Real-world effectiveness of COVID-19 vaccines among Colombian adults: A retrospective, population-based study of the ESPERANZA cohort.

COVID-19 vaccines have been essential for reducing the impact of the pandemic; nevertheless, population-based data under real-life conditions are needed to compare their effectiveness in various contexts. The objective of this study was to estimate the effectiveness of vaccines in preventing hospitalization and death from COVID-19 in Colombia under real-life conditions among people aged 18 years and older, according to sex, age, confirmed history of COVID-19 and vaccination series, including the effects of boosters. This investigation was an observational, retrospective, population-based study based on the Colombian cohort "Esperanza". A total of 14,213,409 individuals aged 18 years and older were analyzed, who were matched in a 1:1 ratio of vaccinated to unvaccinated. The study groups consisted of unvaccinated individuals, those with a complete series (CS) and individuals with a CS plus booster. The vaccinated individuals received either homologous or heterologous vaccinations with Ad26.COV2-S, BNT162b2, ChAdOx1 nCoV-19, CoronaVac and mRNA-1273 vaccines. Follow-up was conducted between February 2021 and June 2022. Cox proportional hazards models were used, adjusted for potential confounders, to estimate the effectiveness of different vaccination series. For adults aged 18 years and older, the overall effectiveness of the vaccines in preventing hospitalization was 82.7% (95% CI 82.1-83.2) for CS and 80.2% (95%CI 78.7-81.6) for CS + booster. The effectiveness in preventing death was 86.0% (95%CI 85.5-86.5) for CS and 83.1% (95%CI 81.5-84.5) for CS + booster. Effectiveness decreased with age. While all efficacies were high, CoronaVac offered significantly lower protection, although this improved with a booster. Continued mass vaccination is pivotal, especially in low- and middle-income countries. The study highlights both the real-world effectiveness of these vaccines and the challenges in understanding waning immunity and the influence of different VoC(Variants of Concern) on results.

Real-world Evidence of COVID-19 Vaccines Effectiveness in Solid-organ Transplant Recipient Population in Colombia: A Study Nested in the Esperanza Cohort.

BACKGROUND: Solid-organ transplant recipients (SOTRs) have a higher risk of coronavirus disease 2019 (COVID-19) complications and death and a less powerful and lasting response to vaccines and to natural infection. In Colombia, this population was prioritized in the National Vaccination Plan against COVID-19 and received vaccines from different platforms. The aim of this study was to estimate the effectiveness of the complete vaccination schedule and of the vaccine booster for COVID-19 administered to SOTRs in Colombia. METHODS: A nested-cohort was assembled within the population-based ESPERANZA cohort and included the subset of 16 y and older SOTRs (n = 6963); the follow-up period spanned March 11, 2021, to May 11, 2022. The vaccine effectiveness was estimated with Cox proportional-hazards models so that the overall effectiveness of the complete vaccination schedule, the vaccine booster, each used vaccine, and the homologous and heterologous schedules were estimated, adjusting by the main confounders. RESULTS: The overall effectiveness of being fully vaccinated was 73.7% (95% confidence interval [CI], 68.9%-77.0%) to prevent COVID-19 infection, 83.7% (95% CI, 78.7%-87.5%) to prevent hospitalization, and 92.1% (95% CI, 88.8%-94.4%) to prevent death due to COVID-19. Similarly, the effectiveness of the vaccine booster was 76.7% (95% CI, 70.6%-81.5%), 86.9% (95% CI, 79.4%-91.6%), and 94.5% (95% CI, 89.8%-97.1%) to prevent confirmed COVID-19 infection, hospitalization, and death due to COVID-19, respectively. In both cases, there were no statistically significant differences across age groups. CONCLUSIONS: Findings from this work show a high protection of vaccination against infection, hospitalization, and death due to COVID-19 in SOTRs, which increases with the vaccine booster.

Estimated number of deaths directly avoided because of COVID-19 vaccination among older adults in Colombia in 2021: an ecological, longitudinal observational study.

