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Ethnic-Racial Inequity in Health Insurance in Colombia

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Ethnic-Racial Inequity in Health Insurance in Colombia 01 Original research 02 03 04 05 06 Ethnic-racial inequity in health insurance in Colombia: 07 08 a cross-sectional study* 09 10 11 1 2 3 Carlos Augusto Viáfara-López , Glenda Palacios-Quejada , and Alexander Banguera-Obregón 12 13 14 15 Suggested citation Viáfara-López CA, Palacios-Quejada G, Banguera-Obregón A. Ethnic-racial inequity in health insurance in Colombia: 16 a cross-sectional study. Rev Panam Salud Publica. 2021;45:e77. https://doi.org/10.26633/RPSP.2021.77 17 18 19 20 ABSTRACT Objective. Characterize the relationship between ethnic-racial inequity and type of health insurance in 21 Colombia. 22 Methods. Cross-sectional study based on data from the 2019 Quality of Life Survey. We analyzed the type 23 of health insurance (contributory, subsidized, or none) and its relationship to ethnic-racial status and pre- 24 disposing variables (sex, age, marital status), demographic variables (area and region of residence), and socioeconomic variables (education, type of employment, income, and unmet basic needs) through simple 25 and multivariate regression analyses. The association between ethnic-racial status and type of health insur- 26 ance was estimated using odds ratios (OR) and their 95% confidence intervals, through a multinomial logistic 27 model. 28 Results. A statistically significant association was found between ethnic-racial status and type of health insur- 29 ance. In comparison with the contributory system, the probabilities of being a member of the subsidized 30 system were 1.8 and 1.4 times greater in the indigenous population (OR x 1.891; 95%CI: 1.600-2.236) and 31 people of African descent (OR = 1.415; 95%CI: 1.236-1.620), respectively (p <0.01) than in the population 32 group that did not identify as belonging to one of those ethnic-racial groups. 33 Conclusions. There is an association between ethnic-racial status and type of insurance in the contributory 34 and subsidized health systems in Colombia. Ethnic-racial status is a structural component of inequity in access 35 to health services and heightens the disadvantages of people and population groups with low socioeconomic 36 status. 37 38 39 Keywords Health services accessibility; social determinants of health; socioeconomic factors; ethnic inequality; Colombia. 40 41 42 43 In Latin America, certain ethnic-racial groups1 have been sys- The scientific literature shows that ethnic-racial status plays a 44 tematically exposed to multiple forms of material and social key role in the different manifestations of inequity that affect 45 deprivation that generally manifest as low socioeconomic health (3-7). There is also consensus that socioeconomic position 46 status (2). Health inequity occurs when there are unjust, avoid- and type of health insurance are social determinants of health 47 able, or remediable inequalities between social groups (3). that influence access to and quality of health services in some 48 ethnic-racial groups (3, 8). Several authors have shown that hav- 49 1 ing or not having health insurance is the main factor in health Although from a biological standpoint humanity is one and indivisible, in 50 this study the term “race” (and “racial”) is used as a sociological concept access disparities between different ethnic-racial groups (8-10). developed on the basis of phenotypic differentiations and the physical appear- 51 In Colombia, the 1991 Constitution reaffirmed the multi- ance of people, which are used in many areas to classify and establish social 52 hierarchies (1). ethnic and multicultural nature of the country. According to 53 54 * English translation from the original Spanish manuscript revised by the 2 Independent consultant, Bogota, Colombia. 55 3 authors. In case of discrepancy, the original version shall prevail. Access to Universidad del Valle, Colombia. 56 original manuscript: https://doi.org/10.26633/RPSP.2021.18 1 Economics Department, Universidad del Valle, Cali, Colombia. * Carlos 57 Viáfara.López, [email protected] 58 59 This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO License, which permits use, distribution, and reproduction in any medium, provided the 60 original work is properly cited. No modifications or commercial use of this article are permitted. In any reproduction of this article there should not be any suggestion that PAHO or this article endorse any specific organization or products. The use of the PAHO logo is not permitted. This notice should be preserved along with the article’s original URL. Open access logo and text by PLoS, under the Creative Commons Attribution-Share Alike 3.0 N61 Unported license. Rev Panam Salud Publica 45, 2021 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2021.77 1 Original research Viáfara-López et al. • Ethnic-racial inequity in health insurance in Colombia the 2005 Census, 10.4% of respondents self-identified as peo- calculation purposes, each observation was weighted by the ple of African descent, 3.2% as indigenous, 0.012% as Romani