PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Case study from Colombia

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Case study from Colombia

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Case study from Colombia Jaime Hernán Rodríguez Moreno, Laura Julieta Vivas Martinez Colombian Health Technology Assessment Institute (IETS)

WHO/HIS/HSR/17.28 World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Primary health care systems (PRIMASYS): case study from Colombia. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Editing and design by Inís Communication www.iniscommunication.com PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Contents Abbreviations and acronyms............................................ 1 1. Background to PRIMASYS case studies..................................... 2 2. Overview of the PHC system........................................... 3 3. Methods....................................................... 4 4. Overview of primary health care statistics.................................. 6 5. Governance and health services architecture............................... 12 5.1 Financing................................................... 14 5.2 Human resources.............................................. 18 5.3 Planning and implementation....................................... 22 5.4 Regulatory process.............................................. 26 5.5 Monitoring and information systems................................... 28 6. The way forward and policy considerations................................ 32 References...................................................... 33 CASE STUDY FROM COLOMBIA

Figures Figure 1. Change in percentage of Colombia s population volume by sex and age, 2000 2010... 8 Figure 2. Timeline for primary health care system in Colombia...................... 10 Figure 3. Architecture of health care system in Colombia.......................... 13 Figure 4. Distribution of health system resources, 2014........................... 15 Figure 5. Distribution of health professionals in Colombia, 2011..................... 22 Tables Table 1. Databases consulted to obtain quantitative data.......................... 4 Table 2. Key informants identified for obtaining information......................... 4 Table 3. Identification of stakeholders...................................... 5 Table 4. Colombia s main indicators........................................ 7 Table 5. Demographic, macroeconomic and health profile of Colombia................. 8 Table 6. Public and private responsibilities for provision of health services............... 14 Table 7. UPC contributory regime, Colombia 2017.............................. 16 Table 8. UPC subsidized regime, Colombia 2017............................... 17 Table 9. UPC subsidized regime, indigenous population, Colombia 2017................ 17 Table 10. Regional goals for human resources in health.......................... 19 Table 11. Dimensions and their tracking indicators in PDSP........................ 31 Table 11. Human resources in Colombia.................................... 21 iv PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Abbreviations and acronyms DANE ENDS EPS GDP ICFES IETS INS National Administrative Department of Statistics National Demographic and Health Survey health insurance entity gross domestic product Colombian Institute for the Promotion of Higher Education Institute of Health Technology Assessment National Health Institution PAIS PBS PDSP PIC RETHUS RIPS Comprehensive Health Care Policy Health Benefits Plan Public Health Ten-year Plan Public Health Plan for Collective Interventions National Unique Registry of Human Talent in Health Individual Registry of Health Services Delivery ROSS-MSPS registries, observatories, monitoring systems and situation rooms IPS MDG MIAS NCD OECD ONS-INS PAHO Public Providers Health Institution Millennium Development Goal Health Care Comprehensive Model noncommunicable disease Organisation for Economic Co-operation and Development National Health Observatory Pan American Health Organization (of the World Health Organization) SGSSS SISMED SISPRO SIVIGILA UPC WHO General System of Social Security in Health Drug Price Information System System of Information in Health and Social Protection Public Health National Surveillance System Capitation Payment Unit World Health Organization PAI Expanded Programme on Immunization CASE STUDY FROM COLOMBIA 1

1. Background to PRIMASYS case studies Health systems around the globe still fall short of providing accessible, good-quality, comprehensive and integrated care. As the global health community is setting ambitious goals of universal health coverage and health equity in line with the 2030 Agenda for Sustainable Development, there is increasing interest in access to and utilization of primary health care in low- and middle-income countries. A wide array of stakeholders, including development agencies, global health funders, policy planners and health system decision-makers, require a better understanding of primary health care systems in order to plan and support complex health system interventions. There is thus a need to fill the knowledge gaps concerning strategic information on front-line primary health care systems at national and subnational levels in low- and middle-income settings. The Alliance for Health Policy and Systems Research, in collaboration with the Bill & Melinda Gates Foundation, is developing a set of 20 case studies of primary health care systems in selected low- and middle-income countries as part of an initiative entitled Primary Care Systems Profiles and Performance (PRIMASYS). PRIMASYS aims to advance the science of primary health care in lowand middle-income countries in order to support efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system, tailored to a primary audience of policymakers and global health stakeholders interested in understanding the key entry points to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems in selected low- and middle-income countries. Furthermore, the case studies will serve as the basis for a multicountry analysis of primary health care systems, focusing on the implementation of policies and programmes, and the barriers to and facilitators of primary health care system reform. Evidence from the case studies and the multi-country analysis will in turn provide strategic evidence to enhance the performance and responsiveness of primary health care systems in low- and middle-income countries. 2 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

