Colombia: Colombia Health Profile 2011

The Colombian welfare regime was privatized to a certain extent in the 1990s. The social security law of November 1993 created private health entities (Empresas Prestadoras de Salud, EPS) and private pension funds. Law No. 100 of December 1993 transformed the Colombian national health care system, then based on governmental assistance and being integrated into a general social security system. The reform started off by defining two regimes: the contributory regime, aimed at people who can afford contributing to the social security system through their jobs or independent incomes, and the subsidized regime, aimed at those who cannot afford contributions and therefore must be subsidized by the government for the total or partial cost of the obligatory insurance.

In February 2007, the National Planning Department (Departamento Nacional de Planeación, DNP) presented a bill to Congress to restructure the social security system (ISS) and other state entities. The government emphasized that it would guarantee workers’ acquired rights. Each worker costs the state about COP 3.1 million (about $1,600) each month. Trade unions, on the contrary, hold that the problem rose because the government owes COP 60 billion (about $30 million) to the ISS. In August 2008 the ISS was finally closed. Thus, three million insured persons had to look for a new private health insurance in one of the EPS.

Article 49 of the constitution guarantees all Colombians access to the health care system. The Uribe government set itself the goal of reaching this point by 2010. Although coverage levels were about 70% in 2006, universal coverage remains a distant prospect. Expenditures rose from 6.2% of GDP (1993) to 7.7% in 2007. As a result, it is still very difficult to finance the system. The aim of the 1993 reform was to raise the number of insured persons in order to help to reduce public financing of hospitals. This aim could not be reached. In the health care sector there is thus a disparity of service which leads to undertreatment of the poor.

During 2008, the two main items of state expenditure were transfers to the departments and to social security (totaling 12.5% of GDP) and debt payments (10.3% of GDP). Together they account for two-thirds of the budget. Social security (pensions) payments accounted for 4.2% of GDP in 2007, rising to 4.5% in 2008, and are forecast at 4.7% in 2009. These are then expected to remain steady at 4.8% thereafter.

The pension system has been converted from a state allocation system to a combination of pay-as-you-go financing and capital-based financing. The privatization of the pension system has led to new forms of discrimination against certain groups, such as women, single parents and casual laborers. Only 25% of Colombians participate in the pension system, with another 18% in the private system. Former Finance Minister Juan Camilo Restrepo has described the situation as a time bomb, due to corruption and lack of planning. The Uribe administration has discussed further reform of the pension system; this appears prompted by high expenditure levels rather than system quality, however. The pension system has several times been subject to corruption, as when COP 500 billion were stolen from the public employees’ pension fund (Caja Nacional de Previsión Social, CAJANAL). Several politicians, including the president of the Senate, seem to have received contributions out of the stolen money.

There is no unemployment insurance in Colombia. During the Uribe administration, the official unemployment rate decreased in 2007 to 9.4%, but rose in 2008. In October 2008 the president himself saw the rising unemployment figures (by that time above 10%) as a danger to the fight against poverty and to the prospects of reaching Millennium Development Goals. Although absolute poverty figures have improved, there has been a clear tendency toward “anti-poor growth.” Poverty, violence and forced internal displacement also constrain informal social networks, especially among the Afro-Colombian and indigenous populations.

In recent years, new forms of labor organization have emerged, such as the Associated Work Cooperatives (Cooperativas de Trabajo Asociado), a subcontracting system that helps employers to save money, thereby influencing social security. Only 2,100 out of a total of 3,296 of these cooperatives paid social security contributions.

Equal opportunity Programs and institutions to compensate for gross social differences exist, but are limited in scope and quality. Poverty reduction is an explicit priority of the Uribe government. According to official data from DANE, the portion of the population in poverty fell from 55.7% in 2002 to 45.1% in 2006 (as compared to a Latin American average of 36.5%); in the same time period, the share of the population deemed extremely poor fell from 21.6% to 12%. However, two key problems remain: regional heterogeneity and inequality between the income of the rich and the poor.

The government has promised several times to reduce poverty and to diminish inequality. Though some efforts to reduce poverty rates have been made, the goal of reducing inequality has not been reached. When the president of the World Bank visited Colombia in May 2008, he made particular criticism of the country’s persistent inequality. The poorest 20% of the population receives just 2.5% of national income, while the richest 20% controls 61% of income. The government argues that the “Familias en acción” program has increased the consumption of basic goods in poor families and reduced chronic malnutrition among small children, but critics emphasize that this type of program does not constitute a sustainable solution to poverty. Another major problem is the poverty of displaced people, who live under conditions of extreme poverty.

Women formally have the same access to education as men. Nonetheless, there are de facto restrictions for economically disadvantaged persons, especially women. The political access of women to parliament improved after changes in the constitution in 1991, but there has been no substantial improvement since then. Women entered into Congress as successors of politicians involved in the “parapolitica” scandal, but some of these newcomers are only proxy persons for the accused politicians, with gender playing no substantial role. The resignation of Senator Gina Parody, a former Uribe ally who disagreed with the direction of some government policies, was symbolic. Parody had advocated on behalf of a new children’s law, a law against violence against women, and the habeas data law.

In the 2008 Global Gender Gap Report, Colombia fell from 24th place to 50th place, out of 130 countries. The change was justified by growing wage differences between women and men, and a decline in the number of state ministries led by women (only 23%). This latter statistic indicates that the Uribe administration did not fully implement the Quota Act, which mandates that at least 30% of leading state officeholders must be women. During the election of the new Ombudsman in 2008, no woman was proposed as a candidate, even though Law No. 581 of 2000 demands this. When the election was repeated, the woman appearing on the list of candidates was considered to be a mere formal requisite, with no real chance of winning the election.

