PRIMARY HEALTH CARE SYSTEMS

(PRIMASYS)
Case study from Colombia

Abridged Version
WHO/HIS/HSR/17.5

© World Health Organization 2017

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 Primary Health Care Systems
(PRIMASYS)
Case study from Colombia

Overview of primary health care system

Colombia is a tropical middle-income country, located
in the north-west of South America. According to the
Colombian National Administrative Department of
Statistics (Departamento Administrativo Nacional de
Estadística, DANE), Colombia has 49 million inhabitants in
its 1 141 748 square kilometres of territory. It is estimated
that 76% of the population lives in urban areas, while the
remaining 24% lives in rural areas.1 Life expectancy at
birth in Colombia increased from 57 years in 1960 to 74
years in 2014.2
According to the Colombian Health Situation Analysis
(Análisis de Situación de Salud, ASIS), 2015, the main
reasons for consultation in health services in Colombia
are noncommunicable diseases, accounting for 65.45%
of doctor visits made between 2009 and 2014, followed
by nutritional and communicable disease conditions
(14.73%), injuries by different causes (5.2%), and maternal
and perinatal conditions (2.12%).3 The main cause of death
is circulatory problems (29.92%), followed by neoplasm
(17.79%) and external causes (injuries) (16.79%).4
Indicators related to the Millennium Development Goals
show that the maternal mortality rate has reduced from
104.9 to 55.2 maternal deaths per 100 000 live births;
however, maternal mortality is still concentrated in the
poorest areas, where there are major problems of equity
in access to health services. Neonatal mortality between
2005 and 2013 declined from 9.9 to 7.3 neonatal deaths
per 1000 live births. Mortality in children aged under 1
year declined from 19.5 to 11.6 deaths per 1000 live births.
Mortality in children aged under 5 years declined steadily
from 24.3 deaths per 1000 live births in 1998 to 14.1 in
2013. Vaccination coverage among children in the last 10
years has remained above 85%, and in the last five years
has been above 90%.5
The National Demographic and Health Survey (Encuesta
Nacional de Demografía y Salud, ENDS), 2015, showed
that 98% of pregnant women in Colombia had received
skilled birth attendance during delivery; in addition, 92%
of women had received four or more prenatal check-ups
during their previous pregnancy and 78% had received
postnatal care following their previous delivery.6 In
contrast to the positive health indicators, Colombia has
the second highest level of inequality in the region (after
Honduras), with a Gini coefficient of 53.5 (2015). However,
in the last 15 years the rate of poverty in Colombia has
decreased from 50% to 28.5%. Colombia’s gross domestic
product (GDP) per capita was US$  6056.1 (US$ actual
prices) in 2015.7 Table 1 summarizes demographic and
health indicators for Colombia.

1 Proyecciones nacionales y departamentales de población 2005–2020 [National and departmental population projections 2005–2020]. Bogotá, Colombia: Colombian National Administrative
Department of Statistics (DANE); 2010 (https://www.dane.gov.co/files/investigaciones/poblacion/proyepobla06_20/7Proyecciones_poblacion.pdf, accessed 21 February 2017).
2 Ibid.
3 ASIS: Análisis de la situación de salud (ASIS) Colombia, 2015 [Analysis of the health situation (ASIS) Colombia, 2015]. Bogotá, Colombia: Ministry of Health and Social Protection; 2015 (https://www.
minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/ED/PSP/asis-2015.pdf, accessed 21 February 2017).
4 Ibid.
5 Ibid.
6 Encuesta Nacional de Demografía y Salud (ENDS) 2015 [National Demographic and Health Survey (ENDS) 2015]. Bogotá, Colombia: Ministry of Health and Social Protection; 2016. https://www.
minsalud.gov.co/Documents/General/Libro_Resumen.pdf, accessed 21 February 2017).
7 World Bank: Indicators. Washington (DC): World Bank (http://data.worldbank.org/indicator/, accessed 21 February 2017).
 Colombia Case Study

Table 1. Colombia: demographic and health indicators

Indicator Results Information source Year

Total population of country 49 million DANE 2016
Distribution of population: urban/rural 76% urban, 24% rural DANE 2016
Growth rate 0.9% World Bank 2015
Fertility rate 2.0 Ministry of Health 2015
Life expectancy of birth 74 years World Bank 2014
Infant mortality 11.6/1000 live births ASIS
Under 5 mortality rate 14.1/1000 live births ASIS 2013
Maternal mortality rate 55.2/100 000 live births ASIS 2013
Immunization coverage under 1 year Up to 90% ASIS 2013
Skilled birth attendance (% of pregnant women) 98.6% ASIS 2015
Four recommended prenatal care visits 92% ASIS 2015
Income or wealth inequality (Gini coefficient) 53.5 World Bank 2015
Total health expenditure as proportion of GDP 7.2% World Bank 2014
Primary health care expenditure as % of total health expenditure 56% Ministry of Health 2015
% total public sector expenditure on primary health care 100% Ministry of Health 2016
Total expenditure on health per capita US$ 962 WHO 2014
Public expenditure on health as proportion of total health 75.2% Bank of the Republic 2011
expenditure
Out-of-pocket payments as proportion of total expenditure on health 15.9% Bank of the Republic 2013

