Country Report: Colombia
Colombia is located in the northwest of South America, and borders Brazil, Ecuador, Panama, Peru, and Venezuela. It is divided into 32 departments, a capital district, 1,121 municipalities, and indigenous territories.
Population growth in the period 1990-2016 was 42.0%, during which time the population structure became regressive and older. By 2015, the population reached 48,747,708, with 79% living in urban areas.
Life expectancy at birth is 74.4 years.
Also between 1990 and 2015, the basic health indicators reflected remarkable improvement overall.
- The National Pharmaceutical Policy seeks to safeguard the quality of medicinal drugs and people’s access to them.
- This policy provides for price regulation instruments based on international benchmarks, the registration of biosimilar products, and the strengthening of national capacity, as well as mechanisms for incorporating marketing authorization procedures.
- The policy proposes 10 strategies related to the accessibility, timeliness, quality, and rational use of medicines, regardless of individual ability to pay.
- Cross-cutting strategies include making available reliable, timely, and public data on access to drugs, drug prices, utilization, and quality; the establishment of an effective, efficient, and coherent institutional system; and improvement of the availability and competences of the pharmaceutical sector workforce.
- The National Food and Drug Surveillance Institute (INVIMA) has been certified as a National Regulatory Authority for Regional Reference on medicines and biologics.
- The country has also established requirements for bioavailability and bioequivalence studies of medicines.
- Another highlight was the development of price regulation and market regulation instruments based on international benchmarks, as noted above.
Figure 1. Distribution of the population by age and sex, Colombia, 1990 and 2015
Proportional mortality (% of all deaths, all ages, both sexes), 2013
Source: Pan American Health Organization. Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Source: UN Population and Statistics Divisions, 1990; PAHO Health Information Platform (PHIP), 2013, 2014, and 2015.
SOCIAL DETERMINANTS OF HEALTH
- In 2015, income inequality was high, as reflected by a Gini coefficient of 0.522; 27.8% of the population lived below the poverty line. The introduction of wage reforms contributed to a reduction in unemployment down to 8.9% in 2015.
The El Nino and La Nina climate phenomena had both direct (deaths and injuries) and indirect impacts on the health of the population, negatively affecting determinants such as poverty, food insecurity, and access to safe water.
In 2015, 91.2% of the population had access to improved sources of drinking water and 81.1% to improved sanitation, although coverage in rural areas and among the indigenous population is low.
Violence and public insecurity constitute an important problem, compounded by the impact of more than five decades of armed conflict with guerrilla forces. This has spawned phenomena such as organized crime, forced displacement, and the confinement of an estimated 8 million people.
In 2013, homicide was the second leading external cause of death in men (57.38 deaths per 100,000 population), and the tenth leading cause in women (5.05 per 100,000 population).
Emigration is a significant phenomenon, especially to the United States (34.6%), Spain (23.1%), Venezuela (20.0%), and Ecuador (3.1%), with Colombian nationals representing 98% of all immigrants in this latter country.
Vulnerability and inequity in the population are exacerbated by the limited presence of institutions in areas where indigenous, rural, and Afro.Colombian populations reside. Further contributing factors are illegal farming and mining, as well as sparse settlement in isolated regions.
HEALTH SITUATION AND THE HEALTH SYSTEM
- In 2014, the maternal mortality rate was 53 deaths per 100,000 live births. However, the rate was 2.8 times higher in departments in the highest poverty quintile. Up to 60% of maternal deaths were recorded in the poorest and most illiterate 50% of the population; 18% of the total was in mothers between the ages of 10 and 19; 24% in the indigenous and Afro-Colombian populations; and 30% in mothers with a primary education or less.
- In 2013, the infant mortality rate was 17.25 deaths per 1,000 live births. This rate is higher in the poorer sectors of society and among mothers with a low educational level. Infant mortality accounts for 82% of deaths of children under 5 (a rate of 14.1 per 10,000); leading causes include prematurity, congenital malformations, respiratory disorders, neonatal bacterial sepsis, infections of the respiratory and digestive systems, and malnutrition.
- In 2014, the country was declared free of measles, rubella, and congenital rubella syndrome. In 2015, MMR vaccine coverage was 93.9% for the first dose and 87.5% for the second dose.
- Between 2005 and 2013, 29.9% of all deaths were caused by diseases of the circulatory system.
