Sustainable Financing for Migrant Health: Learning from Colombia
By Jonathan Cali and Ximena McCollum
The Latin America and Caribbean region has experienced unprecedented migration flows over the last decade, forcing governments to rethink their policies for public services. Colombia is the largest recipient of migrants in the region: between 2014 and 2021, the number of Venezuelan migrants living in the country increased from an estimated 23,600 to 1.8 million.[1] [2] But what most countries would see as a daunting challenge, Colombia sees as an opportunity. The country has emerged as a leader in developing policies to integrate migrants into the economy and society, guaranteeing their universal right to health and mobilizing domestic resources to meet the increased demand for health services.
Colombia’s strategy for sustainably financing health care for migrants can be summarized as: 1) enroll migrants with legal documentation, or “regular” migrants, into the country’s general social insurance system; 2) regularize undocumented, or “irregular” migrants and enroll them in the insurance system; and 3) finance essential care to migrants who remain ineligible for health insurance by improving efficiency of health spending and better coordinating international assistance.
In an ideal world, health care for migrant populations should be financed and delivered through the same mechanisms as those for natural-born citizens. In practice, many migrants, especially those without legal status, are excluded from national health systems. Colombia’s strategy for financing migrant health approaches the ideal by regularizing most migrants, allowing their integration into the general social health insurance system while still guaranteeing essential and emergency services to the uninsured. Colombia’s potentially more cost-effective and sustainable strategy to expand access to health care for migrants could serve as a model for other countries faced with high levels of migration.
Regularization Pays Off
Extending the country’s health and social services to millions of migrants can be costly up front, but regularization of migrants has the potential to both increase revenue and reduce health care costs over the long term. Colombia’s migrant response is built around a policy change to grant Temporary Protected Status (TPS) to the country’s 1.5 million irregular Venezuelan migrants. The TPS grants Venezuelan migrants who entered Colombia without legal documentation any time before January 31, 2021 the documentation necessary to live, work, and access social services in Colombia for ten years while they apply for resident permits. New migrants crossing into Colombia through formal border checkpoints through May 2023 are also eligible for the protection.[3]
Migrants with TPS have the same rights as Colombians to enroll in the country’s General Social Health Insurance System, granting them access to a comprehensive package of health services. Financing health care for regularized migrants will be expensive in the short term — LHSS estimated that enrolling eligible Venezuelan migrants would cost about 1.2 billion Colombian pesos ($300 million USD), or 0.12 percent of 2019 GDP annually.[4]
Regularization, however, has the potential to mobilize resources for financing health care over the long term through several mechanisms. First, many regular migrants will enter the formal workforce, where both employees and their employers are required to make contributions directly to Colombia’s national health insurance fund. Second, the World Bank estimates that economic integration of the migrant population can add more than one percentage point to Colombia’s annual GDP growth over the next decade.[5] Resulting increases in general tax revenue can help to offset the Colombian government’s cost of enrolling migrants in the “subsidized” insurance scheme for low-income families and individuals. Finally, regularizing and enrolling migrants in the General Social Health Insurance System will expand their access to primary care services, which are less expensive to deliver than the emergency services that uninsured migrants rely on and have the potential to reduce the need for costly care for chronic diseases.
Financing Services for Irregular and Pendular Migrants
Colombia’s TPS provides a path for integrating millions of Venezuelan migrants into the Colombian health system, but political, legal, and practical barriers will prevent some migrants from regularizing and enrolling in health insurance. Venezuelan migrants who cross the Colombian border at informal border crossings after January 31, 2021, are not eligible for the TPS. Meanwhile, an additional 1.9 million “pendular” migrants reside in Venezuela but frequently cross into Colombia to access health services before returning home to Venezuela.[6] How will Colombia finance health services for these populations?
First, Colombia will improve efficiency. Financial pressure from the migrant and COVID-19 crises is motivating Colombia’s Ministry of Health and departmental health secretariats to identify ways to improve the efficiency of health spending. LHSS is supporting the Colombian government to identify opportunities for improving efficiency of service use, the patient referral system, information systems, and insurance contracting mechanisms. LHSS will work closely with health system stakeholders to agree upon several strategies for reducing administrative and operational costs of the health system without adversely impacting health outcomes.
