Health Care system in Colombia

The paper will be 3 to 4 pages (excluding the title page and reference page) and written in APA format. A minimum of three (3) current references (within the last five years) should be cited on the reference list.

PLEASE VIEW ATTACHMENTS, ALL INSTRUCTIONS AND ARTICLES FOR REFERENCE ARE ATTACHED.  MUST USE THE ARTICLES PROVIDED, APA STYLE.

NUR 4667 Globalization in Nursing

Scholarly Paper Guidelines

For this paper the student will choose one topic from either of the two main subject areas of:

1) Description of a Health System

2) Global Health Issue

The paper will be 3 to 4 pages (excluding the title page and reference page) and written in APA

format. A minimum of three (3) current references (within the last five years) should be cited

on the reference list. This paper will be submitted via TURN-IT-IN on the course Blackboard

website. After submission, a rating of 0-15% similarity will be considered acceptable. Over

15% will not be considered acceptable.

A) Healthcare Delivery System of a Country (Choose your country from the list below, or if

you wish to do another country please gain approval from the instructor). You should attempt to

answer the following questions in your paper:

1. How is health care delivered? Ex. in hospitals, private clinics, public clinics?
2. How is health care acquired? Ex. private pay, insurance, government subsidy?
3. Who pays for health care? Ex. if insurance is available does the employer pay, or is

privately purchased?

4. How is the population cared for when chronically ill? Ex. family members, hospitals for
rehabilitation, private houses who care for the ill?

5. How is the population cared for when dying? Ex. family members? Hospice? At home or
hospital?

6. How is the patient selected to have a procedure done or not? Ex. Is the patient able to
decide how to be treated?

You may choose one of the following Countries to explore their Healthcare System. More

than one student may choose the same country, but this is individual work:

Mexico, Japan, Canada, Brazil, Cuba, France, Spain, Germany, Israel, Italy, Denmark,

Greece, Belgium, Ecuador, Haiti, Chile, Colombia, Argentina, United Arab Emirates

B) Global Health Problem – Choose from the following issues and discuss how they affect the

world. Include examples and statistics which show how underdeveloped countries as well as

developed countries are affected. (Please note there are chapters in the book about these topics,

however you should not copy from your text!!)

1. Environmental Health
2. Maternal & Child Health
3. Nutrition
4. Ethical Issues/Human Rights

César Ernesto Abadı́a-Barrero
Department of Anthropology and Human Rights Institute
University of Connecticut and Centro de Estudios Sociales
Universidad Nacional de Colombia (E-mail: cesar_abadia@post.harvard.edu)

Neoliberal Justice and the Transformation
of the Moral: The Privatization of the Right to
Health Care in Colombia

Neoliberal reforms have transformed the legislative scope and everyday dynamics
around the right to health care from welfare state social contracts to insurance mar-
kets administered by transnational financial capital. This article presents experiences
of health care–seeking treatment, judicial rulings about the right to health care, and
market-based health care legislation in Colombia. When insurance companies deny
services, citizens petition the judiciary to issue a writ affirming their right to health
care. The judiciary evaluates the finances of all relevant parties to rule whether a
service should be provided and who should be responsible for the costs. A 2011 law
claimed that citizens who demand, physicians who prescribe, and judges who grant
uncovered services use the system’s limited economic resources and undermine the
state’s capacity to expand coverage to the poor. This article shows how the consol-
idation of neoliberal ideology in health care requires the transformation of moral
values around life. [neoliberalism, morality, justice, health care reform, health as a
human right]

Starting in the mid-1980s, the International Monetary Fund and the World Bank,
the two main international lending agencies, conditioned lending new funds to the
majority of Latin American countries on their implementation of structural adjust-
ment policies (Iriart et al. 2001). In health, the World Bank argued that the private
sector was more efficient than the public sector and that the deep crisis around
financing the region’s health care systems was largely attributable to their public
administration. The policies that they imposed intended to force the incorporation
of foreign financial institutions as administrators of private health insurance mar-
kets (Homedes and Ugalde 2005; Iriart et al. 2011; Iriart et al. 2001). Neoliberal,
managed care, and market-based health care reforms are all terms that have been
used to refer to the legal restructuring that allowed insurance companies to access
the country’s social security funds.

Colombia followed World Bank guidelines most closely. Through Law 100 of
1993 (Congreso de la República de Colombia, Diario Oficial 41.148, December

62

MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 30, Issue 1, pp. 62–79, ISSN 0745-
5194, online ISSN 1548-1387. C© 2015 by the American Anthropological Association. All rights
reserved. DOI: 10.1111/maq.12161

Privatization of the Right to Health Care in Colombia 63

23, 1993) and subsequent laws and decrees, the health and pension components of
the country’s social security system were funneled into mandatory individual health
plans incorporated (in many cases with subsidies) into a market made up of compet-
ing insurance companies (De Groote et al. 2005; Homedes and Ugalde 2005). This
market-based transformation resulted in problems of equity, efficiency, quality, and
corruption, which have resulted in significant setbacks in public health indicators
(Homedes and Ugalde 2005; Molina et al. 2009; Yepes et al. 2010). The office of
the national ombudsman condemned the practice of forcing people to file for writs
when providers or insurance companies deny access to treatments, medications,
surgeries, and referrals for the diagnosis, treatment, and control of common dis-
eases (Ramı́rez 2010). From 1999 to 2012, the judicial system in Colombia received
over one million legal filings for the right to receive health care services—known as
tutelas, or writs for the protection of constitutional rights—including close to or well
over 100,000 per year in 2006–2012 (Defensorı́a del Pueblo 2013). Problems in the
health care system result from both lack of coverage and standardized “de facto dis-
entitlements” (Lopez 2005), given that over 60% of the legal filings were for legally
covered services (Defensorı́a del Pueblo 2013). The existence of enrollment barriers
disguised as technical problems (Lopez 2005) and lengthy administrative and legal
battles to access guaranteed services corroborate that having health insurance does
not guarantee access to care (Abadı́a-Barrero and Oviedo 2009; Arrivillaga et al.
2009).

Access to health care in Colombia reflects a field of power relations between,
on the one hand, a fusion of state and corporate interests in a complex bureau-
cratic system “buttressed by discourses that emphasize competition, efficiency, and
individual choice” (Abadı́a-Barrero and Oviedo 2010; Lamphere 2005:19), and,
on the other hand, citizens who must resort to the judiciary to avail themselves of
their constitutional right to health care. Insurers argue that their refusal to provide
certain services conforms to the law, while patients use the same law to gain access
to services denied. In this process, legislation becomes an emblematic vehicle for
understanding the social construction of neoliberal justice in health care.

This article aims to underscore that neoliberal form of justice in health care (i.e.,
individual and institutional moral struggles around what is just, good, or worthy
in terms of health care rights) at a moment when market ideology has become a
dominant force in global health. At stake is the transformation of a “moral contract”
by which social value is assigned to people’s lives depending on affordability and
disease patterns. I present an ethnography of this transformation of moral contracts
that studies the links among people’s judicial petitions to protect their right to health
care, judicial rulings on this matter, and legislation regarding the for-profit health
care system in Colombia.

The article links theoretical reflections on political economy with morality to
investigate the cultural dynamics of justice in health care. It explores how justice
in health care is a social dynamic at the core of people’s demands, judicial rulings,
and legal change. I propose looking at justice as a sociocultural construct that
allows us to study ideology ethnographically, given that it effectively connects the
transformation of the law with the transformation of the moral. In this kind of
transformation, it is equally important to explore what is being stressed through
language as what is being hidden or made impossible to talk about.

64 Medical Anthropology Quarterly

Neoliberalism and Morality in Health Care

Around the globe, neoliberal reforms have transformed the social contract of the
welfare state, particularly around the notion of the public’s right to health. Given
the administrative, emotional, and economic challenges that market-based reforms
impose on the health care safety net (Lamphere 2005), NGOs and other private
sector entities have gained a prominent role in the provision of health care under
managed care (Horton et al. 2014). With the exportation of managed care, financial
capital represented by insurance companies challenged the consolidated economic
power of industrial capital in health care (Iriart et al. 2011).

Several anthropologists have written about how “market ideology and corpo-
rate structures are shaping medicine and health care delivery” (Horton et al. 2014;
Lamphere 2005; Rylko-Bauer and Farmer 2002:476). Mulligan’s research shows
how “market values come to displace competing notions of what is “good” or
“right” in health care” (Mulligan 2010:308–309). She argues that quality in health
care is not only a technical matter for evaluating the performance of systems, but,
more importantly, it is a particular epistemology, a specific way of knowing. The
information that is produced in technical public health policy terms, and, I would
add, in technical legal terms, is “a knowledge-making practice that creates infor-
mation about the health care system and for managing the system in new ways”
(Mulligan 2010:309).

Managing for-profit health care systems successfully requires innovative mecha-
nisms of population control (Abadı́a-Barrero et al. 2011), including people’s ac-
ceptance of market principles. In this historical context, what is crucial is the
understanding of the relationship between techniques of governance and the pro-
duction of social inequality (i.e., an ideological domination reflected in people’s
support for political practices that are antithetical to their interests). According to
Fassin (2009), Foucault’s undeveloped concept of a Politics of Life can illuminate
how in regulating populations and normalizing societies, moral ideas about the
meaning of life and about how life is valued are enforced. An understanding of
moral definitions of human life must take into account how history becomes em-
bodied, which then illuminates the political tensions that support differential values
by which life is organized, represented, and responded to, for example through
public policy (Fassin 2007).

Hence, a larger historical framework allows us to see the relationship between
moral definitions of life and public policy. This relationship is recreated, challenged,
or transformed by people’s actions (such as individual legal claims, group actions,
or social mobilization) and by the specific practices of bureaucrats and institutions.
For example, Horton describes how health care institutions play a crucial role
in elaborating and deploying value-laden conceptions about cultural difference and
“deservingness” of public benefits (Horton 2004:473). She argues that only through
an analysis that takes into account local and national political–economic contexts
is it possible to understand the construction of Mexican immigrants in the United
States as financially irresponsible and unworthy of benefits, as opposed to successful
and hard-working Cubans.

Privatization of the Right to Health Care in Colombia 65

This body of literature signals a connection between political economy and
the constitution of morality, which can shed light on the workings of neoliberal
ideology. Indeed, moral hazard is the foundational idea of health insurance eco-
nomics and “the most powerful narrative in American health policy” (Stone
2011:887). Based on laws of supply and demand, it is suggested that people with
insurance use more medical care than they would if they were uninsured. Disguised
as a technical term, moral hazard “does Herculean moral and ideological work. . . .
Moral hazard transforms health insurance from a social hero into a social villain. It
transforms the social safety net from a mode of security against danger to the very
danger itself” (Stone 2011:887).

Methods

Data in this article stem from a larger ethnographic endeavor around the right to
health care in Colombia conducted under a Participatory Action Research (PAR)
framework. I am an active member of an NGO called Salud al Derecho, which
fights for the effective provision of health as a human right. As a university profes-
sor, I serve as an expert whose testimony (Hall 2006) helps further the cause. The
methodological challenge of an activist approach to ethnographic inquiry entails
being accountable to both the participants in the political process and to academia.
While activist research recognizes that “knowledge is produced, in part, through
active involvement in the political problem at hand,” those engaged in this kind of
work are also aware that their participation requires a careful and systematic anal-
ysis of the relevant facet of the political process (Hall 2006:108). This ethnography
argues for a politicized view congruent with participation and interaction (Escobar
2000; Victoria et al. 2004).

Salud al Derecho helps citizens navigate the health and judicial systems free of
charge. It also coordinates popular education activities and participates in larger
advocacy and social mobilization initiatives. I became a member of Salud al Dere-
cho in 2006 and helped established its research committee. I initiated a systematic
analysis of the legal process while helping people file for writs and follow legal
procedures. In addition, I organized the office’s information in a database and con-
ducted informal conversations with people who came to the office asking for help.
I conducted in-depth interviews to explore their experiences with the health care
and judicial systems. Data from the NGO also come from notes, minutes, memos,
and recordings of everyday discussions and formal meetings with the director and
board members of the association, many of whom are attorneys who help with
legal claims and provide expertise on the interpretation of the law. A previous
publication describes the results of the systematization of 458 legal actions and 12
semi-structured interviews (Abadı́a-Barrero and Oviedo 2009).

As a university professor, I have organized and been invited to academic forums
addressing the status of the right to health care in Colombia. In this context, I have
met with like-minded professors and activists to debate relevant news, legislative
issues, research reports, and the work of different organizations. Besides the for-
mal presentations in paper, visual, or audio formats, data include discussions that
preceded or followed the different events. Data and analyses are backed up by a
non-systematic and extensive database that I have collected and organized by year.

66 Medical Anthropology Quarterly

This database contains media discussions, newspaper articles, and notes about the
status of the right to health care in Colombia.

The results section is divided into two parts, the first of which consists of a case
study in which I describe the interactions of a woman named Esperanza with the
health care and judicial systems. I highlight this case because it led to several ju-
dicial rulings, including one from the Constitutional Court, the most authoritative
institution with respect to the moral status of health care law and policy. I also
chose it because it exemplifies how the health care system’s market structure frames
the arguments for seeking and ruling on justice in health care. As I will explain,
Esperanza’s extensive social capital makes this case particularly relevant, given the
quality of the argumentation around deservedness and justice in health care. In this
sense, the case is not intended to be representative of the majority of the writs that
are requested by people with less social capital and have a more straightforward dis-
cursive presentation and legal process. The reconstruction of the case corresponds
to several conversations I had with Esperanza between 2006 and 2010 and three
formal interviews conducted with two graduate students in 2010. The reconstruc-
tion of the case is also possible given Esperanza’s well-organized 20-pound bag of
documents that she collected over the years. It also includes the careful reading
of the legal petitions and rulings (primary archival material) and the finding and
organization of relevant rules and regulations (secondary archival material) that are
necessary to understand the petitions and the rulings.

The second part of the results section comprises the presentation and analysis of
two government health care reform efforts (in 2010 and 2011) that represent how
legislative change was implemented for the purpose of keeping the system’s market-
based structure. These legal changes also contain language that specifically addresses
the threats that petitions for uncovered care present to market hegemony. The
analysis of these “techniques of language” allows me to underscore how neoliberal
governance responds in moralistic terms. Between 2009 and 2011, I organized one
major lecture and made presentations at two academic forums and one political
event. Students, researchers, professors, and members of Salud al Derecho have
commented extensively on the material, providing an additional source of data
and interpretation. In these conversations and presentations, I have stressed the
ideological aspects that I see behind legislation and the public debate to better
understand how the transformation of the political connects with transformation
of the moral.

To avoid repetitions and facilitate a narrative tone, supporting material and
interviews, all translated by me, are clearly identified in the text but are not cited
each time they appear.

Esperanza

In 2005, Emiliano, a man in his mid-fifties, was starting to enjoy an early retirement.
Suddenly, he had such a severe headache that he called his sister Esperanza and
said, “Sister, come save my life!” She picked him up and rushed him to a hospital,
where doctors diagnosed a massive stroke and conducted two operations to control
intracranial bleeding. After three months in an intensive care unit (ICU), Emiliano

Privatization of the Right to Health Care in Colombia 67

was transferred to a hospital ward. A doctor explained to Esperanza that given his
delicate and demanding condition, Emiliano needed 24-hour nursing care, a service
that the hospital offered but that was not covered by Emiliano’s health plan. “So,
I paid for those first three months [of nursing care] while he was hospitalized,”
Esperanza said. Then, she continued,

[in Emiano’s fourth month] the biggest agony starts. The doctor tells me
“I’m going to discharge your brother because the EPS [insurance company]
is putting a lot of pressure on me to discharge him.” “But doctor,” I said,
“where do I take him?” And he said, “That’s not my problem.” My world
fell apart. . . .

Following the advice of a close family friend who is a professor of critical care
medicine, Esperanza found a bed for Emiliano in a semi-intensive care institution.
She started paying for his stay there and for 24-hour nursing care.

Esperanza’s narrative is useful for underscoring the consequences of health care
systems organized around individual service packages and administered by for-
profit companies. While Emiliano’s emergency neurosurgeries, ICU care, and first
months of hospitalization were covered by the health plan, Esperanza had to pay
out of pocket for 24-hour nursing care and the semi-intensive care facility because
she was his legal guardian. Esperanza’s story also shows how the political debate
about the system’s coverage, structure, and financing frame an important part of
the discussions and immediate decisions that physicians and family members are
forced to make.

Emiliano’s initial treatment was included in the health coverage manual as emer-
gency care, which is mandated to be provided to all people when their “life or
functionality is compromised and requires prompt attention” (Ministerio de Salud,
República de Colombia, Resolution 5261, 1994, p. 3). His initial hospitalization
in the ICU also followed what is included in the manual’s Article 29 (Ministerio
de Salud, República de Colombia, Resolution 5261, 1994), which describes the
conditions and patients that qualify for ICU care. Under “neurological disorder,”
the manual includes “hemorrhagic and occlusive cerebrovascular accidents with
signs of endocranial hypertension, cerebral edema . . . that . . . offer the possibility
of recovery.” Once Emiliano’s condition was categorized as “irreversible,” it no
longer matched this description. The manual’s Article 30 lists cases who will not
be admitted in the ICU, including “patients with signs of brain death.” Although
semi-intensive care units are included in Article 32, they are covered only for burn
patients.

Procedures in managed care are reviewed to fit new concepts of “medical ne-
cessity” (Wagner 2005) that follow a cost-containment logic rather than treatment
requirements established by medical guidelines or clinical assessments. The for-profit
logic behind managed care was evident in Emiliano’s case. When the insurance com-
pany categorized his case as an uncovered medical need, they were legally released
from paying for his continued hospitalization, which included 24-hour nursing care
at a semi-intensive institution.

68 Medical Anthropology Quarterly

The Judicialization of Health: Granting Rights or Administering the For-Profit
Health Care Business

I couldn’t afford it any more. I asked the EPS to provide the 24-hour nursing
care but they said no, that it was [uncovered]. So, I petitioned for a writ,
which was approved two weeks later.

Esperanza’s story conveys how navigating the system requires a mastery of its
legal, administrative, and business terminology. When a citizen requests that a writ
be issued, the assessment of his or her health care needs and the final decision over
whether to grant services are transferred to the judiciary. The judicialization of
health care policy refers to an “expansion of powers to legislate and enforce laws
by the judicial system. [It] represents a transfer of decision-making power from the
Executive and Legislative to judges and courts” (Gonçalves and Machado 2010:39).

Law 100 stipulates that citizens have a right to uncovered services only when they
prove that they cannot cover the costs. The logic behind this “deserving citizenship”
(Horton 2004) is that people with the ability to pay should not receive resources that
are reserved for subsidized care, which would be contrary to the system’s “financial
solidarity.”1 People who do not initiate legal procedures and those found to have
the economic wherewithal to assume associated costs must pay in full for uncovered
services. This responsibility is acknowledged with the signing of a promissory note
at the time of hospital admission.

To initiate the legal process, people must present the court with proof that a
service was requested and denied. This means that claimants must officially petition
the EPS to provide the service. The EPS then produces a document, which, over
time, has been standardized as a Service Denial Form. On July 21, 2005, Esperanza
presented a petition to the EPS asking it to provide indefinite 24-hour nursing care
for Emiliano. On the denial form that she received, an administrative employee
of the EPS justified the denial and stated that “it is not an activity, intervention,
or procedure explicitly considered in the manual. Resolution No. 0561 of 1994,
article 18.” In the space under the heading “Alternatives for the user to access
the requested health care service and have his/her legal and constitutional rights
granted,” the employee wrote “The patient assumes the costs.”

With this document in hand, Esperanza requested the writ, explaining Emil-
iano’s clinical situation to the judge and providing the physician’s order for 24-hour
nursing care as supporting documentation. The judge initiated an investigation and
asked the EPS to clarify why Esperanza was initiating a legal process against them
and why she argued that Emiliano’s rights were being violated by not providing
the 24-hour nursing care. In response to the judge, a lawyer for the EPS provided
additional information and argued that the EPS had not violated the patient’s rights
in any way. He explained that the health policy does not cover indefinite 24-hour
nursing care, adding that the current medical orders include “home based care ap-
propriate to medical needs” and that the institution offered to provide Esperanza
with an educational component regarding supportive care, “in which we will teach
you, as the person responsible for your relative, and the people to whom you dele-
gate his care, the best way to handle his condition at home.” The lawyer provided

Privatization of the Right to Health Care in Colombia 69

a supporting copy of this memo dated July 26, and went on to tell the judge that
what seemed to be happening was that no family member was willing to care for
the patient, thus it would be unfair to demand that the EPS assume responsibility
for his care. “It is indispensable,” he added, “to establish the minimal civic re-
sponsibility of family members to their relative once necessary medical management
has been largely granted.” The lawyer concluded by requesting that the judge deny
Esperanza’s petition.

Esperanza received a copy of the lawyer’s response and had an opportunity
to further advocate for her petition to be approved. She explained how nursing
support and occasional home visits are not equivalent to the 24-hour nursing care
that his physician had ordered. She also described two clinical complications (a
bronchoaspiration and an obstruction of a vesical catheter) to argue that “If these
two events had occurred at my house, my brother would have died, which makes it
clear that home-based care is not adequate in this case.”

As in Brazil (Biehl et al. 2012), public defenders in Colombia help people with-
out income or basic literacy to file for writs, greatly facilitating the use of this legal
mechanism. Besides public entities, NGOs and attorneys (pro bono or not) can file
for writs. People can file on their own with the help of formats that are available on
the Internet. The majority of writs are relatively straightforward and judges gener-
ally approve them (Abadı́a-Barrero and Oviedo 2009; Defensorı́a del Pueblo 2013).
Nonetheless, it is clear that in judicial investigations regarding most cases, there is
an unequal contest between EPS lawyers and citizens who must write convincing
medical arguments supported by the law. However, in Esperanza’s case, her social
capital played a key role in the legal confrontation: She is a health care professional
and a retired university professor with a doctoral degree. Her arguments and evi-
dence prompted the judge to rule in her favor; he ordered the EPS to provide the
requested 24-hour nursing care, given that its denial, in his words, “indeed affects
the physical integrity of the patient and also his peace of mind and that of his nuclear
family, which amounts to a lack of acknowledgment of his right to a dignified life
and constitutes a violation of his fundamental rights to health and social security”
(Writ 2005–0929, 59th Municipal Civil District Court, Bogotá). As in other rulings,
though, the writ also protected corporate interests by authorizing the EPS to charge
these uncovered costs to a public fund. This has become standard procedure that
follows the administrative and economic logic of the system’s structure.

Esperanza further explained the moral and economic burden that results from
dealing with the system’s complex requirements. Insurance companies refuse to
grant services even when they are covered by the plan or ordered by a writ, requiring
people to pay out of pocket.

The system is so complicated, the number of requirements and documents
needed to solve any kind of problem [is so great that] you have to follow a
labyrinth. The number of offices that the EPSs have come up with and the
amount of time you need to spend every step of the way! It’s lines here and
lines there. . . . You have to tramitar (do paperwork for) administrative
requirements at different windows and in different sections. The supplies in
one place, the food in another, the referrals in a different one. It went on and
on until I collapsed. I thought I was going to go crazy. There wasn’t enough

70 Medical Anthropology Quarterly

time and I didn’t know what to do. So I asked a cousin who was kind of
broke if I could pay him to do all this running around for me.

