During the late 1980s and 1990s, and under the influence of multilateral organizations like the World Bank and the International Monetary Fund,1 numerous nations undertook reforms based on market models in their social sectors, including healthcare; Colombia was not removed from this. Thus, in 1993 the General System of Social Security in Health (Sistema General de Seguridad Social en Salud, SGSSS) was created,2 frameworked in the Political Constitution of 1991,3 that did not grant healthcare the status of a fundamental human right but regarded it merely as an essential public service of obligatory compliance to be provided under state direction, coordination, and control. Stated principles of the SGSSS are2: universality, solidarity, comprehensiveness, equity, freedom of choice of health insurer and of healthcare provider, quality of service, and social participation.

With this reform, Colombia became one of the first middle-income countries to adopt a model of managed competition.4 It created an extraordinarily complex healthcare system, made up of two insurance schemes: the contributory regime, for formal-sector employees and individuals with ability to pay, financed by mandatory contributions; and subsidized regime, for people unable to pay, funded by resources from the contributory scheme and other sources of financing, such as taxes. Health insurers were introduced to manage the contributory regime (empresas promotoras de salud, EPS) and the subsidized regime (empresas promotoras de salud - subsidiadas, EPS-S). Private insurers compete to enrol the population and public and private healthcare providers (instituciones prestadoras del servicio, IPS) for contracts with insurers. In 1994, a comprehensive policy for social participation in health was also formulated, which established participation in management, planning, and evaluation at various levels: from information to decision making5 and through different types of health participation: citizen participation (based on a market approach), community participation and participation within healthcare institutions. In neoliberal models, participation is central: private enterprises are called upon to participate in managing and providing services, and citizens to participate, among others, in quality control: the latter is the focus of this article.

Users’ awareness of the healthcare system, and of their rights to healthcare, empowers them for effective interaction with health services: for participating in various aspects of the healthcare system6; for making informed health decisions7;8; as well as for accessing services9 and hence, it is one of the fundamental conditions for users to exercise their right to healthcare,10 among others.

Therefore, user awareness of the healthcare system and policies, and of their rights are relevant social determinants of healthcare use, which are closely related to other social determinants, such as socioeconomic level, education levels, gender, and living in rural or urban areas, among others, and can lead to inequities in health.11,12 Nevertheless, analysis of user awareness has been limitedly conducted, in general.6 This also applies to Latin America with few researches available on user awareness of healthcare systems, their functioning, or their healthcare rights. Studies conducted in Colombia indicate that individuals of higher socioeconomic and education levels are those that best know the SGSSS,13 and their right to healthcare.14 Moreover, according to a recent analysis,15 user's awareness of mechanisms for social participation in health in Colombia did not improve, but rather, tended to diminish during the last decade. This article seeks to analyze changes in factors that influence the users’ awareness of the SGSSS and their rights to health care in Colombia in the last ten years.

In the 2000 survey, 51.4% of respondents resided in urban areas; 63.7% were female; 42.7% reported to belong to the lower socioeconomic strata; and 47.8% had no schooling or primary education. In the 2010 survey, 51% resided in urban areas; 56% were female; 71% reported to belong to the lower socioeconomic strata and 65.4%, had no schooling or primary education (Table 1).

Changes in level of awareness of the SGSSS and of healthcare rights

A low level of awareness of the SGSSS, of EPSs, of IPSs, and of the participation norm is noted in the results of both surveys. In 2000, approximately 12% of participants were aware of some system's characteristics (they mentioned at least three), while in 2010 only 8% (Fig. 1). Moreover, responses provided tended to be quite limited, describing very general characteristics of the SGSSS like “to offer healthcare services for everyone”, “to provide healthcare for the poor”, or “you must have your membership card”. Freedom of choice of healthcare institutions or the right to participate in health was only rarely mentioned; in 2010, awareness of healthcare institutions had slightly increased –EPS 14.6% and IPS 15.4% versus EPS 11.3% and IPS 11.7% in 2000– (Table 2). The level of awareness of social participation in health norms was 9.4% in 2000, and 6.1% in 2010. Also, for the question “What do you consider are your healthcare rights?”, more than 90% in both surveys mentioned some rights, and the most common response continued being, the right to health care: “to receive healthcare” and “to be attended to”, 61% in 2000 and 68.3% in 2010; relating the rest to some aspects of health care. Participation was rarely mentioned as a healthcare right (Fig. 1). In the logistical regression model, differences in levels of knowledge between both years were statistically significant, once adjusted by the other explanatory variables (area, sex, level of education and socioeconomic strata) except in the knowledge of healthcare rights (Table 2).

Figure 1.

User's awareness of SGSSS, participation policy and rights to healthcare in 2000 and 2010.

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Table 2.

Change in the level of awareness: bivariate (prevalence and confidence interval of awareness) and multivariate association between awareness and year.

