Rerouting Colombia's Health System Towards Health Equity

Three in ten Colombians in the subsidised regime who fall ill treat themselves 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, which tells us that the persisting distance between them is not about what the system promises. It is about everything standing 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 be spent on a system whose users have been drifting away from it, and the evidence for that drift is not in any ministry's dashboard. It is in the National Quality of Life Survey, 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.

The survey's headline is a success. In 2025, 97.4 percent of Colombians were enrolled, the highest figure it has ever recorded.³ Enrolment, though, is a measure of paperwork. 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.

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, not just on solvency, and measured on it 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.

That is not a statistic about paperwork. 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 survey has recorded. Colombians did not stop getting sick. They stopped believing it was 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, which in a survey this size cannot be told apart from not moving at all.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.

One caution against reading that as the rich being fine. On medicines the top fifth did badly too, with full delivery falling from 63 to 51 percent between 2023 and 2025. Wealth bought a consultation. It did not buy a prescription.

The same benefits, very different access

Colombians sit on four rungs. At the top, a small group buying a private plan on top of their public cover. Then the 22.1 million in the contributory regime. Then the 28.5 million in the subsidised regime. At the bottom, roughly 1.4 million with nothing 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 treat themselves 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 in 2012, and adjusting for age and sex leaves the sixteen-point difference between them essentially intact.³ Both groups are promised the same care. One of them gets considerably less of it. The reform Colombia spent four years arguing about was a redesign of that entitlement, and it would not have closed this.

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. It is worth being precise here: prepaid coverage is not growing, it has drifted down from 3.2 percent of the population in 2021 to 2.2 in 2025.³ There is no stampede toward private cover. There is something arguably worse, which is that the households losing access have nowhere else to go.

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, neither remote nor poorly served, lost twelve and fourteen points and La Guajira and Arauca improved from among the worst-served departments in the country.³ Bogotá needs reading with care: its measured rate did not move, and residents will tell you their experience got worse anyway. Colombia does not have one access problem. It has several, they are not where a national emergency plan would assume, and a plan that treats the country as a single patient will over-treat some regions and miss others entirely.

Medicines: a harder problem than the headline suggests

The sharpest deterioration is in medicines. The share of patients who received every medicine they were prescribed fell from 68.0 percent in 2023 to 53.1 in 2025, the lowest in the series. 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 Place is a different matter: a patient in Bolívar had roughly a three in four chance of walking out with everything prescribed, and a patient in Cauca closer to one in three.

The politics of this issue have pushed everyone toward one-word explanations, and the data resist all of them. Colombia's medicines regulator was tracking 416 products in June 2026, of which eight were classified as unavailable nationally.⁵ That register watches the national market rather than the shelf of any particular pharmacy, and it comes a year after the survey, so it settles nothing on its own. What it does suggest is that "the country ran out of medicines" is too simple a story for a fifteen-point fall. Something in the chain between a prescription and a patient is also failing, which is why the outgoing Ministry of Health ordered insurers in May 2026 to deliver pending medicines to patients' homes within 48 hours and reminded them that contractual and financial disputes are not a reason to interrupt treatment.⁶

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, distributors, pharmacies, providers and patient organisations. A plan built on the assumption that this is only a shortage will fail, and so will one built on the assumption that it is only an administrative dispute.

The cost of not fixing it is already visible and it is 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.⁷ 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.

One corner of the system did not stratify. 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, and they are the part of Colombian health care that currently delivers most evenly. That is worth saying out loud, because programmes that work quietly are the easiest to damage during a fiscal emergency.

Three lessons for the incoming government

Colombia cannot manage this system on an annual survey. The evidence in this article 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 not more frequent surveys. It is knowing, 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 evenly distributed.

Medicine dispensing needs an owner, a plan and a realistic scope. The Ministry of Health 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 patients who are hurt fastest, starting with chronic conditions. It also means being honest about what works: home delivery for chronic and vulnerable patients is worth doing properly rather than announcing, and widening the network of pharmacies where a prescription can actually be filled, beyond those contracted by each insurer, may do more for delivery rates than another instruction to comply.

Basic Health Teams should be evaluated and redesigned before they are expanded. They are the vehicle Colombia already has for territorial reach, and nothing yet shows they narrow the access gap: the programme counts households visited rather than health outcomes, and its own 2024 records report no transfers to Amazonas or Atlántico.⁸ The question is not how many teams exist but whether people in the places that lost access are seeing a doctor when they get sick. A programme judged on outputs will keep producing outputs, and it needs enough flexibility to look different in Chocó than it does in Cundinamarca.

Colombia did the hard part first. It brought almost everyone into the system in a region where many countries are still arguing about how to start, and it unified what that coverage entitles people to. That achievement is real, and none of what is above is an argument for tearing it up.

But recovering the ground lost in the past two years is the floor, not the goal. Colombia spent four years fighting over the architecture of its health system rather than improving what that system delivers, and it emerged from that fight with access lower for every income group except the richest and the widest distance between top and bottom the survey has recorded. A crisis that lands unevenly does not leave an even system behind it.

So the work ahead is not only repair, it is rerouting: pointing a system built to enrol people at the harder target of making sure they are actually seen and actually treated, and pointing it there first at the places and the households that lost the most. Most of that can be done with surgical changes rather than a new law, and most of this term will be needed for it.

Colombia will need a reform eventually, and it should be honest about which one. Not another attempt to redesign the architecture, but a second phase built on what already exists, aimed at a country ageing quickly and carrying a disease burden shifting towards chronic conditions that demand continuity rather than episodes. That system will have to be far more integrated and far more centred on the patient than today's. The mistake would be to design it now, before the recovery has shown which parts of the system can still deliver. The last four years are the argument for that sequence: the country debated the blueprint while the building emptied. Repair first, measure what works, and let the evidence write the reform.