In managed care, what labor economists call labor shifting corresponds to both
the new administrative demands that health care personnel are forced to meet to
comply with the insurance company’s payment forms and the “changing position of
the customer to one of part-time employee rather than a consumer of services” (Batt
1988, cited in Lamphere 2005:8). This administrative burden adds to caretakers’
emotional, economic, and physical exhaustion and to the uneven conflict between
broke and burned out citizens and powerful institutions.

A Second Writ: Justice Has Been Remade

Esperanza comments that in addition to the nursing care and the semi-intensive
care unit that she pays for as “direct costs,” her expenses include parking, food,
diapers, supplies, a wheel chair, a special mattress, and so on, which are explicitly
excluded in the aforementioned manual. Each diaper, Esperanza comments, “is
around 2 dollars and you need about 8 in a 24-hour period.” On February 28,
2008, Esperanza decided to file for a second writ to have the system cover the costs
of the semi-intensive care unit and the eight daily diapers. After a month of back-
and-forth communications with the EPS and a different judge, Esperanza stressed
in her new filing the specialized level of care that Emiliano required and provided
documentation for all her additional expenses. She demonstrated that her income
was insufficient to continue paying out of pocket. She included an official memo from
Emiliano’s pension fund, stating that his monthly pension was equivalent to USD
$1,320, that his 12.5% monthly contribution to the EPS was worth USD $160, and
that 35% of his pension, equal to USD $400, went directly to his son’s education. As
his legal guardian, Esperanza was left with an amount that was insufficient to cover
the cost of the semi-intensive care unit (equal to about USD $900 per month), and
she was forced to pay out of her own monthly pension for the diapers (about USD
$480) and additional expenses of about USD $260 per month. After Esperanza filed
the required paperwork, there were back and forth arguments between the judge,
the EPS lawyers, and her, but the judge denied her claim. This was on July 31,
2008. In his ruling, the judge stated that he was unable to rule in Esperanza’s favor
since the medical order was to discharge the patient and that it was the petitioner
(Esperanza) herself who “of her own free will considered it necessary to hospitalize
her brother, given that she has no time to take care of him.” (Writ 2008–1216, 51st
Municipal Civil District Court. Bogotá).

Esperanza appealed the judge’s ruling. When a person appeals a ruling, a superior
judge reexamines the case and provides a second ruling. In her appeal, Esperanza
argued that:

The judge of the Fifty-first Municipal Civil District Court wrongly
understood that the need to keep my brother Emiliano hospitalized in a
semi-intensive care unit was the result of my own wishes . . . that it was I
who decided that my brother needed the kind of care I described, an
assumption that unfortunately prompted him to rule against my petition.

Privatization of the Right to Health Care in Colombia 71

With this and other arguments, Esperanza hoped that the new ruling would be
in her favor. On September 1, 2008, however, she lost for a second time:

What is now evident is that the EPS COMPENSAR R© has not only provided
all the services that the patient EMILIANO is entitled to as a result of his
affiliation with that institution, but that it has also complied with the writ by
providing services that are not included in the Mandatory Health Plan. It has
thus protected his fundamental rights by providing comprehensive care
appropriate to his pathology, even offering home-based care as well. (Writ
2008–1216, 18th Municipal Civil District Court, Bogotá)

This second ruling illustrates the judiciary’s understanding of caring for the sick as
an individual responsibility and its position that the legal responsibility of insurance
companies goes so far and no farther. The separation of individual and market
responsibilities in health care is presented as a moral judgment on the behavior of
both parties. The ruling on the appeal echoes that of the first judge and the EPS
attorney when it argues that Esperanza declined to take responsibility for her brother
and added the principle of moral hazard when it commented on her unjustified
attempt to force the system to pay for what was her own responsibility. With this new
ruling, the judge also made a connection between expenses and morality, pointing
out that the EPS had already gone beyond its obligations, incurring additional
expenses in doing so. In the end, the medical necessity/economic argument of the EPS
did not trump Esperanza’s position. I argue that market morality is established as
another powerful technology that, as Mulligan argues for quality-of-care indicators
(2010), creates realities and influences how the system is managed.

All the Way to the Constitutional Court: Market-driven Justice

Following the advice of her son, who was a law student at the time, Esperanza
asked the Constitutional Court (considered the court of last resort for matters
regarding the moral basis of citizens’ rights) to review her petition for a writ
in the case. The Constitutional Court reviews such petitions only in selected
cases, and the court’s rulings are final. On May 7, 2009, magistrate Jorge Palacio
ruled in favor of Esperanza. According to the magistrate, the current constitu-
tional order “guarantees every person, at the least, access to health care services
required for the person’s existential minimum and dignity” (Decision T-320/09.
http://www.corteconstitucional.gov.co/relatoria/2009/t-320–09.htm). The magis-
trate ruled that the EPS did not assess the patient and that it was clear that the
medical orders provided as evidence by Esperanza, even though originating from
an out-of-network physician, demonstrated that due to his medical condition,
Emiliano required specialized care. Here, the magistrate used a pro hominem
argument to rule outside the legal parameters of the system, which dictated that
medical orders had to come from network providers.

Nonetheless, in a section discussing the legal grounds for the decision, there was
extensive discussion contrasting the idea of health as an individual right with the
need to protect the solvency of the system. This reflected the core tension within
the judicialization of health care as a structured negotiation between the needs of

72 Medical Anthropology Quarterly

individuals and the social conception of citizenship. By granting goods demanded
through individual legal action, the judiciary “interferes in the accomplishment of
public choices that were made by the public health manager, regulating consump-
tion opportunities according to a concentrating logic” (Gonçalves and Machado
2010:35). The magistrate clarified that when EPSs do not provide services included
in the health plan, they violate the fundamental right to health. For uncovered ser-
vices, the magistrate explained that Colombian jurisprudence on health established
that the system needs to take into account the economic condition of the patient
to assess his or her ability to assume the cost of such services without affecting
his or her own well-being. After considering extensive calculations based on Esper-
anza’s documented expenses and pension income, the magistrate decided that “the
costs of [the semi-intensive care unit] would be over half his income. This amount
would disproportionately affect a person’s existential minimum. Nonetheless, this
does not apply to the cost of diapers or other items that are indispensable for the
personal care of the patient, since this cost is not excessive” (Decision T-320/09.
http://www.corteconstitucional.gov.co/relatoria/2009/t-320–09.htm).

Thus, cost calculations become prescriptive of the right to health care granted
within the system and illustrate how market logic frames the construction of jus-
tice. The market structure of the system determines that the entitlements that are
part of the right to health care are those that, if paid, would disproportionately
affect people’s ability to afford a dignified life, also known as an “existential
minimum.”

The Moralizing Role of For-Profit Legislation: Citizens Harm Others when They
Demand Too Much Health Care

At the end of 2009, former president Alvaro Uribe (2002–2010)—an emblematic
figure known for his rightist politics, high popularity, and alleged involvement with
paramilitary death squads—declared a “state of social emergency” in the provision
of health care, which allowed him to legislate by decree (i.e., without congressional
debate or approval). Early in 2010, the government announced several new decrees,
including further cost-controlling limitations to physician autonomy and increasing
health care funding through higher taxes and out of pocket payments. The principal
decree regarding the social emergency made the following arguments:

Services not included in the Mandatory Health Plan were neither
contemplated in Law 100 of 1993 nor submitted for approval in subsequent
economic calculations. However, the provision of such medications and
services is becoming common practice in an unforeseen and unusual way,
threatening the financial equilibrium of the system … [and] significantly
compromising the resources available for insuring the population. This has
severely deteriorated the finances of numerous Health Promotion Companies
[EPSs] and Service Providing Institutions … creating a serious risk for the
continuity of providing services and the effective provision of the right to life
and health. In fact, … some regulators and agents of the system promote the
demanding of services not included in the benefits package without taking

Privatization of the Right to Health Care in Colombia 73

into consideration criteria of effectiveness, sustainability, cost-efficiency,
rationality in the use of resources, or the socio-economic capacity of the
patients. (Decree 4975 of 2009. http://www.minsalud.gov.co/sites/rid/Lists/
BibliotecaDigital/RIDE/DE/DIJ/Decreto%204975%20de%202009 )

Here governmental understanding of unforeseen expenses is framed in terms
of the moral hazard implicit in the population’s misuse of the system. EPSs
are presented as victims rather than accomplices in the financial crisis. After
the decrees were issued, government officials granted numerous interviews and
used newspaper columns and other official publications to provide examples
of how physicians, judges, and citizens were taking legal action to force the
system to pay for “luxurious” and “costly” services. The new law established
higher premiums for people who utilized the system’s resources “irresponsibly”
or failed to fulfill “the duty of self-care.” This law transferred the financing of
excluded services from the public fund to the patient by tapping individual or
family assets, pension or severance payments, or individual loans (Decree 128
of 2010. http://www.alcaldiabogota.gov.co/sisjur/normas/Norma1.jsp?i=38663).
Clearly, there is a two-fold strategy to stabilize the market by imposing stricter
legal limits on what is covered and expanding individual financing of uncovered
care.

The principal decree redefines the health plan as covering “low complex-
ity care in medicine and dentistry” and conditions the coverage of specialized
care on documented evidence of need and the state of the system’s finances.
It also orders the control of plan usage through disciplinary measures: “When
physicians diverge from [health plan] standards … and cause economic harm to
the system, they will be held liable and sanctioned with fines ranging from an
amount equal to 10 to 50 months’ salary at the minimum wage” (Decree 131
of 2010. http://www.acin.org/acin/new/Portals/0/decreto%20131%20de%202010
).

A technical issue—rather than the massive and sustained social pressure that
lasted around three months—prompted the Constitutional Court to declare the
state of social emergency and the resulting decrees as unconstitutional (Decision
C-252, 2010. http://www.corteconstitucional.gov.co/relatoria/2010/c-252-10.htm).
At the end of 2010, Uribe’s former defense minister and newly elected president
Juan Manuel Santos presented Congress with new legislation that to a great ex-
tent formalized the content of Uribe’s decrees. Despite the same strong influence
of moral hazard ideology, the new legislation eliminated some of the provisions
that had generated the strongest objections, such as economic sanctions on pro-
fessionals and direct threats to individual property and savings. In the document
“Statement of Legal Grounds for the Law” (later codified as Law 1438 of 2011),
the ministers of health and finance presented Congress with several arguments,
including:

It has become necessary to adopt a statute that regulates the right to health
care so that access to health care services is equitable and so that the services
that a few receive do not imperil or diminish current or future services for
the majority of the population or the sustainability of the system. (Statement

74 Medical Anthropology Quarterly

of Legal Grounds for the Law, 2010. http://www.minsalud.gov.co/
Normatividad/PROYECTO%20DE%20LEY%20ESTATUTARIA-
%20Exposici%C3%B3n%20de%20motivos )

In these arguments, market needs conditioned the definition of the right to
health care, citizen duties, and state responsibilities. It is clear that the intention
was to discipline irresponsible people who wanted the collective to pay for care
that they should be paying for themselves. In addition, the ministers of health and
finance used previous constitutional court rulings to support this logic: “Given
the budgetary limitations that exist at the national level,” legislation must “confer
the primacy of guaranteeing the rights of those most in need, given that they
generally lack the means indispensable to independently carrying out their life
projects in a dignified way” (Statement of Legal Grounds for the Law, 2010.
http://www.corteconstitucional.gov.co/relatoria/2008/t-760-08.htm). The ministers
concluded: “Legislators’ priority and main task is their duty to establish the scope
of the right to healthcare” (Statement of Legal Grounds for the Law, 2010.
http://www.minsalud.gov.co/Normatividad/PROYECTO%20DE%20LEY%20-
ESTATUTARIA-%20Exposici%C3%B3n%20de%20motivos ).

Since the meaning of economic statistics is contingent on historical and political
analyses, data regarding a country’s limited economic resources do more than merely
provide empty numbers. Presenting them as irrefutable facts, however, establishes a
powerful rhetorical technology that benefits market ideology. Moreover, the text of
the proposed law adds another “language technology” for moral domination. The
state’s role in eliminating wrongful misuse of the system is justified, given that it
impedes the fulfillment of its duty to provide adequate health to all, especially “the
poor” and “the vulnerable.” Thus, the law suggests that citizens who bring legal
action to demand additional care are morally liable for constricting the present and
future rights of their fellow citizens.

The power of legal language must not be overlooked. Legal language, as I have
shown, establishes the construct by means of which judges struggle to respond in
ways that are considered just, both for individual citizens and the system overall. At
the same time, it is incumbent on citizens to conceptualize and express their needs
within the possibilities of accepted legal language or pay for alternatives outside of
the system.

Under this new legislation, judges will need to consider even more deeply a
principle of distributive justice attuned to market logic, since by granting the right
to health care to individuals who challenge the system they implicitly harm the
most vulnerable. What goes unsaid in this technology of ideological domination, of
course, are the exponential profits of insurance companies, their corrupt practices,
and the fact that they have no role to play in more efficient and equitable health
care systems (Hernández and Tovar 2010; Robledo 2012).

Discussion: Neoliberal Justice and the Transformation of the Moral

The need for people to file legal petitions to protect their right to health care indicates
problems in the functioning of a health care system (Abadı́a-Barrero and Oviedo
2009; Biehl et al. 2012). In Brazil, people’s growing use of the judicial system to

Privatization of the Right to Health Care in Colombia 75

demand services can be attributed to unresolved shortages in the unified health
system (Biehl et al. 2012) as well as pharmaceutical companies’ efforts to increase
their share in global health care markets by conditioning consumers to force public
administrators to buy their products (Iriart et al. 2011). Given the time it takes for
this legal process to reach a conclusion, it is also emotionally taxing and further
compromises the health of the patient. In addition, there is no guaranty that people’s
expectations or needs will be matched by judicial findings. The results show how
citizens and judges are forced to assess medical needs and arguments around the
right to health care in terms of moral hazard, the responsibility of the patient, and
budgetary restrictions. While individuals demonstrate their deservedness based on
their inability to pay for care, judges calculate caps on how much of the money
required for additional services should come from within the system. Interestingly,
insurance companies are presented as the targets of complaints, even when a ruling
against them authorizes them to charge uncovered care to a public fund, a win–win
situation.

Esperanza’s case and an analysis of the 2010–2011 legislation illustrate efforts by
the state/corporate fusion (Lamphere 2005) to protect insurance company profits,
primarily by establishing limits to coverage and evaluating people’s demands on a
moral basis. Nonetheless, the data also show how the judicialization of health care
policy in Colombia had begun to threaten the projected profits of financial capital
derived from health care services and those of other industrial sectors that profit
from the market-based system. The escalating costs of uncovered care, although
paid for by individuals and from the public fund, had started to challenge market
stability and profit projections based on growing discontent with the system, the
burden on the judiciary, and an inability to allocate more resources to the public
fund (Ramı́rez 2010).

The last piece of legislation approved in 2011 presents some powerful techniques
of language to protect the system’s market structure by controlling the expansion of
the right to health care through the judiciary. Tropes such as “the country’s limited
resources” and “protecting the system’s finances to guarantee the rights of the most
vulnerable sectors of society” can be utilized to create a new social contract around
a limited right to health care. This kind of social contract, I argue, would require
a transformation of society’s moral values. As others have argued (Horton 2004;
Mulligan 2010), these techniques of language are used to begin shifting people’s
ideas of rights and entitlements and create new distinctions of self and other in
terms of deservedness. If Law 100 constructed a scenario in which rights were pre-
sented as a function of deservedness versus finances, the results show how the 2011
legislation points to a debate around the idea of justice in terms of how much social
harm is morally acceptable when granting people’s individual petitions. In relation
to market ideology in medical care, this research also shows how these techniques of
language hide some of the most important reasons for escalating medical expenses
from the public debate around justice. The most relevant of these reasons are the
immense profits and corrupt practices of insurance companies, rising expenses of
the medical industrial complex, and the patents by which pharmaceutical companies
ensure years of further profits.

76 Medical Anthropology Quarterly

Altogether, Esperanza’s struggle, the judicial rulings, and changes in legislation
illustrate how neoliberalism transforms the dynamics of seeking and winning health
care justice in Colombia and the moral compass through which the right to health
care is demanded, contested, and won. It is relevant to these ethnographic explo-
rations and theoretical debates around justice in health care to understand how life
is constantly redefined through history, technology, and capital (Rose 2007; Sunder
Rajan 2006). Taking life itself as a conceptual category, or “life as such” in the
words of Fassin (2009), requires us to think about the historical construction of
judicial rulings over life, and the notions of justice thereby created. But how does
the transformation of discourse on justice in health care result in moral frameworks
that connect public policy with citizen’s individual and collective experiences? Zigon
argues that morality is made up of “discourses articulated by various institutions
and public outlets within a society, each of which has varying degrees of power to
enforce these discourses. On the other hand, I speak of morality as the embodied
dispositions that allow for non-consciously acceptable ways of living in the world.”
(Zigon 2010:5). In a similar vein, Fassin thinks that moral issues are about:

adopting, redefining, and contesting norms and values. They analyze the
dissemination, appropriation and transformation of sensibilities and
sentiments . . . my intention is to underline how moral issues are profoundly
entangled within larger social, historical and political issues which are often
missed when one singularizes moralities or ethics. Reintroducing history and
politics is a major reason for my promoting the concept of moral economy.
(Fassin 2011:486, 489)

If moral experience is transformed by larger historical processes, I argue that
the historical and political forces that change, shape, and transform the moral in
regard to the right to health care in Colombia are those of neoliberalism. In this
research, it is possible to see how the forces that shape moral economies go hand
in hand with market forces. In the Colombian case, the transformation of the law
by capitalist sectors and the judicialization of health care policy connects moral
choice in its different scales of social interaction (between patients and insurance
companies, between judges and public administrators, and between legislators and
the public).

Under neoliberalism, the discourse of health as a human right and the cultural
dynamics of justice in health care need to be understood as connecting the moral
experience of the individual with the politics of life that define the value of life,
understood in both its moral and material worth. In this case, the economic interests
of insurance companies expressed in legal discourse are seen as the main ideological
expression that redefines the right to life and, consequently, rights in life.

Note

1. “Solidarity of financial contribution” was a new neoliberal indicator created
to promote the Colombian health care system as one with excellent performance.
This approach, meaning that people with greater resources pay more and thus

Privatization of the Right to Health Care in Colombia 77

subsidize others with fewer resources, was adopted by WHO in its 2000 world
health report but was strongly criticized by several scholars.

References Cited

Abadı́a-Barrero, C. E, M. A. Melo Moreno, M. Y. Pinilla, K. Ariza, and C. Ruı́z
2011 Algunas violencias del capitalismo en Colombia. Dispositivos de tortura y autode-

strucción. Maguaré 25:203–240.
Abadı́a-Barrero, C. E., and D. Oviedo

2009 Bureaucratic Itineraries in Colombia. A Theoretical and Methodological Tool to
Assess Managed-care Health Care Systems. Social Science & Medicine 68:1153–
1160.

2010 Itinerarios burocráticos de la salud en Colombia: La burocracia neoliberal, su
estado y la ciudadanı́a en salud. Revista Gerencia y Polı́ticas en Salud 18:86–102.

Arrivillaga, M., M. Ross, B. Useche, M. L. Alzate, and D. Correa
2009 Social Position, Gender Role, and Treatment Adherence among Colombian

Women Living with HIV/AIDS: Social Determinants of Health Approach. Revista
Panamericana de Salud Pública—Pan American Journal of Public Health 26:502–
510.

Biehl, J., J. J. Amon, M. P. Socal, and A. Petryna
2012 Between the Court and the Clinic: Lawsuits for Medicines and the Right to Health

in Brazil. Health and Human Rights: An International Journal 14:484.
De Groote, T, P. De Paepe, and J. P Unger

2005 The Consequences of Neoliberalism. Colombia: In Vivo Test of Health Sector Pri-
vatization in the Developing World. International Journal of Health Services 35:125–
141.

Defensorı́a del Pueblo
2013 La tutela y el derecho a la salud 2012. Bogota: Defensorı́a del Pueblo.

Escobar, A.
2000 El lugar de la naturaleza y la naturaleza del lugar: ¿Globalización o postdesarrollo?

In La colonialidad del saber. E. Dussel, ed. Pp. 113–143. Buenos Aires: CLACSO.
Fassin, D.

2007 When Bodies Remember. Experiences and Politics of AIDS in South Africa. Berke-
ley: University of California Press.

2009 Another Politics of Life Is Possible. Theory Culture Society 26:44–60.
2011 A Contribution to the Critique of Moral Reason. Anthropological Theory 11:481–

491.
Gonçalves, T. M, and J. A. Machado

2010 Judicialization of Health Policy in the Definition of Access to Public Goods:
Individual Rights versus Collective Rights. Brazilian Political Science Review 4:33–
68.

Hall, C. R.
2006 Activist Research v. Cultural Critique: Indigenous Land Rights and the Contra-

dictions of Politically Engaged Anthropology. Cultural Anthropology 21:96–120.
Hernández, M., and M. Tovar

2010 Nueva reforma en el sector salud en Colombia: Portarse bien para la salud fi-
nanciera del sistema. Medicina Social 5:241–245.

Homedes, N., and A. Ugalde
2005 Why Neoliberal Health Reforms Have Failed in Latin America. Health Policy

71:83–96.

78 Medical Anthropology Quarterly

Horton, S.
2004 Different Subjects: The Health Care System’s Participation in the Differential Con-

struction of the Cultural Citizenship of Cuban Refugees and Mexican Immigrants.
Medical Anthropology Quarterly 18:472–489.

Horton, S., C. E. Abadı́a-Barrero, J. Mulligan, and J. J. Thompson
2014 Critical Anthropology of Global Health “Takes a Stand” Statement: A Criti-

cal Medical Anthropological Approach to the U.S.’s Affordable Care Act. Medical
Anthropology Quarterly 28:1–22.

Iriart, C., T. Franco, and E. E. Merhy
2011 The Creation of the Health Consumer: Challenges on Health Sector Regulation

after Managed Care Era. Globalization and Health 7:2. doi:10.1186/1744-8603-7-2.
Iriart, C., E. E. Merhy, and H. Waitzkin

2001 Managed Care in Latin America: The New Common Sense in Health Policy
Reform. Social Science & Medicine 52:1243–1253.

Lamphere, L.
2005 Providers and Staff Respond to Medicaid Managed Care: The Unintended Con-

sequences of Reform in New Mexico. Medical Anthropology Quarterly 19:3–25.
Lopez, L.

2005 De facto Disentitlement in an Information Economy: Enrollment Issues in Medi-
caid Managed Care. Medical Anthropology Quarterly 19:26–46.

Molina, G., I. F. Muñóz, and A. Ramı́rez, eds.
2009 Dilemas en las decisiones en la atención en salud. Etica, derechos y deberes con-

stitucionales frente a la rentabilidad financiera. Bogota: Universidad de Antioquia,
Procuradurı́a General de la Nación, Insituto de Estudios del Ministerio Público,
COLCIENCIAS, Universidad Industrial de Santander.