Lesbian, gay, bisexual and transgender (LGBT) rights in Colombia have progressed since consensual homosexual activity was decriminalized in 1980 through amendments to the criminal code. On 19 June 2007, a gay rights bill that would have treated unregistered same-sex partners the same way as unregistered opposite-sex partners was defeated in Congress. The bill, which had been endorsed by President Uribe, would have made Colombia the first country in Latin America to grant gay couples in long-term relationships the same rights to health insurance, inheritance and social security as heterosexual couples. However, slightly different versions of the bill passed in each house of the legislature. A compromise bill then passed one house but failed in the other. The bill was finally defeated by a bloc of conservative senators on 8 October 2008.

Between February 2007 and February 2009, four Constitutional Court rulings granted registered same-sex couples the same pension, social security and property rights as registered heterosexual couples. These rulings collectively replace the Civil Union Law, which was defeated in Congress. Thus, Constitutional Court rulings have given same-sex couples today much the same rights that the failed bill would have given them. As such, Colombia joins Uruguay as the only two countries in Latin America that give same-sex couples a nationwide legal mechanism to register and protect the rights of their civil unions, as well as all the legal rights (civil, political, criminal and tax-related) enjoyed by heterosexual couples. As far as civil rights for the LGBT community are concerned, all that is missing in Colombia are civil marriage and adoption rights. Nevertheless, violence against gays is not uncommon; stereotypes and discrimination remain a recurring problem.

OPPORTUNITIES

• The 2006-2010 Country Cooperation Strategy Agreement, signed betweenthe Ministry of Social Protection and PAHO/WHO Representative in September 2006.
• The recognition and positioning gained by PAHO/WHO in the country. During the last biennium the Representation has managed financial resources amounting to over 12 Million USD. In addition, PAHO/WHO contributes with 55 international and national professionals distributed in 7  offices throughout the country (Bogota, Cali, Medellin, Pasto, Quibdó, Cucuta, Huila). These country offices are supported by the regional and global experts of the Organization; 5 collaborating PAHO/WHO centers established in the country; a network of national and local governmental institutions (which transfer financial resources to PAHO/WHO to implement technical cooperation); the Academia; bilateral organizations (including 5 donors in Colombia: AECI, ECHO, CIDA-Canada, PMR-US State Department); NGOs; the private sector; and a pool of Colombian experts. Thanks to the high professional quality and dynamism typical of this country the latter are constantly building new initiatives with a high degree of innovation that promotes best practices useful to the entire American Region.
• The decentralized Colombian institutional framework is characterized by legal and social instruments, approved by the National Congress, that aim at the following: poverty reduction, the achievement of the Millennium Developing Goals (MDG), and equity for women, ethnic populations and Internally Displaced Persons (IDPs). Such instruments are included in the National Development Plan 2006-2010, the Public Health National Plan, The Social and Economic Council (CONPES) 91, and the Constitutional Court’s T025 bill for the right to social protection of IDPs, victim of the internal violence.
• The Law 1122 of January 9th 2007, which reforms and complements the Law 100 of 1993, enhancy the regulation of the social protection system in Colombia –integrating health, work and pension- in coherence with WHO’s general work program. Highlighted in this law are: the universalization of quality access to health; primary care; focus on health results; inspection, surveillance and control; antitrust norms; the implementation of CRES, a national coordination body which includes the Ministry of Social Protection.
• - The existence of a national entity, ‘Accion Social de la Presidencia’ that oversees and coordinates the international community’s technical cooperation. This organ has initiated a process of analysis and alignment of the international cooperation (The Paris Declaration, 2003), which PAHO/WHO has been actively participating to. ‘Accion Social’ has also developed the National Strategy for Extreme Poverty Reduction –Red Juntos. PAHO/WHO seeks to support such initiative from the perspective of the UNDAF (the country’s UN Joint Program), approved by the Ministry of Foreign Affairs in July 2007.
• The presence of 23 UN Agencies, Funds and Programs in the country, and the appointment of PAHO/WHO as President of the Thematic Group on “Poverty, Equity and Social Development”. This committee has the overall purpose of coordinating efforts towards the MDG related results defined in the UNDAF. PAHO/WHO has also been assigned (together with UNICEF and WFP) the biannual rotating presidency of the IASC Group for Humanitarian Assistance, and has been co-leading during the past four years the Humanitarian Health Platform with the Ministry of Social  Protection.
• A MoU for the implementation of the Healthy Settings strategy was signed in January 2007 by the Ministries of Social Protection, Environment and  Housing, Education, SENA, ‘Accion Social’ and PAHO/WHO.

CHALLENGES

• - Improving the figures for poverty (45% in 2006); unemployment (11,1% in December 2007), and illiteracy in the population over the age of 15 (9,6% in 2005). Overcome inequality (Gini: 0.56 in 2004) and the violence caused by the armed conflict and drug trafficking
• - Meeting the MDG targets, closing gaps between population groups with emphasis in ethnic groups and IDP.
• - Strengthening the steering role of the national and sub-national health authority as well as the  regulatory function - Expanding the coverage and quality of the General Social Security Health System
• - Strengthening promotion activities of health protection factors, such us the environmental in order to build healthy environments
• - Promoting access to international public health goods
• - Strengthening partnerships and horizontal cooperation