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By insuring more than 80 percent of its population, Colombia provides a valuable opportunity to gather evidence on a hotly debated health policy issue. Results from three studies evaluating the impact of universal health insurance in Colombia show that it has greatly increased access to and use of health services, even those that are free for all, and has reduced the incidence of catastrophic health spending. The impact has been more dramatic among those most vulnerable to health shocks: those living in rural areas, the poorest, and the self-employed.

The rationing problem is common to all health systems-the challenge of managing finite resources to address unlimited demand for services. In most low- and middle-income countries, rationing occurs as an ad hoc, haphazard series of nontransparent choices that reflect the competing interests of governments, donors, and other stakeholders. Yet in a growing number of countries, more explicit processes, with strengths and limitations, are under development that merit better support. Against this background, the purpose of the Center for Global Development Working Group, which is to examine how priorities are set currently, and to propose institutional arrangements that promote country ownership and improve health outcomes by more systematically managing this complex process of politics and economics, is discussed. Current global and national priority-setting practices in low- and middle-income countries, the potential for strengthened national institutions, and increased global support are reviewed. Recommendations for action are provided.

For a health care system to be considered equitable in its financing, the financial burden of contributions has to be progressive or at least proportional. Out-of-pocket financing takes a larger proportion of poor than of non-poor households' income. To remedy this regressive burden, among other goals, Colombia launched a health care reform based on social insurance as a means to reduce health care financing through out-of-pocket payments, and to reduce financial barriers to access. This paper analyzes the evolution of regressivity in out-of-pocket financing from 1984 to 1997, in order to detect if the 1993 health care reform had an impact on such regressivity. The Kakwani index of progressivity was estimated using three national household surveys. Kakwani indices showed a constant trend towards more regressivity (-0.126 in 1984, to -0.3498 in 1997) when using income to build the index, but a trend towards progressivity (-0.0092 in 1984, to 0.0026 in 1997) when using expenses. Our findings suggest that there was a progressive impact of the reform on out-of-pocket financing when household expenses are used to build the Kakwani index; however, due to issues of comparability between surveys, the findings are not conclusive.

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