Colombia

Overall Context

The 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 (1). 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) (2). In 2015, inequality, expressed as the Gini coefficient, was 0.522, and 27.8% of the population lived below the poverty line (3). 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 (4). In 2015, 91.2% of the population had access to improved drinking water sources and 81.1%, to improved sanitation facilities (5).

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 (6), 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 (7). In 2011, the theft rate was 135.2 per 100,000 population and the rape rate, 7.6 (8).

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 (9).

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 (10).

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 (11).

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 (12).

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 (11), in keeping with the National Development Plan 2014-2018, whose purpose is to build a peaceful, equitable, and educated country (13).

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 (11). 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 (14).

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 (15). As of 2016, 1,272,267 individuals were registered by the National Observatory on Disability (16). 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 (17).

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 (18). 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 (18).

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.(18).

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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 (12).

The cost of new health technologies, an aging population, and wider insurance coverage are driving up the cost of care plans in the country (19). 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 (20).

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 (12, 13).

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 (21).

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 (22). 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 (12). 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 (23).

Further, the Comprehensive Social Protection Information System (SISPRO, for its Spanish acronym) (24) 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 (25).

The Environment and Human Security

The National Development Plan 2014-2018 aims to achieve resilient growth and reduce vulnerability to disasters and climate change (13), 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 (26).

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 (1).

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 (1). 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 (1).

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 (27).

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 (24).

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 (13).

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 (28).

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Health Situation and Trends

Health of Population Groups

Maternal and Reproductive Health

In 2015, the estimated total fertility rate was two children per woman, a slight decline over the 2010 quinquennium, when it was 2.1. A woman’s average age at first delivery was 21.7 years and the median birth interval, 50.7 months. The use of modern family planning methods by women aged 13 49 who were in stable relationships was 80.9%, with the most commonly used method being female sterilization, followed by oral contraceptives. Some 42.4% of women in stable relationships did not want more children, and the average ideal number of children was 1.6. Ninety-two percent of urban women and 83.7% of rural women had had four or more prenatal check-ups, and 96.9% had delivered in an institutional setting (29, 30).

During 2010 2014, maternal mortality fell from 71.64 to 53 per 100,000 live births and was 2.84 times higher in departments that fell in the quintile with a higher poverty index. More than half (60%) of maternal deaths occurred among the 50% poorest, most illiterate population. In 2014, 18% of maternal deaths occurred in mothers aged 10 19, 24% of them among the indigenous and Afro-Colombian population and 30% among mothers who had attained a primary school education or less (29, 30).

Direct obstetric causes accounted for 46.6% of maternal deaths, with gestational hypertension (25%), hemorrhage (14%), and abortion (7.5%) being the most common causes. Indirect obstetric causes accounted for 33% of maternal deaths, 24% from diseases of the respiratory system and 18% from diseases of the circulatory system. Late maternal deaths increased by 21.4% between 2013 and 2014 (31).

Child Health

In 2010-2013, infant mortality declined from 18.36 to 17.25 per 1,000 live births and mortality in children under 5, from 15.7 to 14.1 per 10,000. These rates are 20 times higher in the children of poor, uneducated rural mothers. Neonatal mortality accounted for 62% of the deaths in children under 1 year, at 7.3 per 1,000 live births in 2013 (31).

In 2013, 82% of deaths in children under 5 occurred during the first year of life. The leading causes were prematurity, congenital malformations, respiratory disorders, newborn bacterial sepsis, respiratory and intestinal infections, and malnutrition. The leading causes in children aged 1 4 years were congenital malformations, pneumonia, and accidental suffocation. Specific mortality from respiratory diseases in children aged 1 4 years accounted for 15.42% of the deaths, although a decline from 12.01 to 7.17 deaths per 100,000 children was observed in 2010 2013. Certain infectious and parasitic diseases were responsible for 10.94% of deaths (31).

Health of Schoolchildren

Schoolchildren (aged 6 11) represent 16% of the population. During 2009 2014, the leading cause for medical consultations in this group was noncommunicable diseases (53.17%), followed by communicable diseases and nutritional disorders (24.80%). The leading causes of death for the group in 2013 were hematologic neoplasms and traffic accidents (31).

Health of Adolescents and young Adults (15 17 Years Old and 18 24 Years Old)

Between 2009 and 2014, noncommunicable diseases were the leading reason for medical consultations by adolescents (56.86%), followed by communicable diseases and nutritional disorders (17.55), with no differences between the sexes. In 2013, the leading causes of death in both sexes were homicides and traffic accidents, with higher rates in men than in women (31).