2. Overview of the PHC system Colombia is a tropical middle-income country, located in the north-west of South America and is the fourth country in territorial extension of Latin American countries. According to the projections developed by the Colombian National Administrative Department of Statistics (DANE), Colombia has 49 million inhabitants in its 1 141 748 sq.km territory. About 76% of the population lives in urban areas, while the remaining 24% live in rural areas (1). Life expectancy at birth in Colombia has increased from 57 years in 1960 to 74 years in 2014 (1). Colombia is geographically divided into departments (32), districts (1101) and municipalities (6). Municipalities are the smallest unit from the administrative point of view, and are further divided according to categories, from 1 to 6, and the capacity for management, income by taxes and the population. Municipalities of category 1 have more income, more capacity and a larger population. Municipalities have more or less responsibilities for activities to be developed in relation to public health and health provision management services in the territory. Departments are groups of municipalities that administratively assume the responsibilities of smaller municipalities and supervise larger municipalities to fulfil their functions optimally, verifying and monitoring population health conditions, and adequately managing assigned financial resources. Districts are territorial entities that are determined by the Colombian law as very large municipalities, with certain special management characteristics or stage of socioeconomic development. The functions of a district are a mix between those of a department and a municipality. Districts must report directly to the national government. Colombia is a centralized State, which assigns functions to departments and municipalities according to their management capacity, population and resource availability. The regulatory and governing body is the Ministry of Health and Social Protection, which is responsible for issuing the technical rules and regulations that control the management, organization and monitoring of the health system, norms related with finances and relationships between the different entities (2). CASE STUDY FROM COLOMBIA 3

3. Methods For elaboration of this primary case, a literature review was carried out in the Colombian context. Reports submitted by the Ministry of Health and Social Protection and other public entities for the national public or for international entities were reviewed, interviews undertaken with key actors at the national and territorial levels, and different entities of the health sector in Colombia taken into account. Quantitative data were obtained from official public sources (Table 1). Table 1. Databases consulted to obtain quantitative data Source of information Main area of expertise Institution SISPRO: System of Information in Health and Social Protection ENDS: National Demographic and Health Survey DANE: National Administrative Statistics Department. Postcensal studies Indicators related to provision of health services in Colombia, and health outcomes. This integrates all information, affiliation, services provided, care costs and payment for services sources. Population demographic data, use of health services perspective Population projection post-census studies. National, departmental, and municipal revision and population typology Ministry of Health and Social Protection Ministry of Health and Social Protection DANE World Bank Data Economic data, population indicators and health outcomes Data on the results of global goals for each country WHO: Report cards by country (Colombia) Health financial indicators World Health Organization SGSSS: Sources of funding and use of the resources of the General System of Social Security in Health Source: Authors elaboration Report on sources and uses of health resources Ministry of Health and Social Protection Table 2. Key informants identified for obtaining information Descriptor Human Talent Directorate, Ministry of Health Health care provider outpatient services leader Health promotion and disease prevention department officers, Ministry of Health Quality leader in a low- and mediumcomplexity public hospital Main areas of expertise Human resources Outpatient health services provision Health promotion services Provision of quality services Main constituency represented Governmental Providers of health services Governmental Health service providers Head of Public Health Programme Health education/public health Academic Production guides and routes of care leader Institute of Health Technology Assessment (IETS) Academic, research, public health Academic Medicines and Technology Directorate Access to medicines Governmental Territorial health entity of Public Health Directorate Health promotion and disease prevention, public health Governmental /local Leader of family compensation entities Public health, health management Health-promoting companies Source: Authors elaboration 4 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

For the identification of key actors, we took into account representatives of different organizations that intervene in the health sector, and are part of diverse elements addressed within the strategies of primary health care (Table 2). Selection of stakeholders, the structure of the health system in Colombia, and elements that constituted the primary health care process were taken into account. Later, actors were sought in each of the types of entities for provision of information and obtaining qualitative data for the case study (Table 3). Table 3. Identification of stakeholders Descriptor Main constituency represented Level of health system at which active Remarks Ambulatory entity providing health services Institutions providing health services Health service provision Private entity Ambulatory and hospital entities providing health services Institutions providing health services Health service provision Public entity Territorial health directorate Local government Local government Public entity Health-promoting companies Insurance Institutions Private entity Medication management representative National Goverment Central Government Public entity Human talent management representative National Goverment Central Government Public entity Promotion and prevention management representative National Goverment Central Government Public entity Public University Health Programme Leader Academia Health education Public entity Evidence-based policy-making process leader IETS Investigation Investigation Mixed entity (public private) Source: Authors elaboration CASE STUDY FROM COLOMBIA 5

