This blog originally appeared in Spanish on: Foco económico: un blog latinoamericano de economía y política
Sonia Bhalotra (University of Essex) and Manuel Fernandez Sierra (Universidad Los Andes)
Since 1993, when the current Colombian social security system came into force, the health insurance coverage rate has increased from 27% to 95%, approaching universal health coverage. In line with this, there has been an increase in rates of use of medical services and an improvement in health indicators, including an increase in life expectancy at birth and a drop in infant mortality (Latorre and Barbosa, 2012). These have been some of the most important social achievements of the country in recent decades.
However, effective access to essential health services is not quite universal. There are barriers that restrict timely access to medical care for all. Some of these barriers are geographical, reflecting more limited supply of specialized care centres and medical personnel in the most remote areas with the lowest population density. Other barriers are administrative and institutional, and include bureaucratic obstacles and restrictions imposed by insurance companies (e.g. denial or delay of authorizations) to limit the provision of services and reduce costs given a financing scheme based mainly on fixed capitation payments. In recently completed research work, we study the impact of barriers to access to health services on health outcomes in the population. To do this we use administrative data containing comprehensive information on health-related procedures and use age, gender and cause-specific mortality rates as outcomes. Our hypothesis is that access barriers result in an unrealized demand for medical care which reflects in mortality, a widely used indicator of population health.
A challenge to addressing this question is that there are no direct measures of unrealized demand for healthcare: there is no information that allows us to know which health services were asked for and denied – instead we only observe health services that are actually delivered. In fact, the administrative data we have record every health service delivered. To solve this problem, we approximate the prevalence of barriers to access to medical services using information on legal claims brought by citizens to the Constitutional Court to assert their right to health.
The right to health in Colombia, as in many other countries (Backman et al., 2008), is constitutionally protected. This means that ensuring universal access to health services and essential medicines is an obligation of the State. As a constitutional right, the right to health is enforceable, and there is a widely known route that makes it fairly straightforward for individuals to appeal to the Constitutional Court. Colombian jurisprudence has been clear that many of the barriers mentioned above represent a violation of the right to health (for example, Judgment T-760 of 2008 of the Constitutional Court). This has led to the judicialization of health in Colombia.
The main mechanism to demand the protection of fundamental rights in Colombia is the tutela claim. These are judicial claims that are costless, simple, can be filed to any judge within the local jurisdiction, and have preferential proceeding such that the judge is mandated to return a decision within ten days. The ease of filing tutela claims, together with a judiciary proactive in the protection of social rights, has encouraged their use (Rodríguez, 2012). Between 2010 and 2016, more than 675,000 tutelas were filed invoking the right to health (2.3 tutelas per 1,000 enrollees of the system). Although the use of litigation to access health services has been seen in other countries, including Argentina, Brazil and Costa Rica (Bergallo, 2011), the phenomenon is of unparalleled magnitude in Colombia.
Administrative data reveal that tutela claims are made in regard to all possible health services and for a variety of diseases, indicating systemic problems in access. According to a recent report by the Ombudsman’s Office, plaintiffs have brought claims pertaining to their access to medication, medical appointment, medical examination, surgery or treatment being restricted. In 80% of cases, the claim is granted. A recent report by the Ministry of Health and Social Protection shows that 11.6 percent of the tutelas are supported by medical diagnoses of neoplasia, 9.9 percent on diseases of the nervous system, and 8.7 percent on diseases of the circulatory system. Furthermore, 10 of the 21 chapters of the International Classification of Diseases (ICD-10) appeared in more than 5 percent of the tutelas demanding medical services.
For the econometric analysis, we calculate tutela rates (number of health related tutelas per 1,000 enrollees), and mortality rates (number of deaths per 1,000 enrollees) for the entire population during 2010-2016 using administrative data. The level of detail of the data allows us to create these statistics for each insurer within each municipality in each year. There are 1,120 municipalities in Colombia and in each municipality are, on average, 10.7 insurers (including contributory and subsidized regimes), which gives us approximately 11,984 observations per year. We use a statistical technique called triple differencing that acts to purge from the data all fixed differences at the level of municipality X insurer, municipality X year, and insurer X year. This approach renders the residual variation in the data quasi-experimental, allowing us to generate estimates of the relationship of interest that can be deemed causal.
We found that an increase in tutela claims is associated with a sharp increase in overall mortality rates (see Figure 1): a 10 percent increase in the tutela rate is associated with an increase of between 0.5 and 1 percent in the mortality rate. These results imply that between 870 and 1,700 additional deaths per year are generated as a result of restrictions on access to health services. The estimated effects are stronger for the subsidized regime (covering relatively poor individuals) than for the contributory one, but given the uncertainty associated with the estimate, we cannot reject that they are equal at traditional levels of significance. The impact of the increase in claims on mortality rates is evident across causes of death (see Figure 2). These results suggest that the effects are not focused on specific morbidities, but that their impact is much more general.