Mulligan, J.
2010 It Gets Better if You Do? Measuring Quality Care in Puerto Rico. Medical An-

thropology 29:303–329.
Ramı́rez, J.

2010 La emergencia social en salud: De las contingencias regulatorias a la desilusión
ciudadana. Revista Gerencia y Polı́ticas de Salud 9 (Suppl. 1):124–143.

Robledo, J. E.
2012 El verdadero ministerio de salud es el “Cartel de las EPS.” Economı́a Colombiana

336:35–46.
Rose, N.

2007 The Politics of Life Itself. Biomedicine, Power, and Subjectivity in the Twenty-first
Century. P. Rabinow, ed. Princeton: Princeton University Press.

Rylko-Bauer, B., and P. Farmer
2002 Managed Care or Managed Inequality? A Call for Critiques of Market-based

Medicine. Medical Anthropology Quarterly 16:476–502.
Stone, D.

2011 Behind the Jargon Moral Hazard. Journal of Health Politics Policy and Law
36:887–896.

Sunder Rajan, K.
2006 Biocapital. The Constitution of Postgenomic Life. Durham: Duke University Press.

Victoria, C., R. G. Oliven, M. E. Maciel, and A. P. Oro, eds.
2004 Antropologı́a e etica. O debate atual no Brasil. Niteroi: EdUFF.

Wagner, W. G.
2005 Confronting Utilization Review in New Mexico’s Medicaid Mental Health System:

The Critical Role of “Medical Necessity.” Medical Anthropology Quarterly 19:64–
83.

Privatization of the Right to Health Care in Colombia 79

Yepes, J. F., M. Ramı́rez, L. H. Sánchez, M. L. Ramı́rez, and I. Jaramillo
2010 Luces y sombras de la reforma de la salud en Colombia. Ley 100 de 1993. Bogotá:

Assalud, Universidad del Rosario, Facultad de Economı́a; Mayol Ediciones.
Zigon, J.

2010 Moral and Ethical Assemblages A Response to Fassin and Stoczkowski. Anthro-
pological Theory 10:3–15.

Copyright of Medical Anthropology Quarterly is the property of Wiley-Blackwell and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.

D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l 49

Closing the Gap Between Formal and Material Health
Care Coverage in Colombia

everald o l amprea and johnat tan garcía

Abstract

This paper explores Colombia’s road toward universal health care coverage. Using a policy-based

approach, we show how, in Colombia, the legal expansion of health coverage is not sufficient and require

s

the development of appropriate and effective institutions. We distinguish between formal and material

health coverage in order to underscore that, despite the rapid legal expansion of health care coverage, a

considerable number of Colombians—especially those living in poor regions of the country—still lack

material access to health care services. As a result of this gap between formal and material coverage,

an individual living in a rich region has a much better chance of accessing basic health care than an

inhabitant of a poor region. This gap between formal and material health coverage has also resulted

in hundreds of thousands of citizens filing lawsuits—tutelas—demanding access to medications and

treatments that are covered by the health system, but that health insurance companies—also known as

EPS— refuse to provide. We explore why part of the population that is formally insured is still unable to

gain material access to health care and has to litigate in order to access mandatory health services. We

conclude by discussing the current policy efforts to reform the health sector in order to achieve material,

universal health care coverage.

Everaldo Lamprea, LLB, JSD, is Assistant Professor at University of Los Andes Law School, Bogotá, Colombia.

Johnattan García, LLB, is Clinical Instructor at the Environmental and Public Health Law and Policy Clinic at the University of Los
Andes, Bogotá, Colombia.

Please address correspondence to the authors c/o Everaldo Lamprea, Facultad de Derecho, Universidad de los Andes, Bogotá, D.C.,
Colombia. Email: e-lampre@uniandes.edu.co.

Competing interests: None declared.

Copyright: ©Lamprea and García. This is an open access article distributed under the terms of the Creative Commons Attribution Non-
Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted noncommercial use, distribution,
and reproduction in any medium, provided the original author and source are credited.

H ea l t h a n d H u m a n R i g h ts J o u r n a l

HHr

HHR_final_logo_alone.indd 1 10/19/15 10:53 AM

E. lamprea and J. garcía / UHC and Human Rights, 49-65

50
D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l

Introduction

During the period 1991-2016, the growth of health
care coverage in Colombia has been remarkable,
going from 25% of the population covered in 1992
to approximately 96% today. This rapid surge in
health care coverage represents a key dimension of
the right to health, because access to health care,
previously restricted to a minority of Colombians,
has increasingly become a matter of basic rights for
the majority of citizens. As the Colombian Consti-
tutional Court stated in opinion T-760 of 2008, if the
right to health is to be taken seriously, then the gov-
ernment has to guarantee that all Colombians have
access to health care without any type of distinctions.
However, as we will explore in this paper,
many regulatory and institutional shortcomings
of Colombia’s health sector have impeded the
fact that all Colombians’ can ostensibly access
the same basket of health services. Many inhabi-
tants of poor regions carry a social security card
as identification, yet their access to basic health
care is very limited. As a result, despite the rap-
id growth in coverage, thousands of vulnerable
citizens are not able to enjoy their right to health
care, which was mandated by the 1991 Constitution
and the precedent of the Constitutional Court.
This paper starts with a discussion of the
1993 congressional bill that introduced Health
Sector Reform (HSR) in Colombia. Widely known
as Law 100 of 1993, the reform bill uprooted a
failed health system that covered less than 25%
of the population. The main objective of the 1993
reform was to achieve universal health care cov-
erage through a comprehensive and mandatory
social insurance system in which private, public,
or mixed health insurers and providers compet-
ed for patients among themselves, and also with
state-owned institutions such as the Social Secu-
rity Institute (ISS or Instituto de Seguros Sociales,
privatized and ceased to exist in 2007 as a state-
owned health insurer and provider). The principles
that guided the 1993 health reform were universal
health coverage, efficiency, quality, and equity, as
explicitly stated in Article 2 of Law 100 of 1993.
Colombia’s minister of health at the time
coined the term “structured pluralism” to describe

the reform. According to this model, govern-
mental regulation was the key mechanism for
ensuring that the new private, public, or mixed
health insurers and health care providers were
guided in the direction of public interest.1
Much has been written about the short-
comings of the 1993 health reform.2 The abrupt
implementation of the bill brought unintended
effects, such as the poor performance of key
governmental and regulatory agencies that were
unable to rein in private stakeholders like health
insurance and pharmaceutical companies.3
Largely as a result of the regulatory shortcom-
ings in Colombia’s health system, patients who are
refused treatments, exams, and pharmaceuticals—
whether or not these are included in the baskets of
health services—are left with no better alternative
than to file a lawsuit using an informal judicial
mechanism for the protection of basic rights, wide-
ly known as tutela, which was incorporated into the
1991 Constitution.4 Since the implementation of the
1993 health reform, Colombia has become the most
litigious country in Latin America in the area of
the right to health.5 As Table 1 shows, more than 1.3
million lawsuits were filed between 1999-2014 de-
manding access to health care services, treatments,
and pharmaceuticals.6

Some authors suggest that the key variable to
explain Colombia’s uncommonly high volume of
right to health litigation is the institutional arrange-
ment and performance of Colombia’s health system.
Yamin et al. argue, for instance, that the “charac-
teristics of the Colombian health system are central
to understanding why the volume of litigation has
been greater in Colombia than anywhere else.”7
Several authors underline that the agenda of
international financial institutions like the World
Bank was the most important determinant of
Colombia’s 1993 health care overhaul.8 Authors
like Yamin stress that the privatization and dereg-
ulation of Colombia’s health care system that was
unleashed by the 1993 health care reform incentiv-
ized health rights litigation. According to Yamin,
at the heart of Colombia’s uncommon escalation
of right to health litigation lies a clash between
the health system’s neoliberal “push toward com-

E. lamprea and J. garcía / UHC and Human Rights, 49-65

D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l 51

modification, commercialization, and privatization
[that] undermines both the concept and enjoyment
of a right to health” and the reactive role of litigants
and courts, which have acted as “bulwarks against
the hegemonic onslaught of neoliberalism.”9
More concretely, according to this account,
Colombia’s implementation of a neoliberal man-
aged competition health care overhaul brought
about rapid growth in health care coverage, but
also a widespread infringement of patients’ rights,
who used the easy access to courts and the highly
effective legal mechanisms introduced by the 1991
Constitution to fight off the increased rogue behav-
ior of private health insurance companies. As these
companies escalated their infringement of patients’
rights—thanks in great part to the government’s
poor regulation of the health system—patients
escalated their reliance on health rights litigation.
Indeed, patients used litigation consistently as the
only effective mechanism to mitigate the harm-

ful effects of privatized/managed competition
health care.10 Furthermore, it was not until 2012
that the government approved integration of the
basket of health services for the contributory and
subsidized regimes, a change prompted by opin-
ion T-760 of 2008 from the Constitutional Court.
From 1993 until 2012, the subsidized population
was entitled to fewer health services than the con-
tributory population, which the Constitutional
Court ruled an encroachment on the right to equal
treatment entrenched in the 1991 Constitution.
Much less has been written about the achieve-
ments of the 1993 health reform.11 Arguably, the
most remarkable accomplishment of the reform
was the abrupt rise in health care insurance cov-
erage. Over 20 years (1993-2013), coverage jumped
from 21% of the population to 96%.12 This dramatic
expansion awarded to most Colombians social se-
curity entitlements that were previously restricted
to a privileged minority, along with a substantial in-

Table 1. Growth of tutela claims relating to the right to health, 1999-2014

Year Number of tutelas  Health- related share Annual growth

Health related Total Health related Total

1999 21,301 86,313 24.68% – –

2000 24,843 131,764 18.85% 16.63% 52.66%

2001 34,319 133,272 25.75% 38.14% 1.14%

2002 42,734 143,887 29.70% 24.52% 7.96%

2003 51,944 149,439 34.76% 21.55% 3.86%

2004 72,033 198,125 36.36% 38.67% 32.58%

2005 81,017 224,270 36.12% 12.47% 13.20%

2006 96,226 256,166 37.56% 18.77% 14.22%

2007 107,238 283,637 37.81% 11.44% 10.72%

2008 142,957 344,468 41.50% 33.31% 21.45%

2009 100,490 370,640 27.11% -29.71% 7.60%

2010 94,502 403,380 23.43% -5.96% 8.83%

2011 105,947 405,359 26.14% 12.11% 0.49%

2012 114,313 424,400 26.94% 7.90% 4.70%

2013 115,147 454,500 25.33% 0.73% 7.09%

2014 118,281 498,240 23.74% 2.72% 9.62%

TOTAL 1,323,292 4,507,860 30.66%

Source: Defensoría del Pueblo, La Tutela y los Derechos a la Salud y a la Seguridad Social 2014 (Bogotá: Defensoría del Pueblo, 2015).

E. lamprea and J. garcía / UHC and Human Rights, 49-65

52
D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l

crease in equity in access and strengthened financial
protection for the most vulnerable population.
This rapid growth came at great cost to the
government. Over the two years that followed the
1993 reform, 4.6 million people were included in
the subsidized regime.13 Public funds committed
to subsidize the most vulnerable groups went
from US$42 million in 1994 to US$550 million in
1995.14 Furthermore, although coverage rose rapidly
across the country, there were marked inequali-
ties between poor and rich departments in terms
of health outputs and access to basic health care.
The dramatic surge in right to health litiga-
tion in a context of an abrupt rise in health care
coverage indicates that despite the formal or legal
expansion of coverage, private insurance compa-
nies and public hospitals have denied health care
services to hundreds of thousands of Colombians.
In the following sections, we explore this gap be-

tween formal and material health care coverage
and attempt to uncover the main variables driving
this phenomenon. We also look at the policies put
forward by Colombia’s government to deliver not
only formal health care coverage, but also mate-
rial access to health care to all Colombians. The
regulatory reform mandated by opinion T-760 was
ultimately crystallized in a statute passed by Con-
gress in 2015 (Law 1751).

Evolution of health care coverage in
Colombia, 1991-2013

Setting the foundations, 1991-2003
In 1991, the National Constituent Assembly, a dem-
ocratically elected assembly in charge of drafting
a new Constitution, opened the path for the 1993
health care reform, which introduced from scratch
a social insurance scheme for the provision of

Source: Authors’ own calculations based on Ministerio de Salud y Protección Social, “Informe al Congreso de la República 2014-2015. Sector
administrativo de salud y protección social.” (Bogotá, 2015); Organization for Economic Co-operation and Development, OECD Reviews of Health
Systems: Colombia 2015 (Paris: OECD Publishing, 2015); U. Giedion and A. Wüllner, La Unidad de Pago Por Capacitación Y Equilibrio Financiero
Del Sistema de Salud (San José: Fundación para la Educación Superior y el Desarrollo, Fedesarrollo, 1994); Ministerio de Desarrollo Social, Informe
de Desarrollo Social 2015, (Santiago, 2015); and Programa Estado de la Nación (PEN), Vigesimoprimer Informe Estado de la Nación en Desarrollo
Humano Sostenible (Costa Rica), (San José, 2015).

Figure 1. Health care coverage in Colombia, Costa Rica, and Chile, 1993-2013

Year Colombia Costa Rica Chile
12/31/93 24% 86% 88%
12/31/94 29% 86% 92%
12/31/95 29% 86% 92%
12/31/96 48% 90% 89%
12/31/97 56% 88% 89%
12/31/98 52% 89% 89%
12/31/99 56% 89% 89%
12/31/00 56% 88% 90%
12/31/01 60% 88% 90%
12/31/02 60% 87% 90%
12/31/03 61% 85% 93%
12/31/04 63% 88% 93%
12/31/05 76% 88% 93%
12/31/06 88% 88% 95%
12/31/07 89% 88% 95%
12/31/08 95% 89% 95%
12/31/09 92% 90% 96%
12/31/10 89% 92% 96%
12/31/11 92% 94% 97%
12/31/12 92% 94% 97%
12/31/13 92% 94% 97%
12/31/14 95% 92% 97%

0%

20%

40%

60%

80%

100%

120%

1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013

Colombia Costa Rica Chile

E. lamprea and J. garcía / UHC and Human Rights, 49-65

D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l 53

health services. Colombia’s social insurance model,
as outlined by the 1991 Constitution and by Law
100 of 1993, encouraged the regulated competition
of private, public, and mixed health providers as a
means to accomplish universal health coverage. Yet
it was a model that required active governmental
intervention and regulation.15

As displayed in Figure 1, the Colombi-
an health care system experienced a late and
abrupt expansion during the 1990s. By 1993, the
social security systems in Costa Rica and Chile
offered coverage to approximately 90% of the
population, whereas Colombia’s social security
system offered coverage to less than 25%. Over a
period of 20 years (1993-2013) health care cover-
age jumped from 21% of the population to 96%. 16
In 1993—the year health reform was imple-
mented—76% of the Colombian population was
uninsured (See Figure 2). By 2015, the percentage
covered by the contributory regime, composed
of the households of pensioners and citizens who
are formally employed and who contributed to the
social security system with 12.5% of their salaries,
amounted to 45% of the population. The percentage

of the population covered by the subsidized regime,
composed of the households of the unemployed
and informally employed, represented 48% of the
population. As a result, only 3% of the population
was uninsured by 2015.

As previously mentioned, the touchstone
of the 1993 health reform was the creation of two
different insurance regimes: the contributive and
the subsidized regimes. The contributive regime
is funded, primarily, by payroll taxes from formal
employees and employers; independent workers
who earn more than twice the minimum month-
ly income; pensioners; and corporate income tax
known as the income tax for equality (CREE).
Funding for the health insurance companies
(EPS) that insure the contributive population and
its households comes from the following sources:
formally employed Colombians contribute 12.5%
of their salaries, retirees contribute 12% of their
pensions, and those earning less than 10 minimum
monthly wages (approximately US$2,300) contrib-
ute 4% of their wages. Members of the contributive
regime also help fund the plan through copayments.
The subsidized regime is financed by public

Figure 2. Health care coverage in Colombia, 1993-2013

Source: Authors’ own calculations based on Organization for Economic Co-operation and Development, OECD Reviews of Health Systems:
Colombia 2015 (Paris: OECD Publishing, 2015).

Year % of population covered % population uncovered
12/31/93 8,581,085 27,626,023
12/31/94 10,705,718 26,148,187
12/31/95 11,000,000 26,472,184
12/31/96 18,397,000 19,671,050
12/31/97 21,798,000 16,837,691
12/31/98 20,387,061 18,797,395
12/31/99 22,329,832 17,400,966
12/31/00 22,573,566 17,721,997
12/31/01 24,405,182 16,408,359
12/31/02 24,604,347 16,724,477
12/31/03 25,673,148 16,175,811
12/31/04 26,752,547 15,615,942
12/31/05 32,708,711 10,179,881
12/31/06 38,121,898 5,284,058
12/31/07 39,029,965 4,896,964
12/31/08 42,006,579 2,444,568
12/31/09 41,420,657 3,558,175
12/31/10 40,303,807 5,205,777
12/31/11 42,286,802 3,757,799
12/31/12 42,952,766 3,629,057
12/31/13 43,207,473 3,913,616
12/31/14 45,492,407 2,169,380
12/31/15 46,671,720 1,531,685

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 201

5

% of popula3on covered % popula3on uncovered

E. lamprea and J. garcía / UHC and Human Rights, 49-65

54
D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l

funds, which the national government transfers to
municipalities and departments. Once municipal-
ities and departments receive the funds from the
national government, they transfer the money to
insurance companies that provide health care to
the subsidized population. These transfers from the
national to local governments are known as Gener-
al System of Participation (SGP or Sistema General
de Participación). Additionally, formal employees,
employers, and independent workers contribute
1.5% of their monthly salaries to the subsidized
regime through the “solidarity” mechanism of Law
100 of 1993. Finally, municipalities and depart-
ments provide funding by means of regional taxes
on liquor, tobacco, and gambling, among others.
The early expansion of health care coverage
among the subsidized population was bolstered by a
1994 presidential decree (Decree 2491 of 1994), which
ordered the national government, municipalities, and
departments to create specific subsidies in order to
incorporate their poorest citizens into the subsidized
regime. A nationally established but locally applied

survey, SISBEN, classifies Colombians according
to financial need, with the poorest Colombians cat-
egorized as SISBEN 1. Those classified as SISBEN 3,
although poor, are not as destitute as individuals and
families classified as SISBEN 1 and SISBEN 2.

Decree 2491 ordered municipalities and depart-
ments to incorporate into the subsidized regime only
the population classified as SISBEN 1 and SISBEN 2.
As a result of the subsidies created by Decree 2491,
more than 5.8 million individuals joined the subsi-
dized regime between 1994 and 1996 (see Figure 3).
However, one of the most important assump-
tions of the technocrats who designed Law 100 of
1993 was that unemployment and informal labor
would decrease over the following decade, resulting
in the contributive population growing faster than
the subsidized population. Under this assumption,
it was expected that the “solidarity mechanism,”
whereby the formally employed contribute with
1.5% of their salary, would become the financial
bedrock of the subsidized regime. This forecast
proved to be wrong, and informal labor and unem-

Figure 3. Population insured through the contributive and subsidized regimes and evolution of health care
insurance coverage, 1993-2003

Source: Authors’ own calculations based on Organization for Economic Co-operation and Development, OECD Reviews of Health Systems:
Colombia 2015 (Paris: OECD Publishing, 2015).

National Health Care Coverage (%) Contributive Regime Subsidiary Regime
1993 24%

94-95 35% 6,317,718 4,629,193
1996 49% 11,039,735 5,794,882
1997 56% 12,749,778 6,776,168
1998 61% 13,910,482 8,184,039
1999 61% 13,240,338 8,909,140
2000 61% 12,900,000 9,500,000
2001 64% 13,000,000 11,036,193
2002 66% 13,700,000 11,434,468
2003 67% 14,100,000 11,858,264
2004 75% 14,400,000 15,541,595
2005 84% 15,500,000 18,564,128
2006 87% 16,400,000 19,510,572
2007 91% 17,500,000 20,347,538
2008 91% 18,000,000 20,421,027
2009 91% 18,232,720 20,494,516
2010 94% 18,723,118 21,665,210
2011 96% 19,756,257 22,295,165
2012 96% 19,957,739 22,605,295
2013 96% 20,150,266 22,669,543
2014 97% 20,760,123 22,882,669

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%

$

0

$5

$

10

$

15

$

20

$

25

$

30

1993 94-95 1996 1997 1998 1999 2000 2001 2002 2003

M
ill

io
ns

Contribu:ve Regime Subsidiary Regime Na:onal Health Care Coverage (%)

E. lamprea and J. garcía / UHC and Human Rights, 49-65

D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l 55

ployment rose.17 Over the next 20 years (1993-2013),
the subsidized population grew faster than the con-
tributory population (see Figure 3), and as a result,
the government had to invest heavily to finance
the expansion of health care coverage among the
subsidized population.

While in 1994 only 579,289 individuals were
part of the subsidized regime, in 2000 the subsidized
regime covered more than 9.5 million beneficia-
ries.18 As previously mentioned, this expansion cost
the government dearly: whereas in 1994 they spent
US$42 million financing the subsidized regime, in
2000 they spent US$594 million (see Table 2).

The cost of expanding coverage among the
contributive population was also high. However,
in this case it was the workforce—formal employ-

ees and employers—that shouldered the cost of
expanding health care coverage among the con-
tributive population. Whereas in 1993, employees
and employers contributed US$1.2 billion through
payroll taxes, by 2003 that amount had climbed to
US$3 billion (see Figure 4).

Paying the price of universalization,
2003-2013

In 2003, health care coverage received an additional
boost thanks to an executive order from the health
regulatory agency, Consejo Nacional de Seguridad
Social en Salud or CNSSS.19 The order created new
governmental subsidies geared towards the incor-
poration into the subsidized regime of individuals

Year Number of people covered by subsidized regime Public funds (current USD)

1994 579.289 $42,050,595
1995 4.800.916 $554,950,810
1996 5.981.774 $577,603,589
1997 7.026.692 $655,508,596
1998 8.527.061 $784,256,413
1999 9.325.832 $708,187,686
2000 9.510.566 $594,638,245

Source: Ministerio de la Protección Social, ¿Ha mejorado el acceso en salud? Evaluación de los procesos del régimen subsidiado, Colección de Estudios
sobre Protección Social 3, (Bogotá: Universidad Nacional de Colombia, Centro de Investigaciones para el Desarrollo, 2007), p. 260.

Table 2. Number of people covered and public funds invested in the subsidized regime, 1994-2000

Figure 4. Evolution of payroll taxes in the contributory regime, 1993-2003

Source: Authors’ own calculations based on G. Barón, Cuentas de Salud de Colombia 1993-2003: El Gasto nacional en salud y su financiamiento
(Bogotá: Ministerio de Protección Social and Departamento Nacional de Planeación, 2007).

