Structural re-organization and reform in the Colombian Healthcare System

Colombia provides a universal medical system known as the “General System of Social Security in Health” or “Sistema General de Seguridad Social en Salud (SGSSS)” which covers about 97 percent of the population.

The Health and Social Security System in Colombia, functions under the Ministry of Health and Social Protection (MoHSP) as a highly decentralized regime in which employee insurance is the main source of funding.

Affiliation under the healthcare system is mandatory (Compulsory Health Plan or Plan Obligatorio de Salud “POS”) and there are three main types of insurance plans that include both public and private providers: The Contributory Regime (CR), the Subsidized Regime (SR) and Special Regimes (SRE).

Traditional Roles, Previous Reforms and Current Challenges

The role of the state and central government has been largely reduced since the reform of 1993, in favor of an increased role for the private sector. Challenges arose due to the fact that this highly private and decentralized system was put in place during a time when it was:

  • Lacking qualified administrative staff
  • Vulnerable to political influence
  • Lacking community representation

One of the initial results was a marked differentiation in services, where the wealthier and urban areas ended up with a concentration of high quality and modern private hospitals, while poorer areas were left to rely on often underfunded public services.

Under this healthcare model, preventive care was put on a proverbial back burner and the practice of contracting-out of services led to high levels of fragmentation within the system.

Due to a high level of autonomy held by hospitals (which are treated as independent commercial entities) and the decreased role of the government in the areas of health provision: regulation and monitoring of services became weak and is in many cases absent. These factors left the system vulnerable to manipulation and influence from private intermediaries.

As a result:

  • Many unnecessarily complex routines were put in place
  • Firms often deny liability to pay for treatments
  • There are frequent patient disputes to establish rights to care
  • Overly complex cost containment mechanisms that delay and limit care were put in place
  • Fast growing and highly profitable insurance companies are common
  • Vast inequalities between the CR and the SR

Additional challenges include:

  • Underfunded public hospitals
  • Fragmented System
  • Inequalities in accessibility to care
  • Variable (low) quality of public hospital care
  • Limited regulation and monitoring
  • Lack of preventive care
  • Lack of focus on primary care services

Recent Reforms

In an attempt to deal with the challenges currently faced by the healthcare system, the government has created a new entity called “Salud-Mia” or “My-Health” which is aimed at reducing the decentralized nature of the system.

According to the MoHSP, some of the roles of “Salud-Mia” include:

In Relation to Providers

  • To make sure all current legislation is enforced
  • Penal responsibility in the practice of medicine
  • Responsibility for healthcare finances that were previously managed by the “Entidades Promotoras de Salud (EPS)”
  • In turn, the EPS’s will continue to exist and play an administrative role for providers, but will no longer be involved in the management of funds.

In Relation to Patients:

  • Administrative support in matters of health and accessibility
  • Legal support and accompaniment
  • Physiotherapy program for patients with severe Rheumatoid Arthritis
  • Health education

Changes in the Health Plan

Under the new reform a new health benefits plan called “Mi-Plan” has been created with a published list of covered services as well as excluded technologies.

The new system is divided into two major components: “Public Health Services” and “Individual Benefits”.

Public Health Services

This part of the system encompasses activities related to the promotion of health, prevention of illnesses and regional health planning.

Regional entities will take charge of public health activities, which can be undertaken by either public or private providers that meet the necessary criteria and have the relevant authorization.

Individual Benefits

There are two types Individual Benefit Services : primary and complementary, which are both bestowed through health service providers.

Under the reform, “Primary Health Service providers”, serve as a first point of care or gateway for patients to enter the healthcare system.

On the other hand “Complementary Health Providers” are responsible for individual health benefits that require human, technological and infrastructural resources that are more complex in terms of technology and expertise (secondary care). These services can be offered by: Health service administrators, prepaid medicine firms and insurance firms.

The reform has also incorporated “Gestores de Servicios de Salud” or “administrative entities” to serve as intermediaries between “Salud-Mia” and the country’s healthcare providers. The administrators will be responsible for the organization and administration of care given at both the primary and complimentary levels as well as the payment of funds to providers.

In order to efficiently provide these services, different health management areas have been created, each representing several “networks” of healthcare providers, administered by a manager who will be responsible for a particular population group.

The area divisions do not necessarily coincide with the political and administrative divisions.

According to the newspaper “El Paìs” there are three network categories:

  • Basic Network: providing basic services to maintain and improve the health status of the population.
  • Specialized Network: serving patients with complex diseases, seeking to improve their respective conditions so that they can be part of the basic level again.
  • Special network: serving more complex diseases requiring, integrated multidisciplinary management.

Although the new reform addresses many of the prevalent challenges in the Colombian Healthcare system (i.e. excessive decentralization, lack of primary care services, complex financial distribution systems etc.), there are still a number a issues to be defined such as higher and more uniform quality of care and the shortage of funds suffered by many of the more important hospitals.

As the reform was just put into practice this year, only time will tell if the effort and investments will yield the desired effect.

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About Ritza Suazo

Researches and creates Clinical Pathways and Country Deep Dive Reports at TforG. With almost a decade of experience in Clinical Market research she also manages and recruits the TforG advisory board. She graduated with a double major in psychology and international business management from Stony Brook University in New York and continues to apply her experience in research specializing in the US, UK, Spain and South American Markets.