Impact of the universal health insurance benefits on cervical cancer mortality in Colombia

Abstract

Background: Cervical cancer patients in Colombia have a lower likelihood of survival compared to breast cancer patients. In 1993, Colombia enrolled citizens in one of two health insurance regimes (contributory-private insurance and subsidized- public insurance) with fewer benefits in the subsidized regime. In 2008, the Constitutional Court required the Colombian government to unify services of both regimes by 2012. This study evaluated the impact of this insurance change on cervical cancer mortality before and after 2012.

Methods: We accessed 24,491 cervical cancer mortality records for 2006-2020 from the vital statistics of Colombia's National Administrative Department of Statistics (DANE). We calculated crude mortality rates by health insurance type and departments (geopolitical division). Changes by department were analyzed by rate differences between 2006 and 2012 and 2013-2020, for each health insurance type. We analyzed trends using join-point regressions by health insurance and the two time-periods.

Results: The contributory regime (private insurance) exhibited a significant decline in cervical cancer mortality from 2006 to 2012, characterized by a noteworthy average annual percentage change (AAPC) of -3.27% (P = 0.02; 95% CI [-5.81, -0.65]), followed by a marginal non-significant increase from 2013 to 2020 (AAPC 0.08%; P = 0.92; 95% CI [-1.63, 1.82]). In the subsidized regime (public insurance), there is a non-significant decrease in mortality between 2006 and 2012 (AAPC - 0.29%; P = 0.76; 95% CI [-2.17, 1.62]), followed by a significant increase from 2013 to 2020 (AAPC of 2.28%; P < 0.001; 95% CI [1.21, 3.36]). Examining departments from 2013 to 2020 versus 2006 to 2012, the subsidized regime showed fewer cervical cancer-related deaths in 5 out of 32 departments, while 6 departments had higher mortality. In 21 departments, mortality rates remained similar between both regimes.

Conclusion: Improvement of health benefits of the subsidized regime did not show a positive impact on cervical cancer mortality in women enrolled in this health insurance scheme, possibly due to unresolved administrative and socioeconomic barriers that hinder access to quality cancer screening and treatment.

Keywords: Cervical Cancer mortality; Colombia; Disparities in access; Health insurance; Policy.

Fig. 1

Data Management of DANE mortality data from 2006 to 2020 in Colombia. How data was organized (managed), from the all-mortality Death dataset to the final dataset used for this study. The original dataset had 3,439,098 all-mortality cases and the final dataset had 24,491 cervical cancer mortality cases

Graph 1

Crude Cervical Cancer Mortality Trends by health insurance status from 2006 to 2020 in Colombia. Graph 1: *Indicates that the AAPC is significantly different from zero at alpha = 0.05. ∼ If the Average Annual Percentage Change (AAPC) is within one segment, the t-distribution is used. Otherwise, the normal (z) distribution is used

Map 1

Crude Cervical Cancer Mortality Difference Between Subsidized Regime Compared to the Contributory Regime, from 2006 to 2012 versus 2013 to 2020, in Colombia’s 32 Departments. Map 1: Due to limited space, all department names are not featured on the map. The positive numbers (darker colors) mean that compared to the period 2006–2012, the period 2013–2020 had more cervical cancer-related deaths in the subsidized regime compared to the contributory regime. The negative numbers (lighter colors) mean that, compared to the period 2006–2012, the period 2013–2020 had fewer cervical cancer-related deaths in the subsidized regime compared to the contributory regime