Background: Colombia's national COVID-19 vaccination plan began in February of 2021. It gave priority to older adults, who constituted 77.7% of deaths from this illness in the year 2020. The main goal of the plan is to decrease specific mortality and the number of serious COVID-19 cases, however, the number of deaths avoided by this strategy is unknown. The objective of this study was to estimate the number of avoided deaths in Colombia by fully vaccinating older adults against COVID-19, during the first year of the implementation of the national vaccination plan. Methods: This study took on the design of an ecological, longitudinal study. Full vaccination coverage for older adults was calculated for each epidemiological week and age group from March to December 2021, based on which the number of avoided COVID-19 deaths was estimated. A sensitivity analysis was performed taking into account variations in the vaccines' effectiveness by age group. Results: In Colombia, over 5.3 million adults 60 years of age and older received full COVID-19 vaccinations between March and December 2021. During that same period, nearly 46,000 deaths of older adults from this cause were registered. We estimated that vaccination has avoided around 22,000 more older adults from dying from COVID-19 in Colombia, that is, 32.4% of expected deaths in 2021. According to the sensitivity analysis, the number of lives saved ranged from 19,597 to 36,507. Conclusions: Colombia's strategy to vaccinate older adults against COVID-19 has avoided mortality for this age group from being 48.0% higher than what was observed during the study period. Even more lives have been saved when taking into account the parameters that were defined and the omission of the contribution from partial vaccinations.

Effectiveness of COVID-19 vaccines in older adults in Colombia: a retrospective, population-based study of the ESPERANZA cohort.

Background: Although clinical trials showed that vaccines have high efficacy and safety, differences in study designs and populations do not allow for comparison between vaccines and age groups. The objective of this study was to evaluate the effectiveness of vaccines against COVID-19 in real-world conditions in adults aged 60 years and older in Colombia. Methods: In this retrospective, population-based, matched cohort study, we evaluated the effectiveness of vaccines against COVID-19-related hospitalisation and death in people aged 60 years and older. The full cohort consisted of every person who was eligible to receive a COVID-19 vaccine in Colombia (the ESPERANZA cohort). The exposed cohort consisted of older adults who were fully vaccinated with Ad26.COV2-S, BNT162b2, ChAdOx1 nCoV-19, or CoronaVac, and who did not have a history of confirmed SARS-CoV-2 infection. The unexposed cohort were people aged 60 years and older who had not received any dose of a COVID-19 vaccine during the study period. Participant follow-up was done between March 11, 2021, and Oct 26, 2021. Vaccine effectiveness was estimated as 1- hazard ratio from cause-specific proportional hazards models in the presence of competing risks. We estimated the overall effectiveness of being fully vaccinated, as well as effectiveness for each vaccine, adjusting by main potential confounders. The effectiveness of each vaccine was also assessed by age groups (ages 60-69 years, 70-79 years, and ≥80 years). Findings: 2 828 294 participants were assessed between March 11 and Oct 26, 2021. For all ages, the overall effectiveness across all assessed COVID-19 vaccines at preventing hospitalisation without subsequent death was 61·6% (95% CI 58·0-65·0, p<0·0001), 79·8% (78·5-81·1, p<0·0001) for preventing death after hospitalisation with COVID-19, and 72·8% (70·1-75·3, p<0·0001) for preventing death without previous COVID-19 hospitalisation. The effectiveness of all vaccines analysed at preventing death after hospitalisation for COVID-19 was 22·6% lower in adults who were aged 80 and older (68·4% [65·7-70·9], p<0·0001) compared with adults aged between 60 and 69 years (91·0% [89·0-92·6], p<0·0001). Interpretation: All vaccines analysed in this study were effective at preventing hospitalisation and death from COVID-19 in fully vaccinated older adults, which is a promising result for the national vaccination programme against COVID-19 in Colombia and in countries where these biologics have been applied. Efforts should be improved to increase coverage among older adults. In addition, given that we observed that the effectiveness of vaccines declined with increasing age, a booster dose is also justified, which should be prioritised for older adults. Funding: Colombian Ministry of Health and Social Protection.