Alcohol use begins at the age of 16 among men and at 18 among women. Some 49.2% of young adults aged 18 24 drink alcohol. The highest use of illicit substances in the year prior to the survey was 8.7% in the 18 24 age group and 4.8% in adolescents. The highest marijuana use was observed in young adults aged 18 24 (8.2%), followed by adolescents (4.3%). Cocaine is the second leading substance of choice among young adults aged 18 24 (2%) (32).

In 2014, the violence rate was 81.9 per 100,000 in children aged 10-14, and 96.24 in adolescents aged 15 19, with a prevalence among females of 9% and 28%, respectively. Some 52% of cases of intimate partner violence occurred in the population aged 15 29, with a rate of 57.9 per 100,000 in the 15 17 age group, and 18.5 times more victims seen among women than men. The rate of forensic examinations in cases of sexual assault was 192.91 per 100,000 children aged 10 14 and 90.44 per 100,000 adolescents (aged 15 17) (7).

Health of Adults

Noncommunicable diseases were the main reason for seeking medical care, accounting for 68.68% of consultations during 2009-2014. The pattern of leading causes of death among adults aged 20 44 differs markedly from that of those aged 45 64: for the former, the leading causes are homicide and traffic accidents; for the latter, cardiovascular disease, diabetes, and certain types of cancer (31).

Health of the Elderly

In 2013, 30% of those aged 60 or older and 7% of those aged 80 or older continued to work. According to information in the 2013 quality of life survey, 50% of older persons considered themselves to be in good health and did not report any limitations in their daily activities (33).
The leading cause of morbidity in people aged 60 or older was hypertension, followed by arthritis or arthrosis, diabetes, and cardiovascular disease. In 2013, the leading causes of death in people aged 65 and over in both sexes were ischemic heart disease, cerebrovascular disease, and chronic obstructive pulmonary disease, with higher rates in men than women (31).

Health of the Family

In 2015, the proportion of households led by women increased to 36.4%. The average size of urban and rural households was 3.5 3.6 persons. The nuclear family was the most commonly seen type of family (33.2%), followed by extended and biparental (12.8%) (29). Some 64.1% of women have experienced psychological abuse with their partners attempting to exert control over them, especially through jealousy and intimidation. Some 31.9% of women currently or formerly in a stable relationship reported having experienced physical abuse by their current or former partner (29); 16.1% of the women assaulted sought treatment or counseling, more of them in urban than rural areas (29).

Health of Workers

The accident rate in 2014 was 7.7 per 1,000 members of the General Occupational Risk System. The sectors with the highest rates were agriculture and livestock production, hunting, and forestry (17.7), followed by utility workers (electricity, gas, and water supply) (12.1), construction (11.1), manufacturing (10.9), and mining and quarrying (10.2%).

In 2014, the occupational disease rate was 115.85 per 100,000 workers, with the highest seen in agriculture and livestock production, hunting, and forestry (385.03), manufacturing (295.24), and mining and quarrying (216.96); the rate dropped 4% compared to 2013 (34). Colombia has an Occupational Safety and Health Management System that identifies promotion and prevention activities in the context of the occupational primary health care strategy; it has also created a compulsory quality assurance system for occupational risks, which the Ministry of Labor monitors through visits to verify that standards are met (18).

Health of Ethnic and Racial Groups

According to the 2005 census, Afro-descendants represented 10.62% of Colombia’s total population; indigenous groups, 3.43%; and Rom (Gypsy) people, 0.01% (1). The 2015 National Survey of the Nutritional Situation (ENDS) reported that 14.4% of women self-identified as indigenous or Afro-descendant (29). The Ministry of Health works directly with the indigenous, Afro descendant, and Rom health commissions, which makes it possible to include any needed activities designed to interface with health institutions within the National Development Plan (13).

In 2015, the information disaggregated by ethnicity indicated that 87.85% of death certificates provide information on ethnicity; of these, 91.57% of the deceased were classified as pertaining to “other” ethnic groups, 6.40% as Afro descendants, and 2.02% as indigenous, Rom, Raizales, or Palenqueros (31).

In 2013, the highest maternal mortality was observed among Palenquero populations of San Basilio and among indigenous populations, with 1,075.3 and 355.7 deaths per 100,000 live births, respectively. Between 2008 and 2013 the indigenous population reported 17,600 deaths, for an average of 2,933 deaths annually (35).