Second, Colombia is improving the coordination of international assistance. While the Venezuelan migration crisis has attracted fewer international resources than other refugee crises,[7] international assistance is an important source of financing for health care for irregular and pendular migrants. This assistance is most impactful when development partners are coordinated to avoid duplication of services, promote sharing of information, and leverage their competitive advantages. One way to improve coordination is to establish working groups for international partners. In Colombia, the Interagency Group about Mixed Migratory Flows (Grupo Interagencial Sobre Flujos Migratorios Mixtos — GIFMM) coordinates migrant-related international assistance while the Health Cluster coordinates international partners working in the health sector.
Another approach for improving coordination being considered by the Colombian government is to consolidate and direct financial resources from donors to fund services for uninsured migrants at existing primary care networks. LHSS is supporting the Colombian government to develop and cost a package of essential services for irregular and pendular migrants, starting with maternal health and HIV services. Although less generous than the comprehensive package offered to citizens and regular migrants, if funded, the package would guarantee access to the covered services, provide financial protection, improve continuity of care, and could reduce the strain on emergency departments and reduce associated costs.
LHSS supported the Ministry of Health in preparing an implementation guide for maternal health services and the World Bank costed the package. Now, LHSS is supporting the validation and costing of a services for migrants living with HIV. In the short term, multilateral development banks and some private foundations have expressed interest in funding the maternity services through a results-based financing scheme. If migratory flows from Venezuela to Colombia continue at high levels over the long term, the Colombian government may need to consider strategies for sustainable financing such as contributing funding for these services or extending eligibility of the TPS to additional irregular migrants.
Lessons for Other Countries
Inclusive policies to facilitate migrants’ integration into the health system are essential for advancing universal health coverage. Colombia is also betting that adopting a humanitarian, comprehensive, and inclusive approach will be cost-effective over the long run. Learning from the Colombian example would be beneficial for other countries in the region that are experiencing high migration flows and seeking to leverage international assistance to offer cost-effective care. Regularizing migrants has the potential to increase government revenue and reduce health care costs in the long term, while guaranteeing essential services to both pendular and irregular migrants can benefit host countries and improve health outcomes for vulnerable groups, including migrant women.
Read Blogs 1 and 2 of this series, Humanitarian Assistance or System Strengthening? Both Are Needed for Migrant Health and Five Steps to Strengthen Health Access for Migrant Women.
About the authors:
Jonathan Cali is a Country Manager for Abt Associates and manages the LHSS Colombia program. Ximena McCollum was formerly a Country Manager for Abt Associates and managed the LHSS Peru and LHSS Latin America and Caribbean Bureau programs.
Additional contributors:
Camila Franco Restrepo is the Monitoring and Evaluation Manager for LHSS Colombia.
Jose Luis Ortiz was formerly the Senior Health Financing Lead for LHSS Colombia.
Michelle Barliza is the Senior Health Financing Lead for LHSS Colombia.
Notes:
[1] https://www.r4v.info/es/colombia
[2] Migración Colombia. Distribución de Venezolanos en Colombia 2021.
[3] https://imgcdn.larepublica.co/cms/2021/02/08185401/ABC-ESTATUTO-1.pdf
[4] Ortiz-Hoyos, Jose Luis, Michelle Barliza. El Proyecto de Sostenibilidad del Sistema de Salud Local (LHSS) bajo el IDIQ de los Sistemas Integrados de Salud de USAID. Octubre 2020. Análisis de necesidades financieras y mecanismos de financiación para la atención en salud de la población migrante: Reporte de Entregables. Rockville, MD: Abt Associates.
[5] https://blogs.worldbank.org/latinamerica/future-opportunities-colombia-and-its-migrants; https://www.larepublica.co/economia/migrantes-venezolanos-generarian-un-crecimiento-del-pib-de-01-puntos-en-esta-decada-3122955; https://www.elnuevosiglo.com.co/articulos/02-22-2021-moodys-regularizacion-de-migrantes-venezolanos-elevara-pib-de-colombia
[6] 1.87 million pendular migrants, https://www.r4v.info/es/colombia
[7] https://www.brookings.edu/blog/up-front/2021/02/26/venezuelan-refugees-and-their-receiving-communities-need-funding-not-sympathy/