Column1 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Health Expenditure Contributory Regime (in USD converted from 2000 constant Colombian Pesos -COP- and 2000 USD – COP Exchange Rate)1,170,767,407 1,193,179,954 1,514,393,510 1,977,573,799 2,299,674,287 2,697,233,762 2,925,841,853 2,524,365,101 2,677,654,090 2,557,829,090
National Healthcare Coverage (%)24% 29% 29% 48% 56% 52% 56% 56% 60% 60%

1.17 1.19

1.51

1.98

2.30

2.70
2.93

2.52
2.68

2.56

3.04

–

1

1

2

2

3

3

4

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Bi
lli
on

s
(U

SD
)

Health Expenditure Contributory Regime (in USD converted from 2000 constant Colombian Pesos -COP- and 2000 USD – COP Exchange Rate)

E. lamprea and J. garcía / UHC and Human Rights, 49-65

56
D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l

who were classified as SISBEN 2 and SISBEN 3.
Starting in 2004, not only the poorest and most
vulnerable Colombians—that is, people classified as
SISBEN 1—were able to join the subsidized regime,
but also individuals who were not as poor and vul-
nerable. In 2011, the Ministry of Health issued an
executive order (Resolution 3778) that reverted the
CNSSS 2004 decision, allowing only SISBEN 1 and
2 populations to join the subsidized regime. But as
a result of the CNSSS executive order, more than
3.5 million individuals classified as SISBEN 2 and
3 joined the subsidized regime in 2004.20 As shown
in Figure 5, the subsidized population surpassed
the contributory population in 2005, a trend that
remained constant from 2005 to 2013.

The rapid growth of the subsidized population
placed massive pressure on the government’s health
budget. In 2011, for example, 68% of the funds
used to finance the subsidized regime were public
(transfers from the national to the local govern-
ment through the General System of Participation).
Only 25% of the funding came from payroll taxes.
Furthermore, municipalities and departments con-

tributed with only 1 and 6% of the funding for the
subsidized regime, respectively (see Figure 6).

From 2003-2009, the average yearly health
expenditure for the subsidized regime represented
1.1% of Colombia’s GDP, whereas payroll taxes paid
by employees and employers amounted to 2.2%.21
Given these figures, why did the government
push forward with the universalization of health
care coverage? The answer is not straightforward.
One could argue that the government expanded
health care coverage among the subsidized popu-
lation because the 1991 Constitution and Law 10

0

1993 ordered Congress and the executive branch to
achieve universalization. Additionally, in 2008 the
Colombian Constitutional Court (CCC) handed
down Opinion T-760 of 2008, a 400-page ruling
that instantly captured the attention of experts, civil
society organizations, patients’ groups, and the me-
dia.22 In Opinion T-760, the CCC reviewed its own
vast jurisprudence on the right to health, showing
how the evolution of the Court’s precedent led to the
conclusion that health care was a basic right which
could be autonomously enforced—that is, not only

Figure 5. Population insured through the contributory and subsidized regimes and evolution of health care
coverage, 2003-2013

Source: Authors’ own calculations based on Organization for Economic Co-operation and Development, OECD Reviews of Health Systems:
Colombia 2015 (Paris: OECD Publishing, 2015).
National Health Care Coverage (%) Contributive Regime Subsidiary Regime
1993 24%
94-95 35% 6,317,718 4,629,193
1996 49% 11,039,735 5,794,882
1997 56% 12,749,778 6,776,168
1998 61% 13,910,482 8,184,039
1999 61% 13,240,338 8,909,140
2000 61% 12,900,000 9,500,000
2001 64% 13,000,000 11,036,193
2002 66% 13,700,000 11,434,468
2003 67% 14,100,000 11,858,264
2004 75% 14,400,000 15,541,595
2005 84% 15,500,000 18,564,128
2006 87% 16,400,000 19,510,572
2007 91% 17,500,000 20,347,538
2008 91% 18,000,000 20,421,027
2009 91% 18,232,720 20,494,516
2010 94% 18,723,118 21,665,210
2011 96% 19,756,257 22,295,165
2012 96% 19,957,739 22,605,295
2013 96% 20,150,266 22,669,543
2014 97% 20,760,123 22,882,669

60%

65%

70%

75%

80%

85%

90%

95%

100%

$0

$

5

$

10

$

15

$

20

$

25

$

30

$

35

$

40

$45

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

M
ill
io
ns

Contributive Regime Subsidiary Regime National Health Care Coverage (%)

E. lamprea and J. garcía / UHC and Human Rights, 49-65

D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l 57

Share
General System of Participation68
Municipalities’ contribution1
Departments’ contribution6
Payroll tax contribution25

General System of
Participation

68%

Municipalities’ contribution
1%

Departments’ contribution
6%

Payroll tax contribution
25%

Figure 6. Financial sources for the subsidized regime in 2011

Source: J. N. Méndez et al., La
sostenibilidad financiera del
sistema de salud colombiano:
Dinámica del gasto y principales
retos de cara al futuro (Bogotá:
Fedesarrollo, 2012).

when the right to life of the plaintiff was threatened.
Additionally, the CCC concluded that although the
right to health created programmatic duties that
the government had to comply with gradually, it
also created immediate duties for the government.
Opinion T-760/08 contained 32 orders. The
first 16 commanded health insurance companies
(EPS) to deliver the health care services demand-
ed by the 22 individual plaintiffs who filed the
lawsuits. The remaining 16 were addressed to the
Ministry of Health and other regulatory agencies,
such as the Regulatory Health Commission (CRES)
or the National Superintendence of Health. These
“structural” orders cover regulatory measures that
the CCC considered the government should imple-
ment to protect Colombian patients’ right to health.

Some deal with the government’s duty to reach uni-
versal health coverage and provide a unified basket
of health services to both the contributive and the
subsidized regimes (see Table 3).

Although the CCC’s orders may have persuad-
ed the government to strengthen its commitment
to universal health care coverage despite mounting
fiscal costs, it must also be acknowledged that in
previous decades, the Colombian government used
health and social subsidies as a populist mechanism
to gain votes among the poorest and most vulner-
able citizens.23 Additionally, members of congress
and local politicians pressed the executive branch
to expand the SGP. According to some researchers,
the transfers of public funds from the national to
the municipal and department levels transformed

Orders 21 and
22

Ordering the Ministry of Health to unify the two existing baskets of health services, incorporating the participation of patients.
According to the CCC, having a more comprehensive basket of health services for the “contributive” population who had
formal jobs and a less comprehensive for the “subsidized” population who lacked a formal job, ran counter to equity principles
entrenched in the Constitution and incentivized right to health litigation.

Order 29 Ordering the Ministry of Health to implement measures aimed at accomplishing universal health care coverage.

Table 3. Colombian Constitutional Court’s orders regarding universal health coverage

E. lamprea and J. garcía / UHC and Human Rights, 49-65

58
D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l

the financing mechanisms of the subsidized regime
into a source of political grafting and rent-seeking.24
Finally, there are indications that part of the
population insured by both the contributive and
the subsidized regimes have limited or no access
to health care. While most of these individuals are

formally covered by the health system—that is,
they carry a social security card—they often lack
material access to health care. In the final section
of this paper we explore the gap between formal
and material health care coverage, and also discuss
policymakers’ efforts to close that gap.

Table 4. Reasons why people remain uninsured despite eligibility for the subsidized or contributive regimes

Reasons Share of response

Lack of money 14.1%

Too much red tape 13.8%

Uninterested/neglect 16.9%

Unaware that they can be insured 2%

No relation with a formal employee (informal workers) 15.6%

Currently going through the application procedure 27.2%

No health insurance company close to home 1.2%

Other reasons 9.3%

Source: Departamento Administrativo Nacional de Estadística, “Encuesta Nacional de Calidad de Vida 2014” (Bogotá: Departamento
Administrativo Nacional de Estadística, 2014).

Sum of Cobertura
Wealthier RegionsBogota D.C. 93.5%

Antioquia 93.7%
Valle del Cauca 91.6%
Atlántico 98.7%

Poorer and Vulnerable RegionsLa Guajira 87.5%
Chocó 84.8%
Amazonas 89.4%
Vichada 100.0%
Vaupés 70.9%
Guainía 100.0%

94% 94% 92% 99% 87% 85% 89% 100% 71% 100%
0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Bogota D.C.

Antioquia Valle del
Cauca

Atlántico La Guajira Chocó Amazonas Vichada Vaupés Guainía

Wealthier Regions Poorer and Vulnerable Regions

Source: Ministerio de Salud y Protección Social, “Sistema Integral de Información de la Protección Social (SISPRO),” Ficha Departamental y
Municipal (October 2016). Available at http://sispro.gov.co.

Figure 7. Health care coverage in Colombia by selected departments, 2016

E. lamprea and J. garcía / UHC and Human Rights, 49-65

D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l 59

Closing the gap between formal and
material health care coverage in Colombia

Uninsured poor population (UPP)
The government has conceded that part of
Colombia’s population is still uninsured. More sig-
nificantly, the Ministry of Health has classified this
population as the Uninsured Poor Population (UPP).
According to recent estimates from the Min-
istry of Health, 46.4 million people are insured by
either the contributive or the subsidized regimes.
Official estimates from the government’s statistics
agency, DANE, put Colombia’s population at ap-
proximately 48.7 million. Thus, according to the
Ministry’s data, approximately 2.3 million remain
uninsured. However, DANE’s 2014 Quality of Life
Survey (Encuesta de Calidad de Vida) suggests
that the number of uninsured is larger—approxi-
mately 2.7 million people. According to this survey,
there are multiple reasons why eligible individ-
uals remain uninsured (See Table 4). Some of the
UPP have not been included in the government’s

SISBEN. Some people who are in the process of ap-
plying for insurance are also part of the UPP. And
those individuals who are still uninsured despite
being poor enough to qualify for the subsidized
regime make up another part of the identified UPP.

Perhaps the most worrying category of UPP
is “sandwiched” individuals. The first type of
“sandwiched” UPP are those who switch jobs fre-
quently or are short-term contract workers. When
they are formally employed, they are insured by
the contributory regime, but when they become
temporarily unemployed, they abandon it. They
cannot be incorporated into the subsidized regime
because their changing working status makes them
difficult to classify as permanently unemployed
or as vulnerable individuals (SISBEN 1 and 2).
Another category of “sandwiched” UPP was
created in 2011 when the Ministry of Health issued
an executive order (Resolution 3778) excluding
SISBEN 3 individuals from the subsidized regime.
The Ministry reasoned that SISBEN 3 individuals
were not as poor and vulnerable as those classified

Figure 8. Maternal mortality ratio (per 100,000 live births) and mortality rate of children under 5 years old
(per 1,000 live births) in Colombia by selected departments, 2014

Source: Ministerio de Salud y Protección Social, “Sistema Integral de Información de la Protección Social (SISPRO),” Ficha Departamental y
Municipal (October 2016). Available at http://sispro.gov.co.

Maternal mortality ratio Column2Column1Under-5 mortality rate
National Colombia 53.65 13.67
Wealthier Regions Bogota D.C. 33.70 11.76

Antioquia 28.79 12.00
Valle del Cauca 37.43 11.08
Atlántico 53.64 15.92

Poorer and Vulnerable RegionsLa Guajira 170.21 22.13
Chocó 181.64 31.86
Amazonas 65.62 27.56
Vichada 349.34 26.20
Vaupés 233.10 37.30
Guainía 665.56 28.29

12.69
28.89 2.28

0
5
10
15
20
25
30
35
40
0

100

200

300

400

500

600

700

800

Colombia Bogota
D.C.

Antioquia Valle del
Cauca
Atlántico La Guajira Chocó Amazonas Vichada Vaupés Guainía

National Wealthier Regions Poorer and Vulnerable Regions

U
nder-5 m

ortality rate
M

at
er

na
l m

or
ta

lit
y

ra
tio

Maternal mortality ratio Under-5 mortality rate

E. lamprea and J. garcía / UHC and Human Rights, 49-65

60
D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l

SISBEN 1 and 2. On the contrary, many had enough
income to join the contributory regime as indepen-
dent workers earning more than two minimum
monthly incomes, but they were getting a free ride
in the subsidized regime. It is unclear, though,
whether the government had solid data on the so-
cioeconomic composition of SISBEN 3 population.
Some individuals are currently uninsured because
they are considered to be above the poverty line and
therefore are expected to join the contributory re-
gime as independent workers. Yet it is possible that
the real incomes of these individuals are lower than
expected, and thus they are unable to pay taxes as
independent workers. As a result, the “sandwiched”
population is in a lose-lose situation: excluded from
the subsidized regime because they are not poor
enough, and unable to join the contributory re-
gime as independent workers because they are not
wealthy enough.

Unequal access to health care across
departments and regions
Although health care coverage in Colombia is high
and equally distributed among departments, there

are strong indications that health outcomes and
actual access to health services vary dramatically.
Consider, for instance, the performance of
health care coverage in the four wealthiest de-
partments vis-à-vis the five poorest departments.
According to DANE, Bogotá, Antioquia, Valle
del Cauca, and Atlántico have the largest partic-
ipation in the country’s GDP. La Guajira, Chocó,
Amazonas, Vichada, and Guainía are the poorest
departments in terms of their participation in the
country’s GDP. As Figure 7 shows, the variation of
health care coverage among poor and wealthy de-
partments is not marked. On the contrary, a poor
department like Guainía has better health care in-
surance coverage than the two richest Colombian
departments.

One way to assess the gap between coverage and
actual access to health care is by comparing health
outcomes and health services between rich and
poor departments. We can assess health outcomes,
like maternal and child mortality, and health ser-
vices, such as per capita numbers of health facilities,
pediatric intensive care units, operation rooms, che-
motherapy units, and ambulances, among others.

Chemotherapy Chairs Operating Rooms Pediatric ICU
Wealthier Regions Bogota D.C. 31.58 7.92 2.04

Antioquia 42.85 5.98 0.70
Valle del Cauca 37.55 7.64 1.63
Atlántico 31.33 9.68 3.98

Poorer and Vulnerable Regions La Guajira 0.00 3.86 1.93
Chocó 0.00 2.77 0.00
Amazonas 0.00 3.89 0.00
Vichada 0.00 2.71 0.00
Vaupés 0.00 0.00 0.00
Guainía 0.00 4.75 0.00

32

43

38

31

0 0 0 0 0 0

8
6

8
10

4
3

4
3
0

5
2

1 2
4

2
0 0 0 0 0

0
5
10
15
20
25
30

35

40

45

Bogota D.C. AnIoquia Valle del Cauca AtlánIco La Guajira Chocó Amazonas Vichada Vaupés Guainía

Wealthier Regions Poorer and Vulnerable Regions

Chemotherapy Chairs OperaIng Rooms Pediatric ICU

Source: Authors’ own calculation based on Ministerio de Salud y Protección Social, Registro Especial de Prestadores de Servicios de Salud (March
2016). Available at http://prestadores.minsalud.gov.co/habilitacion/.

Figure 9. Pediatric ICUs, chemotherapy chairs, and operating rooms (per 100,000 inhabitants) in Colombia by
selected departments, 2016

E. lamprea and J. garcía / UHC and Human Rights, 49-65

D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l 61

Figure 8 shows the different patterns of
maternal and child mortality in poor and rich
departments. In rich departments, the number of
women who die from pregnancy-related causes
is, on average, 38.4 per 100,000 births, whereas in
poor departments the figure is 277.5. Similarly, the
number of children younger than 5 years who die
per 1,000 live births is, on average, 2.3 times greater
in poor departments than in rich ones.

Furthermore, Figure 9 shows major disparities
between rich and poor departments in terms of op-
erating rooms (OR). Whereas in rich departments
there are on average 8 ORs per 100,000 individ-
uals, poor departments have only 3 per 100,000.
The disparities are even greater when it comes to
pediatric intensive care units (ICU). La Guajira is
the only poor department that has an ICU. Final-
ly, whereas rich departments have, on average, 35
chemotherapy chairs per 100,000 individuals, poor
departments do not offer such health services.

Figure 10 shows two health care activity rates
(medical appointments and procedures) in each
selected department in 2015 (per 1,000 inhabitants).
Medical appointments rate is on average 3.5 times

higher in the four richest departments (2,259) than
in the six poorest departments (674). Similarly,
whereas in the four richest departments 3,898
procedures on average were performed in 2015
per 1,000 inhabitants, the poorest departments
only registered 1,202 medical procedures per

1,000

inhabitants. The procedure rate in 2015 was three
times lower in the poorest departments compared
to the richest.

The health disparities illustrated in Figures 8,
9, and 10 suggest a profound gap between formal and
material health care coverage in poor departments.
In other words, in Guainía most people are formally
insured but lack access to basic health services such
as operating rooms, pediatric ICUs, and chemo-
therapy units. Similarly, basic health outcomes like
maternal and child mortality are much worse in a
poor state like Guainía than in rich departments
like Bogotá and Antioquia. In Vaupés, the lack of
health service infrastructure and poor health care
outcomes collide with the lowest medical appoint-
ment and procedures rates in the country.
It could be expected that in poor states with
low health outcomes levels of health rights litiga-

Medical appointments Procedures
National Colombia 2210.9 3560.2
Wealthier Regions Bogota D.C. 2375.96 3790.49

Antioquia 2138.27 3530.61
Valle del Cauca 2183.62 4559.29
Atlántico 2339.87 3712.27

Poorer and Vulnerable Regions La Guajira 1310.88 2043.73
Chocó 1072.46 1809.48
Amazonas 442.73 791.41
Vichada 771.30 1572.94
Vaupés 50.93 128.20
Guainía 396.43 870.52

2259.43 3898.16
674.12 1202.72
3.35 3.24

Colombia 48,747,708 107,777,142 173550549
Bogota D.C. 7,980,001 18960194 30248075
Antioquia 6,534,857 13,973,286 23072063

Valle del Cauca 4,660,741 10,177,299 21249662
Atlántico 2,489,514 5,825,150 9241736
La Guajira 985,452 1291810 2014002

Chocó 505,016 541,608 913818
Amazonas 77,088 34,129 61008
Vichada 73,702 56,846 115929
Vaupés 44,079 2,245 5651
Guainía 42,123 16,699 36669

Colombia 2,210.92 3,560.18
Bogota D.C. 2,375.96 3,790.49
Antioquia 2,138.27 3,530.61

Valle del Cauca 2,183.62 4,559.29
Atlántico 2,339.87 3,712.27
La Guajira 1,310.88 2,043.73

Chocó 1,072.46 1,809.48
Amazonas 442.73 791.41
Vichada 771.30 1,572.94

2,211
2,376

2,138 2,184
2,340

1,311
1,072

443
771

51
396

3,560
3,790

3,531

4,559

3,712

2,044
1,809

791

1,573

128

871

0
500
1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

Colombia Bogota
D.C.
Antioquia Valle del
Cauca
Atlántico La Guajira Chocó Amazonas Vichada Vaupés Guainía

National Wealthier Regions Poorer and Vulnerable Regions

N
um

be
r

of
h

ea
lth

c
ar

e
ac

tiv
iti

es
p

er
1

,0
00

in

ha
bi

ta
nt

s

Medical appointments Procedures

Source: Authors’ own calculation based on Ministerio de Salud y Protección Social, “Sistema Integral de Información de la Protección Social
(SISPRO),” Prestaciones (October 2016). Available at http://sispro.gov.co.

Figure 10. Medical appointments and procedures rates (per 1,000 inhabitants) in Colombia by selected
departments, 2015

E. lamprea and J. garcía / UHC and Human Rights, 49-65

62
D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l

Sum of Cobertura
Wealthier RegionsBogota D.C. 16.30

Antioquia 38.00
Valle del Cauca 29.63
Atlántico 15.87

Poorer and Vulnerable RegionsLa Guajira 6.99
Chocó 8.10
Amazonas 27.33
Vichada 8.11
Vaupés 4.86
Guainía 15.67

16.3 38.0 29.6 15.9 7.0 8.1 27.3 8.1 4.9 15.7
0

5
10
15
20
25
30
35
40

Bogota D.C. AnGoquia Valle del Cauca AtlánGco La Guajira Chocó Amazonas Vichada Vaupés Guainía

Wealthier Regions Poorer and Vulnerable Regions
N
um

be
r o

f t
ut
el
a
cl
ai
m
s
pe
r 1

0,
00

0
in
ha

bi
ta
nt
s

Figure 11. Number of tutela claims relating to the right to health per 10,000 inhabitants by selected departments, 2014

Source: Defensoría del Pueblo, La Tutela y los Derechos a la Salud y a la Seguridad Social 2014 (Bogotá: Defensoría del Pueblo, 2015).

tions would be higher. However, as shown in Figure
11, departments in both wealthy and poor regions
share near the same rate of tutela claims relating to
the right to health.

