Pan American Health Organization

Colombia

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Outlook
  • References
  • Full Article
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Overall Context

Flag of ColombiaThe Republic of Colombia is located in South America’s northern Andes. Its territory extends for 1,141,748 km2, reaching heights of up to 6,000 m. Its rivers drain into the Pacific and Atlantic Oceans. Colombia shares borders with Brazil, Ecuador, Panama, Peru, and Venezuela. The 1991 Constitution structures the country as a unitary republic with a decentralized state-level administration organized into 32 departments, the Capital District, 1,121 municipalities, and indigenous territories.

Demographics

In 2016, Colombia’s population was estimated at 48,747,708, with 50.8% women and a dependency ratio of 54%. The population is predominantly urban (79%), with a population density of 42.7 inhabitants per km2. Life expectancy at birth in 2010 2015 was estimated at 73.74 years (77.39 for women and 70.19 for men); the crude death rate was 5.8 deaths per 100,000 population; the birth rate, 18.8 births per 1,000 population; and the total fertility rate, 1.93 children per woman, with average growth of 1.3% annually. The natural growth rate fell from 22.03 per 1,000 population in 1985 1990 to 13.07 in 2010-2015, with a rate of 12.08 per 1,000 population expected for 2015 2020 (). Figure 1 shows the country’s population structure in 1990 and 2015.

Figure 1. Population structure, by age and sex, Colombia, 1990 and 2015

Colombia’s population grew 40.7% between 1990 and 2015. In 1990, the structure was pyramidal, with most of the population beign under 25 years old. By 2015, the population structure was regressive, with fertility and mortality rates lower than those of the previous three decades.

Source: Pan American Health Organization, based on data from the UN Department of Economic and Social Affairs. Population Division. 2015 Revision. New York; 2015.

The Economy

The World Bank classifies Colombia as a middle-to-high-income country. The global economic slump and the drop in oil prices reduced the country’s 6.6% economic growth in 2011 to 3.1% in 2015, resulting in a deficit of 2.2% of the gross domestic product (GDP) (). In 2015, inequality, expressed as the Gini coefficient, was 0.522, and 27.8% of the population lived below the poverty line (). Thanks to wage reforms, unemployment fell from 12.5% in 2009 to 8.9% in 2015. Currency depreciation, the effects of climate change, and agricultural and transportation strikes raised the consumer price index (CPI) from 4.3% in 2015 to 6.9% in 2016 (). In 2015, 91.2% of the population had access to improved drinking water sources and 81.1%, to improved sanitation facilities ().

Violence and Security

In addition to civil violence and insecurity, the country has felt the impact of more than five decades of armed conflict that, in turn, has spawned organized crime, displacement of population groups, and the isolation of eight million people (), which have made Colombia the world’s top-ranking country in terms of internal displacement.

In 2014, a homicide rate of 26.49 per 100,000 population was reported, representing a sharp decline from the 40.18 rate reported in 2005. Persons aged 20 29 were the most affected, with 92.4% of the victims being male (). In 2011, the theft rate was 135.2 per 100,000 population and the rape rate, 7.6 ().

Leading Environmental Problems

The El Niño and La Niña climate phenomena had both direct health impacts (flood-related deaths/injuries) and indirect impacts (poverty, food insecurity, no access to safe water, etc.). In 2015 2016, 719 municipalities in 28 departments were hit by serious disasters or emergencies (SDEs), and 367 disasters were declared due to water shortages and wildfires ().

Mining and oil drilling were health and environmental determinants, especially with respect to disabling and fatal work accidents, not to mention water pollution from oil spills and mercury contamination from gold mining ().

Social Determinants of Health

The 10-Year Public Health Plan 2012-2021 (PDSP) aims to attain equity in health, positively influence the social determinants of health, and mitigate the impact of the burden of disease on years of life ().

The 2015 Statutory Health Law No. 1751 places the responsibility for guaranteeing the right to health with the health system, not with the General Social Security Health System (SGSSS), recognizes health as a basic social right, and makes it the State’s obligation to pursue a societal approach in health promotion and disease prevention.

Finally, in 2016, the Ministry of Health and Social Protection (MSPS) introduced the Comprehensive Health Care Policy (PAIS for its Spanisch acronym), placing the individual, the family, and society, at the center of health action, rather than health providers and insurers. PAIS includes a strategic component, which sets the long-term priorities, and an operational component (the Comprehensive Health Care Model, for its Spanish acronym, MIAS), which is the organizational and coordination framework for guaranteeing access to safe, human-centered health services. MIAS is currently being adapted to the local level ().

The PDSP is designed to increase social equity, foster changes in management, and improve the population’s health and living conditions. Its activities include public policy making, social mobilization, the creation of healthy spaces, social and individual capacity building, citizen engagement, and health education (), in keeping with the National Development Plan 2014-2018, whose purpose is to build a peaceful, equitable, and educated country ().

