In Colombia, between 1980 and 1990, total health expenditure fell from 7.1 per cent to 6.1 per cent of GDP through a reduction to almost half of the public expenditure (private expenditure accounted for 3.9 per cent of GDP in the latter year).
The new Constitution of 1991 (OPS, 1994c, Vol. II, pp. 124-125):
a) defined (Article 48) the National Health System as a public service to be offered under State control following principles of efficiency, universality and solidarity.
b) declared (Article 49) health as a right of all citizens; established that health care and environmental efficiency are public health services in the State's hands; consolidated the participation of the private sector in supplying benefits; ordered that the health services be organized in a decentralized way by levels of complexity, and with participation of the community; declared basic health care free of charge and compulsory, and established a duty towards individual and community health.
In December 1993, within the framework of a profound legal modification of Social Security, the health system was reformed by creating a «System of Social Security for Health» which substituted systems of protection for general risks of illness and maternity and, when appropriate, the health protection of public care beneficiaries (CONGRESO DE COLOMBIA, 1993).
The reform set off from three basic premises: a) that one third of the population, probably the poorest, did not have regular access to health services; b) that the State was already spending on health more or less what could be expected in view of the country's economic development, and c) that insufficient coverage reflected not so much a global insufficiency of financial resources, as the inequity of the system and its inefficiency, derived from its institutional fragmentation.
The reform aims to: a) guarantee universal coverage in a «reasonable period of time», for which it is compulsory to be affiliated to the Social Security System; b) increase solidarity, via the establishment of a Compulsory Health Plan and a Special Subsidized System (including pharmaceutical care) for the poorest and most vulnerable groups (pregnant women and children less than one year old, the disabled and the elderly) financed among other sources by a Solidarity and Guarantee Fund supported through a one point increase of employer's contributions, additional State support, and a percentage of voluntary primes, and c) an increase in efficiency through the introduction of competition and free choice between public and private insurers (Promoting Entities) and their undertaking of provision.
From the start, the Promoting Entities will be supervised by a National Health Superintendency. They have to provide, either by their own means or by arrangement with Provider Entities, the benefits included in the Compulsory Health Plan in exchange of a minimum guaranteed per capita contribution, and to offer their members more than one provision option. They may establish complementary plans financed by additional voluntary contributions, and they cannot reject and insured person who pays him or her primes whether or not subsidized.
Since the General System of Social Security for Health designed by the Reform Law had a time-limit for implementation of one year from its publication; two years for Institutions, Funds and Insurance Entities of the Public Sector to be transformed into Promoting Entities or instead to be liquidated; and three years for one part of the public subsidy system on supply to be transformed into a subsidy system for demand, it will be difficult to evaluate its first outcomes before the end of 1997.
The Colombian reform starts from different premises and takes into account many criticisms made at the time to the reform in Chile; in particular, those referring to universal coverage, adverse selection and government control of private insurance entities.
Nevertheless, the following points of concern could be advanced: a) without a substantial increase in the proportion of public expenditure in health (today, around 37 per cent of total expenditure), it will not be possible to make progress in solidarity; b) in the previous system, public insurance system fragmentation (in more than 100 entities) was considered one of the causes for inefficiency, and it is unclear whether the new model will reduce it, since it does not limit in any way the possibility of forming Promotional Entities; c) the regulation raises the possibility that Promotional Entities may not diversify supply; d) in principle, the Compulsory Health Plan is variable by departments (provinces) or even by Promotional Entities within each department (although there is subsequent supervision of the Superintendency to adjust departmental Plans to directives of the National Social Security Council for Health).