4. Overview of primary health care statistics Over the past 20 years, there has been a positive change in the performance of the health system in Colombia with respect to health expenditure, and the outcomes of implementation and provision of health services. In general, it is important to note that Colombia has had a substantial increase in life expectancy at birth, vaccine coverage of immunopreventable diseases, insurance coverage and effective access to health services, and an increase in the number of benefits available in health plans, among others. According to the Colombian Health Situation Analysis (ASIS) 2015, the main causes of consultation in the health services in Colombia are noncommunicable diseases (NCDs) (65.45% of doctors visits made between 2009 and 2014), followed by nutritional and communicable diseases (14.73%), injuries due to different causes (5.2%), and maternal and perinatal conditions (2.12%) (1). Regarding mortality, and according to ASIS 2015, the main cause of death was attributed to circulatory problems (29.92%), followed by neoplasms (17.79%), and external causes (injuries; 16.79%) during this period (1). Indicators related to the Millennium Development Goals (MDGs) have shown that maternal mortality has reduced from 104.9 to 55.2 maternal deaths per 100 000 live births; however, maternal mortality is higher in the poorest areas where there are major problems of equity in access to health services. The main cause of mortality in Colombia has changed in the past 15 years, where violent deaths have moved from first to second place, and mortality associated with chronic NCDs has moved to the first place. According to the ASIS 2015, the highest mortality in Colombia is due to ischaemic heart disease, followed by cerebrovascular accidents and arterial hypertension. In fourth place is polytrauma caused by accidents, specifically traffic accidents (pedestrians and drivers) and, finally, gastric cancer deaths. The National Demographic and Health Survey (ENDS), which was conducted in 2015, shows that in Colombia, 98% of women who had deliveries received antenatal care by trained personnel (doctors and nurses); 92% of these women received four or more prenatal check-ups during their last pregnancy, and 78% of the women received postnatal care at their last delivery (3). In contrast to health indicators, Colombia is one of the countries with the highest inequalities in the region, the second after Honduras; the Gini index is 53.5 (2015). However, in the past 15 years, the prevalence of poverty in Colombia has decreased from 50% to 28.5%. Colombia s gross domestic product (GDP) per capita is US$ 6056.1 (2015) (Table 4) (1). Between 2005 and 2013, neonatal mortality fell from 9.9 to 7.3 neonatal deaths per 1000 live births. Similarly, mortality in children under 1 year of age fell from 19.5 to 11.6 deaths per 1000 live births. In children under 5 years, there has been a steady decline from 24.3 in 1998 to 14.1 deaths per 1000 live births in 2013. Vaccination coverage in the past 10 years in the child population has remained above 85%, and in the past 5 years has been above 90% (1). 6 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Table 4. Colombia s main indicators Results Source of information Remarks Total population 49 million DANE (1) 2016 Distribution of population urban/rural 76% urban/24% rural DANE (1) 2016 Sex ratio: male/female 97.5/100 Ministry of Health (4) 2015 Growth rate 0.9% World Bank (5) 2015 Population density (people/sq.km) 42 Ministry of Health (4) 2015 Fertility rate 2.0 Ministry of Health (4) 2015 Life expectancy at birth 74 years World Bank (5) 2014 Infant mortality 11.6/1000 live births ASIS (4) 2015 Top 5 main causes of death (ICD-10 classification) I249, I64X, I10X, T07X, C169 ASIS (4) 2015 Under-5 mortality rate 14.1/1000 live births ASIS (4) 2013 Maternal mortality rate 55.2 /100 000 ASIS (4) 2013 Immunization coverage under 1 year Up to 90% ASIS (4) 2013 Skilled birth attendance (% of pregnant women) 98.6% ASIS (4) 2015 Four recommended antenatal care (ANC) visits 92% ASIS (4) 2015 Income or wealth inequality (Gini coefficient) 53.5 World Bank (5) 2015 Total health expenditure as proportion of GDP 7.2% World Bank (5) 2014 Primary health care (PHC) expenditure as % of total health expenditure 56% Ministry of Health (6) 2015 % total public sector expenditure on PHC 100% Ministry of Health (6) 2016 Total expenditure on health per capita US$ 962 OMS (7) 2014 Proportion of households experiencing catastrophic health expenditure N/A The health services are paid for by insurance enterprises Voluntarily health insurance as proportion of total expenditure on health 7.1% Fedesarrollo (8) 2012 Public expenditure as % of total health expenditure 75.2% The Bank of Republic (9) 2011 Out-of-pocket payments as proportion of total expenditure on health 15.9% The Bank of Republic (9) 2013 Source: Authors elaboration, with data from different entities Colombia s health system structure is based on an inalienable right to health, with public health expenditure based on taxes from different sources. However, it is important to note that this condition has an impact on the expenditure of the main indicators in the Colombian population. In this sense, in Colombia, there is no report and no measurement of catastrophic expenditure on health by families. In Colombia, health spending associated with health policies prepaid medical plans, complementary health plans and special insurance policies are an additional expense for the system. This primarily affects the population with the highest income. Companies also offer additional benefit plans within welfare plans but these plans offer health benefits that are already included in Colombia s mandatory health benefits plan. Prepaid health care and complementary health plans offer more better CASE STUDY FROM COLOMBIA 7

