Mothers receive instruction in dental hygiene
Courtesy United States Agency for International Development

In the late 1980s, the national public health care infrastructure was buiÍÍÍÍlt around a network of approximately 640 hospitals classified as local (73 percent), regional (17 percent), specialized (8 percent), and university (2 percent) hospitals. There were 35,000 beds in the public sector of the system, excluding those available at health care centers and basic care units.

The other three major components of the health care infrastructure were the ISS, the paragovernmental social security institutions, and the private sector. The ISS and related organizations managed approximately 6,500 beds (13 percent) paragovernmental social security institutions handled around 2,300 (4 percent) and the private sector--one of the most dynamic components of the system--had reached 8,000 beds (15 percent). The total availability of hospital beds amounted to only approximately 51,800--a figure that was equivalent to a ratio of 1.9 beds per 1,000 citizens. This ratio was less than half of the capacity for the health sectors of Costa Rica, Chile, Argentina, or even Brazil and not far from the performance of the most underdeveloped countries in the region.

Nevertheless, approximately 80 percent of the population had access to some form of medical and health care services. The national public health system offered coverage to 46 percent of the population, the private sector to 16 percent, the ISS system to 12 percent, and other social security organizations to 6 percent. The remaining 20 percent lacked formal health care coverage and had access only sporadically to professional medical consultation. Furthermore, a considerable proportion of the 12.7 million people served by the national public health system did not have real access to modern forms of diagnosis and treatment.

Urban and rural residents experienced significant differences in access to health care. The coverage in the three largest cities- -Bogotá, Medellín, and Cali--was almost 95 percent. At the rural level, the best services were delivered by the departments in the coffee-growing areas. At the bottom of the scale--in terms of quality and coverage--were the rural areas in the non-Andean regions as well as the marginal neighborhoods in medium-sized and small cities.

In 1985 the country had an estimated 20,500 physicians. Thus, Colombia had almost one physician for every 1,300 inhabitants, a good ratio by international standards. The data were misleading, however, in terms of the real availability of medical care for the population. Almost 70 percent of physicians were located in the twenty-five major cities, which together contained only 45 percent of the population. The problem with professional nursing care was even worse. There was an even greater urban concentration of nurse professionals than of physicians.

The medical doctor was a very important social actor in Colombian history. The doctor' 7f0s statusus in the community usually gave him or her responsibilities that went far beyond health and healing, such as acting as mediator of disputes and electoral power broker. The social reputation and political power of physicians normally was accompanied by above-average economic rewards, thus creating a very attractive professional path for social mobility. Socially, the title of "doctor" was highly desirable and was a goal for the youth of middle-class families that could afford the high cost of this type of education.

Despite a doubling in the number of medical schools between the early 1970s and the late 1980s, university facilities were not able to cope with the huge demand for medical education. In addition, although many medical graduates had not been absorbed by the health system, they were generally not willing to move into the nonurban areas where they were most desperately needed. The high cost of medical education--considered as an investment with unusually high expectations for return--discouraged physicians from considering voluntary moves to areas in need that offered considerably less profitability.

Data as of December 1988