud, SGSSS), has expanded to cover nearly all, or 97%, of Colombians since it was established in 1993.

While the SGSSS is public, it is intermediated by private companies known as health service providers (entidades promotoras de salud, EPSs). The EPSs play a role equivalent to US health insurance firms. They affiliate patients, arrange for treatment and collect a 10% payment for their services. A key difference, however, is that EPSs collect premiums from the Solidarity and Guarantee Fund (Fondo de Solidaridad y Garantía, Fosyga), the central financial pillar of the health care system. The centres, clinics and hospitals where treatments take place are called health service institutions (instituciones prestadoras de salud, IPSs) and include both privately held and government-managed health facilities.

International EPSs have recently entered the market in response to sector expansion. In 2018 two US firms, UnitedHealth and CHRISTUS Health, established operations in Colombia. Authorities hope participation of international players will raise standards of health service providers across the board.

MinSalud has several agencies under its supervision, each of which plays a key role in supervising the sector and executing policy, such as SuperSalud, which aims to ensure the rights of people in relation to health, and the National Institute of Food and Drug Mentoring, which supervises the pharmaceutical industry. The private sector participates through service provision, whether as EPSs or IPSs. Although EPS and IPS actors support the SGSSS with the provision of services, private health care is mostly utilised by those who can afford to purchase private insurance and cover out-of-pocket expenses.

Spending

Financial strains on the system have necessitated significant government health budget increases. The 2019 budget, which focused on social development, boosted funding for health, as well as education and social inclusion. The government allocated COP32.3trn ($11bn) for 2019, a 30% increase of COP7.7trn ($2.6bn) from the previous year’s budget.

Overall, per capita health care spending in Colombia is $358, according to the 2018 Financing Global Health Database. The majority of the spending ($233) is from government contributions, with the remainder from out-of-pocket expenses ($74) and prepaid private spending ($51). Improvements in the provision of health services have developed in parallel with increases in costs of care. This trend is expected to continue, with per capita spending projected to rise to $584 per person by 2050. The government spending on health care accounted for 5.9% of GDP in 2016 and amounted to $215m, according to the most recent figures from the World Bank.

General Indicators

Over the past three decades Colombia has made marked improvements in several health indicators. Life expectancy has risen from 74.8 in 1990 to 82.7 for females and 77.5 for males in 2017. Infant mortality halved, from 33.5 deaths per 1000 live births in 1990 to 14.2 deaths in 2017. Similarly, maternal mortality in Colombia has experienced a steady decline since the start of the century. In 2000 the incidence of maternal mortality was 104.9 deaths per 100,000 births. In 2016 this figure had fallen to 51.2 and is expected to fall further, to 24.7 in 2021. Disparities in quality of service and health outcomes between rural and urban areas are significant, however, and are not reflected in health indicators. Therefore, these improvements are only a partial reflection of the sector’s overall performance.

While Colombia’s health indicators have been improving, the country still struggles to attract enough medical professionals. Colombia’s doctor-to-patient ratio is just over half the OECD average of 3.4 doctors per 1000 inhabitants, at 1.8 doctors. The ratio of nurses to patients fared worse, at 1.1 per 1000 inhabitants, under the OECD median of nine.

Hospitals

Colombia’s hospitals compare favourably with those in other Latin American countries, with economics-focused América Economía (America Economy) naming 23 of Colombia’s out of 58 institutions in the 2018 edition of its annual list of the region’s top hospitals. All of the Colombian hospitals listed were private, with the top-ranked in Colombia being Fundación Valle del Lili in Cali (third regionally), followed by Fundación Cardioinfanti in Bogotá (fifth regionally) and Hospital Pablo Tobón Uribe in Medellín (ninth). Five of the Colombian hospitals on the list were Joint Commission International accredited, the highest possible rating around the world.

While hospitals in the private sector are generally known for the quality of their services provided, the public system has room for improvement. In December 2018 Medellín’s largest public hospital, University Hospital León XIII, was forced to close because of financial issues. The hospital’s struggles mirror a wider trend throughout the country, with hospitals and clinics unable to collect on outstanding debts. Increased coverage and rising treatment costs have also outstripped financial inflows to the system, leading to calls for greater efficiency.

In May 2019 a survey by the Colombian Association of Hospitals and Clinics found that 207 institutions were owed COP10.1bn ($3.5m), of which 59.1% was delinquent debt, having exceeded 60 days. The largest debtors were EPSs in the contributory regime, which owed COP4bn ($1.4m). Additionally, the government owed COP1.1bn ($376,000) to the facilities.

To address this issue MinSalud and the Ministry of Finance have been working to create fiscal and financial clearing programmes for public hospitals since September 2018. Additionally, the Financial Superintendency of Colombia was given regulatory authority over EPSs, allowing the government to supervise and audit the entities. As a result, 22 ESPs were under audit as of December 2018, and 2019 authorities began closing facilities that had failed audits, including Comfacor, Medimas and Comparta.

