Rerouting Colombia's Health System Towards Health Equity

Three in ten Colombians in the subsidised regime who fall ill turn to self-care instead of seeing a professional. In the contributory regime it is fewer than two in ten. Both groups have been entitled to exactly the same health benefits since 2012. Whatever separates them lives somewhere between the promise and a consulting room.

On 7 August, Abelardo de la Espriella takes office and Ana María Vesga, designated on 30 July, becomes Minister of Health.¹ The campaign promised to stabilise the system within ninety days, with an injection of 10 trillion pesos.² Whatever else that money does, it will go to a system whose users have been drifting away from it, and the evidence of that drift is in the National Quality of Life Survey (ECV), the household survey DANE runs every year and the only instrument in the country that asks Colombians whether they were sick and what they did about it, among many other questions that capture the reality of access to health services.

In 2025, the ECV confirmed that 97.4 percent of Colombians were enrolled in the system, the highest figure the survey has recorded.³ Affiliation, while fundamental, is only the first step. The same survey shows that among people who had a health problem in the previous month, 64 percent went to a health professional, against 75 percent two years earlier. That eleven-point fall between 2023 and 2025 reached every income group in the country except the richest fifth. In recent years, access to health care has been more unequal than at any point on record.

The incoming plan reads the crisis as a financing failure, which is a large part of the problem and not all of it. Money can restore an insurer's balance sheet without changing who walks through a clinic door. So the question worth asking of those ten trillion pesos is not only whether the accounts recover, but whether the people who stopped seeking care start again. That means the plan needs to be measured on access and trust, not just on solvency, and measured from the start rather than at the end of four years.

The fall reached almost everyone

Between 2023 and 2025, the share of Colombians who saw a health professional when they had a health problem fell from roughly three in four to roughly two in three, from 74.8 to 64.1 percent.

Put that in people: around 1.9 million Colombians reported a health problem in any given month of 2025. Had the 2023 rate held, roughly 200,000 more of them would have seen a professional that month: people who felt unwell and decided that the pharmacy counter, a relative's advice, or simply waiting was a better bet than their own health system. The share who went to a drugstore instead of a doctor more than doubled in a single year, to the highest level the ECV has recorded. Colombians did not stop getting sick; somewhere along the way, going stopped seeming worth the trouble.

The distribution of that retreat is where the equity problem sits. The four lowest income groups all pulled back by margins too large to be sampling noise, with the poorest fifth falling about fifteen points and the fourth group thirteen. The richest fifth moved four points.³ By 2025 the distance between top and bottom had reached 25 points, the largest the survey has recorded, though the series has bounced around enough that the level matters more than the trend.

The same benefits, very different access

Colombians are distributed across four rungs. At the top, a small group holding a private health plan (prepaid medicine or an insurance policy) on top of the public system's coverage. Then the 22.1 million who rely on the contributory regime alone. On the next rung, the 28.5 million in the subsidised regime, and finally, on the last rung, roughly 1.4 million who report not being affiliated to the health system at all.

In 2025 those four groups saw a professional at 83.9, 72.8, 56.5 and 43.1 percent.³ Self-medication runs the other way, and the spread is the part to hold onto: someone at the bottom of that ladder is almost five times more likely to self-medicate than someone at the top.

The gap between the two large regimes is the one that should concentrate minds, because it is not a gap in entitlements. Colombia unified the benefit plans of the contributory and subsidised regimes, and after adjusting for age and sex the sixteen-point difference between them remains essentially intact.³ Both groups are promised the same care. One of them receives considerably less.

Two things happening right now make that gap a live risk rather than a stable feature. The first is the financial condition of the subsidised regime, and above all of Nueva EPS. The incoming minister has described it as the country's principal insurer, covering a fifth of the population, operating without audited financial statements since 2024, and has put its stabilisation at the top of her list.⁴ When the entity that insures a large share of the poorest is also the one in most trouble, the access gap will not close on its own. The second is quieter. Private prepaid plans reach 9.4 percent of the richest fifth and under one percent of everyone else, which means the escape route from a struggling system exists for one group and not for the other four. The poorest households face an increasingly stark dilemma: wait for their EPS to come out of the crisis, or start paying out of pocket for private care at far higher cost.

The retreat was not the same everywhere

Access fell almost everywhere and collapsed in some places. In Norte de Santander, Cauca and Caquetá the share of sick people who saw a professional dropped by roughly a third in two years, while Antioquia and Santander, which are neither remote nor short of infrastructure and health workers, lost twelve and fourteen points.³ Colombia has several access problems, and they differ across regions. A national emergency plan will need to be careful not to treat the country as a single patient, at the risk of over-treating some regions and overlooking others.

