Macroeconomics and Universal. The Case of Colombia. The Case of Colombia. 2. Colombia s road towards. Macroeconomics and Universal Health Coverage

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1 Macroeconomics and Universal Health Coverage The Case of Colombia Prince Mahidol Award Conference 2012 Juan Pablo Uribe Macroeconomics and Universal Health Coverage The Case of Colombia 1. Colombia at a glance 2. Colombia s road towards universal health coverage 3. Discussion i (current stress) points

2 1. COLOMBIA AT A GLANCE Colombia at a Glance COLOMBIA: TOTAL, URBAN AND RURAL POPULATION AND URBAN POPULATION PERCENTAGE (Period ) (In thousands at midyear ) Colombia Total population p Urban population Rural population Urban percentage Rural population Urban population Source: Demographic Bulletin Nº 63, CEPAL

3 Colombia at a Glance (i) Medium income country with a stable democracy Positive economic growth (with limited back steps) during the last decades Strong and expanding private sector (aprox. US $14 billion foreign private investment in 2011) Free trade agreement with the USA Colombia at a Glance Source: Latin Focus June 2011

4 Colombia at a Glance (ii) Deep social challenges (education, health, social protection, employment, justice, peace = human development) 2 nd highest inequality levels in LAC (Gini 0.58) 45% population p in poverty y( (16% in extreme poverty); 55% informality (Parenthesis) Fundación Santa Fe de Bogotá Our Mission Contribute to the progress of Colombia s health sector and improve thewell being of individuals and communities.

5 Six (6) Units Working Together 2. COLOMBIA SROAD TOWARDS UNIVERSAL HEALTH COVERAGE

6 Colombia s 1993 Health Reform Core Elements Mandatory (individual) insurance enrollment Mandatory payroll contributions (employers & employees; independent workers) Contributiveand Subsidized Regimes (according to income level) Explicit health benefit package (extensive list) Per capita (premiums partially adjusted) Competing (?) multiple insurers/multiple providers Government control l(t (at various levels) l Colombia s Social Security System (in Health) Law % income UPC = per capita premium Contributive Regime UPC EPS IPS $$$ Subsidized Regime Solidarity Fund FOSYGA UPC-S EPS EPS EPS EPS IPS IPS IPS IPS Mandatory Health Benefit Plans (POS-C &S) Fiscal $ (complex) EPS = insurers IPS = providers

7 Colombia s Health System Pre (1993) Reform and Today 1993 classic (LAC) system 18% insured population Dominance by the Social Security Institute (ISS) 8% payroll contributions for formal private sector Health expenditure < 5% of GDP High OOPE, low subsidies (poorly focused) 2011 managed competition model 96% insured population Multiple (public and private) insurers 13% mandatory payroll contributions (for all) Health expenditure > 8.5% of GDP Low OOPE (but rising?), high subsidies (properly focused) Health sector in crisis ii Health sector in crisis ii Colombia s Health System Mandatory Health Insurance Affiliates (%) % 41.08% 47.63% Subsidized Coverage 2010 Contributive Coverage 2010 No Coverage Source: Ministry of Social Protection, DANE

8 Colombia s Health System Social Security Coverage (in Health), Cove erage/pop pulation Total Million Affiliates Contributive Affiliates Contributive Coverage Subsidized Affiliates Subsidized Coverage Source: Informs CNSSS Colombia s Health System Sources as a percentage (%) of total health expenditure 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % Of pocket % Private expenditure % Public expenditure % Offer Subsidies Expenditure % Subsidized dregime % Contributive ti Regime Source: DANE

9 Complex Decisions Then Reliance on financing reform via (higher) mandatory payroll contributions Explicit health benefit plan with a (roughly) estimated premium Differentiated benefits plans for Contributive and Subsidized dregimes during a transition period Multiple insurers (multiple payers) model Regulatory capacity assumption (in spite of no information system) Followed by a Surprising Road Towards Universal Coverage Slower economic growth + higher h unemployment rates = smaller contributive regime + larger subsidized regime = greater fiscal pressure. Incapacity to equalize contributive and subsidized benefits plans = structural inequality ; subsequent court rulings. Weak regulatory and institutional capacity (government, insurers, providers public hospitals; information system).