Key to sources:

DANE: Proyecciones nacionales y departamentales de población 2005–2020 [National and departmental population projections 2005–2020]. Bogotá, Colombia: Colombi-
an National Administrative Department of Statistics (DANE); 2010 (https://www.dane.gov.co/files/investigaciones/poblacion/proyepobla06_20/7Proyecciones_poblacion.pdf,
accessed 21 February 2017).

World Bank: Indicators. Washington (DC): World Bank (http://data.worldbank.org/indicator/, accessed 21 February 2017).

Ministry of Health and Social Protection: Estudio de suficiencia y mecanismo de ajuste para la UPC para el plan de beneficios de 2016 [Study of sufficiency and mechanism of
adjustment for the UPC for the benefit plan of 2016]. Bogotá, Colombia: Ministry of Health and Social Protection; 2016.

ASIS: Análisis de la situación de salud (ASIS) Colombia, 2015 [Analysis of the health situation (ASIS) Colombia, 2015]. Bogotá, Colombia: Ministry of Health and Social Protection;
2015 (https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/ED/PSP/asis-2015.pdf, accessed 21 February 2017).

WHO: Statistical data: Colombia. Geneva: World Health Organization; 2015.

Bank of the Republic: Documentos de trabajo sobre economía regional: una mirada a los gastos de bolsillo de salud para Colombia [Working papers on regional economics:
a look at the out-of-pocket health expenditures for Colombia]. Bogotá, Colombia: Bank of the Republic; 2015 (http://www.banrep.gov.co/docum/Lectura_finanzas/pdf/dts-
er_218.pdf, accessed 21 February 2017).

4
 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)

Figure 1. Timeline for primary health care system in Colombia

2007 2016
1993 Health Care Integration
Health care system Primary care approach
re-establishment; Policy and Comprehensive
establishment
1996 2000 National Public 2011 Health
based on Care Model
assurance, Health Information Primary health care
Establishment of Release of policy Development Plan (MIAS) development
individual activities a Basic information related model development
(different for Care Plan (health to health promotion, by law is deployed,
workers and non- promotion, specific protection reorganizing
workers) risk factors control, targets and early health roles and
and collective and disease detection of diseases responsibilities
health prevention of
public health
importance)

2001 2014
1991 Reorganization of functions
Political Constitution: in municipalities and states 2008 Articulation of a
health as a fundamental right new model and health
By court order, the same policy for Colombia,
health plan for workers and based
non-workers (poor population) on the determinants of
must be unified health and primary
health care

Timeline
The basis of Colombia’s current health system was
established in 1993, as a mechanism for implementation
of the 1991 National Constitution, wherein health is
considered as a fundamental right (Figure 1). As established,
the health system was based on assurance of provision
of health services to the population. Later, in 1996, the
conditions for population health care were defined based
on collective activities under the Basic Attention Plan.8
In 2000, regulations were issued in order to ensure effective
and efficient care in activities of public health interest,
such as prevention of common diseases and healthy
population measures, including vaccination, maternal and
child health, and early detection of diseases such as breast
and cervical cancer. As of 2001, responsibility for specific
protection, implementation and early detection activities
was assigned to municipalities and states. Performance in
health issues is assessed against indicators related to the
aforementioned activities.
In 2007, a law was passed mandating the national
government to issue national public health policies
and plans, in order to ensure integration of actions and
implementation of long-term programmes to improve
health conditions for the Colombian population,
including in relation to emerging diseases. To protect the
fundamental right to health care, in 2008, Judgement
T760 of the Constitutional Court of Colombia mandated
equality in health benefit plans for the entire population,
and a review and update of benefit plans, in accordance
with technological advances in health care.9 In 2011,
as part of compliance with Judgement T-760, a law
was issued ordering the creation of a health model
strengthening primary health care, development of a
permanent functional structure for updating health
plans, and formulation of a national pharmaceutical
industry policy. In 2014, a new law was created amending
the fundamental right to health care, which was now
deemed an inalienable right that should be guaranteed

8 República de Colombia, Ley 100 de 1993: Libro II del Sistema General de Seguridad Social en Salud [Republic of Colombia, Law 100 of 1993: Book II of the General System of Social Security in
Health]. Bogotá, Colombia: 1993 (http://www.alcaldiabogota.gov.co/sisjur/normas/Norma1.jsp?i=5248, accessed 21 February 2017).
9 Sentencia T-760 de 2008 [Judgement T-760 of 2008]. Bogotá, Colombia: Constitutional Court; 2008 (http://seguimientot760.corteconstitucional.gov.co/T-760–08.php, accessed 21 February 2017).