inverse probability of being sampled in the ECV-2019 (29). or Gypsy, and 86.1% did not identify as part of any of these ethnic-racial groups. The people included in these minorities Variables and measurements have not had equal access to power, prestige, and resources (11, 12), and are characterized as having higher mortality, lower Type of health insurance was used as a dependent variable in chances of survival when faced with disease (13), worse indi- this study: a) affiliation with the contributory regime, b) affilia- cators of self-perceived health (14), worse health status (14, 15), tion with the subsidized regime, and c) not affiliated with either insufficient health insurance (16), and less access to medical ser- of those two regimes. vices (17-19). Independent variables were selected from ECV-2019 survey Given that health insurance is a component of health service questions about the individual factors that predispose and access (20), in 1993 the Colombian government passed Law 100 enable an individual to use health services, based on the Aday (21) to ensure that the most vulnerable populations have access and Anderson model for accessing these services (20) and the to health services through what is called the subsidized regime social determinants of health proposed by Solar and Irwing (3). (22). The other insurance system in Colombia, called contribu- Ethnic-racial status is considered a structural component tory, is only for individuals with employment contracts or the of social determinants and is therefore a mediator of access to ability to pay. Individuals who cannot afford to pay and are not health services (3). This variable was based on answers to the yet affiliated with the subsidized regime are considered associ- question: “According to your culture, people, or physical traits, ate members (22). It follows then that a person’s type of health you are or identify as: (a) Indigenous; b) Gypsy (Romani); c) insurance is associated with their social position and ability Raizal from the Colombian archipelago of San Andres, Pro- to pay. videncia and Santa Catalina d) Palenquero from San Basilio; e) Studies indicate that there are major differences in the use of Black, Mulatto, Afro-descendant, Afro-Colombian; f) None of the health services among insured and uninsured individuals (23), above”. For analysis purposes, these six categories were reduced as well as in populations insured through the contributory and to three: 1) indigenous: people who self-identified as such, 2) Afro- subsidized regimes (24). The subsidized insurance system is descendants: those who self-identified as Raizal, Palenquero, associated with poor medical care (25) and reduced access to Black, Mulatto, Afro-Colombian, or Afro-descendant, and preventive primary care services and specialized consultations 3) those with no self-reported ethnicity (no-SRE), i.e. people (26), a worse state of health and longer wait times to receive who answered “None of the above.” The self-reported eth- care (27), a higher incidence of poverty-related infectious and nicity model used by DANE was used, which independently communicable diseases including malaria, and a higher risk of shows only ethnic-racial minorities and not people of European, dying before the age of 5 (26). There are also extreme inequali- Asian, or other descent who do not identify as part of the specific ties in sexual and reproductive health care (26). minorities mentioned. Socio-economic deprivation is the main barrier to having The structural determinants or predisposing factors for adequate health insurance (16, 22, 26) and full access to health accessing health services were sex, age (completed years), and services (27). However, there is insufficient literature that marital status (in a formal or consensual marital union, or no analyzes inequity due to ethnic-racial status based on socioeco- marital union). nomic position and affiliation with different health insurance Demographic factors that enable an individual to access systems. There are even fewer studies on improving welfare health services included the area of residence (municipal capital: systems in Latin America and subsequently insuring a signif- the urban center where the mayor’s office is located; populated icant part of the vulnerable population currently associated area: a corregimiento [subdivision of a municipality], inspección with the subsidized system (28). The objective of this study is to de policía [smaller subdivision of a municipality], hamlet, par- characterize the relationship between ethnic-racial inequity and ish, or agricultural area), and the region in which it is located. type of health insurance in Colombia. Socio-economic position, which covers different aspects of social stratification (3), was estimated by the following vari- MATERIALS AND METHODS ables: years of education (school years completed); type of employment (formal or informal); and employment income, A cross-sectional study was conducted, based on data from quantified as the number of current monthly legal minimum Colombia’s 2019 National Quality of Life Survey (ECV-2019) wages.
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