	Survey 2000N=1495		Survey 2010N=1405		aOR	(95%CI)
	%	(95%CI)	%	(95%CI)
Awareness of the SGSSS	12	(10-14)	8	(5-11.4)	0.90	(0.88-0.98)
Awareness of EPSs	11.3	(8.9-13.9)	14.6	(10.5-18.7)	1.71	(1.12-2.23)
Awareness of IPSs	11.7	(9.1-14.1)	15.4	(11.2-19.4)	1.20	(1.05-1.69)
Awareness of the participation norm	9.4	(7.2-11.6)	6.1	(3.3-8.9)	0.65	(0.47-0.89)
Awareness of rights to health	91.5	(89.2-93.5)	89.5	(87.7-91.2)	0.98	(0.95-1.02)

Reference level year 2000.

aOR: odds ratios adjusted for area, sex, socioeconomic and educational level; 95%CI: confidence interval of 95%; SGSSS: general system of social security in health; EPS: health insurers; IPS: healthcare providers.

Reforms to healthcare systems that are based on the application of market mechanisms to improve service quality include, as an inherent element, good awareness and information of users about the healthcare system to participate in its control and to make informed decisions, in addition to accessing the services and to demand their rights. The results of this study show that in the last ten years, and 17 years after the implementation of the SGSSS in Colombia, the level of awareness of the healthcare system is limited and shows a tendency to decrease; only a small improvement was observed in the awareness of health insurers and providers, which was expected as they are the institutions with which users relate to on a daily basis in pursuit of healthcare. The most underprivileged –in general terms– are those with lower odds to be aware of the SGSSS and its institutions. This result indicates a major weakness of the system, which contradicts its fundamental principles. Previous studies19,20 about awareness of participation in health, conducted in Colombia, had observed very limited “users’ awareness” of the healthcare system. The results of this study also show that few users –with a tendency to decrease in the second survey– are aware of the existence of a norm that establishes the right to participate in the control of the system, in accordance to previous studies19,21; these users were men in the high and medium socioeconomic level, and higher and intermediate education. These indicate that awareness of the SGSSS and of the opportunities for participation in its control in order to influence, among others, the quality of healthcare services, is far from improving, and even less in low-income groups. This is especially relevant, considering that these population groups are precisely the ones which suffer most from healthcare services of poor quality, as demonstrated by several studies.1,22–24

Awareness of the healthcare system and its functioning is also a determinant of access to services, with limited awareness being a significant barrier to care.9 The results of this study show that the most disadvantaged groups (those of low socioeconomic and educational levels) are the ones who are the least likely of being aware of the SGSSS, in both surveys. The most disadvantaged population groups are also those who face the greatest barriers to accessing healthcare services.22,24–26 Thus, these results seem to indicate a tendency to increase inequities in access to healthcare, as users of higher strata and educational levels, besides having a better understanding of the SGSSS, tend to improve it, meaning probably a better relationship with it. This probably relates to the perception of users of upper strata of no barriers to access, found in another study.27

The limited awareness of the SGSSS that is broadly observed in this study also indicates, that health authorities and institutions responsible for promoting awareness and keeping users informed, as established by the Ministry of Health,28 still do not comply with this function, and that State agencies responsible for monitoring that these tasks are carried out, do not comply either.1,24,29 These results are in concordance with some studies of recent years that suggest little call for users to know the system, its functions, norms, and participation mechanisms, among others, both on the part of the SGSSS's institutions as well as on the local authorities.14,29–31

Fundamental rights have been socially and progressively built based on perceptions, life experiences, and above all, on the concept of human nature that individuals and social groups have developed.32 Thus, from the individual consciousness built in modernism, fundamental rights are currently presented as universal, that is, extensive to all members of society and supported by the moral principle of equal respect that all people deserve due to their human nature.33 But the validity of fundamental rights in a particular society32 will be given by three circumstances: by the strength of the collective consciousness of its existence; by the ability of society to create a must be or a recognition of rights in the legal order; and, by the ability of social groups to enforce them and exercise them in everyday's life. In our results, in contrast with the limited awareness of the SGSSS, the vast majority of users, about 90% in both surveys, reveal an awareness of some healthcare rights, but above all, of their right to receive healthcare (more than 60%); which clearly coincides with a recent study in Colombia.14 The understanding of the inter-subjective elements and processes, based on which users of the SGSSS, without knowing it well symbolically build their health rights, those which often are denied to them, requires further research.

In conclusion, after 17 years of the SGSSS implementation, users, and above all the most underprivileged, still do not know it, similarly to what had happened in other low income countries.34 This limited awareness not only weakens users individually for accessing services, but also weakens them politically as key players of the system when it comes to participating in its control. In contrast, an element that favors the possibility of exercising the right to healthcare in Colombia is awareness of it among a vast users’ majority; which has been recently strengthened also in the legal field, with recognition of healthcare as a fundamental right.35 The empowerment of the user begins with their awareness, and in order to redress the inequality of awareness of the healthcare system –which affects access and the quality of health services for people who are the most underprivileged–, it is urgent that health institutions comply with their constitutional obligation of informing users. Moreover, governments of low and middle income countries, such as Colombia, should begin to introduce effective measures outside the health sector12; to fight the unequal distribution of power, to improve opportunities to access education and worthy and better paid employment for men and women in order to achieve better health for all.

M.E. Delgado Gallego has contributed to the study conception, design, implementation and interpretation of data analysis and the writing of the paper, she was also responsible for the supervision of the fieldwork. M.L. Vázquez-Navarrete has contributed to the study conception, design and implementation, the supervision of all phases of the research and the writing of the article.

This research was partially financed by Universidad del Valle and the DG XII European Commission (IC18-CT98-0340).

None.