conditions during hospital stays, direct access to some health specialties or better opportunities for service provision. This health spending does not necessarily strengthen primary health care in these population groups; on the contrary, it moves them away from the basic programmes in the system. Within the health system in Colombia, activities that are part of collective primary health care are not subject to co-payments that regulate their use. Health conditions catalogued as being of public health interest are included, such as pregnancy care, childbirth and the puerperium, care of the healthy newborn, care of children under 5 years of age, diseases such as high blood pressure, diabetes mellitus, among others, as well as initial emergency care (10). Ambulatory care in general and specialized medicine, medicines and diagnostic procedures are subject to co-payments. However, current regulations state that payment of this money cannot be a condition for health service provision. In summary, out-of-pocket health expenditure in Colombia is basically determined by payment of these co-payments and moderating fees for provision of health services (Figure 1 and Table 5). Figure 1. Change in percentage of Colombia s population volume by sex and age, 2000 2010-5.6-5.5 4.1 3.5 6 9.3 13.5 17.8 25.5 32.8 33.5 33.3 30.3 31.7 49.8 51.4 47.6 51.7 80+ years 70 79 60 69 50 59 40 49 30 39 20 29 10 19 0 9 Age group -10 0 10 20 30 40 50 Percentage (%) Men Source: Colombia s demographic ageing, 1951 2020 (11) Women Table 5. Demographic, macroeconomic and health profile of Colombia Summary Relevance for primary health care (PHC) Source of information Demographic profile Since the end of the 20th century, Colombia has undergone a series of changes in the demographic structure as a consequence of different elements and positive outcomes. These changes are leading to a transition where the Colombian population will progressively present demographic ageing (Figure 1). Factors that have influenced this include: increase in life expectancy at birth decrease in the fertility rate decrease in infant and young adult mortality rates social changes in the country, such as a decrease in violence. These demographic changes have a major impact on PHC. Since services must be modified to serve the elderly population, it requires the allocation of more resources for care of chronic diseases and complications of these. Specialized services have to be strengthened for the population with comorbidities. Minsalud (11) 8 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Summary Relevance for primary health care (PHC) Source of information Macroeconomic profile Colombia is the third-largest economy in Latin America. This is due to elements such as stabilization of inflation and its human development index (0.719). Colombia is a country whose main sources of income are mining and hydrocarbons, construction and agricultural activity. Colombia is a country that produces raw materials, rather than one that transforms these materials with added value. For the past four years, negotiations on peace process agreements have begun. The country can expect a notable increase in investment and will be subject to an economic transition. In the post-conflict setting, there is potential for change in social policies, economic growth and economic goals of the State. Health care processes and health model planning for the Colombian population should consider aspects of changes related to key factors, such as greater difference in accessibility, economic strengthening, higher employment rate and population growth conditions. These aspects will lead to a change in population distribution in large rural areas, reorganizing health services and providing processes where there is foreign investment. OECD (12) Health profile Colombia is in the process of epidemiological transition. It is a susceptible country with a high burden of acute infectious diseases and with a growing prevalence of chronic noncommunicable diseases, to the point that, at present, when analysing general morbidity in Colombia, they occupy the first place as the main cause of health services use. However, it is very important to note that, given the geographical location of Colombia and the characteristics of a tropical country, Colombia has a high prevalence of vectorborne diseases and other diseases prevalent in the region. The analysis of the main causes of consultation and morbidity of the population show that the most prevalent conditions are hypertension, diabetes mellitus, dental caries, injuries (accidents, violence or self-inflicted), and prevention of maternal and perinatal diseases. However, when analysing population conditions by age group, it must be taken into account that in the child population, prevalence of preventable communicable diseases such as acute diarrhoeal disease and respiratory infections, and noncommunicable infections such as malnutrition are still important, so they should not be left out. Likewise, in adulthood, the prevalence of diseases such as cancer is of greater importance in the care process. Efforts should be made so that the Colombian population is seen as a whole, but also understanding the characteristics of each of the regions and the different age groups. Changes in the Colombian health profile and in the causes of morbidity and mortality have led to health processes focused on the care of a population that has a higher rate of ageing and that suffers from diseases of the adult population. On the other hand, the maintenance of a strong structure of support and care for the young population, which largely suffers from communicable diseases, requires a much more social dynamic interaction with other sectors in order to ensure that health activities have a greater impact, and must be built on the basis of environmental health. The Colombian health profile shows that work must be done within the standards of complex care that guarantees supply of medicines and new health technologies. This supposes an increase in health resources, by increasing the frequency of use of the health services. Minsalud (4) Source: Authors elaboration, with data from different sources Timeline Colombia s current health system was established in 1993 as a mechanism for implementation of the 1991 National Constitution, in which health is considered as a fundamental right. The health system was established based on the assurance of provision of health services to the population. Later in 1996, the conditions for population health care were defined based on collective activities under the Basic Attention Plan (Figure 2) (13). In 2000, regulations were issued in order to ensure effective and efficient care in activities of public health interest, such as prevention and control of common diseases and healthy population measures, including vaccination, maternal care, child health, and early detection of diseases such as breast and cervical cancer. As of 2004, specific protection activities, and implementation of activities related to early detection were assigned to municipalities and states. Performance in health is assessed against indicators related to the coverage of these activities (see Figure 2). Development of the health system in Colombia had two problems related to the low level of compliance with the objectives. The first was related to insurance CASE STUDY FROM COLOMBIA 9

