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VI. Access to Public Health Services

The Colombian constitution guarantees free basic health care to all residents.¹⁹⁰  But health care in Colombia is delivered through a patchwork of two formal systems and an informal arrangement for those who are left out of the formal system.  Those who are not enrolled in the formal system are often turned away when they seek medical care.  Others do not know how to get access to the benefits to which they are entitled.  “The public health policy is very fragile, fragmented, and very erratic,” said Harvey Suárez, then the executive director of CODHES, a local nongovernmental organization that focuses on the rights of displaced persons.¹⁹¹

Addressing the health needs of Colombia’s displaced population is a complicated task, but the health experts we interviewed suggest several points of entry.  First, health authorities should ensure that no person is turned away from the emergency care to which he or she is entitled as a matter of law.  Second, the cost of medications represents a significant burden for displaced families; the government should consider extending the coverage of the subsidized health system to include medication, at least for displaced families.  Third, because malnutrition is a significant health concern among displaced families, the government should consider extending the period of humanitarian food aid beyond the usual three- or six-month period authorized by Law 387.  Finally, improved access to health information, including information on sexual and reproductive health, is likely to be a low-cost preventive measure with a significant return in public health terms.

The Health Needs of Displaced Families

Many of the health needs of displaced families are common to people living in overcrowded conditions.  Others are a consequence of the change in climate when families travel from Colombia’s lowlying coastal areas to the cordillera running though the center of the country, or the consequence of the stress and trauma of displacement and the abuses which led to that displacement.  “Some common health problems are respiratory illnesses, skin infections, and sexually transmitted diseases.  Intra-family violence is also of great concern,” said Patricia Ospina, the head of Profamilia’s program on displacement.¹⁹²

In Bogotá, mental health issues, domestic violence, and inadequate nutrition were most frequently raised by those interviewed for a 2003 study of the health concerns of the displaced population.  In addition, the study found that many displaced persons have trouble gaining access to health services, difficulties occasioned by bureaucratic requirements, discriminatory treatment, and inability to pay for medication, or consultations (for those not covered by the formal public health system), or transport to and from health clinics.¹⁹³

Ms. Ospina told us that sexual and reproductive health services, including information on these topics, are a particular need for displaced persons.  To explain this need, she compared early pregnancy rates for adolescent girls in the general population with those for displaced adolescent girls.  “The rate is one out of every three adolescents in the general population.  That’s high as it is, but the rate for displaced adolescents is significantly higher.  Two of every three displaced adolescents become pregnant by age nineteen,” she said.¹⁹⁴

Many of the displaced individuals who spoke with Human Rights Watch reported that they did not get enough to eat every day, and humanitarian workers confirmed that malnutrition is a significant problem for displaced families.¹⁹⁵  “Sometimes I have lunch, sometimes no,” said Carmela E., explaining that she ate during the day if she went to an event where lunch was provided.  “In my house I don’t eat lunch.  If there’s enough for dinner, there isn’t anything for lunch.  I don’t have breakfast.  I just go to school like that, without eating.  There’s breakfast at the school, but you have to pay for it, and I can’t.”¹⁹⁶  At Eduardo E.’s school, students could pay for meals at the cafeteria, but his family could not afford the expense.  “I don’t eat breakfast,” he said.  Sometimes he does not eat at all.  “I prefer to go without than to see my little brother hungry.”¹⁹⁷  The IOM found that 80 percent of households surveyed for its 2001 study reported an illness within the prior three months.¹⁹⁸  Forty-one percent of households reported that children under the age of twelve had lost weight within the previous six months,¹⁹⁹ an indication that children in those homes were not getting enough to eat.

A further complicating factor is that many displaced families live in communities with poor sanitation and inadequate access to water.  “We don’t have running water in our houses,” said Carolina Q., interviewed in Altos de Cazucá.  “We have to go to San Mateo,” she told us, referring to another neighborhood that she said was far from her house.²⁰⁰  “There are children who come in with dirty clothes, who haven’t bathed in eight days” because they had no access to water, reported a teacher in Cazucá.²⁰¹  As a result, a community worker with the nongovernmental organization Profamilia told us, “Skin problems are very common.”²⁰²

The prevalence of AIDS in Colombia is relatively low, with an estimated 0.7 percent of Colombia’s population of 45 million living with HIV/AIDS at the end of 2003, according to UNAIDS and the World Health Organization.²⁰³  Cases of AIDS are not frequent among the displaced population Profamilia serves, but staff members expressed concern that HIV and AIDS would be a greater problem in the future.  A case in point is Cúcuta, a town on the border with Venezuela that is a receiving community for large numbers of displaced persons.  “A lot of trucks pass through there, and there is a high risk of prostitution,” Patricia Ospina told Human Rights Watch.  “The same goes for any of the various towns along the truck routes.”²⁰⁴  Profamilia staff reported that the vast majority of their patients who are HIV positive are adolescents and young adults.²⁰⁵

Colombia’s Health Care Systems

Colombia’ s Law 100, enacted in 1993, created two health care systems, one for those who can afford to pay for health care (known as the régimen contributivo) and one for those who cannot (the régimen subsidiado).  Because the subsidized health care system does not have the capacity to meet demand, a third system has developed for those who are “linked” (vinculados) to the subsidized health care system but are not part of it.  “Those who are vinculados receive a document attesting to their status, and they can receive emergency care.  They pay 30 percent of the cost of medical services,” said Ana Lucía Casalles, an official with the Bogotá office of the International Committee of the Red Cross.²⁰⁶