In 2009 2013, neonatal mortality in the indigenous population fell by 2.5 deaths per 1,000 live births, from 13.96 to 11.42 deaths per 1,000 live births, an 18% reduction. In 2009, the rate was 67% higher than that of the non-indigenous population. However, toward the end of the period, the rate ratio had fallen to 59% (31).

The highest infant mortality was observed among the Rom; in 2013, 125 deaths per 1,000 live births were reported, with 30.44 estimated deaths in the indigenous population, 18 in the Raizal population, 16 among Afro-descendants, and 11 among the Palenqueros of San Basilio (31).

Health of the Disabled

In 2016, persons with disabilities accounted for 2.7% of the population (1,272,267 persons). Approximately 2.28% of them belonged to some ethnic group, 45.5% were over the age of 60, and 12.4% were victims of the armed conflict. In 2013, 2.3% of the population had a disability. The leading disabilities were related to motor impairments of the body, hand, and leg (30.3%); followed by disorders of the nervous system (21.6%); cardiorespiratory system (15.0%); vision problems (14.8%); voice and speech issues (5.3%); and hearing (4.9%) impairments (16).

The group reporting the highest rates of disability were 41 64-year-olds (2.7%), followed by the age group 65 years and over (12.1%). Some 71.5% of the population with a disability was affiliated with the health system, 69.3% of them in the subsidized regime. The most common permanent disabilities were gross motor impairments, which affect walking, running, and jumping (51.7%); cognitive impairments, which affect thinking or memory (38.6%); and communication impairments (30.4%) (16).

There were 11,446 victims of landmines and other explosive devices reported as of July 2016, 7,021 were members of the security forces and 4,425, were civilians (36).

Mortality

In 2013, the leading cause of death was diseases of the circulatory system, accounting for 29.9% of deaths and 16.1% of potential years of life lost (PYLL) and showing a downward trend, from 166.43 deaths per 100,000 population in 2005 to 144.65 in 2013. This cause was followed by neoplasms (17.9% and 14.5%, respectively), especially stomach cancer (16.5% of all cancers) in men and breast cancer (12.6% of all cancers) in women (31).

Between 2005 and 2013, the adjusted homicide rate fell by 30%, resulting in 13.22 fewer deaths per 100,000 population, a drop from 44.05 to 30.83 (31). The leading cause among communicable diseases in that same period was acute respiratory disease, whose adjusted rate fell by 8.52%, from 18.43 per 100,000 population in 2005 to 16.86 in 2013; HIV/AIDS rates during the period ranged from 5.10 to 6.03 (31).
In 2014, a crude death rate of 4.41 per 10,000 population was reported.

Morbidity

Communicable Diseases

In 2014, the country was declared free of measles, rubella, and congenital rubella syndrome, and in 2015, achieved 93.96% coverage for the first dose of the measles, mumps, and rubella vaccine, and 87.5% coverage for the second dose. A total of 1,430 suspected measles cases were reported between 2012 and 2015, 3 of them imported. Furthermore, vaccination coverage for diphtheria, Bordetella pertussis, and tetanus (DPT) was 93% for the first dose and 91% for the third dose (37). The last three whooping cough epidemic peaks were in 2006, 2009, and 2012. The incidence in this last year was 8.5 cases per 100,000 population, the highest in the previous 20 years (38).

Dengue is a reemerging health problem in Colombia, marked by an increase in transmission, a rise in severe dengue outbreaks, the simultaneous circulation of several serotypes, Aedes aegypti infestation, the introduction of Aedes albopictus, urbanization, and epidemic cycles every two to three years. In 2010 2014, case-fatality from severe dengue rose from 2.3% to 6.3% (39).

The first indigenous cases of chikungunya were confirmed in September 2014. The incidence of the disease in 2014 was 396 per 100,000 at-risk population, with a case fatality of 0.02%; by 2015, the incidence had skyrocketed to 1,359 cases per 100,000, with the same case-fatality. In 2015, 359,282 cases were reported in 712 of the 951 municipalities where Aedes aegypti was reported. On 24 September 2015, the epidemic was declared over (40).