Figure 2. Timeline for primary health care system in Colombia 1993 Health care system establishment based on assurance, individual activities (different for workers and nonworkers) and collective health 1996 Establishment of a Basic Care Plan (health promotion, risk factors control, and disease prevention of public health importance) 2000 Release of policy information related to health promotion, specific protection targets and early detection of diseases 2007 Primary care approach re-establishment; National Public Health Information Development Plan 2011 Primary health care model development by law is deployed, reorganizing health roles and responsibilities 2016 Health Care Integration Policy and Comprehensive Health Care Model (MIAS) development 1991 Political Constitution: health as a fundamental right 2001 Reorganization of functions in municipalities and states 2008 By court order, the same health plan for workers and non-workers (poor population) must be unified 2014 Articulation of a new model and health policy for Colombia, based on the determinants of health and primary health care coverage, which did not reach the proposed goal of 100%, as the contributory regime did not reach the expected levels and resources for the subsidized regime were not sufficient. The second problem was related to the low impact of health promotion, disease prevention and early detection of diseases. This latter situation was generated due to lack of clarity in terms of commitment to carry out specific activities, and the low level of articulation between the collective interventions plan and the one for individual health. In 2002, the National Government decided to remove some basic activities (vaccination, cervical cancer early detection programme, family planning programme, including contraceptive delivery and intrauterine device insertion) from the responsibility of the subsidized regime. Administration and regulation of these activities were then handed over to the territorial entity. Provision of these health services should preferably be contracted to the low complexity public providers health institutions (IPS in Spanish) of each municipality. In the contributory regime, this did not change (14). In 2007, a law was passed mandating that the national government must issue national public health policies and plans, in order to ensure integration of actions and implementation of longterm programmes to improve the health of the Colombian population, including in relation to emerging infectious diseases (see Figure 2). Among the situations that led to the enactment of this law was information asymmetry between the knowledge of health expenditure of the health insurance entities (EPS in Spanish) and the poor knowledge of the IPS in this respect. There was a lack of regulation of the contractual relationship between the EPS and IPS, problems related to the flow of resources between payers and health service providers, and delays in auditing processes among stakeholders (15). Problems accumulated related to the quality of health services, resulting from the lack of updating 10 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