“The number of those in the régimen vinculado is very large,” Ana Lucía Casalles told Human Rights Watch.  “It’s now a crisis.”²⁰⁷  In Soacha, for example, “there are 98,490 people who have been identified as poor by the government that are still waiting to receive the proper certification” to enter the subsidized health care system, a Medecins Sans Frontieres newsletter noted in June 2005.²⁰⁸  “President Uribe’s National Development Plan calls for the addition for 5 million places in the subsidized health care system, but there were 18 million outside the system two years ago,” Casalles said.²⁰⁹  In fact, the government’s proposals have been more modest.  Government officials spoke to us of a proposal that would add 100,000 slots to the public health system in the coming year, with similar increases over the next several years.²¹⁰

An important limitation of this proposal is that most of the additional spaces will go to people with a higher income level than attained by the majority of displaced persons.  The subsidized health care system designates recipients by income level—Level Zero, One, Two, and so on.  The levels are used, among other things, to determine how much an individual will pay for the health care services he or she receives.  Most of the 100,000 new slots were for those in Levels One and Two, according to one news account.²¹¹

Additionally, as noted earlier, some displaced persons are reportedly afraid to register for health benefits. Médecins sans Frontières has found, for example:

Colombia’s health care laws are progressive, and on paper, at least, the benefits offered to the internally displaced are exemplary; but these theoretical benefits often remain unrealized.  For example, registration for a government health plan requires detailed information to prevent fraud and abuse.  This includes confirmation of identity by the local municipality as well as from the area that the person has fled.  But if details of displaced peoples’ current residence fall into the wrong hands, it can cost them their lives.  Understandably, many opt not to enter the system.²¹²

Of the displaced persons we spoke with who were in the subsidized system, all had been placed Level Zero, the lowest of the low-income designations.  “These are the absolute poor.  The great majority is persons who have been displaced, but some members of the receiving community are also at this level,” Patricia Ospina told us.²¹³  A Profamilia nurse in Ciudad Bolívar told us her rule of thumb:  “At Level Zero, they have nothing.  Level One means they have a roof over their heads.”²¹⁴

Enrollment in the subsidized health system means that the cost of health care is partially covered, on a sliding scale depending on one’s level.  Those at Level Zero do not pay to see a doctor, but they are responsible for the cost of their medication.  In general, we heard that medications cost between 1,000 and 10,000 pesos (U.S.$0.40 to U.S.$4),²¹⁵ but we occasionally heard figures that were much higher.  The last time ten-year-old Marisa L. needed medications, for example, her family paid 100,000 pesos (U.S.$40).²¹⁶

Even moderately priced medications may be out of the reach of displaced families.  Sixteen-year-old Carmela E. told us that she had recently seen a doctor in Bogotá about an eye condition, but she did not plan to fill the prescription she was given.  “I don’t have any way to pay for the medication,” she explained.²¹⁷  A Médécins sans Frontiéres study of displaced families living in the Altos de Cazucá noted that many are living on less than one dollar a day.  “Just getting 1,000 pesos [U.S.$0.40] to buy a half-kilo of cornmeal and feed the entire family is a daily challenge for many families in Soacha,” the group reported.²¹⁸

For those not enrolled in the subsidized health system, routine visits add another 3,000 to 10,000 pesos (U.S.$1.20 to U.S.$4) to the cost of medical care.²¹⁹  Specialized medical consultations cost more and are usually prohibitively expensive.  For instance, José F., age ten, told us that his eyes had been damaged after he contracted cerebral malaria when he was younger.  “There’s no money for eye exams,” he reported.²²⁰

Transport is an additional cost and often a significant investment in time.  “The clinic is far from here.  You have to take two buses to get there,” said Isabel R., who told us that the round-trip bus fare was 1,400 pesos (U.S.$0.56).²²¹  “Everything is far,” Teresa Díaz told us.  “It takes three hours to get back” to Ciudad Bolívar from the health clinic, she said.²²²

In total, then, a run-of-the-mill medical problem might cost a family U.S.$5 to U.S.$10 or more, including the cost of transport for at least two family members and, for those who must pay it, the cost of the consultation.  “It’s hard enough for someone who has a job,” a teacher in Cazucá commented, pointing out that incomes in the community were minimal.  “How can it be for someone who isn’t earning anything?”²²³

Discrimination in Access to Health Services

Those who are not enrolled in the subsidized health system may be turned away when they seek medical care.  For example, Winston N., a thirteen-year-old with a heart condition, told us that his parents had been unable to get him an appointment with a doctor because he did not have his identity card.  “My father went to make an appointment in Busa,” he reported.  “They asked him for my identity card.  I haven’t gotten my identity card yet, so I couldn’t see the doctor.”  He told us that he had a photocopy of his card, a fact that would suggest that he had lost it at some point, but the copy was not acceptable to the hospital.  “They asked for the original.  My father went a number of times to make an appointment for me, but they always asked for the card,” he told us.²²⁴

Those familiar with the Colombian health system told us that such accounts are not uncommon, despite the entitlement of displaced persons to emergency care.  “A pregnant woman has to go from hospital to hospital, sometimes to the point of giving birth on the streets,” said an official with MSF Spain.²²⁵  He explained that hospitals have no incentive to provide services to those who are not enrolled in the health system because they will not be reimbursed for the cost of providing those services.