10 Economic Growth: Expectations vs Reality % PIB Comportamiento PIB % P.I.B. Real % P.I.B. Esperado Unemployment in Colombia 25,0% 20,0% 20,1% 20,5% 18,50% p 15,0% 10,0% 0% 5,0% 8,7% 7,8% 15% 16% 0,0% % Desempleo

11 3. DISCUSSION (CURRENT STRESS) POINTS 3.1 How to ensure sustainable universal coverage in Colombia?

12 Ensuring Universal Coverage (initially) implies Unifying the Contributive and Subsidized health benefit plans into ONE single plan but which one? how deep? Court rulings? Raising more funds but via higher payroll contributions, i greater fiscal efforts or a combination? i Reaching out to informal and rural populations but with the same (individual) insurance model? 3.2 What more are we paying in health as a country?

13 Unemployment in Colombia Colombia, Unemplyment Rate 20,0 18,0 16,0 14,0 12,0 10,0 8,0 60 6,0 4,0 2,0 00 0, Source: Statistics Annual 2011, CEPAL Unemployment Colombia and the LAC Region Average annualrate, LA Source: Statistics Annual 2011, CEPAL

14 Informal Labor in Colombia Percentage distribution of total employed population, by sex informal and formal Total 13 areas (april - june) Concept April - June Total 13 áreas employed 100,0 100,0 100,0 100,0 100,0 100,0 100,0 Informal 60,5 61,3 60,6 58,6 58,7 58,5 56,6 Formal 39,5 38,7 39,4 41,4 41,3 41,5 43,4 Males employed 100,00 100,00 100,00 100,00 100,00 100,00 100,00 Informal 60,0 59,6 59,5 57,4 57,5 56,8 54,8 Formal 40,0 40,4 40,5 42,6 42,5 43,2 45,2 Females employed 100,0 100,0 100,0 100,0 100,0 100,0 100,0 Informal 61,1 63,2 61,9 60,0 60,1 60,4 58,7 Formal 38,9 36,8 38,1 40,0 39,9 39,6 41,3 Source: DANE Competitiveness Colombia in Ranking of Competitiveness Source: World Economic Forum in Davos, Switzerland

15 What are we buying as a nation with a greater fiscal and social effort? Colombia: Health Results Infant Mortality Males Females 120 Maternal mortality ratio per 100,000 live births Sources: DANE - Vital Statistics

16 Colombia: Health Results 9 8,5 Prevalence of low birth weight Percentage of children aged 1 year vaccinated against measles, MMR , , Source: DANE Percentage of children aged 1 year vaccinated against measles, MMR Source: DANE Malaria Annual Parasite Index Source: DANE Source: DANE 3.4 How to deal with additional (structural) stress points?

17 Furtherstresspoints Proper management of an explicit health benefit package in all its dimensions (technical, financial, legal, political) or walk away from it? Ensure multiple insurers really compete and add value, or change to another model? Control lincreasing i health expenditures and corruption (price regulation, limits to vertical integration), i and restore public confidence. Overcome the pressure of interest groups in order to be able to advance needed reforms. In sum: Colombia s Health System Today Has (almost) (l achieved UNIVERSAL COVERAGE 96% health insurance enrolment yet remains in deep crisis Stretched financing Troubled insurers andproviders Profound inefficiencies / corruption allegations Citizens uncomfortable with services Overall quality questioned

18 For real universal coverage, Colombia s health system will need to do better in: Guaranteeing / investing in quality care Appropriate p health personnel Continuous safety and quality improvement Technological renovation / innovation Achieving citizen satisfaction Service attitude and commitment care more about caring Thanks org

Jorge Augusto Diaz Rojas, MSc, PhD candidate

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