Vulnerable Populations

The PDSP also is responsible for developing sector interventions targeted to vulnerable populations (children, adolescents, various ethnic groups, people with disabilities, older persons, and victims of the domestic armed conflict) as a cross-cutting effort (). The armed conflict has hit the poorest regions of the country and rural, indigenous, and Afro-descendant communities especially hard. In 2012 2015, 1,843 incidents involving antipersonnel mines and unexploded ordnance, 2,084 crimes against liberty and sexual integrity, and 473 cases involving children were reported ().

Although Colombia has had a National Disability and Social Inclusion Policy in place since 2013, people with disabilities continue to grapple with barriers to their full enjoyment of their rights. These barriers include fragmented organizations, insufficient resources, and noncompliance with the law (). As of 2016, 1,272,267 individuals were registered by the National Observatory on Disability (). Furthermore, the growing proportion of people over age 60 exceeds the capacity of state and social protection agencies to provide health care and economic protection for them.

The Comprehensive Psychosocial Health Services and Victim Care Program (PAPSIVI) provides care and physical and mental care to victims of the armed conflict at the individual, family, and community levels. In 2011, 9,614 people were reported to be living on the streets of Bogotá that is, 12.87 per 10,000; Law No. 1641 of 2013 was enacted to provide care for this group ().

The Health System

Colombia’s health system is made up of a social security sector and a private sector. The backbone of the system is the General Social Security Health System, which has two plans, contributory and subsidized; workers from certain institutions (5.4%) are covered by a third plan. The contributory regime covers salaried workers, pensioners, and independent workers, with the subsidized plan covering anyone who cannot pay (). Enrollment coverage increased from 96.6% in 2014 to 97.6% in 2015.

The National Health Authority’s functions under the system include improving the quality of health care and strengthening supervision, surveillance, and control of health insurance ().

Enrollment in the General Social Security Health System is compulsory and is handled through public or private health promotion agencies (known as EPS, from their Spanish acronym). The EPS deliver the funds from premium payments to the Solidarity and Guarantee Fund (FOSYGA), which then returns to them the amount equivalent to the payment per person, adjusted for risk, according to the number of members. Health care is provided by institutional health service providers, which may or may not be part of the EPS. Those who can afford to purchase health insurance coverage on their own and who can pay for any uncovered fees out-of-pocket use the private sector.().

Leading Health Challenges

Critical Health Problems

The population’s vulnerability and inequity have been exacerbated by the armed conflict and the scant institutional coverage in those locations with high proportions of vulnerable populations, such as indigenous, peasant-farmer, and Afro descendant groups. Illegal farming and mining further complicates the situation, as does the fact that some of these settlements are scattered in isolated regions. The vulnerability factors in these populations, which include nutritional deficiencies and little access to health care, education, and decent housing, lead, among other things, to higher maternal mortality and child morbidity and mortality rates. Indigenous and Afro-descendant women have less access than other women to family planning, institutional delivery care, immunization, and preventable mortality, generating an equity gap. The introduction of the Comprehensive Health Care Model represents an opportunity to deliver effective primary health care by tailoring it to the needs of specific groups and locations ().

The cost of new health technologies, an aging population, and wider insurance coverage are driving up the cost of care plans in the country (). In 2014 alone, the Constitutional Court received 498,240 requests for constitutional protection for alleged violations of the right to health, which highlights the challenge in being able to provide timely access to health services ().

Chronic Conditions

In 2015, the Government made a commitment to reducing premature death from cardiovascular disease, diabetes, cancer, and chronic respiratory diseases by 8% among the population aged 30 70, which would reduce deaths from 221 per 100,000 population to 192 by 2018. The Comprehensive Health Care Model is tackling this challenge through strategies designed to upgrade human resources and improve health infrastructure, health care procedures, and clinical practice guidelines ().

The 10-year Plan for Cancer Control, 2012-2021, aims at reducing mortality from cancer by 30% during that period through strategies aimed at controlling risk factors such as tobacco use, physical inactivity, consumption of sugar-sweetened beverages, and obesity. The Cuenta de Alto Costo showed that chronic kidney disease and its precursors diabetes and hypertension are health problems for which early detection, research, and adequate monitoring are insufficient ().

Human Resources

According to data from the Ministry of Health there is 1 physician for every 0.6 nurses. In 2012, the ratio of physicians per 10,000 population was 17.7, 10.3 for nurses, and 8.3 for dentists (). Colombia has 55 medical programs, graduating an average of 5,000 physicians annually; the country has 65 nursing programs, graduating an annual average of 3,600 nurses. A family and community medicine approach is being developed under the Comprehensive Health Care Model to upgrade the skills of human resources (). In 2015, the National Registry of Human Talent in Health listed 600,000 health professionals, technicians, and auxiliaries licensed to practice.

Health Knowledge, Technology, and Information

As a way to overcome barriers related to geographic and functional access, comprehensiveness, and continuity of care, Colombia is promoting improvements in telemedicine. In 2016, 242 public health institutions provided telemedicine services to remote areas or regions where health services were in short supply ().