5
 Colombia Case Study

by the government at the same level as the right to life.
The law mandated creation of a health model based on
the social determinants of health, taking into account
the geographical characteristics of the Colombian
territory. Additionally, it created an unlimited health plan,
by which the Colombian population is entitled to any
technology available in Colombia, with treatment paid
for through the health system using public resources,
except in the case of technological solutions that are
too extravagant, cosmetic, or experimental, or that lack
evidence of effectiveness and safety. In compliance with
these laws, in 2016, a new Comprehensive Health Care
Model (Modelo Integral de Atención en Salud, MIAS)
was introduced, which strengthens primary health care
delivery, including through increasing the responsibility
and decision-making capacity of health teams. It is a
model that improves access of the population to health
care, aims to achieve user satisfaction, and optimizes
fulfilment of health system goals.
Governance and health services
architecture
Colombia is a centralized State, which assigns functions
to departments and municipalities according to their
management capacity, population and availability of
resources. The regulatory and governing body for health
is the Ministry of Health and Social Protection, which is
responsible for issuing the technical rules and regulations
that control the health system, and the management
components, norms, and organizational, monitoring and
control elements related to finance and the relationships
between the different entities in the system (Figure 2).10

Figure 2. Architecture of health care system in Colombia

Health promotion companies

Payment for services in PHC

Stewardship Ambulatory health Surveillance

and regulation services and control

Private PHC Public PHC

Ministry of Quality and institutions institutions
Health public health Population Superintendence
and Social actions information of Health
Protection surveillance

Multidisciplinary health
professionals Public teams in
local government

Operational authorization PHC

Local authorities

10 Decreto 4107 de 2011, por medio del cual se expiden las funciones del Ministerio de Salud [Decree 4107 of 2011, by means of which the functions of the Ministry of Health are issued]. Bogotá,
Colombia: Presidency of the Republic of Colombia; 2011 (http://www.alcaldiabogota.gov.co/sisjur/normas/Norma1.jsp?i=44615, accessed 21 February 2017).