There have been improvements in this area in some parts of the country, for example, in 2018 Bogotá’s Health Secretariat’s debt for public hospitals fell by 14%. As part of a wider effort to boost liquidity in the system in December 2018, the government announced an injection of COP488bn ($166.9m) into the sector. Among other provisions, the initiative provides COP80bn ($27.4m) to cover portfolios owed to providers and suppliers, a COP100bn ($34.2m) credit line for EPSs and IPSs, and COP20bn ($6.8m) for public hospitals that deal with significant populations of migrants, especially Venezuelans.

In a bid to boost hospitals’ operations the government has also launched a programme, the Immediate Action Programme to Strengthen Public Hospitals, or AI Hospital, to improve services, invest in infrastructure and reduce the financial liabilities of hospitals. In January 2019 the Office of the Presidency announced COP187bn ($64m) had been invested in the programme. In particular, AI Hospital is focused on facilities in critical need, which are primarily in more marginalised regions such as Buenaventura on the Pacific coast, Leticia in the Amazon, San Andrés, and Maicao on the Venezuelan border.

Patient-Centric Approach

In 2015 the Statutory Health Law (Ley Estatutaria de Salud, LES) was passed, recognising health as a basic right. The following year MinSalud implemented a comprehensive health care policy that shifted the focus of the health care sector to patients, instead of EPSs and IPSs. Its operational component, the Comprehensive Health Care Model, has been adopted as the framework to ensure institutions deliver on this commitment. In February 2017 the LES entered into force, becoming the most significant change to Colombian health care in approximately 25 years, with wide ramifications for the provision of services.

The policy is part of a wider Public Health Plan 2012-21, which is focused on boosting health outcomes by improving on equity in service provision, mitigating the impact of disease on life expectancy and positively influencing the social determinants of health. In May 2019 the government reaffirmed its commitment to health equality with the 2018-22 National Development Plan (Plan Nacional de Desarrollo, PND), which seeks to guarantee universal health coverage and includes provisions on electronic medical records, expanded subsidies for health coverage and tools to reduce or even eliminate debt for hospitals. The PND also gives SuperSalud more regulatory authority over EPSs.

Obligatory Coverage

One of the most significant changes made in the 1993 reform of the health care sector was a stipulation that health insurance be obligatory, with patients having a choice of providers who, in turn, would be given administrative authority. It was under the auspice of MinSalud that the SGSSS was created, which split Colombians into three categories: those in the contributory category are able to contribute to health payments, and include pensioners and salaried workers; there is a subsidised category for those unable to pay; and an exemption category for certain public sector employees, including ministry and security personnel, as well as employees of Ecopetrol, the national oil company.

Under the current guidelines, 8.5% of a worker’s salary is paid into Fosyga by the employer, with the employee contributing an additional 4%. Fosyga was designed to redistribute financial resources between those that have the most and least, and essentially controls liquidity in the system. In 2019 MinSalud raised rates for both the contributory and subsidised categories, up 5.3% and 9.4%, respectively, from the year before. In 2018 MinSalud had increased contributions by 8.2% from 2017.

Disease Burden

Economic growth and a shift in lifestyle has resulted in increasing incidences of non-communicable diseases (NCDs). A WHO study found that in 2016, 43% of Colombians were physically inactive, 9% smoked cigarettes and 18% had raised blood pressure. The risk of death due to high blood pressure has risen by 21.7% between 2007 and 2017, while dietary risks have increased by 15.4%, and high body mass index by about 33.3%. Although regular cigarette use appears to be on the decline among both men and women, both obesity and raised blood pressure are expected to remain above global targets through to at least 2025.

Higher rates of NCDs have also led to increased mortality rates from these afflictions. These diseases account for an estimated 75% of all deaths. According to a 2018 WHO report, 30% of deaths are from cardiovascular diseases, 20% from cancer, 6% from chronic respiratory diseases, 3% from diabetes and 15% from other NCDs. Communicable maternal, perinatal and nutritional conditions account for 10% of deaths, while injuries account for 15% overall.

While NCDs are on the rise, there have been improvements in other indicators. The risk of death from malnutrition and air pollution have fallen by 38.1% and 7.6%, respectively. A focus on prevention has also contributed to improvements in indicators, with Colombia performing better than the OECD average in almost all metrics. Colombia experiences 89 hospitalisations per 100,000 inhabitants for asthma and chronic lung problems, compared to the OECD average of 237. In terms of congestive heart failure, Colombia receives 47 cases per 100,000 inhabitants, compared to OECD’s average of 228.

Mosquito-Transmitted Diseases

Because of Colombia’s climate and geography, mosquito-transmitted diseases are prevalent. Dengue continues to be a major public health challenge for the country, which treated 44,825 cases of the disease in 2018. An increase in incidence is considered to be likely for 2019, as in January of that year alone there were a reported 6310 cases of the disease.

The government is aiming to use preventative measures and public awareness campaigns to reduce the four types of dengue in the country. The “Cut Off Dengue’s Wings” campaign aims to not only increase awareness about the disease, but also encourage individuals to adopt prevention measures. Uribe told local press in February 2019 that diligence on the part of Colombians would be vital in managing the disease, as well as regular coordination between national, provincial and municipal governments. “It is also vital that each citizen take the measures required to reduce the number of cases and their potential complications,” he stated.