of a benefit plan. To protect the fundamental right to health care, the judicial system in 2008 passed Judgment T-760 of the Constitutional Court, which mandates, among other actions, equality in health benefit plans for the entire population, and a review and update of the benefit plans, in accordance with technological advances in health care (16). In 2011, as part of compliance with Judgment T-760, a law was issued ordering the creation of a health model strengthening primary health care, organizing a permanent functional structure for updating health plans, and formulation of a policy for the national pharmaceutical industry (see Figure 2). It ordered the development of clinical guidelines and care protocols to strengthen decision-making and clinical interactions between hospitals of low-, medium- and high complexity. Law 1438 of 2011 establishes that in Colombia, health care processes based on primary health care will be strengthened. It recognizes the need for intersectoral and transectoral collaboration with other national and territorial agencies that, although they do not provide health services, are key actors in health decision-making. One more element included in this law was related to the regulation of the operation of insurance. After reaching an insurance coverage of more than 95%, it would be necessary to regulate the mobility of the system and to anticipate situations that can occur when users change their domicile or decide to change their insurer. In addition, a person may change his location, if he obtains a new job or, on the other hand, loses his job, which forces him to move from a subsidized to a contributory regime or vice versa (17). Another important aspect included in Law 1438 of 2011 relates to adjustments to the financing of the health system. This law regulates the use of resources from created taxes to strengthen the provision of individual health services and funding. It includes a plan to clean up the debts of public hospitals, in order to strengthen the process of service delivery in the most vulnerable municipalities and departments. In 2014, due to an initiative by medical professionals, a new law was created that amended the fundamental right to health care, and made it an inalienable right that should be guaranteed by the government at the same level as the right to life. The law mandates the creation of a health model based on the social determinants of health, taking into account the geographical characteristics of the Colombian territory. Additionally, it created an unlimited health plan, by which the Colombian population is entitled to any technology available in Colombia, which should be paid for using public resources of the health system, except those technologies that are extravagant, cosmetic or experimental, or lack evidence of effectiveness and safety. In compliance with these laws, in 2016, a new model of health care, the Health Care Comprehensive Model (MIAS in Spanish), was introduced, which strengthens primary health care delivery, including through increasing the responsibility and decision-making capacity of health teams. It is a model that improves access of the population to health, aims to achieve user satisfaction and optimizes the fulfilment of health system goals (see Figure 2) (18). The process of regulating this law is still under development so it is necessary to wait for possible outcomes, especially as it predicts that two years of transition must occur, which end in 2017. One of the problems that must be regulated and strengthened through the implementation of this law is improvement of the flow of financial resources in health, to avoid the growing portfolio for service provision and to strengthen the quality of provision of health care services. CASE STUDY FROM COLOMBIA 11

5. Governance and health services architecture The structure of the General System of Social Security in Health (SGSSS in Spanish), established by the 100 Law of 1993, has been reformed through different standards, particularly Laws 1122 of 2007 and 1438 of 2011. Likewise, the public health component was developed by Law 9 of 1979; Law 10 of 1990 defined the model of decentralization, and Law 715 of 2001 established the powers and the decentralized financial structure. In addition, Law 1164 of 2007 regulated the conditions of human resources talent in health. To these standards, Law 1751 of 2015 or the Statutory Health Law and the National Development Plan Law 1753 of 2015 were added. This set of rules has determined a social insurance model, with public and private integration and two insurance schemes: subsidized for those without the ability to pay and contributory for the population in the formal sector and independent persons with the ability to pay. Nominally, in Colombia, the entire population can access all health technologies through two administrative mechanisms: insurance and a nonmandatory health plan (refund). Central objectives of the 1993 reform emphasized: (i) expansion of protection for families against catastrophic expenditure associated with the health services; and (ii) improvement in access through extension of insurance. Rules and technical regulations controlling the functioning of entities seek to harmonize the relationships between payers and service providers, to provide patient-centred care, good-quality service delivery, and the best clinical practices. Development of studies on the effectiveness and safety of health technologies and procedures is financed by the Ministry of Health and Social Protection, which also produces clinical guidelines and protocols, to help those in the system improve the quality of health care services with a clear articulation of clinical management in different health conditions. Within the Colombian regulatory framework, the government must formulate policies that have a long-term horizon (10 years), called decennial plans. Among them are the 10-year Public Health Plan, the National Pharmaceutical Policy, the Comprehensive Health Care Policy (PAIS in Spanish), among others. It also states that in each presidential period (every four years) a government plan must be established, aligned with the above, indicating the programmes that will be developed to achieve the health goals of the Colombian population. At the territorial level, departments, districts and municipalities are responsible for health promotion activities, tracking of actions of public health interest, financing collective health activities, monitoring, control, inspection of the health services plan, and ensuring quality in providing these. The territorial entities are in charge of certification of health providers, monitoring health indicators of the population and facilitating relationships between the health sector and allied sectors, such as education, culture and infrastructure. Organization of health service networks is under the charge of the health insurance entities, which have the function of connecting to Colombian inhabitants (national or foreign), manage population risk of disease, and supervise financial resources for the provision of individual health services to the population. The EPS s function of surveillance is done by the National Superintendent of Health, a State agency, independent of Colombia s Ministry of Health. Health services are provided by public and private hospitals, as well as independent health professionals. Service networks are in conformity with general medical services (general practitioners, nursing, dentistry, individual health education 12 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