Further, the Comprehensive Social Protection Information System (SISPRO, for its Spanish acronym) () makes it possible to gather and consolidate information on health, pensions, occupational risks, and health promotion as it relates to insurance and the use, financing, and supply and demand for health services.

Scientific output is spearheaded by the country’s public universities, with health being the most important research topic (44%). Seven private universities are among the 20 most productive institutions in this field ().

The Environment and Human Security

The National Development Plan 2014-2018 aims to achieve resilient growth and reduce vulnerability to disasters and climate change (), calling on the various sectors to draw up plans for adapting to that change. In 2016, the Ministry of Health issued guidelines for drafting territorial plans for adaptation to climate change under the environmental health component.

Within this framework, the sector has produced evidence on climate change’s impact on health, and has put forward specific measures for adapting to climate change, that include analyzing trends for malaria and other diseases for the medium term, and projecting a rising incidence if current economic and entomological conditions persist. In the case of dengue, climate change fosters transmission due to insecurity in access to drinking water ().

Aging

In 2015, 10.8% of the population was over the age of 60, 9.9% of men and 11.8% of women. It is projected that the population aged 65 and older will account for 7% of men and 15% of women in 2017 2037 ().

Between 2010 and 2015, total dependency fell from 62.4% to 60.6%, as a result of the aging of the population and a steady decline in fertility. Dependency in the older population has risen, increasing from 16% to 17.8% between 2010 and 2015 (). Population projections from 2020 onward point to a steady increase in the relative proportion of this group, meaning that the age dependency ratio will begin to grow ().

Migration

The net migration rate, which fell from -0.33 to -0.3 in 2000 2009, rose to -0.68 between 2010 and 2011. The main destinations of migrants were the United States (34.6%), Spain (23.1%), Venezuela (20%), and Ecuador (3.1%). A full 98% of refugees in Ecuador are Colombian nationals ().

Monitoring the Health System’s Organization, Provision of Care, and Performance

The Ministry of Health uses a Health System Performance Evaluation System that incorporates criteria set by the Organisation for Economic Co-operation and Development (OECD), which the country is in the process of joining ().

The National Pharmaceutical Policy provides price regulation mechanisms based on international benchmarks, the registration of biosimilars, and the strengthening of national capacity and sanitary registration mechanisms, in keeping with the Development Plan ().

The 2015 Resolution 5592 updates the health benefits plan, which entails establishing the drug formulary, procedures, and laboratory tests that will be underwritten by the EPS. The country also stipulates the requirements for bioavailability and bioequivalence studies of medicines, good laboratory practices, and good manufacturing practices for pharmaceuticals and biologicals. In 2016, during a visit from the Pan American Health Organization/World Health Organization (PAHO/WHO), the National Food and Drug Surveillance Institute (INVIMA) was certified as a national regulatory authority for regional reference on drugs and biologicals, making it one of eight in the Region ().

Outlook

The current health situation is the product of achievements stemming from the political and legal recognition of health as a basic right enshrined in Statutory Health Law (2015), which is the basis for the Comprehensive Health Care Policy and its Comprehensive Health Care Model. Both aim at bridging gaps in health service coverage and access over the next 10 years.

In advance of a peace agreement between the government and the guerrilla forces of the Revolutionary Armed Forces of Colombia (FARC), the following took place: 1) rural health interventions, 2) the establishment of a food security system, 3) the creation of insurance and health care for demobilized guerilla fighters, 4) the creation of a national program for the prevention of illicit drug use and the delivery of care to users, and 5) the delivery of psychosocial and mental health care to victims of the conflict.

Within this context, the Ministry of Health and Social Protection has set forth five lines of cooperation for the coming years: 1) a model of care for sparsely populated rural areas; 2) psychoactive substance use prevention and care; 3) psychosocial and mental health care for victims, demobilized guerilla fighters, and the community at large; 4) a contingency plan during the guerilla disarmament and demobilization phase; and 5) a nutrition and food security plan.

The creation of the Comprehensive Health Care Policy (PAIS) and the Comprehensive Health Care Model (MAIS) represents a strategic step forward for the system in its commitment to guarantee effective citizen access to health services. This commitment should result in quality, sustainability, and equity in activities and benefits through health promotion, disease prevention, treatment, rehabilitation, and social reintegration at all stages of life, insofar as possible providing these services in daily living.

In 2014, Law No. 1733 was enacted, regulating palliative care services for integrated management of patients with chronic, degenerative, and irreversible terminal illnesses at any stage of a disease with a major impact on the quality of life. In compliance with this law, the Ministry of Health modified the qualification criteria through Resolution 1416 of 2016. Pursuant to judgment T-970 of 2014 of the Constitutional Court, the Ministry of Health designed a protocol that guarantees death with dignity to Colombians in every hospital and clinic in the country.

Referencias

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Reference/Note:

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