In October 2015, the Ministry of Health confirmed the first cases of Zika virus infection (ZIKV) and reported its circulation in 34 of the country’s 36 territorial entities. On 25 July 2016, the epidemic was declared over, with 8,826 confirmed cases and 91,640 clinically suspected cases, 6,058 confirmed cases and 11,962 suspected cases in pregnant women, 21 confirmed cases of ZIKV-associated microcephaly, and 608 cases of neurological syndromes (Guillain-Barré syndrome, ascending polyneuropathies, etc.) with a history of febrile illness compatible with ZIKV infection (41).

Leishmaniasis is endemic virtually throughout the country. An estimated 11 million people are at risk, primarily in rural areas. Some 95% 98% of cases are cutaneous. The mucosal form is seen in 1% 4%, and the visceral, between 0.1% and 1.5% (42). In 2010-2013, a reduction in cases of cutaneous and mucosal leishmaniasis was observed (31).

In 2015, 1,018 cases of Chagas disease were reported, 996 of them chronic and 22 acute. Case-fatality from acute cases was 0.07% (43). Colombia participates in the Andean Initiative and the International Initiative for Chagas Disease Surveillance and Control in the Amazon, whose purpose is to improve diagnosis, monitoring, and treatment. In 2013, the interruption of vector-borne household transmission of Trypanosoma cruzi by Rhodnius prolixus was verified in 10 municipalities in four departments.

Malaria is endemic in areas lower than 1,500 m above sea level in the 100 municipalities where 95% of the burden of disease is reported. Reported cases fell from 117,638 in 2010 to 52,416 in 2015 (44). There has been a reversal in the P. vivax/P. falciparum parasite ratio, which has shifted from 3.0:1.0 to 1.0:3.0; this may be due to the increase in cases and outbreaks in the Pacific region, where P. falciparum predominates. In 2010 2015, one case of yellow fever was reported, and in 2016, six cases in five departments (41).

The first trachoma focus was diagnosed in 2010, and by 2013, Colombia was considered an endemic country (45). Trachoma prevalence rates in Vaupés (on the border with Brazil) were 21%-26%, leading to implementation of the SAFE (Surgery, Antibiotics, Face washing, and Environment) strategy in 2012. Between 2012 and 2015, six surgery days were held in Mitú with the collaboration of the Wilmer Eye Institute (a WHO Collaborating Center); surgery was performed on 70% of patients with trachomatous trichiasis, using the bilamellar tarsal rotation technique.

In 2012, a WHO verification commission certified the elimination of onchocerciasis in the focus in Naicioná, López de Micay, and Department of Cauca, making Colombia the first country in the world to boast this achievement (46).

Since Colombia has had a leprosy prevalence of under one case per 100,000 population since 1997, the country has met the goal of eliminating leprosy. However, a territorial analysis reveals municipalities that have maintained higher prevalence rates, particularly in the case of grade 2 disability (47).

The successful treatment of 71% of a cohort in 2013, brought the incidence of pulmonary tuberculosis in 2014 to 24.7 per 100,000 population. Mortality was 2.4 per 100,000, and 2.4% of new cases and 13% of previously treated cases were MDR TB. Some 21% of those with tuberculosis also had HIV. The strategy targeting large cities that has been implemented in three of the country’s major cities led to a decline in mortality in Bogotá, where rates fell from 1.27 per 100,000 population to 0.89 per between 2012 and 2014, as a result of the prioritization of territories and patient-centered care (48).

Colombia’s HIV epidemic had an infection rate of 11.6 per 10,000 population in 2014. HIV prevalence is very high in men who have sex with other men, trans women, injection-drug users, street people, and female sex workers. Its estimated prevalence in the 15 49 age group is 0.45%. The epidemic is concentrated in large cities, which account for 86% of reported cases. There were 101,158 cases reported in 1983 2014, 71% of them in men. The male/female ratio has fallen from 27.5:1 in 1987 to 2.5:1 in 2013. The most affected population is the 15 49 age group, with 86% of reported cases and trending upward. During that period, 22% of HIV cases were in the AIDS stage when reported (49).

Chronic Noncommunicable Diseases

Between 2009 and 2014, 65% of health care services were devited to chronic noncommunicable chronic diseases. The National Health Survey showed that 22.82% of the population was hypertensive; in 2015, 6.4% of the population enrolled in the General Social Security Health System were seen for hypertension and 1.43% had diabetes, a rate lower than the 3.51% calculated by the 2007 National Health Survey. In 2015, the prevalence of chronic kidney disease was 2.5% in women and 1.6% in men (21).