6

Rules and technical regulations controlling the functioning
of entities seek to harmonize the relationships between
payers and service providers, within an environment
of patient-centred care, quality of service delivery, and
best clinical practice. Development of studies on the
effectiveness and safety of health technologies and
procedures is financed by The Ministry of Health and Social
Protection, as well as the production of clinical guidelines
and protocols, to help actors in the system to improve
quality and articulation of clinical care through different
conditions. The government must formulate long-term
policies (10 years), called decennial plans. Among them are
the 10-year Public Health Plan, the National Pharmaceutical
Policy, and the Comprehensive Health Care Policy. In
addition, in each presidential period (every four years) a
government plan must be established aligned with the
above, indicating the programmes that will be developed
to achieve the health goals of the Colombian population.
At the territorial level, departments, districts and
municipalities are responsible for health promotion
activities, tracking actions of public health interest,
financing collective health activities, monitoring, control,
and inspection of the health services plan, and ensuring
quality in the provision of services. The territorial entities
are in charge of certifying the functions of health
providers, monitoring health indicators, and articulation
between the health sector and other allied sectors, such
as education, culture and infrastructure.
Health-promoting companies (empresas promotoras de
salud, EPS) have several functions, including affiliating
Colombian inhabitants (national or foreign) to the
Colombian health system, managing population risk
of disease, and supervising financial resources for the
provision of individual health services to the population
that is affiliated. Surveillance of the EPS is carried out by the
National Superintendence of Health, a State agency but
independent of the Ministry of Health and Social Protection.
Health service provision is performed by public and private
hospitals, as well as independent health professionals.
Service networks are articulated with low-complexity
services (general practice, nursing, dentistry, individual
health education activities, vaccination, prenatal care,
11 Resolution 412 of 2000. Bogotá, Colombia: Ministry of Health and Social Protection; 2000.
12 Statistical data: Colombia. Geneva: World Health Organization; 2015.
13 Fuentes de financiación y uso de los recursos del Sistema General de Seguridad Social en Salud [Sources of financing and use of the resources of the General System of Social Security in Health].
Bogotá, Colombia: Ministry of Health and Social Protection; 2016 (https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VP/FS/fuentes-y-usos-de-recursos-del-sgsss.pdf, accessed 21
February 2017).
PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)
and early detection activities). According to professional
criteria, patients can be referred to specialized services
(doctors or dentists), but in some cases administrative
authorization is required by the EPS.11 Hospitals and clinics
that provide health services in Colombia are organized by
level of complexity: low, medium, and high complexity.
Low-complexity institutions provide services of general
medicine, nursing, labour and delivery care, dentistry,
pharmaceutical services, clinical laboratory (basic tests),
and in some cases nutrition and therapy. Medium-
complexity institutions include basic specialized services
such as internal medicine, gynaecology, general surgery,
orthopaedics, anaesthesiology and paediatrics. High-
complexity institutions include public and private hospitals,
specialized surgical services, more complex medical
and surgical specialties, high-level clinical laboratory
and diagnostic imaging (including magnetic resonance
imaging), tomography, interventional radiology, special
care units (such as intensive adult, paediatric, neonatal
and obstetric care), in addition to specialized units for
cancer treatment, dialysis and transplants, among others.
Financing
Colombia’s health system financing has multiple
sources. Some resources are levied through specific
destination taxes, while others come from project taxes
and investment funds. In the last five years in Colombia
health per capita spending has increased by 25%, from
US$  720 in 2009 to US$  962 in 2014,12 despite the fact
that the percentage of GDP destined for health has been
maintained constant at 7% (+/–  0.2%). Out-of-pocket
health expenditure is 15.9% of total health expenditure.
While sources of revenue for Colombia’s health system
vary, the main source is taxes that workers from the public
and private entities of Colombia contribute. Given the way
the State is organized, an important source of funding
is generated by the financial surpluses arising from
management of resources in the Colombian health system.
There are other sources of finance derived from general
taxes that are transferred to the health system as part of
the national general budget, for example taxes levied on
alcoholic beverages, gaming, tobacco and firearms.13
7
 Colombia Case Study

These resources are distributed based on the Figure 3. Health system resources distribution, 2014
characteristics of use. For example, resources for providing
individual services are made per capita to the EPS. For this 100

purpose a premium insurance was created based on the

90
capitation payment unit (unidad de pago por capitación, 85%
UPC), which is revised and adjusted annually taking
80
into account adjustments in benefit plans, inflation and
population variations. 70

Resources for collective activities, public health activities

60
and basic sanitation are transferred to the municipalities,
districts and departments through the national general
50
budget in accordance with the General Participation
System, which allocates resources according to various 40
criteria, including population conditions, number of
inhabitants, populations with unsatisfied basic needs, 30
special populations, and the municipality category.
Small, low-level municipalities, which lack management 20
capacity, receive resources to be allocated by departments,
while municipalities in higher categories and with good 10
7%
5%
management capacity receive resources directly, and 3%
0 0%
manage them themselves (Figure 3).
Capitation Payment Unit (UPC) Public health

Human resources Services not included in the benefit plan

Catastrophic event
Support providers

Following the guidelines and principles of the Toronto

Call to Action,14 Colombia promulgated Law 1164 in 2007,
which created an Observatory on Human Resources for
Health. This structure seeks to generate an information
system on human resources for health in order to advance
actions to improve the working conditions of workers in
the health sector, and to generate actions and studies
that strengthen the competences and qualities of human
resources for health in Colombia.15 In 2012 Colombia had
26.01 professionals per 10 000 inhabitants, where the
density of doctors was 16.89 per 10 000 inhabitants and
the density of nursing professionals was 9.19 per 10 000
inhabitants. According to the observations made by the
Observatory on Human Resources for Health, Colombia
has surpassed the goal of having more than 40% of the
existing medical staff dedicated to primary care activities.
However, the goal of achieving a nurse–physician ratio of
1:1 has not been met, as the ratio was 0.55:1 in 2011.16
Colombia has 1122 municipalities and in all of them there
are health professionals caring for the population.
Among the actions initiated in the country within the legal
and regulatory framework related to human resources
for health, the training of health personnel has been
strengthened in different categories, including assistants,
technicians, technologists and professionals in the areas
of medicine, nursing, dentistry and other professions.
Credit grant programmes are in place to encourage
professionals to obtain training in areas where there are
fewer specialties in Colombia (Figure 4).