Remaining challenges

There are several factors that could account for the
great divide in terms of health services and out-
comes across the country. Corruption, inefficiency,
mismanagement, and institutional weakness seem
to be more prevalent in poor departments than in
rich ones. The Comptroller General’s office notes
that the national government transferred more
than $US242 million to 17 departments between
2011 and 2013, to be invested in the improvement of
health facilities and hospitals, but the departments
only spent $US97 million. Between 2011 and 2013,
poor departments like Amazonas, Guainía, and
Vaupés received more than $US4 million from the
central government to improve their hospitals and
health facilities, but for unknown reasons, none
of those departments actually used the money.25
In 2015, the General Attorney’s office
conducted 49 investigations on grafting and
widespread corruption in Chocó’s health system.
They found that myriad health services were nev-
er delivered in Chocó, despite having been paid

by local authorities using public funds.26
Additionally, weak institutions can also ex-
plain why health care is so deficient in departments
like Guainía. For instance, in 2014, the Ministry of
Health concluded that in poor and distant depart-
ments like Guainía, the institutional arrangement
for the provision of health care should follow a
different blueprint than in the rest of the country.27
More particularly, providing health care in Guainía,
where the population is scarce and dispersed com-
pared to the rest of the country (.56 inhabitants per
square kilometer versus 43 inhabitants per square
kilometer in the rest of the country), demanded a
new health care model capable of achieving five
main goals: 1) provision of primary care services
adjusted to the real needs of the inhabitants of
Guainía; 2) an intercultural model in a region where
traditional indigenous knowledge can be incorpo-
rated into the local health system; (3) the monopoly
of a single health insurer with knowledge and expe-
rience in the field, capable of administering scarce
resources in a depopulated and vast territory; (4)
improvement of existing medical facilities, and
creation of new, extramural, and mobile facilities;
(5) participation of indigenous communities in the
decision-making process.28 This plan has not been
fully implemented in Guainía and it seems there
is no course of action for the remaining poor de-

E. lamprea and J. garcía / UHC and Human Rights, 49-65

D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l 63

partments. During the past two years, the CCC has
exerted pressure on the government regarding the
state of Chocó, one of the poorest in the country.
According to the CCC, the Ministry of Health has
failed to create and implement a policy plan aimed
at solving the dire health situation in Chocó. The
CCC argued that the government lacks an overarch-
ing policy plan to bring health care coverage to the
poorest and most vulnerable regions of Colombia.29

Conclusions

As some authors have argued, the legacy of Colom-
bia’s 1993 health reform can be summarized in a
single phrase: “from few to many.”30 Undoubtedly,
the rapid growth of health care coverage is one of
the greatest successes of the 1991 Constitution and of
Law 100 of 1993. However, the road toward universal
health care coverage over the past 20 years has been
uneven, especially for individuals who are formally
insured but who lack material access to health care.
Although the government has implemented
some policies aimed at closing the gap between
formal and material health care coverage, much re-
mains to be done. The government has to improve
the mechanisms whereby UPP can be identified and
studied. This identification process has to be con-
ducted not only at the central level of government,
but also at the regional level. The communication
between the Ministry of Health, departments, and
municipalities is key to understanding why many
individuals across the country are still uninsured.
Furthermore, the government should
assess the policy mechanisms to “capture” indi-
viduals who are eligible to join the subsidized or
the contributive regimes but who are current-
ly uninsured. In the case of the “sandwiched”
population, the government should reevaluate,
using reliable data, whether excluding SISBEN 3
individuals from the subsidized regime is a step
backwards in terms of equity and the right to health.
Although the road towards material, univer-
sal health care coverage is still long and uncertain,
there are indications that the government and
Congress are moving in the right direction. Min-
ister of Health Alejandro Gaviria announced major

reforms to the system in September 2012, which
Congress finally enacted in 2015 (Law 1751 of 2015).
One of the most significant changes wrought by
Law 1751 of 2015 is the reversal of the system for
identifying covered services and medications. The
Law requires that, by the beginning of 2017, the
government design and implement a new health
benefit plan based on a negative list of non-essential
medical services. In the future, all services are to be
considered essential, and hence covered by the plan,
unless they appear on the negative list of excluded
services. Article 15 of Law 1751 establishes that the
negative list should be composed of the following
categories of treatments: (1) cosmetic or aesthetic,
(2) experimental, (3) unregulated and (4) those pro-
vided overseas. All other treatments—that is, those
not on the negative list—should be considered
essential, and therefore must be provided by the
government to all Colombians, irrespective of cost.
Furthermore, the CCC ruled that Law 1751 of
2015 was constitutional.31 The Court held that the
minimum-core obligations to provide health care
and protect the right to health furthered the prin-
ciples defined by WHO and General Comment 14,
issued in 2000 by the United Nations Committee
on Economic, Social and Cultural Rights. For the
CCC, the latter document has become an import-
ant source of interpretation as the Committee
attempted to flesh out the ‘minimum core obliga-
tions’ of states with respect to the right to health
under the International Covenant on Economic,
Social and Cultural Rights. These are duties that “a
state party cannot, under any circumstances what-
soever, justify its non-compliance.”32 According to
the CCC, Law 1751 places the protection of the right
to health at the center of Colombia’s health system.
Law 1751 and the CCC’s ruling C-324 are good
indicators that Colombian policymakers and judg-
es are trying to close the gap between formal and
material health care coverage. We are particularly
optimistic about the convergence between the right
to health and health care coverage in Law 1751.
However, the challenges ahead are considerable. If
the government and Congress are not able to cor-
rect the institutional and regulatory dysfunctions
that have plagued the Colombian health system

E. lamprea and J. garcía / UHC and Human Rights, 49-65

64
D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l

since 1993, the efforts to deliver material universal
health coverage will have been in vain.

References
1. J. L. Londoño and J. Frenk, “Structured pluralism:

Towards an innovative model for health system reform in
Latin America,” Health Policy 41/1 (1997), pp. 1–36.

2. N. Homedes and A. Ugalde, “Why neoliberal health
reforms have failed in Latin America,” Health Policy 71/1
(2005), pp. 83–96; A. Yamin, O. Parra-Vera, and C. Gianel-
la, “Colombia: judicial protection of the right to health,”
in A. Yamin and S. Gloppen (eds) Litigating health rights:
Can courts bring more justice to health? (Cambridge, MA:
Harvard Law School, 2011); A. E. Yamin and O. Parra-Vera,
“Judicial protection of the right to health in Colombia:
From social demands to individual claims to public de-
bates,” Hastings Int’ l & Comp. L. Rev. 33/2 (2010), p. 431;
E. Lamprea, “Colombia’s right-to-health litigation in a
context of health care reform,” in C. M. Flood and A. M.
Gross (eds), The right to health at the public/private divide:
A global comparative study, (New York, NY: Cambridge
University Press, 2014).

3. C. Rodriguez-Garavito, “Justicia y salud en Colombia:
Retos y oportunidades creadas mediante la intervención
de los jueces,” in O. Bernal and C. Gutiérrez (eds), Libro
blanco en salud: Logros, retos y recomendaciones (Bogotá:
Los Andes Univ. Press, 2012).

4. Lamprea (see note 2).
5. O. Moestad, O. Ferraz, and L. Rakner, “Assessing the

impact of health rights litigation: A comparative analysis of
Argentina, Brazil, Colombia, Costa Rica, India and South
Africa,” in A. Yamin and S. Gloppen (eds) Litigating health
rights: Can courts bring more justice to health? (Cambridge,
MA: Harvard Law School, 2011), pp. 273–304.

6. Defensoría del Pueblo, La Tutela y los Derechos a la
Salud y a la Seguridad Social 2014 (Bogotá: Defensoría del
Pueblo, 2015).

7. Yamin et al. (2011, see note 2).
8. Homedes and Ugalde (See note 2); T. Groote and J.P.

Unger, “Colombia: In vivo test of health sector privatiza-
tion in the developing world,” International Journal of
Health Services 35/1 (2005), pp. 125–141; M.J. Kurtz and S.M.
Brooks, “Embedding neoliberal reform in Latin America,”
World Politics 60/2 (2008), 231–280; Yamin et al. (see note
2); A. Yamin, “Power, suffering, and courts: Reflections on
promoting health rights through judicialization,” in A.
Yamin and S. Gloppen (eds) Litigating health rights: Can
courts bring more justice to health? (Cambridge, MA: Har-
vard Law School, 2011), pp. 333–372.

9. Yamin (2011, see note 8).
10. Yamin and Parra-Vera (see note 2); Yamin et al. (2011,

see note 2); Yamin (2011, see note 8).

11. A remarkable exception is A. Glassman, M. L. Es-
cobar, and U. Giedion, From Few to Many: Ten Years of
Health Insurance Expansion in Colombia (Inter-American
Development Bank, 2009).

12. Ibid.; J. N. Méndez et al., La sostenibilidad financiera
del sistema de salud colombiano: Dinámica del gasto y
principales retos de cara al futuro (Bogotá: Fedesarrollo,
2012); Congreso de la República de Colombia, Ley 1450 de
2011: Por la cual se expide el Plan Nacional de Desarrollo,
2010-2014 (2011). Available at http://www.alcaldiabogota.
gov.co/sisjur/normas/Norma1.jsp?i=43101.

13. Organization for Economic Co-operation and Devel-
opment, OECD Reviews of Health Systems: Colombia 2015
(Paris: OECD Publishing, 2015), p. 48.

14. Ministerio de la Protección Social, ¿Ha mejorado el
acceso en salud?: Evaluación de los procesos del régimen
subsidiado., Colección de Estudios sobre Protección Social:
3, (Bogotá: Universidad Nacional de Colombia, Centro de
Investigaciones para el Desarrollo, 2007), p. 260.

15. Londoño and Frenk (see note 1).
16. Glassman et al. (see note 11); Méndez et al. (see note

12); Congreso de la República de Colombia (see note 12).
17. See, for example, A. Gaviria and M. Henao, “Compor-

tamiento del desempleo en los últimos años y estrategias
de los hogares para enfrentarlo,” Coyuntura Económica de
Fedesarrollo, (2001), pp. 23–38.

18. Ministerio de la Protección Social, ¿Ha mejorado el
acceso en salud?: Evaluación de los procesos del régimen
subsidiado, Colección de Estudios sobre Protección Social:
3, (Bogotá: Universidad Nacional de Colombia, Centro de
Investigaciones para el Desarrollo, 2007), p. 260.

19. Consejo Nacional de Seguridad Social en Salud de
la República de Colombia, Acuerdo 267 de 2004 (2004).
Available at http://jacevedo.imprenta.gov.co/tempDown-
loads/45D6231459586083463 .

20. Ministerio de la Protección Social, Informe de ac-
tividades 2004-2005 al Congreso de la República (Bogotá:
Ministerio de la Protección Social, 2005). Available at
ht t ps://w w w.m i n s a lud .gov.c o/do c u mentos%2 0y %2 0
publicaciones/iinforme%20de%20actividades%20al%20
congreso%202004-2005 .

21. Méndez et al. (see note 12).
22. Judgment T-760 (Constitutional Court of Co-

lombia, Sentencia T-760 de 2008, July 31, 2008).
Available at http://www.corteconstitucional.gov.co/relato-
ria/2008/T-7609-08.htm.

23. H. Alviar-García, “Social Policy and the New Devel-
opment State: The Case of Colombia,” in D. M. Trubek, H.
Alviar- García, D. R. Coutinho, and A. Santos, Law and the
new developmental state: The Brazilian experience in Latin
American context (New York, NY: Cambridge University
Press, 2014), pp. 345-368.

24. See, for example, A. Gaviria, C. Medina, and C. Me-
jía, “Assessing health reform in Colombia: from theory to

E. lamprea and J. garcía / UHC and Human Rights, 49-65

D E C E M B E R 2 0 1 6 V O L U M E 1 8 N U M B E R 2 H ea l t h a n d H u m a n R i g h ts J o u r n a l 65

practice,” Economia 7/1 (2006), pp. 29–63.
25. Contraloría General de la República, Política Pública

de Salud PND 2010-2014, (Bogotá: Contraloría General de la
República, 2014). Available at http://www.contraloria.gov.
co/documents/10136/188941280/01_ Salud /eb57e224-
6fdc-4b8b-839e-f25efde60344?version=1.1.

26. Fiscalía General de la Nación, Fiscalía Adelanta 49
Investigaciones Por Corrupción En El Sistema de Salud de
Chocó (March 2015). Available at http://www.fiscalia.gov.
co/colombia/noticias/destacada/fiscalia-interviene-la-cor-
rupcion-en-el-sistema-de-salud-de-choco/.

27. Presidencia de la República de Colombia, Decreto 2561
de 2014, 2014. Available at https://www.minsalud.gov.co/
Normatividad_Nuevo/Decreto%202561%20de%202014 .

28. Ministerio de Salud y Protección Social, MinSalud
Presenta Modelo de Atención En Salud Para El Guainía
(June 2014). Available at https://www.minsalud.gov.co/
Paginas/MinSalud-presenta-modelo-de-atención-en-sa-
lud-para-el-Guain%C3%ADa.aspx.

29. Revista Semana, El Estado ‘se raja’ por el sistema de
salud del Chocó (February 19, 2016). Available at http://
www.semana.com/nacion/articulo/corte-constitucional-
sistema-de-salud-del-choco-sigue-en-crisis/461215.

30. Glassman et al. (see note 11).
31. Judgment C-313 (Constitutional Court of Colombia,

Sentencia C-313 de 2014, May 29, 2014). Available at http://
www.corteconstitucional.gov.co/relatoria/2014/C-313-14.htm.

32. Committee on Economic, Social and Cultural
Rights, General Comment No. 14, The Right to the Highest
Attainable Standard of Health, UN Doc. No. E/C.12/2000/4
(2000). Available at http://www1.umn.edu/humanrts/gen-
comm/escgencom14.htm.

Copyright of Health & Human Rights: An International Journal is the property of Harvard
School of Public Health/Francois-Xavier Bagnoud Center for Health & Human Rights and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.

Nursing Inquiry. 2018;25:e12242. wileyonlinelibrary.com/journal/nin  |  1 of 8
https://doi.org/10.1111/nin.12242

© 2018 John Wiley & Sons Ltd

The result is that people come to feel quite happy in their

oppression like the prisoner who after 10 years in jail de-
cides it is not such a bad place, with its warm bed and
three meals a day (David Smith, 1999)

1  | INTRODUC TION

Sometimes, as with the prisoner, we just give up trying to know
what is beyond the bars. Why? Perhaps we are satisfied with the
way we are living or we encounter an overwhelming sense of not
knowing what we would do if we were free. We then become like
the prisoner who considers after 10 years that he only needs a

warm bed and three meals a day. Is this the easy way to feel safe in
the world? How is it possible to feel fulfillment when our world is
limited by others?

Living in the world is a unique experience for all. What do we
do, however, when the experience involves marginalization, alien-
ation, or oppression? Judgments must be made, and actions must
be taken to bring about positive change in those situations. In the
current era of globalization, political power has changed its task
to that of administering life as the machinery of production, and
human beings, as the centerpiece of globalization, must adjust to
the exigencies of the individualized, competitive, and consumer-
ist market to survive (Bourdieu, 1998). In addition, economic de-
velopment as a result of privatization of services has had serious
effects on the quality, accountability, distribution, access, and

Accepted: 11 March 2018

DOI: 10.1111/nin.12242

F E A T U R E

Understanding the space of nursing practice in Colombia: A
critical reflection on the effects of health system reform

Pilar Camargo Plazas

School of Nursing, Queen’s University,
Kingston, ON, Canada

Correspondence
Pilar Camargo Plazas, School of Nursing,
Queen’s University, Kingston, ON, Canada.
Email: mdpc@queensu.ca

Worldwide, healthcare has been touched by neoliberal policies to the extent that it
has some of its characteristics, such as being asymmetrical, competitive, dehuman-
ized, and profit driven. In Colombia, Law 100/93 was created as an ambitious reform
aimed at integrating the social security and public sectors of healthcare in order to
create universal access, and at the same time to generate market competence with
the objective of improving effectiveness and responsiveness. Instead, however,
Colombian health reform has served to generate competition which has aggravated
inequalities among people. Within this context, we practice nursing. As nurses, our
responsibility is to advocate for our patients. We cannot ignore what is happening
worldwide in hospitals and community health settings because our responsibility is
to promote health, prevent disease, and care for human beings. So, today, when the
world pushes for economical profit and competence on one hand, and, on the other,
for moral compromises to care, respect, and advocacy for all human beings, being a
nurse in the Colombian health system represents a challenge for us. This challenge is
especially significant because harm and benefit, justice and injustice, respect and
disrespect are separated by a fine line that is easy to transgress.

K E Y W O R D S

globalization, health inequities, health reform, neoliberalism, nursing practice

www.wileyonlinelibrary.com/journal/nin

http://orcid.org/0000-0002-8349-7723

mailto:mdpc@queensu.ca

http://crossmark.crossref.org/dialog/?doi=10.1111%2Fnin.12242&domain=pdf&date_stamp=2018-04-11

2 of 8  |     CAMARGO PLAZAS

equity of health and social systems around the world (Rotarou &
Sakellariou, 2017). As such, the implementation of neoliberal reg-
ulations in the area of health and the deterioration of the welfare
state has led us to forget that health is considered a human right
(Vargas Bustamante & Mendez, 2014). Healthcare has been seri-
ously altered by globalization and neoliberal policies and has gained
negative characteristics, such as being asymmetrical, competitive,
dehumanized, and profit- seeking. Health, as a part of the economic,
social, and political forces, benefits development and plays a key
role in achieving development. However, the unequal distribution
of healthcare resources affects the lives of people and their free-
dom. If health and life are considered human rights, why are human
beings worldwide exposed to disparities that affect their rights to
health, life, and well- being?

Most healthcare systems worldwide promote universality; under
this principle, all citizens are provided with preventive and curative
care (Camargo Plazas & Cameron, 2015; Camargo Plazas, Cameron,
& Smith, 2012; Rotarou & Sakellariou, 2017). Universality is an ad-
mirable principle; however, in reality, many people have to face re-
strictions and sometimes lack access to healthcare. The Colombian
health system promotes universality and access to healthcare; under
these healthcare principles, citizens should be provided with pre-
ventive and curative care. Colombia’s health system was changed
as a part of wider state reforms and as a consequence of external
pressures; its programs and interventions address external priorities
at the expense of integrated approaches that incorporate internal
realities such as the social determinants of health (Camargo Plazas
et al., 2012). Clearly, healthcare should be addressed for more than
economic purposes. Furthermore, healthcare systems need to build
a more symmetrical and humane system that gives equality and ac-
tual commitment based on the universal principles they promote.
This commercialization changes the scale of human values; compas-
sion, respect, and equality are low priorities, because they do not
produce economic rewards (Camargo Plazas et al., 2012). Thus, de-
spite the ethical issues, healthcare is a victim of global disparities and
economic progress.

Within this context, we practice nursing. Over the last 20 years,
our nursing practice has been influenced by the changes imposed by
neoliberal policies in the healthcare system (Malvarez & Castrillon
Agudelo, 2005). In nursing, we claim that care is the opposite to in-
difference. Indeed, care expresses itself as something natural, nei-
ther imposed nor contrived; it just appears, connecting two people
in a unique moment that emerges from empathy, creating bonds and
connections in a singular way. Through our actions, we can give the
best of our practice. The idea of our attention is to bridge the gap
between health professionals and patients. Are our actions congru-
ent with our essence? Should nurses adapt their practice to the pri-
orities of consumerism, competitiveness, and profit- driven policies
established by health reform? As (Smith, 1994) says, “the idea is to
get people in touch with precisely those parts of their experience
which lie beyond, behind, underneath, and above the superficial
pleasures of merely getting by” (p. 148). Through this paper, my idea
is to get in touch with all aspects and dimensions of the practice of

nursing in Colombia. To do so, I first describe the definitions of glo-
balization and neoliberal policies. Then, I continue with a description
of the Colombian health reform, discussing the nursing practice in
Colombia and conclusion. I have tried to understand the space of our
practice. Etymologically, the word space comes from the Latin word
spatium, meaning place in respect of distance or extent. I discuss the
extent of the space in which nursing practice in Colombia exists and
moves.

2  | GLOBALIZ ATION AND
NEOLIBER ALISM

Globalization describes the process of greater expansion and mutual
integration of markets across political boundaries of nation- states
(Labonte et al., 2015; Martens, Akin, Maud, & Mohsin, 2010). The
interdependence of world economies is the result of the increased
flow of goods, services, capital, and the rapid and expansive spread
of technologies (Labonte et al., 2015; Martens et al., 2010). Since
the 1970s, globalization has challenged the political, economic, and
technological landscapes and has transformed the social, cultural,
and environmental spheres of many societies around the world
(Labonte et al., 2015; Soleymani, 2010). Because of various perspec-
tives, globalization is always at the center of overlapping debates.
One debate is oriented toward exploring the potential effects, either
positive or negative, of the global integration of finance and produc-
tion (Labonte et al., 2015). This debate is framed by a broader issue
that questions whether or not the interconnectedness of globaliza-
tion has benefited most individuals and communities in the world
(Bloom, Henson, & Peters, 2014; Brown & Labonte, 2011; Labonte
et al., 2015). A different debate explores the effects of integrating
markets in the healthcare sector (Labonte et al., 2015). Evidence
shows that economic integration has generated profound changes
that have redefined how international health agencies, financial in-
stitutions, states, government agencies, transnational corporations,
non- governmental organizations, public and private healthcare
sectors, healthcare professionals, and other affinity- based organi-
zations, communities, households, and individuals operate and in-
teract with each other (Bloom et al., 2014; Brown & Labonte, 2011;
Labonte et al., 2015). Economic globalization is regulated by neolib-
eralism, which is defined as an economic theory favoring free trade,
privatization, minimal government intervention, and reduced public
expenditure on social services (Harvey, 2005; Navarro, 2009; Smith,
2010).

The assumption in neoliberalism is that economic growth and
unhindered welfare are the result of free markets, privatization
of companies, and services with limited government intervention
(Bell & Green, 2016; Bockman, 2013). This gives primacy to the in-
teractions between individuals and markets. Neoliberal economic
theory espouses the welfare- maximizing consequences of market
exchange. Under neoliberalism, a role of governments, local authori-
ties, and institutions is the development of guidelines and regulatory
frameworks that allow global markets to successfully function (Bell

     |  3 of 8CAMARGO PLAZAS

& Green, 2016; Rotarou & Sakellariou, 2017). Then, government is
deemed as less able and effective than private institutions at de-
livering social services, including health and education. This results
in the slashing of welfare spending of governments, increasing pov-
erty and inequality. Liberalism stems from the work of Adam Smith’s
The Wealth of Nations, where he encourages minimal government
intervention in the economy so that trade can flourish (Rotarou &
Sakellariou, 2017). This liberal view of economy dominated for the
following 150 years until it was replaced in the 1930s by Keynesian
economics. Keynesian economics endorsed a mixed economy in
which the private sector could function with an interventionist
role of the government, especially during recessions (Rotarou &
Sakellariou, 2017). This economic model was the standard followed
by high- income nations from the later part of the Great Depression
until the oil crisis in the 1970s. At this point, neoliberalism emerged
in the economic and political debate with the introduction of neolib-
eral economic theories by Friedrich Hayek and Milton Friedman, and
neoliberalism then spread after the elections of Margaret Thatcher
in the United Kingdom and Ronald Regan in the United States (Bell &
Green, 2016; Rotarou & Sakellariou, 2017).

In the 1990s, under the guidance of international institutions
such as the International Monetary Fund (IMF) and the World Bank,
middle- income and low- income governments were forced to limit
their interventionist role; instead, they proceeded to reduce capital
controls and massive and unregulated privatization of state enter-
prises and to limit social welfare. Both institutions introduced the
Washington Consensus, a set of economic policy prescriptions for
middle- income and low- income countries. These economic prescrip-
tions imposed by the IMF and the World Bank opened the econ-
omy of the world to neoliberalism (Mukhopadhyay, 2013; Rotarou &
Sakellariou, 2017; Vargas Bustamante & Mendez, 2014). Confidence
in neoliberal policies as the only way to invigorate the economy
faded away in the 1990s when the Washington Consensus received
negative results, as there was no indication that neoliberal policies
had indeed produced economic growth (Hartmann, 2016; Rotarou
& Sakellariou, 2017). As such, neoliberalism has been pinpointed as
the main culprit behind the increases in socioeconomic disparities,
high rates of poverty, unemployment, and violence, worsened work-
ing conditions, and reduced social security (Rotarou & Sakellariou,
2017).

Scholars have considered health a productive asset that affects
the economic growth of any nation (Hartmann, 2016; Mukhopadhyay,
2013), and the market- based dominance of healthcare is a relatively
recent phenomenon in many countries throughout the world. Before
the imposition of neoliberalism in the mid- 1970s, health was con-
sidered a public good and responsibility of governments (Hartmann,
2016; Rotarou & Sakellariou, 2017). In Latin America, health and so-
cial security reforms promote the development of basic benefit pack-
ages, target basic care to the poorest, and stimulate the involvement
of private companies in the provision of healthcare insurance and
services (Vargas Bustamante & Mendez, 2014). However, the pro-
vision of care by private conglomerates has had serious effects on
the quality, accountability, cost, access, and equity of health systems

around the globe. Private companies focus on increasing profits and
not on providing affordable and good- quality care, leading to dete-
riorated health systems, increased urban- rural divide, and increased
inequalities of access to healthcare services (Mooney, 2012; Rotarou
& Sakellariou, 2017; Vargas Bustamante & Mendez, 2014). The regu-
lation of health systems and the welfare state by neoliberal policies
makes it difficult to define health as a basic human right (Rotarou
& Sakellariou, 2017). Yet, neoliberalism perceives healthcare sys-
tems as commodities where productivity and economic growth are
the sources of potential revenue. In neoliberalism, health systems
cannot be public and social goods. Institutions such as the IMF and
World Bank promote healthcare systems with a market- oriented
concept in which reductions in public sectors and the introduction
of user fees and other costs reduce access to healthcare for the poor
(Mooney, 2012; Rotarou & Sakellariou, 2017). As such, neoliberalism
has brought devastating consequences, including the widening so-
cial disparities and the concentration of income and wealth among a
few (Navarro, 2009).