Cost-Effectiveness of the COVID-19 Test, Trace and Isolate Program in Colombia.

BACKGROUND: During the COVID-19 pandemic, Test-Trace-Isolate (TTI) programs have been recommended as a risk mitigation strategy. However, many governments have hesitated to implement them due to their costs. This study aims to estimate the cost-effectiveness of implementing a national TTI program to reduce the number of severe and fatal cases of COVID-19 in Colombia. METHODS: We developed a Markov simulation model of COVID-19 infection combined with a Susceptible-Infected-Recovered structure. We estimated the incremental cost-effectiveness of a comprehensive TTI strategy compared to no intervention over a one-year horizon, from both the health system and the societal perspective. Hospitalization and mortality rates were retrieved from Colombian surveillance data. We included program costs of TTI intervention, health services utilization, PCR diagnosis test, productivity loss, and government social program costs. We used the number of deaths and quality-adjusted life years (QALYs) as health outcomes. Sensitivity analyses were performed. FINDINGS: Compared with no intervention, the TTI strategy reduces COVID-19 mortality by 67%. In addition, the program saves an average of $1,045 and $850 per case when observed from the social and the health system perspective, respectively. These savings are equivalent to two times the current health expenditures in Colombia per year. INTERPRETATION: The TTI program is a highly cost-effective public health intervention to reduce the burden of COVID-19 in Colombia. TTI programs depend on their successful and speedy implementation. FUNDING: This study was supported by the Colombian Ministry of Health through award number PUJ-04519-20 received by EPQ AVO and SDS declined to receive any funding support for this study. The contents are the responsibility of all the individual authors.

Muertes prematuras y años de vida potenciales perdidos, ¿qué ha cambiado en Colombia durante la pandemia por COVID-19? / Premature deaths and years of potential life lost, what has changed in Colombia during the COVID-19 pandemic?

Resumen Introducción: La pandemia por COVID-19 es uno de los mayores desafíos globales de la época. Para la mayor comprensión de sus efectos poblacionales es necesario analizar medidas complentarias a la mortalidad. Objetivos: Estimar los años de vida potenciales perdidos en Colombia debido a muertes prematuras por todas las causas de defunción y por COVID-19 en el periodo marzo-julio entre los años 2015 y 2020. Materiales y métodos: Estudio ecológico, longitudinal y retrospectivo, basado en fuentes de información secundaria. Se calcularon los años de vida potencialmente perdidos según sexo y grupo de edad, utilizando la esperanza de vida y las tablas actuariales del DANE. Resultados: Entre marzo y julio de 2020 se perdieron 2 356 420 años por muertes prematuras, para una tasa de 46,8 años perdidos por cada mil habitantes de Colombia, un resultado superior en un 4,8 % respecto a la media de los últimos cinco años. Debido al COVID-19 se dejaron de vivir 237 725,5 años -con mayor pérdida entre los hombres- y un aporte porcentual del 10,5 % al total de años potenciales perdidos en Colombia. Conclusiones: Durante la pandemia se ha presentado un ligero incremento en los años de vida potenciales perdidos en Colombia. Si bien la pérdida de años atribuibles a las muertes confirmadas por COVID-19 no son los responsables directos de la mayor parte de la pérdida total, los cambios sociales y las condiciones de vida durante el confinamiento sí podrían haber incidido en las variaciones de la mortalidad y su distribución entre subgrupos poblacionales.