activities, vaccination, prenatal control and early detection activities). Referral to specialized services by doctors or dentists can be done but, in some cases, administrative authorization is required by the EPS. Activities developed within national programmes such as prenatal care, birth control, labour and delivery care, newborn baby care, healthy child care, adolescent health care, health care for the elderly, extended immunization programme, early detection of visual and hearing diseases, breast cancer, cervical cancer and special care programmes such as hypertension and vector-borne diseases are free and do not need administrative procedures (19). Hospitals and clinics that provide health services in Colombia are organized by levels of complexity: low, medium and high complexity. Low-complexity institutions provide services in general medicine, nursing, labour and delivery care, dentistry, pharmacy services, clinical laboratory services (basic tests) and, in some cases, nutrition and other therapies, such as physical and respiratory therapy services. Some institutions have basic hospitalization services and radiology as well. All the municipalities in Colombia have at least one headquarters of this type (Figure 3). Medium-complexity institutions include basic specialized services such as internal medicine, gynaecology, general surgery, orthopaedics, anaesthesiology and paediatrics. These institutions are supported by pharmaceutical services, clinical laboratory, diagnostic imaging, hospitalization, and physical therapy services. These types of institutions are geographically available in each of the departments and, in most of them, there is at least one of these services. High-complexity institutions include public and private hospitals, specialized surgical services, more complex medical and surgical specialties, high-level Figure 3. Architecture of health care system in Colombia Health promotion companies Payment for services in PHC Stewardship and regulation Ambulatory health services Surveillance and control Ministry of Health and Social Protection Quality and public health actions surveillance Private PHC institutions Public PHC institutions Population information Superintendence of Health Multidisciplinary health professionals Public teams in local government Operational authorization PHC Local authorities CASE STUDY FROM COLOMBIA 13

clinical laboratory and diagnostic imaging including magnetic resonance imaging, tomography, interventional radiology, and special care units such as intensive adult, paediatric, neonatal and obstetric care. In addition, they have specialized services such as cancer, dialysis units, transplant units, among others. These services are concentrated in the main cities of the country, with more than one in each city. High-complexity institutions are present in only 10 departments of the country (Table 6). Provision of health services for collective activities (information, education and communication), as well as public health surveillance activities, are carried out by territorial health entities (departments, districts and municipalities), through health service providers in each of their territories. For these to be carried out, each territorial government must formulate a territorial health plan for a period of four years, and establish an operational strategy with defined indicators and goals to improve population health conditions (Table 6). 5.1 Financing Colombia s health system is financed by multiple sources. Some resources are through specific destination taxes and, in other cases, from project taxes and investment funds. In the past 5 years in Colombia, per capita spending on health has increased by 25%, from US$ 720 in 2009 to US$ 962 in 2014 (19), despite the fact that the percentage of GDP destined for health has been maintained at a constant 7% (± 0.2%). The population out-of-pocket health expenditure is 15.9% of the total health expenditure. In Colombia, the so-called family financial catastrophic effect due to health care is not measured, and according to the structure of the system, should not exist. This situation is explained by the characteristics of the health system, where there is a very broad health benefit plan, but additionally, where the services excluded from the plan are covered by other mechanisms through State resources. For access to these services, there are two mechanisms. The first mechanism is through request by the treating health professional of a service or technology outside the plan. The EPS delivers the service and recovers it from the State. The second mechanism is through a judicial structure called guardianship, where a judge orders the delivery of the service prescribed by the physician and, based on the judicial decision (15 days delay), the government pays for the health service. Colombia s sources of funding for the health system are varied; however, the main source is taxes contributed by workers from public and private entities of Colombia. Given the way the State is organized, an important source is by the financial surpluses that are generated by the management of resources of the Colombian health system. In addition to the above, there are other sources derived from general taxes that are transferred to the health system, as part of the National General Budget. These are taxes from alcoholic beverages, gaming, tobacco and guns (22). Table 6. Public and private responsibilities for provision of health services Type of sector (public vs private) Nature of facility Mode of employment of providers Range of services provided Remarks Source of information Institutions providing public and private health services Individual benefit plan service provider Service contract with EPS. Can be capitation, payment for services, integral packages or prospective payment Individual health services provision: low, medium and high complexity 2016 Minsalud (20) Public health institutions Providing collective health services Contract for services Collective action plan for service provision 2016 Minsalud (21) Source: Authors elaboration with data from the Ministry of Health 14 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