14 Toronto Call to Action: 2006–2015, towards a decade of human resources in health for the Americas. In: Regional Meeting of the Observatory of Human Resources in Health, 4–7 October, 2005
(http://www.bvsde.paho.org/bvsdeescuelas/fulltext/callaction_eng1.pdf, accessed 21 February 2017).
15 Fuentes de financiación y uso de los recursos del Sistema General de Seguridad Social en Salud [Sources of financing and use of the resources of the General System of Social Security in Health].
Bogotá, Colombia: Ministry of Health and Social Protection; 2016 (https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VP/FS/fuentes-y-usos-de-recursos-del-sgsss.pdf, accessed 21
February 2017).
16 Segunda medición de metas regionales de recursos humanos en salud 2013 [Second measurement of regional health human resource goals, 2013]. Bogotá, Colombia: Ministry of Health and Social
Protection; 2013 (http://www.observatoriorh.org/sites/default/files/webfiles/fulltext/2013/segunda_medicion_metas_col.pdf, accessed 21 February 2017).

8
 PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE (PRIMASYS)

Figure 4. Distribution of health professionals, defining the activities to be developed by each of the
Colombia, 2011 institutions that make up the health system in Colombia.
100 This health model includes regulatory aspects related
to the quality of service, applying the concept of
90 “comprehensive care routes”, whereby, for a clinical
component, the administrative conditions and the
80
best standards in services are determined. The model
also provides a framework for review and regulation of
70
payment mechanisms for health services; development
60
of information systems based on digital clinical charts;
training of human resources for health; and creation of
50 incentive plans for achievement of goals in different
entities of the health sector in Colombia.
40
32% Monitoring and information systems
30
Since the creation of the new health system in Colombia
18%
20 17% 17% in 1993, the government has developed structures that
facilitate information gathering on the activities taking place
9%
10 in the health sector in Colombia. Measurement parameters
3% 2% 2% have been set up for each of the system components, and
0
reporting mechanisms have been put in place to shed light
Physicians Therapists
Nurses Bacteriologists
on coverage and provision of services (quality and quantity),
Dentists Optometrists price systems and performance indicators.
Nutritionists Pharmacists
To assist with these activities, a reporting model – the
Individual Records of Health Services Provision system
Planning and implementation (Registros Individuales de Prestación de Servicios de
Salud, RIPS) – has been established. This mechanism
Implementation of health programmes in Colombia enables data to be gathered on the number of procedures,
occurs within the framework of the current health system appointments, medicines and other services that are
and is developed under the expansion of a health care provided to the population. However, the RIPS system
model that takes account of the characteristics of each does not allow linkages to be made with other systemic
of the regions of the country, establishes linkages with data (demographic, poverty, quality of services, etc.) that
other sectors within their competences, and defines the would help analyse health service provision. For this
functions and responsibilities of actors according to the reason, in the past five years work has been undertaken on
structure of the Colombian State. To define the activities in a platform that integrates all these related features – the
the health system there are general laws that are clustered Comprehensive Information System for Social Protection
through national mandates called decrees. In this respect, (Sistema Integral de Información de la Protección Social,
the Comprehensive Health Care Policy was established by SISPRO).17 It allows accurate review of results for health
Resolution 429 of 2016, and the Comprehensive Health indicators, the health characteristics of each of the
Care Model (MIAS) was established by Resolution 3202 territories, number of services rendered, application of
of 2016. Both decrees institute a series of transversal quality indicators, integration with elements of human
guidelines to the health sector and other related sectors, resources for health, and follow-up on the Colombian
population’s affiliation to the health system.

17 www.sispro.gov.co.

9
 Colombia Case Study

Way forward and policy considerations

In accordance with this analysis of health care provision
in Colombia, it is important to undertake action in the
following areas:
• finalize development of the current care model,
allowing, in parallel, strengthening of the competencies
of regional actors to implement the model;
• define profiles of local officials responsible for the
leadership of primary health care actions and strengthen
the capacity and technological infrastructure necessary
for the deployment of this system;
• define payment mechanisms for health actions that
encourage achievement of goals established at
national level;
• strengthen follow-up actions on human resources for
health policies in Colombia;
• reinforce the technological infrastructure of different
components of the system in order to obtain more
immediate data, with lower adjustment rates;
• strengthen training of human resources for health, for
example in nursing, physician and family medicine
programmes.

Authors
Jaime Hernán Rodríguez Moreno
Colombian Health Technology
Assessment Institute

Laura Julieta Vivas Martinez

Colombian Health Technology
Assessment Institute

10
This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the
World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda
Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support
efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care
interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development
and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage
of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and
abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system,
tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points
to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an
audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health
care systems in selected low- and middle-income countries.

World Health Organization

Avenue Appia 20
CH-1211 Genève 27
Switzerland
alliancehpsr@who.int
http://www.who.int/alliance-hpsr