Medicines: increasingly unequal access

The system's sharpest deterioration is in access to medicines. The share of patients who told the ECV they received every medicine prescribed to them fell from 68.0 percent in 2023 to 53.1 in 2025, the lowest point on record. Among patients with a chronic condition, the people who most need continuity, it fell sixteen points in a single year, from 66.8 percent in 2024 to 50.7 in 2025.³

This failure shows no consistent income gradient. Across the five income groups the delivery rate in 2025 sits between 51 and 57 percent in no particular order.³ There are territorial differences too: a patient in Bolívar had roughly a 75 percent chance of leaving the dispensary with everything prescribed, while in Cauca the chance was closer to just 36 percent.

The politics of this issue have pushed everyone toward simple explanations, but it is something far more complex. INVIMA was tracking 416 products in June 2026, of which only eight were classified as unavailable nationally.⁵ This is scarcity more than a national stockout, but the semantic difference is not what Colombian households care about. Patients are not getting what they need, the way they need it.

That complexity is an argument for taking the problem more seriously, not less. Whoever fixes it has to diagnose it properly first, across national supply, procurement, contracting, insurer liquidity, distribution and the last mile of dispensing, and has to do it with the people who actually move the boxes: insurers, pharmaceutical managers, distributors, pharmacies, providers and patient organisations. A plan built on the assumption that an injection of money alone will fix everything is going to fall short.

The cost of a weakened medicine supply chain is visible and regressive. The pharmacy counter, rather than a doctor, was the first stop for 9.4 percent of people with a health problem in 2025, more than double the 4.2 percent recorded a year earlier.³ In a Defensoría survey at dispensing points in early 2026, 81 percent of roughly 1,400 patients said their medicines arrived late, incomplete or not at all, and around six in ten of them paid for the medicines themselves.⁶ Every one of those payments is a household absorbing a cost the system was built to absorb for them, and a system starved of resources ends up pushing exactly that cost onto the people least able to carry it.

Fortunately, vaccination does not appear to have taken as hard a hit from the system's financial situation, according to the ECV. Among children under five in 2025, 94 percent had complete vaccination schedules and 97 percent attended growth checks, with no income gradient in either and no rural gap in vaccination.³ These are narrow programmes with defined targets and published coverage.

Three lessons for the incoming government

Colombia cannot monitor health equity with an annual survey. The ECV's evidence is a year old by the time it is published, and no government is going to change how often DANE runs a household survey. What is missing is a monitoring layer that does not depend on one instrument or one actor: insurers, providers and patient organisations all hold pieces of the picture, and none of them are currently obliged to publish it in a comparable form. The goal is to know, close to real time, who is missing appointments and medicines and why, so that limited resources can be aimed at those people rather than spread evenly across a country where the problem is not spread evenly.

Medicine dispensing needs an owner, a plan and a realistic scope. The Ministry of Health and Social Protection has to lead this and coordinate the rest, because no single actor in the chain can fix it alone and everyone in it can currently blame someone else. That means an explicit accountability framework, published monthly figures, and priority for the most vulnerable patients, starting with chronic conditions, rare diseases and people with disabilities. The plan must also be honest about what can work in the short term: promises like home delivery for chronic and vulnerable patients need a realistic plan rather than an announcement, and the network of pharmacies where a prescription can actually be filled should be widened beyond those contracted by each EPS.

Basic Health Teams should be evaluated and redesigned before they are expanded. Taking care to people's homes matters for many vulnerable Colombians, but it cannot be the backbone of the system, as President Petro naively intended. These outreach teams were promoted as the way to bring health to the territories, yet almost four years after they were announced there is not a single report showing the policy has helped close the access gaps: the programme merely counts households visited rather than health outcomes, and its own 2024 records reported no transfers to departments like Amazonas.⁷ The question that matters is whether people in the most remote places can reach a health centre when they need it, not simply how many teams exist.

Colombia did the hard part first. It brought almost everyone into a single health system. To some that never counted for much, yet it is something dozens of countries have tried to achieve without success. But recovering the ground lost over the past two years is now the minimum, not the goal. Colombia lost four years fighting over the architecture of its health system instead of improving what that system delivers, and it came out of that fight with less access to care for every income group except the richest, and with the widest distance between those who have the most and those who have the least. Giving people back the access they lost is the new government's first task, and it is not a small one. The ECV's evidence shows a system that is not delivering what it promises, and that the poorest households suffer the most. It also shows that the access gap is not a fixed feature: it can be closed, but only if the system is steered towards those who need it most.

The work ahead goes beyond repair: it is rerouting. It means pointing a system built to enrol people at the harder target of making sure they are actually seen and actually treated, and pointing it first at the places and the households that lost the most. Most of that will have to be done with surgical changes rather than a mega-reform, and most of this term will be needed for it.

Colombia will need a reform sooner or later, but one that amounts to a second phase built on what already exists, not another attempt to redesign the architecture of 1993. The country needs a system designed for the challenges of the coming decades, for a country that is ageing fast and carries a disease burden shifting towards chronic conditions that demand continuity of care. That system will have to be far more integrated and far more centred on the patient than today's.