In this blog Dr Zlatko Nikoloski and Professor Elias Mossialos discuss health inequalities amongst older people in Colombia. While access, equity of access and barriers to access have been studied in the wider Latin American context, there is very little knowledge about these issues in the Colombian context.
In the 2000 World Health Report, the World Health Organization (WHO) awarded Colombia with the top ranking worldwide for fairness in healthcare finance. This accolade came while civil war was ravaging the country. Almost twenty years on, both Colombia’s social and economic landscapes have improved. Colombia is considered to be an upper middle income country. The average growth rate of the Gross Domestic Product (GDP) per capita (a proxy for economic development) was approximately 2.6% over the last twenty years. This was enough to add, by 2019, another two thirds to the average GDP per capita that the country registered in 2000.
Against this backdrop, significant changes occurred in the healthcare sector as well. By 2015, Colombia was spending 6.2% of its GDP, with most of the spending being public (about three quarters of the total healthcare spending). During this period, Colombia’s universal health insurance system saw a further solidifying of the two main insurance schemes in the country: the contributory scheme (CS), mainly targeting workers in the formal economy, and the subsidised scheme (SS), which was introduced in 1993 and mainly targeting the poor and informal workers. By 2017, 94% of the entire population was insured. Nevertheless, challenges remain. There is still a segment of the population which is not covered by any of the two insurance schemes above. Despite some of the improvements mentioned above, some Colombians continue to pay out of pocket when seeking healthcare. This creates further barriers to access (the most recent data from the World Development Indicators reveals that 18% of the total health expenditure in the country is out of pocket).
Nevertheless, challenges remain. There is still a segment of the population which is not covered by any of the two insurance schemes.
Understanding the Colombian context
While access, equity of access and barriers to access have been studied in the wider Latin American context, there is very little knowledge about these issues in the Colombian context. Moreover, bearing in mind that the proportion of older adults in Colombia is expected to double by 2050 (from the current 11% to 25%) and thus health services promoting healthy aging are more important than ever, capturing the use of healthcare among the elderly—particularly with an equality lens—is an important undertaking. Garcia-Ramirez, Nikoloski and Mossialos explore some of these issues in a recent paper published by the International Journal of Equity in Healthcare. More specifically, the authors set two research objectives: first, to identify the correlates of healthcare utilisation for Colombian elderly patients, and second, to analyse the equality of healthcare utilisation among elderly Colombian patients.
In answering these empirical questions, the authors relied on the SABE dataset, a nationally representative population-based cross-sectional dataset of 23,694 adults over 60 years, which was collected by the Ministry of Health in Colombia in 2015. In analysing the equity of access, the authors cast the net widely and focus on three types of care: preventive care (use of pap smear and mammogram for women; prostate cancer lab screening in the last two years for men), outpatient care (doctor visit in the last four months; visit to any health professional—other than a doctor—in the last year), and inpatient care (hospitalisation(s) in the last year). In order to distil the main correlates of the use of the types of care mentioned above, the authors rely on the standard methodology and, in doing so, they are quite comprehensive (relying, at first on a standard multivariate logistic model regression, followed by an analysis of inequality in utilisation using the standard concentration index (CI)).
More importantly, the authors anchor this empirical exercise in the theoretical model on correlates of healthcare utilisation put forth by Andersen. Andersen establishes that utilisation of health services depends on three factors: predisposing, enabling, and need factors. Predisposing factors include individual characteristics present before the occurrence of a disease and are related to demographic conditions like age and gender. Enabling factors describe the means utilised by individuals in order to access the services they need such as socio-economic status captured by income. Finally, need factors refer to the health conditions—either perceived or evaluated—requiring medical care. The usefulness of the model lies in its possibility to capture drivers of inequality from both, an individual’s and health system’s perspective.
Among the sample used, 60.3% of participants were aged 60 to 70 years old, 97.8% had any type of health insurance, and 75.7% suffered from one chronic disease. Using the data and empirical tools described above, and anchoring their research in the theoretical model mentioned in the previous paragraph, the authors arrive at a few important and interesting findings:
First, they find that enabling factors (mainly socio-economic standing) explained most of the variation in utilisation of health services. In other words, wealthiest individuals were more likely to use preventive and outpatient care compared to those belonging to lower socioeconomic groups. These findings are consistent regardless of the empirical strategy used (logit models or concentration index). There are a few explanations for these findings that the authors put forward. Higher socio-economic status provides the economic resources for patients to seek alternative private providers when their health insurance funds deny services.
Moreover, higher socio-economic status is generally linked to higher education attainment, which implies that the wealthiest individuals are enabled to navigate the Colombian health system should they face access barriers. Finally, wealthy individuals have greater health awareness (also, in part, due to higher education levels), which increases their demand for healthcare, especially for preventive care. Some of these findings echo previously established empirical regularities in other countries in the wider Latin American region, such as Brazil and Mexico. This also confirms findings that the authors of the study (Nikoloski and Mossialos) have previously established in Mexico (general population) as well as Brazil and Colombia (focusing on maternal healthcare).
Wealthiest individuals were more likely to use preventive and outpatient care compared to those belonging to lower socioeconomic groups.
Second, the authors also find that the type of insurance coverage is strongly associated with the use of healthcare. More specifically, the study results found higher likelihood of healthcare utilisation by insured elders compared to those uninsured. In addition, and when specifically focusing on the type of health insurance scheme, the authors find that those covered by the contributory health insurance have higher likelihood of using healthcare relative to those covered by the subsidised health insurance. The mechanisms by which the health insurance scheme produce inequality may be related to the design of the Colombian health system. For example, the uninsured population only has access to emergency care, while creating barriers to uninhibited access to other types of care (e.g. preventive care).
The authors find that those covered by the contributory health insurance have higher likelihood of using healthcare relative to those covered by the subsidised health insurance.
In addition, the evidence from this study suggests that supply-side characteristics like urbanicity contribute to higher utilisation of healthcare. In Colombia, health providers, including physicians dedicated to specialty and/or complex care and health professionals other than doctors (i.e. physiotherapists, nutritionists, optometrists), are concentrated in urban areas. Rural areas are often only served by public providers. Therefore, rural residents may lack choice in accessing service providers, and the public providers they do have access to may not offer the full spectrum of health services they need.
To address these issues, the Colombian health system should start by extending health insurance coverage to uninsured populations, who are the most vulnerable. Subsequently, service delivery programs and efforts to reduce access barriers should be targeted towards the poorest and those groups receiving subsidised insurance in rural populations. Finally, preventive care efforts should be strengthened and promoted—especially for women and for the poorest population groups—to improve health outcomes and overall population health.
The views expressed in this post are those of the author(s) and in no way reflect those of the Global Health Initiative blog or the London School of Economics and Political Science.
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