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Health Care System in Colombia 55

and ovarian cancer patients with genetic testing criteria, and found a wide spec-
trum of germline mutations in BRCA1/2 not previously reported in the country
in patients born in different regions, and we also found an unknown recurrent
mutation in Antioquia (Cock-Rada et al., 2017). Therefore we demonstrated
the need for performing a comprehensive analysis of both genes as well as
other cancer-predisposition genes in patients in our population, and the neces-
sity of carrying out more extensive studies in different regions of the country to
determine the prevalence and spectrum of mutations in these genes, in order
to develop more cost-effective strategies for hereditary cancer testing that could
be adopted by the health care system.
With the introduction of genomic medicine in clinical practice, an understand-
ing of the genetic background of the each population is necessary in order
to better guide diagnosis and personalized management of diseases with a
genetic component.

HEALTH CARE SYSTEM IN COLOMBIA

Colombia had an estimated population of 49 million people in 2017, making
it the third most populous country in Latin America after Brazil and Mexico
(DANE, n.d.). The total fertility rate in 2015 was 1.9 births per woman (World
Bank, n.d.). Since the 1960‘s, Colombia experienced a marked decrease in
mortality, especially in children, but also in fertility, changing dramatically
the demographic composition of the country (Profamilia, 2015). In 2015
in Colombia, 26.8% of the population was younger than 15 years, 65.7%
was between 15 and 64 years, and 7.4% was 65 years old or older (Profa-
milia, 2015). The life expectancy at birth rose from 70.1 years in 2000 to 74.2
years in 2015 for both sexes, being 77.8 years for females and 70.7 years for
males (World Bank, 2016).

The health care system was reformed in the 1990s, leading to a considerable
improvement in coverage, but increasing health disparities in different aspects.
The current social security system was created on December 23, 1993, with
the Law 100 (Ley 100) (Congreso, 1993). This system involves three parties:
(1) The state (mainly the Ministry of Health and Social Protection and other
regulatory entities), which regulates and controls the health care system; (2)
the insurance companies or health promoting entities (EPS), which affiliate
the population and manage resources; and (3) the health providing institu-
tions (IPS), which include hospitals, clinics, laboratories, and health profes-
sionals, who directly treat patients. The health care system is divided into two
systems or regimes: (1) the contributive regime, financed mainly by employers,
employees, and independent workers; and (2) the subsidized regime or selection
system of beneficiaries for social programs (SISBEN), for people with the low-
est socioeconomic level, funded by the state mainly through taxes (Fig. 4.2)
(Vargas et al., 2010).