In order to understand the sources and uses of the financial resources of the health system, three scenarios must be taken into account: financing service provision under the contributory regime financing service provision under the subsidized regime financing of public health activities or collective intervention activities. Simultaneously, health resources are used in other ways, such as coverage for traffic accidents ECAT (vehicles, motorcycles and pedestrians), payment for services not included in the benefits plan, and other payments for support and development of the system. Figure 4 shows the distribution of these resources. Contributory regime Provision of individual health services under the contributory scheme (provision of health services for workers and their beneficiaries) is financed by a mechanism called the Capitation Payment Unit (UPC). This UPC is paid by the Colombian State per affiliate to each of the EPS in charge of each partner. The amount of the UPC is fixed annually by the Ministry of Health and is paid monthly to each EPS according to the number of affiliates it has. The amount of UPC depends on multiple factors, such as age and sex (newborns and older adults receive higher values of UPC, as well as women of reproductive age), the place of residence (with differential values for population in larger cities, remote or rural areas, and finally special populations such as indigenous people). Figure 4. Distribution of health system resources, 2014 100 90 80 70 60 50 40 30 20 10 0 85% 7% Taking into account the above, for the contributory regime, an average UPC is established. For the year 2017, this corresponds to Colombian pesos (COP) 746 (approximately US$ 260) (23). However, according to the characteristics of the population, access conditions and use of services change in different regions and populations, as shown in Table 7. 0% Capitation Payment Unit (UPC) Services not included in the benefit plan Catastrophic event 5% Source: Authors elaboration, data obtained from Minsalud (1) 3% Public health Support providers CASE STUDY FROM COLOMBIA 15

Table 7. UPC contributory regime, Colombia 2017 Age group General population (US$) Scattered areas (US$) Department capitals and large municipalities (US$) Insular zone (US$) 1 year or less 763.51 839.87 838.80 1 052.89 1 4 years 245.17 269.68 269.34 338.08 5 14 years 85.64 94.21 94.09 118.10 15 18 years men 81.63 89.79 89.68 112.56 15 18 years women 128.99 141.89 141.71 177.88 19 44 years men 145.25 159.77 159.57 200.30 19 44 years women 269.48 296.43 296.05 371.61 45 49 years 266.54 293.20 292.83 367.56 50 54 years 339.97 373.96 373.49 468.81 55 59 years 415.57 457.13 456.55 573.08 60 64 years 534.84 588.32 587.57 737.54 65 69 years 665.29 731.82 730.89 917.44 70 74 years 798.35 878.18 847.50 1.100.92 75 years and more 1.003.23 1 103.55 1 102.14 1.383.45 Source: Data taken from Minsalud (1) and converted to US$ (representative exchange rates [TRM]: COP$ 2900) Resources that finance the contributory regime come from the following sources: resources collected from workers contributions (worker s income tax deducted by the employer on a monthly basis) financial gains from performance of economic system CREE tax (corporate income tax). Subsidized regime As in the contributory regime, in the subsidized regime, the State pays the EPS a monthly value in terms of population care. The average value for 2017, determined in Resolution 6411 of 2016, is COP$ 667 429.20, which corresponds to US$ 226 (TRM: COP$ 2950). However, it is important to note that in the subsidized regime, there are differential values for the indigenous population. The UPC values for the general and indigenous subsidized populations are shown in Tables 8 and 9. 16 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)