The Colombian health system has shown in more than thirty years progress in coverage and results, with an assurance close to 99% by 2024, compared to 25% recorded in 1993. The life expectancy increased from 69 to 77 years and Infant mortality decreased from 19.7 per 1,000 live births in 1998 to 10.2 in 2024.
However, recent figures show a financial and operational crisis that affects the provision of services and the economic protection of users, taking into account that according to a recent Anif reportpocket expenditure would be reflecting the challenges facing the system today.
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In December 2024, complaints and claims in the tax regime increased by 78.9% compared to the previous year and 69.8% in the subsidized regime. These data reflect the growing difficulty in attention and management within the system. In this context, pocket spending, defined as the direct payments made by users at the time of receiving health services, reached $ 14.5 billion in 2024, with real growth of 1.3% per year.
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Pocket expenditure represented 16.8 % of current health expenditure in 2024, compared to 14.2 % in 2021.
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Pocket expenditure includes co -payment and moderating fees for services that should be covered by health promoting entities (EPS), services excluded from the health benefits plan or that have been denied, the direct purchase of medicines and the recurrence to private services in the face of public system deficiencies. According to Anif, The figure shows that households are assuming higher health costs due to the insufficient capacity of the system to provide financial protection.
According to estimates based on the DANE quality survey, Pocket expenditure as a percentage of current health expenditure grew to 16.8% in 2024 from 14.2% in 2021. This indicator approaches the 20% threshold that the World Health Organization (WHO) considers high risk to families, because above this level there is a high financial risk that can lead to poverty.
The sustained increase in pocket spending occurs in a scenario where the system faces a budget deficit, insufficiency in the Capitation Payment Unit (UPC) and a growing demand for health services. “A greater increase in demand for services, budget deficit and the insufficiency of the UPC have consolidated a crisis in the operational and financial capacity of the systema ”, says an Anif analysis.
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Complaints in the contributory regime increased 78.9 % in December 2024, and in the subsidized, 69.8 %.
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Population level impacts
The financial impact is not the same among the population. The lowest income quintile presented a real growth in 63% pocket expenditure between 2021 and 2024despite the fact that 84.8% of this group belongs to the subsidized regime, which in theory should offer greater financial protection.
In contrast, the middle quintiles experienced minor fluctuations, and The highest quintile showed a 2% reduction in its direct health expenditurereflecting its greatest capacity to access complementary insurance and private services.
The distribution by affiliation regime also reveals marked differences because Only 12.9% of the highest quintile is in the subsidized regimewhile 57.6 % belong to the tax, which generally offers greater coverage and access to services.
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The lowest income quintile had a real accumulated growth of 63 % in pocket expenditure between 2021 and 2024.
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In the lowest quintile, most depends on the subsidized regime, but faces a considerable increase in its pocket expenses, indicating that the financial protection expected of this regime is not being sufficient.
As for the types of spendingprivate medical consultations presented a real significant accumulated increase in all quintiles, highlighting the lowest quintile with 71% growth. Vaccine payments increased considerably, especially in quintiles two and three, with accumulated increases of 155% and 268%, respectively.
Besidesmedication expenses grew mainly in the middle quintiles, and diagnostic exams showed increases in the highest and lowest quintiles. These patterns indicate that even basic public health services are generating growing costs for homes, more severe affecting families with less economic capacity. The system crisis not only limits access to timely medical care, but also increases the financial burden that people must assume.
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84.8 % of the poorest quintile people belong to the subsidized regime.
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Implications of the financial crisis
The financial crisis of the system has also affected the availability and quality of services. Medical appointments are reported, denial of authorizations for procedures and missing medicines. These difficulties have motivated users to look for alternatives in the private sector, further increasing their direct expenses.
Since 2021, health pocket expense has shown a growing trend, despite a momentary drop in 2021, reflecting increasing pressure on family finances. The relationship between pocket expenditure and total current health spending is a key indicator of the level of financial protection offered by a health system.
By 2024, The proportion of pocket expenditure compared to total health expenditure was 16.8%, an increase of 2.6 percentage points compared to 2021. This growth puts at risk the principles of equity and universal access to the health system, since the financial burden falls mainly on the most vulnerable.
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Private medical consultations grew 71 % in the lowest quintile between 2021 and 2024.
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The figures show that households assume expenses that should be covered by EPS, due to the operational and financial crisis facing these entities. Copagings, direct medicines and search for private services They have become responses to public care failures.
This phenomenon has regressive consequences, especially affecting homes with lower income, who do not have the financial capacity to face these additional costs without compromising other basic aspects of their well -being. The increase in pocket spending not only implies an economic, but also social and public health challengesince it can restrict access to necessary services.
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Vaccine payment increased 268 % in quintile three and 155 % in Quintil Dos.
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The proposals
According to Anif, The situation requires the adoption of urgent measures that attend the structural causes of the crisis. Experts warn that without deep reform and improvement in system financing, the trend could continue, putting the advances achieved in coverage and health results in recent decades.
In this context, the discussion about the reform of the health system and the decisions made by the national government are fundamental to reverse the financial and operational crisis and to restore financial protection to users.
Pocket expenditure analysis shows that the system not only faces financial problems, but also It has also weakened in its ability to guarantee timely access and economic protection, essential pillars for an effective and equitable health system.
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Diana K. Rodríguez T.
Portfolio journalist
