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To Ensure Universal Healthcare Coverage, Countries Need To Find A Balance Between Services And Costs
Having a universal healthcare system that ensures an adequate and equalitarian coverage is a main objective of most countries, no matter the region or income level. However, the practical aspects of putting such a system in place are challenging as they depend on many factors. As a consequence, different countries have come up with different models of healthcare systems.
There are two balancing forces when it comes to establishing and operating health care systems. On the one hand, there is an interest to include as many necessary and useful services and technologies as possible and make them available to the whole population. On the other hand, there is a need to keep the costs of the overall system within some limits to avoid putting an unbearable financial burden on the government and private payers that fund the system. (1)
A system that includes a wide array of treatments and services and has the mechanisms to include new technologies ensures, in principle, that users will have access to more appropriate and personalized treatments, thus increasing the perceived quality of healthcare. Additionally, this type of system promotes the development of infrastructure and human resources, thus creating a better opportunity for the country to treat national and international patients.
But finding the balance between coverage and costs has become increasingly challenging in recent years with the accelerated development of medical technologies and the increase in life expectancy.
Countries that have to deal with considerable inequality in their populations – as is the case for the countries in LATAM – find it especially difficult to find the right because they have two very different populations at each end of the spectrum. On the higher end of the socioeconomic scale, we find urban populations of highly educated people who demand to have access to new technologies and personalized treatment. But on the lower end of the socioeconomic scale, we find populations who live in rural areas and might struggle to get access to the most basic health services. (1)
On top of this population disparity, it is worth noticing that the LATAM countries have on average a lower income than regions like Europe or Canada, making it more difficult to finance all the technologies currently available to users.
Within the LATAM region, the healthcare system of Colombia is a good case study. In the last decades, and especially in recent years, this country has committed to a system that ensures health coverage to all its inhabitants independent of their income while keeping a health benefits package open to inclusion of new technologies and services. However, the country still has challenges to overcome. (2)
Since funding the system without putting excessive pressure on the entities that provide the funds is one of the main challenges of any country aiming to provide a universal healthcare system, in the next section, we will discuss how the Colombian healthcare system is funded and what services are included.
Funding And Organization Of The Colombian Healthcare System
Colombia has a solidary healthcare system, where those with the financial capacity pay for the service and help fund those who don’t have the acquisitive capacity to pay for a healthcare plan.
Most funds destined to healthcare are public, with 75,8% of overall resources coming from the government and the remaining 24,2% coming from private sources. The Colombian government contributes a significant amount of annual per capita expenditure on health. This value was $548 in 2012 (corresponding to COP 986.400 in local currency), which is considerably higher than the average annual expenditure of upper-middle-income countries ($371) (3).
As of March 2021, 98.1% of the Colombian population were enrolled in the healthcare system. This system has two main regimes called contributory and subsidized. The former is aimed at employees and independent workers who can contribute partially for health insurance and the latter is aimed at those who lack a formal income. Both regimes cover a similar number of people. As of March 2021, 47,5% of the insured population belonged to the contributory regime and 48% belonged to the subsidized regime. The minister of health oversees the funds that finance these two regimes.
There is a third, smaller exception regime that covers 4.5% of the population. The exception regime includes users in semi-independent health subsystems for army employees (run by the ministry of defense), public school and university teachers and docents (run by the ministry of education), and the national oil company employees (run by the ministry of energy). These users contribute to pay for their health from their own income, however funds and health care benefits are managed with accounts of the corresponding ministries. (4)
Regardless of the regime, every person in Colombia who is covered by the healthcare system has access to the same health benefits package, which includes a list of interventions, medications, and tests. (5) The ministry of health is responsible for determining how to administer this package for all the regimes.
Every year, the Health Technology Assessment Agency of Colombia revises the list of health benefits, and may include new technologies based on the needs of the population and the technologies that can fulfill those needs and are safe and cost-effective. (6, 7). Also, the ministry of health regularly determines what technologies are excluded from the health benefit package.
Additionally, health technologies, not deemed as excluded from the health benefit package can still be paid by the system via alternative reimbursement mechanisms. It is common for users – especially those living in big cities – to undergo legal action to ensure they get coverage for the treatments they deem fit. As a consequence, a significant amount of the funds directed to the healthcare system go to cover treatment not included in the benefits package (1, 8).
On paper, the Colombian healthcare system is one of the most complete of the LATAM region. But in practice, it still faces challenges. For example, the coverage in the contributive regime is still considerably better than that of the subsidized regime, which means that almost half the users cannot easily access the services of the health benefits package.
Additionally, there is an ongoing pressure for a reduction in the public contributions that fund the healthcare system. This would mean decreasing the amount of funding that comes from general taxes and increasing the percentage of funding that comes from the users with an ability to pay. In other works, making the system more solidary.
It is also possible to not only keep the current system working, but improve it over time by putting in place mechanisms that will guarantee a better balance between coverage and funding. These would include mechanisms to keep track of the fund destined to healthcare, which would guarantee an honest administration of the funds, as well as mechanisms that would allows the users to play a significant role in the formation of the system, even if they don’t have a direct say on which treatments are included in the coverage plan.
These mechanisms are currently in place, but they still need to evolve to play a significant role in the Colombian healthcare system.
- Guerrero R, Prada S, et al. Universal Health Coverage Assessment Colombia. Global Network for Health Equity (GNHE). 2015. www.icesi.edu.co/proesa/images/GNHE%20UHC%20assessment_Colombia%204.pdf