Abstract Introduction: The COVID-19 pandemic is one of the greatest global challenges of the time. For a better understanding of its population effects, it is necessary to analyze complementary measures to mortality. Objetive: To estimate the potential years of life lost in Colombia due to premature deaths from all causes and from COVID-19 in the March-July period between 2015 and 2020. Materials and methods: We carried out an ecological, longitudinal and retrospective study, based on secondary sources. Years of life potentially lost were calculated according to sex and age group, using life expectancy and the DANE actuarial tables. Results: Between March and July 2020, 2 356 420 years were lost due to premature deaths, for a rate of 46.8 years lost per thousand inhabitants of Colombia, a result that is 4.8% higher than the average of the last five years. Due to COVID-19, 237 725.5 years were lost -with the greatest loss among men- and a percentage contribution of 10.5% to the total potential years of life lost in Colombia. Conclusions: During the pandemic there has been a slight increase in the potential years of life lost in Colombia. Although the loss of years attributable to deaths confirmed by COVID-19 are not directly responsible for most of the total loss, social changes and living conditions during confinement could have had an impact on variations in mortality and its distribution among population subgroups.

Colombian health care system: results on equity for five health dimensions, 2003-2008.

OBJECTIVE: To assess the change in five health equity dimensions for the Colombian health system: health condition, social health insurance coverage, health services utilization, quality, and health expenditure. METHODS: A common standardization methodology was used to assess equity in countries in the western hemisphere. Data come from the Colombian Life Quality Survey. After indirect standardization, concentration indices and horizontal inequity were estimated. A decomposition analysis was developed. Aggregate household monthly expenditure per equivalent adult was considered as the standard of living. RESULTS: Results show important progress in equity with regard to social health insurance affiliation, access to medicine and curative services, and perception of the quality of health care service. Important gaps persist, which affect poorer populations, especially their perception of having a bad health condition and their access to preventive medical and dental services. CONCLUSIONS: The Colombian model needs to advance in implementing preventive public health strategies to cope with increasing demand concomitant with increased social insurance coverage. The population's access to total services in cases of chronic illness and oral health services must increase and benefit plans must be integrated while preserving the recorded achievements in equity. Decomposition of the concentration index shows that inequities are mostly explained by socioeconomic variables and not by health-related factors.

Colombian health care system: results on equity for five health dimensions, 2003 - 2008 / Análisis de la equidad en cinco dimensiones del sistema de salud de Colombia, 2003 - 2008

OBJECTIVE: To assess the change in five health equity dimensions for the Colombian health system: health condition, social health insurance coverage, health services utilization, quality, and health expenditure. METHODS: A common standardization methodology was used to assess equity in countries in the western hemisphere. Data come from the Colombian Life Quality Survey. After indirect standardization, concentration indices and horizontal inequity were estimated. A decomposition analysis was developed. Aggregate household monthly expenditure per equivalent adult was considered as the standard of living. RESULTS: Results show important progress in equity with regard to social health insurance affiliation, access to medicine and curative services, and perception of the quality of health care service. Important gaps persist, which affect poorer populations, especially their perception of having a bad health condition and their access to preventive medical and dental services. CONCLUSIONS: The Colombian model needs to advance in implementing preventive public health strategies to cope with increasing demand concomitant with increased social insurance coverage. The population's access to total services in cases of chronic illness and oral health services must increase and benefit plans must be integrated while preserving the recorded achievements in equity. Decomposition of the concentration index shows that inequities are mostly explained by socioeconomic variables and not by health-related factors.