Nutritional Disorders

In 2005 2013, there were 3,756 deaths from malnutrition in children under 5, for an average of 417 deaths per year. Between 2005 and 2016, the rate fell from 14.87 per 100,000 children under 5 to 6.77. In 2013, mortality from malnutrition was 8.92 times higher in the first quintile of poverty; 72% of the deaths occurred in the 50% of the population with less access to improved water sources, and 80% in the 50% of the population with greater access barriers to early childhood health services (31).

In Guainía, a predominantly indigenous department, the mortality from malnutrition was 155.70, 22 times the national rate. That same phenomenon was observed in indigenous populations in the departments of Vichada, Vaupés, Amazonas, La Guajira, Chocó, Guaviare, Magdalena, Caquetá, Meta, and Putumayo (31).

The greatest developmental delays were seen in the children of less educated, poorer mothers living in rural areas, in the Atlantic, Orinocan, Amazon, and Pacific regions, and among the indigenous population. In 2010, 18.9% of children aged 5 9 were overweight, compared to 14.3% in 2005, with less poverty, more maternal schooling, and residence in urban areas. In 2010, 16.7% of children aged 10 17 were overweight, compared to 13.7% in 2005. Some 51.2% of the population aged 18 64 was overweight, compared to 45.9% in 2005. Anemia was present in 47.4% of preschool children, 40.9% of women of childbearing age, and 44.7% of pregnant women. Serum retinol was <20 µg/dL in 5.9% of children under 5, and 26.9% of children aged 1 4 years suffered from zinc deficiency. There has been no surveillance of iodine deficiency disorders since 2002 (50). Finally, 34.6% of the adult population was overweight in 2010.

Accidents and Violence

In 2013, homicides were the second leading external cause of death in men (57.38 per 100,000 population) and the seventeenth (5.05 per 100,000 population) in women. Traffic accidents, in turn, were the eighth leading cause of death in men and the sixteenth in women in that same year (51).

Despite the existence of a legal framework for the protection of women, according to the National Institute of Legal Medicine and Forensic Sciences, there were 1,007 cases of homicide with female victims in 2014, 37,881 cases of intimate partner violence against women, and 16,088 cases of sexual violence against women, with female children and female being the most affected group. Of homicides where the victims were female, 27% were committed by their current or former intimate partners, for a rate of 0.6 per 100,000 women (7).

Mental Health

In 2015, 4 in 10 children aged 7 11 had a mental health problem, such as unexplained irritability and problems with peer relations. The main problems among adolescents were anxiety and depression, which were more common in women than men. In the population over 18, 1 in 10 persons had mental health problems, with anxiety, depression, and psychosis being the most common (52).

Concerning access to mental health services, 92% of children aged 7 11 and 38% of adults received treatment. Symptoms of depression and/or anxiety were more common in women than men (9.87% and 7.53%, respectively) (52).

In the age group 13 17 years old, 6.6% experienced suicidal ideation, 7.4% among girls and 5.7% among boys; of those who attempted suicide, 2.9% were male and 2.1% female. An uptick in suicide and psychoactive substance use has been observed among adolescents, particularly in indigenous populations (52).

Other Health Problems

Regarding ocular health, the leading causes of blindness and severe visual impairment between 1999 and 2010 were untreated cataracts, glaucoma, diabetic retinopathy, retinopathy of prematurity, and uncorrected refractive errors (53). In 2013, one of the barriers to the proper management of eye problems was the insufficient number trained ophthalmologists who could perform cataract surgery (54).

Risk and Protective Factors

In 2011, alcohol use among schoolchildren aged 11 18 began at age 12, with no difference between the sexes; 40% of this group reported having drunk alcohol in the month prior to the survey and 56.7% reported having drunk alcohol in in the previous year. Some 24.3% indicated that they had smoked at some time in their life, with the average use during the prior month at 10% (11.9% in men and 7.9% in women) (55).

In 2013, 42.1% of those aged 12 65 had smoked tobacco or cigarettes at some time in their life (53.6% of men and 31.2% of women) and 87% had drunk alcoholic beverages. The highest consumption (49.2%) was found among those aged 18 24 (32).

The age at onset of alcohol steadily dropped, with a median of 16 years for men and 18 for women, and for 31% of people age 12 65, consumption was considered harmful. More than half the people aged 18 64 in urban areas met the recommendations on physical activity, higher among men and among those having attended secondary school or university. In 2010, 16.5% of those aged 18 64 were obese, up from 13.8% in 2005 (31).

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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.

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Referencias

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