Figure 1. Judicial Claims Invoking the Right to Health and General Mortality
Note: The figure reports the estimated effect of an increase in the logarithm of the number of judicial claims for enforcement of the right to health on the logarithm of the general mortality rate of the population. Each observation corresponds to an insurer within a municipality in one year. The parameters are estimated from panel data models that include fixed effects at the level of municipality X insurer, municipality X year, and insurer X year. The models are estimated separately: including affiliated population in either regime or separating the population between contributory and subsidized regime. Standard errors are clustered by municipality, insurer and year X department. The judicial claims data comes from the Ombudsman’s Office, the affiliation data to the health system comes from the Ministry of Health and Social Protection, and the death data comes from the vital statistics records of Colombia.
Figure 2. Judicial Claims Invoking the Right to Health and Mortality According to Cause of Death
Note: The figure reports the estimated effect of an increase in the logarithm of the guardianship rate on the logarithm of the mortality rate according to cause of death. Each observation corresponds to an insurer within a municipality in one year. The parameters are estimated from panel models that include fixed effects at the level of municipality X insurer, municipality X year, and insurer X year. Standard errors clustered by municipality, insurer and year X department. The intervals reported include a Bonferroni correction. The guardianship data comes from the Ombudsman’s Office, the affiliation data to the health system comes from the Ministry of Health and Social Protection, and the death data comes from the vital statistics records of Colombia.
To analyze the potential mechanisms behind these results, we calculated the rates of utilization of health services per person in each municipality and for each year. In particular, we calculated the number of consultations, hospitalizations, procedures, and emergencies per person that actually took place between 2010-2016. This information allows us to study whether increases in judicial claims proxying for access barriers were reflected in lower usage of health services.
We found that an increase in judicial claims is associated with a drop in the utilization rates of health services (see Figure 3): a 10 percent increase in the tutela rate is associated with a 1.4 percent drop in the number of consultations and hospitalizations per member, 2 percent in the number of procedures per member, and 0.7 percent in the number of emergencies per member. The results are consistent with the idea that judicial claims captures the prevalence of restrictions on access to different types of medical services demanded.
Note: The figure reports the estimated effect of an increase in the logarithm of the guardianship rate over the logarithm of the utilization rate of different services. Each observation corresponds to a municipality in one year. The parameters are estimated from panel models that include fixed effects at the municipality level and year. Standard errors clustered by municipality and year X department. The intervals reported include a Bonferroni correction. Guardianship data comes from the Ombudsman’s Office, health system membership data comes from the Ministry of Health and Social Protection, and service utilization data comes from the Integrated Social Protection Information System.
The country has made significant progress in health insurance coverage, to the point that it is very close to reaching universal coverage. Efforts should now be oriented both to guarantee effective access to services and to improve quality. This requires reducing supply barriers that prevent timely access to medical care. The results of our study indicate that these barriers have non-trivial costs in terms of health. Being able to balance the best access with the financial stability of the system is one of the great challenges for the future.
- Ayala G., J. (2017). La salud en Colombia: más cobertura, pero menos acceso. En Bonet, J., Guzmán-Finol, K., y Hahn-De-Castro, L. W., (ed.), La salud en Colombia: una perspectiva regional, Banco de la Republica de Colombia, Cap. 8, 249-279.
- Backman, G., Hunt, P., Khosla, R., Jaramillo-Strouss, C., Fikre, B. M., Rumble, C., Pevalin, D., Páez, D.A., Pineda, M.A., Frisancho, A. and Tarco, D. Tarco, D. (2008). Health systems and the right to health: an assessment of 194 countries. The Lancet, 372(9655), 2047-2085.
- Bergallo, P. (2011). Litigating health rights: can courts bring more justice to health?(Vol. 3). Harvard University Press.
- Gaviria, A. (2016) Sobre la reforma a la salud. [Blog post] (Link)
- Latorre, M. L. y Barbosa, S. D. (2012). Avances y retrocesos en la salud de los colombianos en las últimas décadas. En Bernal, O., y Gutiérrez, C., (ed.), La salud en Colombia, Universidad de los Andes, Cap. 1, 11-65.
- Perry, G. (2013) Salud sin barreras. [Op-ed] (Link)
- Rodríguez, C. (2012) La judicialización de La salud: síntomas, diagnóstico y prescripciones. En Bernal, O., y Gutiérrez, C., (ed.), La salud en Colombia, Universidad de los Andes, Cap. 12, 507-560.