3  | THE COLOMBIAN HE ALTH REFORM

In 1993, the Colombian government introduced its market- oriented
healthcare reform (Arroyave, Cardona, Burdorf, & Avendano, 2013;
Bernal, Forero, & Forde, 2012; Bernal & Zamora, 2014). The main
goal of the health reform addressed the funding crisis in the pub-
lic social security institute through increased healthcare spending
while increasing coverage by encouraging the participation of pub-
lic and private service with regulated competition (Arroyave et al.,
2013; Bernal & Zamora, 2014; Londono & Molano, 2015; Vargas
Bustamante & Mendez, 2014). The Colombian healthcare system is
financed through a combination of payroll contributions and general
taxation. The comprehensive national insurance scheme includes a
contributory regime for those able to pay and a subsidized scheme
for low- income individuals. Users enroll with public or private insur-
ers, have legal rights to an explicit package of health benefits, and
receive care from a mix of public and private providers. Furthermore,
Colombian citizens who are employed and independent workers
earning more than a predetermined minimum income must enroll in
the contributory health insurance regime. Low- income individuals
are identified through a proxy means test (Bernal & Zamora, 2014).
Benefits from the health reform included increased coverage, de-
creased individual spending, and better insurance equity (Arroyave
et al., 2013; Bernal & Zamora, 2014; Cucunuba et al., 2017).

Despite these benefits, the health reform has received some
criticism. The reform has increased the complexity of the healthcare
system, potentially leading to delays in access to health services and
reduced spending in prevention and public health (Arroyave et al.,
2013). The system has also been threatened by the increased af-
filiation of citizens in the subsidized scheme or those who do not
contribute to the system. Thus, even though the benefit plan is
equal, the value per capita paid by the general system of health to
each insurance company is not equal, decreasing the leadership and

4 of 8  |     CAMARGO PLAZAS

legitimacy by the Ministry of Health (Bernal & Zamora, 2014; Bernal
et al., 2012). The health system lacks preparation for the social re-
ality of Colombia, which experiences typical changes of transitional
societies such as an aging population, decreasing fertility, rapid ur-
banization, and the persistence of infectious diseases with concomi-
tant increasing of chronic conditions (Wesbter, 2012).

The health reform in Colombia shifted the financing and pro-
vision boundary between public and private services following im-
posed neoliberal policies. Although the health reform was an attempt
to guarantee the fundamental right to health for all Colombians
(Londono & Molano, 2015), there is still much to do and improve.
The practical application of the health reform has shown signifi-
cant disconnectedness between the public health approach and the
market- driven vision of the government (Londono & Molano, 2015;
Vargas Bustamante & Mendez, 2014). Currently, the healthcare sys-
tem requires a structural reform that is independent from the private
sector. As such, swapping the goal of the health system from being
profit driven to providing health benefits makes health not merely a
legal statement (Londono & Molano, 2015).

4  | NURSING IN COLOMBIA

Nursing started in Colombia as a vocation practiced by Catholic nuns
and monks. The first course for midwives was started on 22 September
1867 in the National University in Bogota. At the end of the 19th cen-
tury and the beginning of the 20th century, the art of nursing was
taught by physicians, nuns, and philanthropic women from prestigious
families of Colombia (Velandia Mora, 1995). The first school for nurs-
ing started in 1924 in Cartagena at the Santa Clara Hospital, and that
course was initiated by two physicians, Drs. Jose Caballero and Rafael
Calvo. Dr. Calvo had been to France and, impressed with how nursing
was organized there, decided to establish the same method of training.
As with others around the world, the initial school was established in
the style of Florence Nightingale’s school (Velandia Mora, 1995).

Meanwhile, in Bogota, the same kind of patron system of nursing
schools was developed. Women from wealthy families were the first
students at those schools and, from 1929 to 1932, the government
addressed the organization of nursing schools that were part of the
faculties of medicine. Those schools were characterized by their
discipline, uniform, and rules that were reminiscent of the convents
(Velandia Mora, 1995). Another important fact concerns how schools
were divided with respect to specialties. For example, in Bogota, the
school was hospital based, while the Cartagena school focused on
public health. In 1937, the National University of Colombia in Bogota
was reorganized to improve the course of nursing and transferred
the program from the San Juan de Dios Hospital to the new San Jose
Hospital. Two types of education were developed: One type was for
nurses who visited patients at home (the origin of the social worker
in Colombia), and the other type was for hospital- based nurses.

At this time, nursing acquired the status of a profession in
Colombia (Velandia Mora, 1995). Colombia had always looked for ad-
vice in nursing from other countries from 1935 to 1954, but in 1935,

Helena Samper, a Colombian nurse trained in the USA, returned to
Colombia and became the director of the faculty of nursing. The fac-
ulty started to become autonomous, but in 1939, Samper died and
the faculty was again directed by a physician. Although the faculty
was part of the university, the entity in charge of the faculty was
the Ministry of Health (Velandia Mora, 1995). In 1942, PAHO sent
to two nurses Bogota, the Canadian Helen Howitt and the American
Johanna Schwarte, to advise the faculty of nursing in the National
University. In 1945, the faculty left the Ministry of Health and started
to be part of the university, and Helen Howitt served as dean of the
faculty of nursing until 1957 (Malvarez & Castrillon Agudelo, 2005).

In 1946, the government determined the modalities of schools in
nursing education as follows: The first group included general nurse and
clinical nurse as 3- year programs and specialist nurse as a 4- year pro-
gram; the second group included auxiliary nurse, clinical auxiliary nurse,
auxiliary midwife nurse, and helpers as 1- year programs (Velandia Mora,
1995). In 1961, a 4- year professional study program was created at the
National University. This degree focused on establishing nursing teach-
ers by having nurses in a 3- year program take an extra course. Nursing
education continued to focus on public health and hospital- based nurs-
ing through the 1960s. This trend of 4- year programs for professionals
and 12 months for auxiliaries has continued over time (Velandia Mora,
1995), although today, undergraduate programs are all 5- year programs.

In terms of education, in Colombia the Asociación Colombiana
de Facultades de Enfermería (ACOFAEN) [Colombian Association of
Faculties of Nursing] oversees accrediting nursing programmes. In
1980, there were 13 universities with nursing programs; in 2004,
the number of universities increased to 30. To date, 50 nursing pro-
grams have been created but only 47 fulfill the regulations of quality
established by ACOFAEN. Colombia also has a long- standing tradi-
tion of graduate education. Master’s degrees and specialization de-
grees have been available for over 30 years (Malvarez & Castrillon
Agudelo, 2005; Velandia Mora, 1995). The doctoral program was
also developed in the 2000s. Law 266/1996 and Law 911/2004 are
the legislative frameworks established to regulate the practice of
nursing in Colombia. Law 266 constituted the National Council of
Nursing and established the Tribunal for Nursing Ethics. It defined
the aims and principles of professional practice, competencies, re-
sponsibilities, quality of care, and the nature and scope of the prac-
tice. It also established the unique national license for professionals.
Before this law, registration was regulated and handled by the gov-
ernment. In addition, Law 911 defined the ethical and disciplinary re-
sponsibility of nursing professional practice. However, these laws do
not regulate nursing salaries, working hours, and the range of duties
for professionals; thus, employment conditions continue to be reg-
ulated and controlled by national legislation that also includes other
health workers (Malvarez & Castrillon Agudelo, 2005).

5  | NURSING PR AC TICE IN COLOMBIA

Nursing is a profession centered in human beings. To watch and learn
about the individual, we need to understand the life of a patient as a

     |  5 of 8CAMARGO PLAZAS

whole, and by understanding the life of a patient, nurses can address
their efforts toward specific necessities. In nursing, we go beyond
what is affecting that unique human being, because it is not possible
to generalize the situation of a person; for example, not all diabetics
suffer the same symptoms. We cannot observe the disease to under-
stand the person; in nursing, it is necessary to see the person to take
care of the disease. As nurses, we open our eyes to the experience
of the other. In nursing, caring for the other is a moment of mutual
accomplishment between nurse and patient. It is a moment when
care is the bridge between two worlds. In addition, it is a moment
with one goal—the recognition of the other through the vicarious
experience of illness. Through these interactions, we get to know
what it is like to experience health and illness (Camargo Plazas &
Cameron, 2015; Camargo Plazas et al., 2012). As human beings, we
need one another to survive, and our actions toward others need
to be based on understanding the perspectives and vulnerabilities
of others (Cameron, Carmargo Plazas, Salas, Bourque- Bearskin, &
Hungler, 2014). Consequently, the interaction implies being a part of
the world of other people, and the interchange experience is always
under parameters of mutual respect and recognition.

Are our actions always congruent with our essence? To answer
this question, I present a particular nursing situation that occurred in
an emergency setting in Colombia. This story evolved from a critical
hermeneutic phenomenological study investigating the experience
of living with a chronic illness in the age of globalization in Colombia
and Canada (Camargo Plazas, 2011). Hermeneutic phenomenology
explores the various dimensions of human experience in human situ-
ations such as embodiment, spatiality, relationality, and temporality.
Critical pedagogy as a theoretical perspective invoking the work of
Paulo Freire and Enrique Dussel was used to examine emerging find-
ings in the context of globalization and its resulting global inequities.
Hannah was the youngest participant of the study, and she was 26
when we met. She had been living with chronic illness for 10 years
of her life. Despite her young age, Hannah has gone through many
difficulties. In particular, many bad experiences with healthcare pro-
fessionals, friends, and some relatives have shaped her experience
with the illness. She became a nurse to fight the indifference she
suffered for a long period in the healthcare system. The following
story portrays Hannah’s perception of what nursing care is when she
is a patient and her reflection of what a nurse should be.

They were running from one side to the other, moving
patients from one side to another, all except me. It was
complete chaos. I understand they were busy, but I was
ill and I just needed at least one stretcher to rest my pain-
ful body. I kept trying to call them, but nothing resulted.
After 2 hr of being in pain, I called my mom, who was
outside in the waiting room, just to see a friendly face.
My mom, on her way in, talked to the nurse and told her,
“My daughter is your colleague. She is a nurse too and
she is suffering. She is in pain. She cannot wait any lon-
ger in a wheelchair. Please help her”. The nurse answered
back with indifference, “Sorry, it’s not my problem. Her

problem is the doctor’s problem.” I know it was not her
problem, because it was not her body, the one in pain. It
was my body, the one in pain. I was the one in pain. I was
just asking for a little compassion. It is sad to see how we
are prepared for one thing, but in practice, we do a dif-
ferent one. As a patient, in my moments of vulnerability
I like to see that there are friendly faces for me. When
you are ill you always need a friendly hand helping you to
go through the moment of crisis. During the moments of
illness, what someone needs is support, a friendly hand
that lets you know everything is going to be all right.
When you are a patient, you need a shoulder to rely on,
someone that makes you laugh, and someone that rec-
ognizes you as a human being. There is something else
besides the painkiller or the nursing procedures, and it is
the presence and understanding of another human being
(Hannah)

Sadly, Hannah’s story is lived every day and everywhere by many
people living with chronic illness in Colombia. Despite their nursing
mandate to care for human beings, Colombian nurses have been com-
pelled to work under the precepts of competence, consumerism, and
individualism of the healthcare system (Camargo Plazas & Cameron,
2015). In this story, Hannah is asking for solidarity and compassion
from the nurses, but on the pathway to recovery and control of her ill-
ness, she found indifference and dehumanizing care. She experienced
abandonment from the nurses who did not appreciate the constraints
placed by her chronic condition. The nurses that cared for Hannah
were indifferent, and she was merely a spectator of their actions. They
worked over her ill body as if she were a car or another object in need
of repair. Furthermore, they acted over her mechanically without con-
sidering her well- being. There was little compassion in the attention
she received. However, she claimed respect.

What makes these nurses act in that way? Perhaps the way the
health system is organized kills the humaneness of healthcare pro-
fessionals. Stories such as Hannah’s are a dramatic example of how
the expansion of private insurance services in Colombia has not im-
proved health services for vulnerable populations. The corporate
push toward extreme efficiency, calculability, predictability, and
control by the health reform has changed the relationship between
healthcare professionals and patients (Camargo Plazas et al., 2012).
As (Austin, 2011) stated,

We find that the growing inflexibility of interactions
demanded by the customer service model glosses over
the mutual vulnerability inherent in the nurse- patient
relationship and reduces the capacity for the nurse’s self-
reflection and- enactment in order to maximize his or her
“productive activity” in a competitive service environ-
ment (p. 161)

In Colombia, under health reform, the relationship between patient
and nurse has become primarily instrumental. Nursing care is then

6 of 8  |     CAMARGO PLAZAS

replaced by the fulfillment of predictable tasks serving expectant con-
sumers, as described in Hannah’s story. Hannah’s experience shows
how people with chronic illness live under the pressure of corporate
agendas and rigid neoliberal structures that serve to dehumanize their
condition (Camargo Plazas et al., 2012). Regardless of the effects of
the health reform on health status, much of nursing work has been
focussed toward the management of pathologies—indeed, it remains
highly medicalized (Camargo Plazas et al., 2012). Health systems orga-
nize themselves around the idea of disease care, rather than healthcare
(Austin, 2011; Eliason, 2015; Rotarou & Sakellariou, 2017).

Since the 1990s, neoliberalism has been the primary ideology
driving the Colombian government, economy, and healthcare de-
livery (Camargo Plazas et al., 2012). Neoliberal policies encourage
the loss of government regulation and funding of health and human
services by replacing government intervention with a private market
economy. This for- profit orientation has changed healthcare systems
around the world from emphasizing patient- centered care and qual-
ity to emphasizing cost- savings and efficiency, transforming nurs-
ing care into a commodity for sale (Eliason, 2015). Although nursing
as a profession has not been the apparent focus of the policy and
program alterations promoted and implemented to restructure the
delivery of healthcare, neoliberalism has profoundly affected the
practice of nursing in Colombia. Restructuring efforts have focused
on organizational restructuring with current changes in how health-
care funding is allocated and how certain services are delivered. The
goal is to provide health services more efficiently and effectively.

The core of nursing is its relationship with the patient, family, and
community (Cameron, 2006), and that relationship must be at the
center of a patient- oriented healthcare system. However, a profit-
oriented healthcare system can neither produce an authentic rela-
tionship nor the intimacy of caring (Austin, 2011). As such, in the
Colombian health system, quality has been exchanged for quantity,
and the eventual result is a healthcare system that is seen as a market
with goals that focus on supply, demand, and competition, thereby
reducing the patient to a mere consumer. Today, worldwide, we
dehumanize and exploit each other for the sake of economic profit
and technological advantage. In some sense, there is no place for
respectful or ethical values, neither for self nor for the other. Both
respect and ethical values are treated with indifference (Camargo
Plazas et al., 2012).

In hospital- based car, a set of new responsibilities in service and
cost management has been imposed on nurses. This means that
nursing work has been relegated to administrative and clerical tasks,
and much of the responsibility for nursing care has been delegated
to less prepared and less trained personnel (Cogollo- Milanes et al.,
2010). In addition, sometimes working in the social enterprises of
the state or old public hospitals means having to face institutional
shortages in human resources, supplies, and equipment, and this
generally creates poor morale and job dissatisfaction (Castillo Avila,
Torres Llanos, Ahumada Gomez, Cardenas Tapia, & Licona Castro,
2014; Cogollo Milanes & Gomez Bustamante, 2010). Due to the re-
duction in costs, nurses have been forced to undertake more work
with fewer auxiliary staff members. In addition, work in hospital

settings is recognized as both physically and mentally demanding.
Staff shortages only increase the exposure of nurses to emotional
stress and fatigue. Nurses also perceive that the social value of the
profession is less appreciated and recognized by society, a situation
that has caused many nurses to resign (Castillo Avila et al., 2014;
Cogollo- Milanes et al., 2010). In Colombia, nurses continue to go to
work and are expected to provide excellent nursing care. But how?

6  | WHERE DO WE GO FROM HERE?

Clearly, market- driven reorganization of the healthcare system goes
against the essence of nursing that is to care for human beings. Is it
possible to find harmony between the two opposites? The panorama
of nursing practice in Colombia seems dark, but to use the words of
Freire (2002), “the future is problematic and not already decided,
fatalistically” (pp. 13–14). Then, the course of our lives is not pre-
determined and there is opportunity for change (Freire, 2004). To
achieve this social change, it is necessary to question the system and
to create new systems and structures (Dussel, 2006).

Neoliberal policies have negatively impacted the humaneness
of healthcare professionals. For instance, most professionals must
fight to position themselves as human beings in the healthcare sys-
tem. Health must be considered as a matter of social justice, because
health and the social determinants of it are issues of human rights;
consequently, an equitable distribution of resources is thought to be
the best approach for good healthcare (Austin, 2011; Eliason, 2015).
Justice in health requires societies to provide individuals with the
necessary conditions to reach the goal of health. A world in which
human beings suffer and die unnecessarily when it is possible to
provide a solution is unfair and unjust (Austin, 2011). To deal with
unfairness and injustice, it is necessary to attend to the underlying
societal causes of disparities (World Health Organization, 2007).

The aim of governments is not to eliminate all health differences
but rather to decrease to the lowest level possible or eliminate those
that result from avoidable and unfair factors (Eliason, 2015). In the-
ory, this aim is a good one; however, in reality, minorities must face
restrictions, and governments are controlled by external forces that
make it impossible to control the widening gap. Thus, instead of fo-
cusing on providing well- being for all, governments have focused on
ensuring market competence, which, when coupled with globaliza-
tion, cause direct and indirect effects on health. The direct effects
of globalization on health are related to the impact on health sys-
tems, health policies, and the exposure to hazards such as tobacco
marketing. The indirect effects are related to trade liberalization
and the availability of resources for public expenditure on health
with its resulting effects on living conditions and household income
(Hartmann, 2016; Labonte et al., 2015). Meanwhile, minorities con-
tinue to expose themselves to risky behaviors and struggle with
a lack of treatment continuity and lack of money to pay for care,
consequently living with uncontrolled illnesses and functional lim-
itations. The state needs to focus on providing adequate attention
on human beings, changing the concept of the creation of wealth as

     |  7 of 8CAMARGO PLAZAS

equivalent to eliminating inequality, and understanding that health
inequities always have moral and ethical dimensions (Austin, 2011;
Eliason, 2015; Selberg, 2013). Health systems need to become more
humane, exemplifying equality and a real commitment in relation to
the universal principles they promote. As nurses and members of the
Colombian healthcare system, our responsibility is to be advocates
for our patients. However, our advocacy in this world of inequalities
must take into consideration that self- determination and freedom
are the most significant and priceless human rights (Austin, 2011).

An example of dedication and commitment toward advocating
for caregivers of people living with chronic conditions occurred in
2008 when Bill 163 was presented to the Colombian senate. This bill
was the result of 14 years of research and leadership of the Chronic
Patients and Families Care Support Group associated with the
Faculty of Nursing at the National University of Colombia (Barrera,
De Camargo, Figueroa, Afanador, & Herrera, 2006). Bill 163 entails
the protection of the rights to health, access to healthcare, and to
pay for full- time caregivers for people with long- term disabilities.
These are rights not contemplated previously in Law 100 (Barrera
et al., 2006; Barrera- Ortiz et al., 2005). This group of nurses decided
not to remain in the background or be added as an afterthought to
the policy arena. They decided to act and, as a result, changed the
reality of that abandonment of the caregivers of people with chronic
conditions (Barrera et al., 2006).

This bill has been a first step in a long and not always friendly
pathway. Through these actions, we have learned that we can have
a voice and a vote. We need to recognize the context of our world
to be able, through actions, to neutralize the oppressive elements of
that reality such as the reality of the lack of access of healthcare for
people with chronic illness in Colombia. We cannot remain neutral
(Freire, 2004), because a profit- driven health system affects how
we practice, educate, research, and develop knowledge in nursing;
therefore, the social mandate must look forward and deal with the
individual and a more inclusive view of human beings. Thus, in nurs-
ing we cannot allow our understanding of and care for human beings
to be restricted to market terms or economic profit. We must neither
forget nor forgo our purpose to treat each person as a unique human
being with diverse needs.

7  | CONCLUSION

As members of the healthcare system and Colombians, we cannot
forget that our response toward privatization and market- oriented
practice must be centered in leadership and in re- orienting our
local and national healthcare systems toward ethics. We cannot
close our eyes to what is happening now in hospitals or community
settings in our country, because our responsibility is to promote
health, prevent disease, and care for human beings. As nurses, we
need to develop the compassion to deal with the asymmetrical, un-
equal, competitive, and consumerist politics of our health system.
In that way, we must try to go beyond the barriers that have built up
within the health system—a health system that pretends to espouse

equality and universality, but it does not in many ways. Adhering to
our mandate, we must follow the ongoing dialogue about wealth,
social position, and health outcomes, because we are there on
the front lines of implementing the healthcare policies of society.
Also, our goals as nurses must include addressing the welfare and
protection of our patients. As such, regarding the policies of com-
petence imposed by the Colombian health system, nurses need to
continue to be socially and politically active to defend the rights of
our patients while considering that the problem does not have an
easy answer. The situation requires compromise and concrete solu-
tions. Therefore, our priority is to prevent and manage disease, to
handle the policies of the health system, and to follow the essence
of our profession by trying to provide quality care.

ORCID

Pilar Camargo Plazas http://orcid.org/0000-0002-8349-7723

R E FE R E N C E S

Arroyave, I., Cardona, D., Burdorf, A., & Avendano, M. (2013). The im-
pact of increasing health insurance coverage on disparities in mor-
tality: Health care reform in Colombia, 1998- 2007. American Journal
of Public Health, 103(3), e100–e106. https://doi.org/10.2105/
AJPH.2012.301143

Austin, W. J. (2011). The incommensurability of nursing as a prac-
tice and the customer service model: An evolutionary threat to
the discipline. Nursing Philosophy, 12(3), 158–166. https://doi.
org/10.1111/j.1466-769X.2011.00492.x

Barrera, L., De Camargo, L. B., Figueroa, I. P., Afanador, N. P., & Herrera,
B. S. (2006). Habilidad de cuidadores familiares de personas con
enfermedad crónica: Mirada internacional [The caregivers’ ability
to care for people living with chronic diseases: An international ap-
proach]. Aquichan, 6(1), 22–23.

Barrera-Ortiz, L., Galvis Lopez, C. R., Moreno Fergusson, M. E., Pinto-
Afanador, N., Pinzon Rocha, M. L., Romero Gozalez, E., & Sanchez
Herrera, B. (2005). La habilidad de cuidado de los cuidadores famil-
iares de personas con enfermedad crónica [The ability to care by
caregivers of people living with chronic conditions]. Investigacion y
Educación en Enfermería, 24(1), 36–46.