In addition to dengue, Colombia has around 60,000 cases of malaria a year, with roughly 1000 becoming complicated and 10 becoming fatal. Given that the disease only occurs below 1500 metres and parts of Colombia is at a high elevation, not all of the country’s departments are at risk. Around 60% of malaria cases occur along the Pacific coast, with around 12.5m people living in areas considered at-risk.

Migration Challenges

Increasing levels of immigration from neighbouring Venezuela have pressured Colombia’s health resources and capacity, and with little sign the of the crisis across the border abating, it is likely this trend will continue into 2019. According to the authorities, Colombia treated 800,000 cases involving 200,000 Venezuelans in 2018. Part of the government’s COP488trn ($166.9bn) injection of liquidity into hospitals and clinics was focused in the regions of Cúcuta, Arauca and La Guajira in which many Venezuelans reside.

Pharmaceuticals 

The pharmaceutical market has posted steady growth for a number of years in Colombia. Between 2014 and 2017 pharmaceutical sales grew by an annual average of 5.3%, with generics growing by an average of 5%, patented products by 5.9%, and over-the-counter medications by 4.8%. Overall, it is estimated that the pharmaceutical market in Colombia is valued at COP11.3bn ($3.9m) and is projected to reach COP13.4bn ($4.6m) by 2022.

The sector is dominated by domestic companies, which account for around two-thirds of those in the market. The presence of multinationals in the sector declined over the past decade, partly due to other countries offering more competitive tax incentives. This has enabled national companies to expand and develop, and as a result Colombia is one of the main exporters of pharmaceutical products in the region.

Pharmaceuticals are also a main driver of foreign direct investment (FDI). Between January 2011 and August 2018, Colombia was the fourth-largest recipient of pharmaceutical FDI in the region after Mexico, Brazil and Argentina. The industry is centred around the capital city, Bogotá, where 66% of pharmaceutical manufacturing companies, 65% of wholesalers and 49% of the workforce are located.

Price Controls

While Colombia’s out-of-pocket expenses are already among the lowest in Latin America, at 16.3%, the government is working to further reduce the financial burden on patients. MinSalud has implemented a series of price controls on medications with the goal of increasing access and affordability. In addition, in January 2019 MinSalud published a notice giving the National Commission for Medicine and Medical Device Prices more power to control the price of certain medicines, reducing the cost of many drugs by 50%. According to the ministry, between January and April 2019 price controls were imposed on nearly 1000 medications, saving Colombians an estimated COP360bn ($123.1m). The authorities are expected to introduce a new methodology in the second half of 2019 to better regulate entry costs and encourage self-regulation.

Medical Marijuana

In December 2015 then-President Juan Manuel Santos signed a decree fully legalising medical marijuana, a move he said would put Colombia “in the group of countries that are at the forefront... in the use of natural resources to fight disease.” Before the decree, the manufacture, export and medical and scientific use of marijuana was allowed, but not formally regulated. The manufacturing of cannabis derivatives is now regulated by MinSalud, and as of February 2019 the ministry had received 374 licence requests, of which 86 had been awarded. That same month, Colombia authorised the first cannabis export to Canada.

The country hopes to grow as much as 40.5 tonnes per year of the substance for use both at home and abroad, which would account for about 44% of medical marijuana produced worldwide (see Agriculture analysis). The use of marijuana in Colombia is strictly limited to scientific research and medicine, and is expected to be used to treat and manage pain, epilepsy, sclerosis and other diseases.

Technology & Innovation

Telemedicine and electronic health, or e-health, have significant potential to boost health indicators and overall well-being. Health officials are looking to technology to help increase access to health services in rural areas, many of which are underserved. However, telemedicine is still in its early stages of development in Colombia, despite the fact the country has quickly adopted various other forms of technology in different sectors. A February 2019 study by the journal Health Affairs found that telemedicine had only been adopted by 25% of hospitals in Colombia, compared to 65% of hospitals in its regional counterpart, Chile.

Authorities are working to incentivise and encourage innovation by creating a stronger framework for intellectual property rights, cutting red tape and increasing financing opportunities to allow Colombia to be increasingly competitive for innovation-focused health sector activities.

The country’s health and technology infrastructure is more advanced than that of many of its counterparts in Latin America, a fact which could encourage the country to continue developing its telemedicine capabilities. However, the necessary financing remains difficult to obtain, and this issue must be addressed before expanding the number of companies offering and developing telemedicine services.

Outlook

Colombia’s health sector continues to struggle with structural issues related to liquidity. However, the government is hoping that a boost in general health spending and a targeted infusion of financing will help alleviate some of the financial pressure the system is experiencing.

The arrival of Venezuelans fleeing the humanitarian situation in the neighbouring country is also expected to continue in the coming years, and it is likely the situation will require international assistance to help the system care for new arrivals, while still maintaining quality and access for citizens.

Meanwhile, efforts to universalise coverage and shift the focus of the system to the patient are expected to result in access and quality improvements. It remains to be seen over the long term what effect the 2015 health law will have on overall health outcomes, but improved indicators in recent years and increased funding positive signs for the future.