- The most prevalent neoplasms included stomach cancer (16.5% of all cancers in men) and breast cancer (12.6% of all cancers in women).
- Malaria is endemic in Colombia. In 2015, there were 52,416 recorded cases of malaria and 1,018 cases of Chagas disease (996 chronic and 22 acute, with a case-fatality rate of 0.07%).
- Since 2010, trachoma has been considered endemic, with rates of up to 21% to 26% along the border with Brazil.
- Dengue is a reemerging problem; outbreaks of the severe form are on the rise, with a case-fatality rate of 6.3% in 2014.
- In 2015, the incidence of chikungunya was 1,359 cases per 100,000 population, with a case-fatality rate of 0.02%. The Zika virus (ZIKV) epidemic ended in mid-2016 with 8,826 confirmed cases, 91,640 clinically suspected cases, and 21 confirmed cases of ZIKV-associated microcephaly.
- In 2014, the rate of HIV infection was 11.6 cases per 10,000 population, with 0.45% of 15-to-49-year-olds affected. The epidemic is concentrated in large cities, which account for 86% of reported cases.
- Between 2005 and 2013, there were 417 deaths from malnutrition in children under 5 per year on average. The problem is greater in predominantly indigenous populations living below the poverty line.
- In 2016, 2.7% of the population was disabled; this percentage rose to 45.5% in people older than 60.
- The Statutory Health Law (2015) enshrined the right to health care within the national health system, recognizing it as a basic social right.
- In 2014, national health expenditure accounted for 7.2% of Gross Domestic Product (GDP) (5.4% public and 1.8% private), while out-of-pocket spending accounted for 15.4% of total expenditure.
- Greater public and private expenditure is required to meet the growing cost of new health technologies, progressive population aging, and increasing insurance coverage. Increasing judicialization of health, i.e., the practice of litigating for the protection of basic health rights, is contributing to these rising costs.
- The Colombian 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 regimes, contributory and subsidized.
- Membership in the General Social Security Health System is compulsory and is handled through public or private health promoting agencies (EPSs). The EPSs turn over the funds from premium payments to the Solidarity and Guarantee Fund (FOSYGA).
- As of 2015, health system membership was 97.6%.
- In 2012, the ratio of health professionals per 10,000 population was 17.7 for physicians, 10.3 for nurses, and 8.3 for dentists.
- The country has 55 medical schools, graduating an average of 5,000 physicians annually, and 65 nursing programs, graduating an average of 3,600 nurses annually.
- As of 2016, 242 public health institutions were registered to use telemedicine services and improve the electronic connection between clinical services, thus providing better functional access to health care. The Comprehensive Social Protection Information System (SISPRO) provides a mechanism for obtaining and consolidating information on health, occupational safety, and social welfare.
- Since 2013, Colombia has had a National Disability and Social Inclusion Policy in place, aimed at ensuring more effective implementation of action related to disability.
- In 2014, Law No. 1733 was enacted, regulating palliative care services for the integrated management of patients with terminal, chronic, degenerative, and irreversible illnesses at any stage of any disease having a major impact on quality of life.
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- In 2016, the Comprehensive Health Care Policy (PAIS) was introduced, making the individual, family, and society, rather than health providers and insurers, the center of health action. The formulation of this policy and of the Comprehensive Health Care Model (MIAS) represent a strategic advance by the health system in its commitment to ensuring that citizens have access to health services. It is the operative component of the PAIS.
- A family and community health and medicine approach, designed to build competencies in the health workforce, is being developed within the framework of the MIAS.
- Both the PAIS and MIAS are meant to improve quality, sustainability, and equity in health. They provide a framework of actions ranging from health promotion and disease prevention to treatment, rehabilitation, and social reintegration at all stages of life, as close as possible to citizens’ daily lives.
- The objectives of the 10-Year Public Health Plan 2012-21 (PDSP) are to attain equity in health, positively influence the social determinants of health, and mitigate the impact of the burden of disease.
- In 2015, the Government committed to reducing premature mortality from cardiovascular disease, diabetes, cancer, and chronic respiratory diseases by 8% in the population aged 30 to 70.
- The 10-year Plan for Cancer Control 2012-2021 seeks to reduce cancer mortality by 30% in this period, integrating the control of risk factors such as smoking, sedentary lifestyle, high sugar intake, and obesity.
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