Bell, K., & Green, J. (2016). On the perils of invoking neoliberalism in
public health critique. Critical Public Health, 26(3), 239–243. https://
doi.org/10.1080/09581596.2016.1144872

Bernal, O., Forero, J. C., & Forde, I. (2012). Colombia’s response to
healthcare crisis. British Medical Journal, 344, e802. https://doi.
org/10.1136/bmj.e802

Bernal, O., & Zamora, D. C. (2014). A better understanding of reasons
for the failure of the healthcare reform in Colombia. Health, 6, 2918–
2926. https://doi.org/10.4236/health.2014.621330

Bloom, G., Henson, S., & Peters, D. H. (2014). Innovation in regulation
of rapidly changing health markets. Globalization and Health, 10(53),
2–11.

Bockman, J. (2013). Neoliberalism: Key concepts in social research.
Contexts, 12(3), 14–15. https://doi.org/10.1177/1536504213499873

Bourdieu, P. (1998). Utopia of endless exploitation: The essence of neolib-
eralism. Le Monde Diplomatique. Retrieved from: https://mondediplo.
com/1998/12/08bourdieu

Brown, G. W., & Labonte, R. (2011). Globalization and its methodological
discontents: Contextualizing globalization through the study of HIV/
AIDS. Global Health, 7, 29. https://doi.org/10.1186/1744-8603-7-29

http://orcid.org/0000-0002-8349-7723

http://orcid.org/0000-0002-8349-7723

https://doi.org/10.2105/AJPH.2012.301143

https://doi.org/10.2105/AJPH.2012.301143

https://doi.org/10.1111/j.1466-769X.2011.00492.x

https://doi.org/10.1111/j.1466-769X.2011.00492.x

https://doi.org/10.1080/09581596.2016.1144872

https://doi.org/10.1080/09581596.2016.1144872

https://doi.org/10.1136/bmj.e802

https://doi.org/10.1136/bmj.e802

https://doi.org/10.4236/health.2014.621330

https://doi.org/10.1177/1536504213499873

https://mondediplo.com/1998/12/08bourdieu

https://mondediplo.com/1998/12/08bourdieu

https://doi.org/10.1186/1744-8603-7-29

8 of 8  |     CAMARGO PLAZAS

Camargo Plazas, M. D. P. (2011). Understanding the experience of living
with chronic illness in the age of globalization (Unpublished doctoral
dissertation). University of Alberta, Edmonton, Canada.

Camargo Plazas, M. D. P., & Cameron, B. L. (2015). Using Freire’s par-
ticipatory educational method to understand the experience
of living with chronic illness in the current age of globalization.
Journal of Nursing Research, 23(2), 83–93. https://doi.org/10.1097/
JNR.0000000000000090

Camargo Plazas, M. D. P., Cameron, B. L., & Smith, D. G. (2012). Neoliberal-
Oriented health care system answer to global competition or a threat to
health equality for people with chronic illness. Advances in Nursing Science,
35(2), 166–181. https://doi.org/10.1097/ANS.0b013e31825372a4

Cameron, B. L. (2006). Towards understanding the unpresentable in nurs-
ing: Some Nursing philosophical considerations. Nursing Philosophy,
7(1), 23–35. https://doi.org/10.1111/j.1466-769X.2006.00246.x

Cameron, B. L., Carmargo Plazas, M. D. P., Salas, A. S., Bourque-Bearskin,
R. L., & Hungler, K. (2014). Understanding Inequalities in access to
health care services for Aboriginal people: A call for Nursing action.
Advances in Nursing Science, 37(3), E1–E16. https://doi.org/10.1097/
ANS.0000000000000039

Castillo Avila, I. Y., Torres Llanos, N., Ahumada Gomez, A., Cardenas Tapia, K.,
& Licona Castro, S. (2014). Estrés laboral en enfermería y factores aso-
ciados [Nursing work- related stress and associative factors]. Cartagena
(Colombia). Salud Uninorte, 30(1), 34–43. https://doi.org/10.14482/sun

Cogollo Milanes, Z., & Gomez Bustamante, E. (2010). Condiciones laborales
en enfermeras de de Cartagena, Colombia [Nursing working conditions
in Cartagena, Colombia]. Avances en Enfermeria, XXVII, I(1), 31–38.

Cogollo-Milanes, Z., Batista, E., Cantillo, C., Jaramillo, A., Rodelo, D.,
& Meriño, G. (2010). Desgaste profesional y factores asociados en
personal de enfermería de servicios de urgencias de Cartagena,
Colombia [Professional attrition and related factors among emer-
gency nursing staff in Cartagena, Colombia]. Revista Aquichan, 10(1),
43–51. https://doi.org/10.5294/aqui

Cucunuba, Z. M., Manne-Goehler, J. M., Diaz, D., Nouvellet, P., Bernal,
O., Marchiol, A., … Conteh, L. (2017). How universal is coverage and
access to diagnosis and treatment for chagas disease in Colombia?
A health systems analysis. Social Science Medicine, 175, 187–198.
https://doi.org/10.1016/j.socscimed.2017.01.002

Dussel, E. (2006). Globalization, organization and the ethics of liberation.
Organization, 13(4), 489–508. https://doi.org/10.1177/1350508406065852

Eliason, M. J. (2015). Neoliberalism and health. Advances in Nursing Science,
38(1), 2–4. https://doi.org/10.1097/ANS.0000000000000055

Freire, P. (2002). Pedagogy of the oppressed. New York: Continuum.
Freire, P. (2004). Pedagogy of indignation. Boulder-London: Paradigm

Publishers.
Hartmann, C. (2016). Postneoliberal public health care reforms:

Neoliberalism, social medicine, and persistent health inequities in
Latin America. Perspectives from the Social Sciences, 106(12), 2145–
2151. https://doi.org/doi: 10.2105/AJPH.2016.303470

Harvey, D. (2005). A brief history of neoliberalism. New York: Oxford
University Press Inc.

Labonte, R., Cobbett, E., Orsini, M., Spitzer, D., Schrecker, T., & Ruckert,
A. (2015). Globalization and the health of Canadians: ‘Having a
job is the most important thing’. Global Health, 11, 19. https://doi.
org/10.1186/s12992-015-0104-1

Londono, E., & Molano, P. (2015). Are Colombia’s reforms enough for
a health- care system in crisis? Lancet, 385(9981), 1943. https://doi.
org/10.1016/S0140-6736(15)60952-7

Malvarez, S., & Castrillon Agudelo, M. C. (2005). Overview of the nurs-
ing workforce in Latin America. In Human Resources Development
Series (No. 39). Washington, DC: Pan American Health Organization.
Retrieved from https://www.hrhresourcecenter.org/node/629

Martens, P., Akin, S. M., Maud, H., & Mohsin, R. (2010). Is global-
ization healthy: A statistical indicator analysis of the impacts
of globalization on health. Global Health, 6, 16. https://doi.
org/10.1186/1744-8603-6-16

Mooney, G. (2012). Neoliberalism is bad for our health. International
Journal of Health Services, 42(3), 383–401. https://doi.org/10.2190/
HS.42.3.b

Mukhopadhyay, I. (2013). Universal health coverage: The new face
of neoliberalism. Social Change, 43(2), 177–190. https://doi.
org/10.1177/0049085713492281

Navarro, V. (2009). What we mean by social determinants of health.
International Journal of Health Services, 39(3), 423–441. https://doi.
org/10.2190/HS.39.3.a

Rotarou, E. S., & Sakellariou, D. (2017). Neoliberal reforms in health sys-
tems and the construction of long- lasting inequalities in health care:
A case study from Chile. Health Policy, 121(5), 495–503. https://doi.
org/10.1016/j.healthpol.2017.03.005

Selberg, R. (2013). Nursing in times of neoliberal change: An ethno-
graphic study of nurses’ experiences of work intensification. Nordic
Journal of Working Life Studies, 3(2), 9–35. https://doi.org/10.19154/
njwls.v3i2.2548

Smith, D. G. (1999). On being critical about language: The critical the-
ory tradition and implications for language education. In D.G. Smith
(Ed.), Pedagon: Mediation of pedagogy and culture (pp. 137–150). Bragg
Creek, AB: Makyo Press.

Smith, D. G. (2010). Can wisdom trump the market as a basis for edu-
cation? In K. Young, & D. Stanley (Eds.), Contemporary studies in
Canadian curriculum: Principles portraits and practices (pp. 1–16).
Calgary, AB: Detseling Publishers.

Soleymani, M. (2010). The heavy price of globalization: Globalization
and sustainable development. Perspectives on Global
Development and Technology, 9(1–2), 101–118. https://doi.
org/10.1163/156914910X487942

Vargas Bustamante, A., & Mendez, C. A. (2014). Health care privatization
in Latin America: Comparing divergent privatization approaches in
Chile, Colombia, and Mexico. Journal of Health Politics, Policy and Law,
39(4), 841–886. https://doi.org/10.1215/03616878-2743063

Velandia Mora, A. L. (1995). Historia de la enfermería en Colombia [History
of nursing in Colombia]. Bogota, Colombia: Universidad Nacional de
Colombia Publisher.

Wesbter, P. C. (2012). Health in Colombia: A system in crisis. Canadian
Medical Association Journal, 184(6), E289–E290. https://doi.
org/10.1503/cmaj.109-4124

World Health Organization (WHO). (2007). The Bangkok Charter for
health promotion in a globalized world. Health Promotion International,
21(81), 10–15.

How to cite this article: Camargo Plazas P. Understanding
the space of nursing practice in Colombia: A critical reflection
on the effects of health system reform. Nurs Inq.
2018;25:e12242. https://doi.org/10.1111/nin.12242

https://doi.org/10.1097/JNR.0000000000000090

https://doi.org/10.1097/JNR.0000000000000090

https://doi.org/10.1097/ANS.0b013e31825372a4

https://doi.org/10.1111/j.1466-769X.2006.00246.x

https://doi.org/10.1097/ANS.0000000000000039

https://doi.org/10.1097/ANS.0000000000000039

https://doi.org/10.14482/sun

https://doi.org/10.5294/aqui

https://doi.org/10.1016/j.socscimed.2017.01.002

https://doi.org/10.1177/1350508406065852

https://doi.org/10.1097/ANS.0000000000000055

https://doi.org/doi:10.2105/AJPH.2016.303470

https://doi.org/10.1186/s12992-015-0104-1

https://doi.org/10.1186/s12992-015-0104-1

https://doi.org/10.1016/S0140-6736(15)60952-7

https://doi.org/10.1016/S0140-6736(15)60952-7

https://www.hrhresourcecenter.org/node/629

https://doi.org/10.1186/1744-8603-6-16

https://doi.org/10.1186/1744-8603-6-16

https://doi.org/10.2190/HS.42.3.b

https://doi.org/10.2190/HS.42.3.b

https://doi.org/10.1177/0049085713492281

https://doi.org/10.1177/0049085713492281

https://doi.org/10.2190/HS.39.3.a

https://doi.org/10.2190/HS.39.3.a

https://doi.org/10.1016/j.healthpol.2017.03.005

https://doi.org/10.1016/j.healthpol.2017.03.005

https://doi.org/10.19154/njwls.v3i2.2548

https://doi.org/10.19154/njwls.v3i2.2548

https://doi.org/10.1163/156914910X487942

https://doi.org/10.1163/156914910X487942

https://doi.org/10.1215/03616878-2743063

https://doi.org/10.1503/cmaj.109-4124

https://doi.org/10.1503/cmaj.109-4124

https://doi.org/10.1111/nin.12242

NUR4667 / Professional Paper

Rubric for NUR 4667 Professional Paper

Criteria Outstanding Acceptable Unacceptable Points

Introduction

Up to 10 points

Provides an introduction to the

topic of the paper. Explains the

significance and rationale for topic

chosen.

Minimally compliant with

guidelines.

Non-compliant with

guidelines.

Content

Up to 30 points

Provides a thorough discussion of

the topic and/or answers specific

questions depending on the topic

chosen:

1) Description of a Health System

2) Global Health Issue

Although discussion of the

topic and/or answers the

questions are provided, they

lack rigor and depth.

Inadequate or minimal

discussion of the topic

and/or questions are left

unanswered. Non-compliant

with guidelines.

Literature Cited

Up to 10 points

A minimum of six (6) current

references (within the last five

years) are cited in the paper. Each

reference should be specifically

related to the

topic or content of the

paper.

Six (6) current references

are selected, however they

were not appropriate to the

topic or content of the
paper.

Less than six (6) references

are selected, and/or one or

more of the references are

not current.

Conclusion

Up to 10 points

The conclusion of the paper

summarizes the information

presented, and relates the

knowledge gained back to the topic

of the paper.

Minimally compliant with
guidelines.

Non-compliant with
guidelines.

Organization &

Clarity of Writing

Up to 20 points

The paper flowed well with clarity,

and was suitably organized.

Writing is crisp, clear, and succinct.

The writer incorporates the active

voice when appropriate.

Writing and organization is

generally clear, but

unnecessary words are

occasionally used. Meaning

is sometimes hidden.

Paragraph or sentence

structure is often repetitive.

The paper poorly organized

and writing was difficult to

follow throughout. It is

hard to know what the

writer is trying to express.

Writing is convoluted.

APA Format,

Grammar,

Spelling,

Plagerism

Up to 20 points

Font, spacing, and APA format are

correct. All needed citations were

included in the report. References

matched the citations, and all were

encoded in APA format. Spelling

and grammar are correct.

Font, spacing, or APA

format

have minimal errors.

Citations and reference list

have minimal errors.

Spelling and grammar

errors are minimal.

Font, spacing, and APA

format are incorrect.

Information is not cited or is

cited incorrectly. Misspelled

words, incorrect grammar,

and improper punctuation

are evident.

Total Points

65MEDICC Review, April–July 2017, Vol 19, No 2–3

Peer Reviewed

INTRODUCTION
Since 1978, WHO has emphasized the importance of primary
health care (PHC) for promoting and protecting population health.
[1] PHC is highlighted as the mechanism through which countries
can provide better health to persons, families and communities,
with greater equity and lower costs,[1,2] because it “brings promo-
tion and prevention, cure and care together in a safe, effective and
socially-productive way at the interface between the population and
the health system.”[2]

Colombi a is a culturally and ethnically diverse country with a
highly varied demographic and epidemiologic profi le, and an
increased burden of chronic non-communicable diseases in the
past decade without yet having eradicated infectious diseases.
[3–5] Until recently, Colombia’s health system favored develop-
ment of a hospital-based, curative health care model, oriented
toward highly specialized care (the system revolving around spe-
cialists) under a free-market model (with users seen as consum-
ers and with a variety of public and private insurers and service
providers) that generates inequities in fi nancing and limits ac-
cess to health care, patient-centered care and community-based
health improvements.[6]

In 2011, Law 1438 modifi ed Colombia’s health system, putting
PHC legally at the center of the system to address the country’s
health priorities, emphasizing:
• public health actions such as health promotion and disease pre-

vention;
• coordination of intersectoral actions;
• a culture of self-care;
• comprehensive health care involving individuals, families and

communities; and
• active community participation and local approaches to attaining

long-term, continuous and intercultural attributes of care.[7–9]

This article describes an intervention based on PHC and commu-
nity-oriented primary care (COPC) principles,[10] aimed at building

capacity for community participation to change population health
status in Colombian communities.

INTERVENTION
Purpose, rationale and participants The Citizenship for Healthy
Environments (CxES), a qualitative participatory action research
(PAR) project to build community capacity to infl uence health, was
carried out from January 2012 through June 2014 (30 months)
with organizations in Bogotá and Cundinamarca, Colombia. In al-
liance with several institutions (Corona Foundation, Universidad
de La Sabana, Organization for Excellence in Health, Community
Development Consortium and Social Foundation) the authors in-
vited several community organizations to become part of a joint
project.

The rationale for CxES was that implementation of PHC initiatives
aimed at solving priority health needs requires the integration of
multiple actors (decision makers, health institutions, academia, hu-
man resources in health, and communities),[11,12] with the com-
munity playing a major role in successfully leading and managing
this type of initiative and adapting it to local conditions.[13,14]
COPC is a n approach that places the community at the center of
PHC; it enables concerted, community-based identifi cation of the
population’s problems and needs and their solutions, transforming
health services and improving local capacity to bring about behav-
ioral changes in the population.[15–17] In Colombia, however, the
population and local health department and hospital offi cials are
barely aware of PHC and COPC concepts or the practical applica-
tion of PHC-based initiatives.[13,18]

PAR was selected because it is a methodology oriented toward
generating change in persons using collective experience as a
starting point (beginning with an assessment of community needs
and problems) through an intersectoral approach and planning and
implementation of actions for health improvement. Both quantita-
tive and qualitative methods can be used for PAR, which serves
as the foundation of COPC because it contributes to community

Building Community Capacity in Leadership
for Primary Health Care in Colombia
Erwin H. Hernández-Rincón MD MS PhD, Francisco Lamus-Lemus MD MS MPH, Concepción Carratalá-Munuera MS DrPH,
Domingo Orozco-Beltrán MD PhD, Carmen L. Jaramillo-Hoyos, Gloria Robles-Hernández

ABSTRACT
Primary health care looks beyond clinical services to health promotion
and primary prevention at the population level. In 2011, Colombia
adopted a normative approach to primary health care, to advance
efforts to set health priorities and transcend a curative, hospital-based
system. An intervention was carried out in eight communities in Bogotá
and Cundinamarca, Colombia to build community capacity to infl uence
health. Activities included training community leaders to design and
implement health improvement initiatives aimed at the most important
health problems identifi ed by their organizations. Twenty-eight leaders
completed the training. They designed and implemented eight health
improvement plans to address the most important health problems in
their respective communities: protecting public spaces for children’s
physical activities, improving family practices in child nutrition, organizing
a health insurance benefi ciaries’ health promotion network, organizing a

service delivery network for homeless persons, connecting people with
cognitive disabilities to treatment services, combatting violence against
women, working against child abuse, and integrating health education
into school curricula. Lessons were learned about capacity-building in
primary care, approaches to strengthening intra- and interinstitutional
conditions, and managing processes for community ownership. The
intervention enabled development of initiatives for solving various
problems by different types of organizations, highlighted participants’
understanding of their role as health agents, and promoted community
participation and intersectoral action.

KEYWORDS
Primary health care, qualitative research, community health agents,
community health planning, health education, community-based
participatory research, Colombia

Lessons from the Field

MEDICC Review, April–July 2017, Vol 19, No 2–366

Lessons from the Field

contextualization, health assessment, prioritization, program imple-
mentation, and ongoing evaluation and improvement.[16,19]

PAR is carried out in complex sociopolitical contexts where dia-
logue and negotiation about objectives and means are integral to
researchers building relationships with participating communities.
In building such relationships, PAR encourages deepening local
knowledge and stimulates interest in becoming part of research
to better understand the community’s health. PAR increases the
community’s understanding of its health status and empowers lo-
cal actors to take committed action.[20] Its results are not limited
to description but rather focus on action to improve public health
practice, complementing common epidemiologic approaches and
promoting capacity to conduct research at the local level.[21,22]

Participating organizations Organizations were recruited that were
involved in various community actions addressing diverse health
problems and vulnerabilities (children, people with disabilities, preg-
nant women, older adults or victims of armed confl ict in Colombia).
[5] Organizations were selected based on the following criteria: or-
ganizational life (people in the organization work collectively toward
a common goal and distribute responsibilities accordingly; develop-
ment of actions oriented toward a specifi c goal and in a particular
community); prioritization of collective over individual interests; and
infl uence in the surrounding area—the organization’s territorial lo-
cation.[23] The eight participating organizations included public,
private, religious or charitable, and community-based groups: two
grassroots women’s organizations in Soacha (Families f or Progress
and the We Are Women, We are Families Association), one school
in Sopó (Paul VI State School), four institutions providing services to
vulnerable communities in Bogotá (Center for Stimulation and Devel-
opment, Royal Friends Foundation, Child Welfare Association, and
Medalla Milagrosa Ambulatory Care Center), and one institution with
links to the rest (the Archdiocese Food Bank).

Activities Training community leaders for health initiative manage-
ment Leadership trainers were eight professors from Universidad
de La Sabana (three physicians and two nurses, all community
health professors with master’s degrees and at least eight years’
experience in their respective professions) and the Community
Development Consortium (a psychologist, a lawyer and a social
worker, all with experience in social development in grassroots
community organizations). Thirty leaders enrolled in the training,
three or four selected by each organization based on the following
criteria: current membership, responsibility for developing actions
related to health or its determinants, length of time in the organiza-
tion, interest, and time commitment. Training was based primarily
on COPC principles[15] and Universidad de La Sabana’s com-
munity health experience. A modular, cyclical training process was
designed to give leaders an opportunity to refl ect on their under-
standing of PHC and COPC concepts, and to identify problems and
needs in their communities.[10,17,24−26] The training lasted a total
of 20 weeks over six months in weekly fi ve-hour sessions using a
variety of pedagogical techniques including master classes, prac-
tical demonstrations, debates, case studies and problem-based
learning, supported by an online learning platform for complemen-
tary asynchronous refl ection and discussion outside meetings.

Development and implementation of organizational improvement
plans As part of the training, each organization developed and sub-
mitted a proposal for an improvement plan to address one priority
problem. Once each proposal was formulated, it was implemented

based on the principles covered in the training (16 months) (Table
1). Four tutors or facilitators supervised and participated (known as
accompaniment) in practical implementation of the plans until the
end of the project. Tutors were professors of community health at
Universidad de La Sabana (three public health physicians and one
public health nurse, all with master’s degrees), who were selected for
having at least fi ve years’ experience in community health actions.

Systematization of experiences and extraction of lessons learned
Systematization was carried out simultaneously with the other two
activities and throughout the process (a progress and adjustment
report refl ecting achievements and challenges midway through the
process, and a fi nal report on achievements, challenges and commit-
ments). Content analysis was carried out on all reports, as well as
photographic records, meeting notes, fi eld journals and recordings of
each plan’s activities. This activity involved analytical refl ection and
reconstruction, leading to knowledge generation from and for practice,
through extraction and comprehension of lessons learned.[27,28]

An external team from the Community Development Consor-
tium (an economist and a psychologist with experience in social
development and qualitative research who were not part of the
training and planning team) conducted systematization. They
held semistructured interviews, triangulated data from all sources,
obtained lessons learned from the pedagogical process, and re-
viewed and performed content analysis on documents generated
by the organizations (community description and needs assess-
ment, improvement plan, progress and adjustment reports, partial
results, and fi nal reports). The four tutors and one representative
of each organization were interviewed based on an open-ended
question: What factors enable or limit citizen capacity-building,
generating a sense of ownership in the community and the terri-

Table 1: Training modules, content and topics

Preparation (weeks 1–5) Introduction to basic concepts and CxES
approach (PHC, COPC, PAR, health promotion, disease prevention,
community leadership, health legislation in Colombia)
Building trust and community (weeks 6–7) Building trust to develop
community work (trust, knowledge of the community, knowledge of
family and community health)
Situational assessment (weeks 8–12) Determining problems, needs
and priorities of each community (health situation assessment, health
planning, health needs, community health diagnosis, epidemiology,
demography and population, priority setting, problem rationales,
problem analysis)
Preparing the work (weeks 13–15) Development of proposed so-
lutions or interventions for problems identifi ed (project management,
educational and intervention techniques, information gathering, inter-
sectoral action, design of health improvement plans)
Field work (week 16) Strategies to deal with situations arising after
implementation (teamwork, negotiation and confl ict resolution) and
specifi c themes (disease groups, life cycle)
Evaluation and adjustment (week 17) Assessment of work so far
(social and community participation, data collection and analysis)
Work sharing (weeks 18–19) Strategies for dissemination and com-
munication of processes and community intervention results, health
communication, research dissemination, report writing)
Sustaining and improving the work (weeks 19–20) Factors that en-
sure initiatives’ continuity and sustainability (proposals for continuity,
sharing of improvement plans)

COPC: community-oriented primary care
CxES: Citizenship for Healthy Environments
PAR: participatory action research

PHC: primary health care

Peer Reviewed

67MEDICC Review, April–July 2017, Vol 19, No 2–3

tory for building a healthy environment? Three analytical categories
were defi ned: (1) citizen capacity-building for PHC (individual and
collective competencies to be developed in grassroots PHC com-
munity managers); (2) intra- and interinstitutional conditions—or-
ganizational and community factors needed for creation of healthy
environments; and (3) sense of ownership—elements that foster
behaviors contributing to healthy environments.

Data were organized and validated by two people from the
systematization team, two tutors and two members of participating
organizations, who identifi ed lessons learned in each category. This
activity was ongoing throughout the process but most intensively in
the six months following implementation.

Ethics All organizations gave written informed consent to par-
ticipate, by means of a voluntary agreement setting out their un-
derstanding that the project originated in the community, whose
participants and organizations were the owners and active subjects
of the process.[29]

RESULTS AND LESSONS LEARNED
Training of community leaders Of the 30 leaders who initiated train-
ing, 28 completed it (93.3%). Training objectives were met, including
comprehension and explanation of their reality based on assessments
of their communities’ principal needs and problems (Table 2). The train-
ing phase included their designing improvement plans and leaders
expressly committing to lead their organizations in implementing them.

Organizational improvement plans Once each organization had
defi ned their problems and needs, they designed an improvement

plan related to one problem, defi ned by type of social response,
vulnerability addressed and organizational characteristics. In all
eight improvement plans, interventions were based on promoting
healthy lifestyles, improving living conditions and fi nding opportuni-
ties for participation. The main results were evaluated per objec-
tives, achievements and indicators set forth in the planning stage,
using quantitative and qualitative instruments according to each
organization and topic (Table 3).

Systematization In the citizen capacity-building for PHC category,
organized actions regarding PHC were understood in direct
relation to participants’ empowerment as central actors in health
promotion, disease prevention and a culture of self-care. The
aforementioned empowerment results were facilitated by having
taken on a community health initiative based on organizations’
protagonism in identifying their own PHC needs and strategies
for action, by breaking with the dynamic usually found in non–
community-oriented interventions. Changes were observed in
perception of health as a collective matter, in which the subjects
are protagonists in generating healthy community environments,
helping overcome a hospital-centric vision. Throughout the training
process and during plan implementation, it was observed that, as
part of the PAR process, organizations made a clear conceptual
and practical differentiation between disease prevention and health
promotion, the latter understood as a collective matter and not the
exclusive purview of the health system.

In the intra- and interinstitutional conditions category, it was em-
phasized that sustainability of building healthy environments with
community participation requires a regional approach and not only

training of people and organizations to act
as replicators in their surroundings. This was
because improvement plans were limited by
organizational characteristics and did not in-
volve all sectors in their context, health institu-
tions among them. Given the heterogeneity of
organizational contexts, these were expected
to have only modest infl uence in their terri-
tory. At the same time, such heterogeneity was
useful for comparing different experiences to
generate lessons learned for creation of a PHC
model with community participation.

Intersectoral work in PHC may be oriented to-
ward infl uencing policies as well as broadening
and improving the quality of interest groups’ ac-
tion strategies. Throughout the training and ac-
companiment process, participants displayed
an interest in connecting with other actors
they had not initially considered infl uential for
achieving healthy life styles; this interest en-
abled leaders to facilitate opening new spaces
for participation by other community members.
Initiatives for creating alliances and seek-
ing opportunities for greater infl uence in their
surroundings varied by type of organization,
organizational structure, fl exibility for change
and ownership of PHC’s conceptual framework
(Table 3).

In the sense of ownership category, commu-
nity leaders expressed and refl ected in the im-

Table 2: Community leader training results

Aspect Indicators and results (8 organizations, 30 leaders, 20 sessions)
Face-to-face
activities

Satisfactory participation and performance in 95% of sessions (fulfi lling
theme objectives and following training process thread), 93.3% (28/30)

Online activities
Participation and completion of followup and support activities, 86.7%
(26/30)

Main lessons
learned (at
conclusion of
process)

Health: understanding that health is not limited to physical health but
involves interaction among >3 components (physical, mental, social,
cultural, spiritual), 93.3% (28/30)
PHC: understanding overall concept from perspective of Alma-Ata and
as fundamental to maintaining population health, 93.3% (28/30)
Health promotion: understanding that health promotion is not about
disease and highlighting importance of self-care, 100%
Community health: need to solve community problems together recog-
nized, 93.3% (28/30)
Healthy environments: environment’s importance for health empha-
sized, 93.3% (28/30)

Completion and
approval

28 community leaders

Products

Each organization satisfactorily submitted three requested products.
Context report: description of context, community characteristics and
possibilities for coalitions
Situational assessment: community needs assessment based on
literature review, local and national regulations, review of documented
socioeconomic, epidemiologic and demographic factors, and other
sources of information, depending on the organization
List of needs and problems obtained, from which one was selected by
agreement among organization members
Improvement plan: selected problem validated and examined more
deeply; intervention objectives and actions defi ned and scheduled
based on a logic model

PHC: primary health care
Lessons from the Field
Peer Reviewed

MEDICC Review, April–July 2017, Vol 19, No 2–368

Table 3: Community improvement plans by issue, reach and main results
Community
(description) Issue or problem Reach Results

Royal Friends Foundation
(child nutrition, Usaquén,
Bogotá)

Diffi culty accessing
public space (parks)
because of lack of
safety and maintenance
(a limitation for physical
activity for different age
groups)

Direct: 689 children and
families in various Foundation
programs

Indirect:
Usaquén population 475,000
(target population 114,000
reproductive-age women and
58,000 children aged <9 years)

• Mutual knowledge and support by allied social actors
• More physical activity in local parks
• Creation of institutional networks for recovery of public

spaces for physical activity
• Raised community awareness of self-care in adoption of

healthy behaviors and environmental transformation
• Opening of public spaces for citizen participation to combat

gang violence
• Increased children’s knowledge of importance of recycling

and care of the environment

Child Welfare Association
(daycare center for
vulnerable children, Suba,
Bogotá)

Poor nutritional practices
in families of children in
daycare center

Direct: 217 children and 355
parents

• More parental interest in good nutrition for their children
• More family participation in growth and development of

children. Greater family awareness of good nutritional
practices

• Parents provided with tools on healthy eating habits
• Improved children’s quality of life

Archdiocese Food Bank
(food bank, Bogotá)

Lack of coordination
of service network for
specifi c needs of client
population

Direct: 801 organizations
Indirect: 113,742 persons
(73,657 children, 14,209
families)

• Strengthened healthy experiences in clients on themes of
healthy eating and behaviors, physical activity and self-
care

• Intervention in benefi ciary organizations: organizational
strengthening, health and nutrition, accompaniment

• Comprehensive approach to food security

Medalla Milagrosa
Ambulatory Care Center
(services for homeless
persons, Los Mártires,
Bogotá)

Need for interinstitution-
al networks supporting
quality of services

Direct: citizens living on the
streets (approximately 100,
variable), persons with addic-
tions, immediate families, and
the Center’s interdisciplinary
team

• Updated Center vision, mission and objectives with PHC
focus

• Participation in district-level task forces with Health Depart-
ment, Social Integration Department, Volunteer Committee

• Strengthened healthy behaviors in homeless persons
• Strengthened interinstitutional networks
• Clients empowered by recognition of their social capacities

and capabilities

Stimulation and
Development Center
(services for persons
with cognitive disabilities,
Teusaquillo, Bogotá)

Need for favorable
settings for families;
students and teachers to
conduct therapeutic in-
terventions that develop
potential of persons with
cognitive disabilities

Direct: families, teachers and
students linked to the Center in
Bogotá and Cundinamarca

Indirect: external community
(potential clients, persons and
institutions interested in cogni-
tive disabilities)

• Improved quality of organizational services for greater con-
sistency with institutional vision and mission

• Greater interest and participation by families, caregivers
and academics in intervention and management processes
with clients

• Increased requests from academic institutions for training
practicums in disabilities at the Center

• Intervention on social and family aspects of antenatal care
and early childhood care for disease prevention, especially
cognitive disability

• Greater interest by Center clients, families and employees
in development of behaviors to improve quality of life

Families for Progress
(women working with
families affected by
violence, Soacha,
Cundinamarca)

Gender-based violence

Direct: 38 women leaders,
Comuna 1, Soacha

Indirect: 114 relatives of wom-
en (husbands and children)

• Strengthened self-esteem and awareness of tools for pre-
venting violence (Law 1257) reported by all women

• Able to respond and reinforce lessons learned reported by
31.6% (12/38) of women

• Organizational strengthening: revised statutes, structure,
internal policies, in keeping with mission

• 6 community-wide workshops, 2 on self-esteem and 4 on
Law 1257

Paul VI State School
(school for children aged
4–18 years, Sopó,
Cundinamarca)

Diffi culty of developing
life skill and health pre-
vention habits in family
and school settings

Direct: 955 pre-school and
primary school children (urban
and rural) and 31 teachers.

Indirect: 1750 students, 66
teachers and administrators,
students’ families and munici-
pal administrators

• Improved basic knowledge of ARD and prevention mea-
sures, 75.2% (718/955) of children

• Teachers’ recognition of importance of knowledge of ARD
prevention; some know when to seek medical help

• Improved knowledge of healthy behaviors, healthy eating,
physical activity, hygiene and their benefi ts for children,
80.6% (25/31) of preschool and primary teachers

• Integration of health themes into curricula (initiated)
• Connections made with municipal health and education

departments for development and replication of initiative
throughout municipality

We Are Women, We Are
Families Association
(women organized for
protection of women and
families, Soacha,
Cundinamarca)

Child abuse and its
implications

Direct: 51 participants from
Comuna 1 in Soacha.

Indirect: neighborhood commu-
nities, especially participants’
families

• Increased members’ knowledge of child abuse
• Increased mothers’ awareness of protection and care,

childrearing guidelines
• Application of new knowledge within members’ families
• Creation of discussion forum with mothers and families

about recognizing types of child abuse and importance of
infant attachment

• Establishment of child abuse documentation center
ARD: acute respiratory disease PHC: primary health care

Lessons from the Field
Peer Reviewed

69MEDICC Review, April–July 2017, Vol 19, No 2–3 Peer Reviewed

provement plans that family and nutrition are two central elements
in community ownership of healthy lifestyles and environments.
Nutrition was not given special emphasis during the training pro-
cess or in drafting improvement plans, but organizations made it
a central focus of their initiatives. This may suggest that nutrition
is a fundamental fi rst step in developing community ownership of
healthy lifestyles. Organizations certainly considered nutrition a
main driver and promoter of healthy behavior within families.

One of the main factors infl uencing the sense of ownership of
healthy lifestyles and environments is related to organizations’
communication mechanisms and strategies. The experience dem-
onstrated the effects of organizations’ participation in local discus-
sion forums and community radio to present ideas, challenges and
strategies promoting the concept of health as a social construct
requiring broad participation.

General lessons This project demonstrates the potential impor-
tance of community participation in developing health programs
and confi rms the utility of working with preexisting social capital
to foster community empowerment.[30,31] PAR methodology fa-
vored development of PHC action in organizations, guaranteeing
the initiatives’ continuity and adjustment to the COPC conceptual
framework,[10,17,19] as well as enabling community members
to claim ownership of the research. The intervention showed that
developing community-based health initiatives is possible and can
generate greater sustainability and sense of ownership.

Experiences in Colombia have traditionally focused primarily on
top-down or institutional PHC initiatives rather than on integrating
the community at the grassroots level.[13,18] It is therefore im-
portant to involve all the actors in order to strengthen PHC initia-

tives and meet the population’s health needs.[11,15] A community
participation approach to building healthy environments requires
overcoming an excessive focus on health care services, which can
encourage people to depend on treating specifi c ailments rather
than addressing their fundamental vulnerabilities and improving
their health (bearing in mind the importance of including the hos-
pital sector to achieve more comprehensive plans). Linking orga-
nizations with PHC training and action processes does not in itself
guarantee that the process will include all social actors present in
a community, nor that it will bring about tangible changes in health
status, but needs to be matched with changes to social determi-
nants and generation of community leadership and empowerment.

CxES contributes important lessons for implementing Colombia’s
new, legislatively mandated,[7] comprehensive health care mod-
el,[32] which includes prevention, promotion, diagnosis, treatment
and palliative care, all under a local approach in which the com-
munity plays a key role. It facilitated and evaluated development
of primary care initiatives in different types of organizations to ad-
dress a variety of problems. In all cases, participants demonstrated
comprehension of their role as health agents, promoting commu-
nity participation and intersectoral action. Forming alliances among
community actors, health services and academic institutions that
train human resources is equally important for achieving knowledge
transfer to all necessary social actors, thus ensuring sustainability
of PHC-based health systems.

ACKNOWLEDGMENTS
The authors thank participating communities and their leaders and
organizations, as well as the tutors and facilitators who accompa-
nied the CxES process.

REFERENCES
1. World Health Organization. Declaration of Alma-

Ata International Conference on Primary Health
Care. Alma Ata: World Health Organization; 1978
Sep 12.

2. World Health Organization. The World Health
Report 2008: Primary Health Care, Now More Than
Ever. Geneva: World Health Organization; 2008.

3. Bernal O, Forero JC, Villamil M del P, Pino R.
Disponibilidad de datos y perfi l de morbilidad
en Colombia. Rev Panam Salud Pública. 2012
Mar;31(3):181−7. Spanish.

4. Ramos-Clason EC. Transición epidemiológica
en Colombia: De las enfermedades infeccio-
sas a las no transmisibles. Rev Cienc Biomed.
2012;3(2):282−90. Spanish.

5. Ministry of Health and Social Protection (CO)
[Internet]. Bogotá: Ministry of Health and Social
Protection (CO); c2017. Plan Decenal de Salud
Pública; 2012 [cited 2015 Apr 15]. Available from:
https://www.minsalud.gov.co/plandecenal/Pagi
nas/home2013.aspx. Spanish.

6. Agudelo Calderón C, Cardona Botero J, Ortega
Bolaños J, Robledo Martínez R. Sistema de salud
en Colombia: 20 años de logros y problemas. Cien
Saúde Colet. 2011 Jun;16(6):2817−28. Spanish.

7. Ministry of Health and Social Protection (CO). Ley
1438 [Internet]. Bogotá: Ministry of Health and
Social Protection; 2011 [cited 2015 Jun 1]. Avail-
able from: https://www.minsalud.gov.co/Norma
tividad_Nuevo/LEY%201438%20DE%202011
. Spanish.

8. Giraldo AF. La última reforma del sistema gen-
eral de seguridad social en salud colombiano.
Rev Salud Pública (Bogotá). 2012;14(5):865−77.
Spanish.

9. Giraldo AF. Referentes teóricos para el análisis de
la reforma del sistema de salud colombiano. Rev
Gerenc Políticas Salud. 2012 Jun;11(22):28−42.
Spanish.

10. Gofi n J, Gofi n R. Community-oriented primary
care: a public health model in primary care. Rev
Panam Salud Pública. 2007 Feb–Mar ;21(2–
3):177−84.

11. Bolduc N, Grand Maison P. Towards Unity
for Health: Lessons for Health Development
in Canada. Educ Health (Abingdon). 2007
Aug;20(2):49.

12. World Health Organization. Towards unity for
health: challenges and opportunities for partner-
ship in health development. A working paper.
Geneva: World Health Organization; 2000.

13. Ruiz-Rodríguez M, Acosta-Ramírez N, Rodríguez
Villamizar LA, Uribe LM, León-Franco M. Experi-
encia de implementación de un modelo de aten-
ción primaria. Rev Salud Pública (Bogotá). 2011
Dec;13(6):885−96. Spanish.

14. Bhuyan K. Health promotion through self- care
and community participation: elements of a pro-
posed programme in the developing countries.
BMC Public Health. 2004 Apr 16;4:11.

15. Foz G, Gofi n J, Montaner G. Atención Primaria
Orientada a la Comunidad. In: Martin Zurro A,
Cano Pérez JF, editors. Atención Primaria. Con-
ceptos, organización y práctica clínica. 5th ed.
Madrid: Elsevier; 2003. p. 345–64. Spanish.

16. Gofi n J, Montaner I, Foz Gil G. Metodología de
la Atención Primaria Orientada a la Comunidad
(APOC). Elementos para su práctica. Rev Clín
Electrón Atención Primaria [Internet]. 2003 [cited
2015 Mar 1];1–7. Available from: https://ddd

.uab.cat/pub/rceap/rceap_a2008m9n16/rceap
_a2008m9n16a5 . Spanish.

17. Montero M. Hacer para transformar: El método de
la psicología comunitaria. Buenos Aires: Edicio-
nes Paidós; 2006. Spanish.

18. Suárez R, Zamora G, Conte G, Olarte M. Resul-
tados, sistematización, análisis y recomendacio-
nes de la evaluación de las experiencias de APS
– RISS. Bogotá: Pan American Health Organiza-
tion; Ministry of Health and Social Protection (CO);
2012. Spanish.

19. Gavilán Moral E, Jiménez de García L, Olivero
FJ. Docencia e investigación en atención primaria
orientada a la comunidad: la experiencia de dos
residentes españoles en Argentina. Atención Pri-
maria. 2006 May;37(9):514−6. Spanish.

20. Cornwall A, Jewkes R. What is participatory
research? Soc Sci Med. 1995 Dec;41(12):1667–76.

21. Bach M, Jordan S, Hartung S, Santos-Hövener C,
Wright MT. Participatory epidemiology: the contri-
bution of participatory research to epidemiology.
Emerg Themes Epidemiol. 2017 Feb 10;14:2.

22. Hills M, Mullet J, Carroll S. Community-based par-
ticipatory action research: transforming multidisci-
plinary practice in primary health care. Rev Panam
Salud Pública. 2007 Feb–Mar;21(2–3):125–35.

23. Fawcett SB, Francisco VT, Paine-Andrews A,
Schultz JA. Working together for healthier com-
munities: A research-based memorandum of
collaboration. Public Health Rep. 2000 Mar–
Jun;115(2–3):174−9.

24. Pickens S, Boumbulian P, Anderson R, Ross S,
Phillips S. Community-oriented primary care in
action: a Dallas story. Am J Public Health. 2002
Nov;92(11):1728−32.

Lessons from the Field

MEDICC Review, April–July 2017, Vol 19, No 2–370

25. Lamus Lemus F, Correal Muñoz C, Hernández
Rincón EH. Construcción de entornos salu-
dables en el marco de la atención primaria en
salud: El caso de la enseñanza de salud comu-
nitaria en el programa de Medicina de la Uni-
versidad de La Sabana. Salud Uninorte. 2015
May–Aug;31(2):424−34. Spanish.

26. Fawcett SB, Francisco VT, Schultz JA, Berkowitz
B, Wolff TJ, Nagy G. The Community Tool Box:
a Web-based resource for building healthier
communities. Public Health Rep. 2000 Mar–
Jun;115(2–3):274−8.

27. Laperrière H. Community health nursing practices
in contexts of poverty, uncertainty and unpredict-
ability: a systematization of personal experiences.
Rev Lat Am Enfermagem. 2007 Sep–Oct;15 Spec
No:721−8.

28. Dubón Abrego MA, Menjívar López D, Espinoza
Fiallos E, Baatz C. La construcción del sistema
comunitario de salud de Guarjila: sistematización
de una experiencia de Atención Primaria de
Salud Integral en El Salvador durante el perio-
do 1987−2007. Saúde em Debate. 2012 Jul–
Sep;36(94):414−20. Spanish.

29. Correal-Muñoz CA, Arango-Restrepo P. Aspec-
tos bioéticos en la salud comunitaria. Pers Bioét.
2014;18(2):194−212. Spanish.

30. Romeo D. Capacidad comunitaria en benefi cio
de promover salud en la colectividad. Med Gen
Integr. 2007 Jul–Sep;23(3). Spanish.

31. Franco-Giraldo A. Promoción de la salud (PS) en
la globalidad. Rev Fac Nac Salud Pública. 2012
May–Aug;30(2):193−201. Spanish.

32. Campbell C, Gillies P. Conceptualizing ‘social
capital’ for health promotion in small local commu-
nities: a micro-qualitative study. J Community Appl
Soc Psychol. 2001 Sep–Oct;11(5):329–46.

THE AUTHORS
Erwin H. Hernández-Rincón (Correspond-
ing author: erwinhr@unisabana.edu.co; amsic
_2005@yahoo.es), public health physician with
master’s degrees in health system governance
and management and in primary care research,
and a doctorate in clinical research. Center for
Studies in Community Health (CESCUS), Uni-
versidad de la Sabana School of Medicine, Chía,
Colombia.

Francisco Lamus-Lemus, pediatrician with
master’s degrees in public health and applied de-
velopment, CESCUS, Universidad de La Sabana
School of Medicine, Chía, Colombia.

Concepción Carratalá-Munuera, nurse with
a master’s degree in nursing and doctorate in
public health, Department of Clinical Medicine,
Miguel Hernández University Division of Medi-
cine, Alicante, Spain.

Domingo Orozco-Beltrán, physician special-
izing in family and community medicine, with a

doctorate in medical sciences, Department of
Clinical Medicine, Miguel Hernández University
Division of Medicine, Alicante, Spain.

Carmen L. Jaramillo-Hoyos, psychologist spe-
cializing in knowledge management, Community
Development Consortium, Bogotá, Colombia.

Gloria Robles-Hernández, economist special-
izing in regional development and in economics,
plan ning, systematization of experiences, fol-
lowup and evaluation, Community Development
Consortium, Bogotá, Colombia.

Submitted: December 1, 2016
Approved for publication: June 9, 2017
Disclosures: Citizenship for Healthy Environ-
ments was a Joint Project of Colombia’s Corona
Foundation, Universidad de La Sabana, Organi-
zation for Excellence in Health, Consortium for
Community Development and Social Founda-
tion from 2012 through 2014. Preparation and
submission of this article is part of a research
project, Comprehensive Primary Health Care in
Colombia: A Regional Focus to Address Chronic
Non-Communicable Diseases, funded by an
internal call for proposals of Universidad de La
Sabana (MED-187-2014).

Lessons from the Field
Peer Reviewed

Copyright of MEDICC Review is the property of Medical Education Cooperation with Cuba
and its content may not be copied or emailed to multiple sites or posted to a listserv without
the copyright holder’s express written permission. However, users may print, download, or
email articles for individual use.