OBJETIVO: Evaluar la evolución de la equidad en el sistema de salud colombiano, según cinco dimensiones: condición de salud, cobertura del seguro social de salud, utilización de los servicios de salud, calidad y gasto en salud. MÉTODOS: Se utilizó una metodología común de estandarización para evaluar la equidad en países del continente americano. Los datos se tomaron de la Encuesta de Calidad de Vida de 2003 y 2008. Después de la estandarización indirecta se estimaron los índices de concentración y de inequidad horizontal. Se aplicó un análisis de descomposición; se estimó el nivel de vida a partir del gasto agregado mensual del hogar por adulto equivalente. RESULTADOS: La equidad aumentó notablemente con respecto a la afiliación al seguro social de salud, el acceso a los servicios médicos y curativos, y la percepción de la calidad del servicio de atención sanitaria. Persisten aún considerables brechas, que afectan a las poblaciones más pobres, especialmente en su percepción de tener problemas de salud y su acceso a servicios preventivos médicos y odontológicos. CONCLUSIONES: Se requiere avanzar en la aplicación de las estrategias de salud pública preventivas en Colombia para afrontar el aumento de la demanda ocasionado por la mayor cobertura del seguro social. Debe mejorarse el acceso de la población a servicios integrales en los casos de enfermedades crónicas y a servicios de salud bucodental, y los planes de beneficios deben integrarse sin afectar a los logros en equidad ya registrados. Las inequidades se explican mejor por las variables socioeconómicas que por los factores relacionados con la salud.

Determining factors of catastrophic health spending in Bogota, Colombia.

This study tests whether the low-income population in Bogota not insured under the General Social Security Health System is able to economically handle unexpected health problems or not. It used data from the Health Services Use and Expenditure Study conducted in Colombia in 2001, for which each household recorded its monthly out-of-pocket health expenditure during the year and the household income was measured as the sum of each member's contribution to the household. Payment capacity or available income and catastrophic health spending were based on the latest methodology proposed by the World Health Organization (WHO) in 2005. A probit model was adjusted to determine the factors that significantly influence the likelihood of a household having catastrophic health spending. The percentage of households with catastrophic health spending in Bogota was 4.9%; incidence was higher in low-income households where none of the members were affiliated to social security, where there had been an in-patient event, and where the heads of household were over 60 years of age. There is no statistical evidence for rejecting the hypothesis under study, which states that low-income households that have no health insurance are more likely to have catastrophic health spending than higher-income households with health insurance.

Health insurance doesn't seem to discourage prevention among diabetes patients in Colombia.

In the South American nation of Colombia, as elsewhere, patients with type 2 diabetes often avoid care that could prevent their condition from worsening. Availability of health insurance may play a role in explaining this behavior. Some patients with diabetes skip preventive measures because they have insurance and calculate that they can access curative services later in life. Insurers may limit preventive services coverage because they can't be assured of sharing in the eventual savings that emerge when a chronic condition such as diabetes is managed properly. Our analysis of a nationally representative sample of Colombians who have type 2 diabetes and who pay premiums into the country's "contributory" insurance program, found no evidence that insurance influences those individuals to avoid preventive services. The evidence is less clear for those participating in a different, fully subsidized insurance program, who-despite the availability of preventive care-are no more likely to seek preventive visits than are uninsured patients. We propose controlled experiments to identify and measure the true causal effects of insurance on prevention and, more broadly, steps to increase patients' understanding of the benefits of prevention.

Carga de la enfermedad en afiliados al instituto Mexicano del seguro social (IMSS): asociación con indicadores socioeconómicos: México 2000 / Carga da doença nos filiados ao instituto mexicano do seguro social (IMSS): associação com indicadores socioeconômicos: México 2000 / Burden of disease in Mexican social insurance institute affiliated: relation with socioeconomic indicators México 2000

Se estimó la carga de enfermedad en el IMSS en el año 2000. Resultados: similitud con subregión AMRO A y Australia en primeros diagnósticos, AVISAS Totales y APMP; mayor semejanza en AVD con subregiones AMRO B y D; esperanzas de vida totales similares a subregión AMRO A; esperanzas de vida con discapacidad semejantes a subregiones AMRO B y D; en entidades federativas, a mayor desarrollo socioeconómico, mayor AVD y esperanzas de vidas con discapacidad y menor APMP. Conclusión: Los afiliados al IMSS acumulan una carga de morbilidad mayor a lo esperado y en entidades federativas se asocia directamente con el desarrollo socioeconómico. Se infiere que, en el 2000, los afiliados al IMSS experimentaban baja mortalidad con expansión de morbilidad.

The burden of disease was estimated in people affiliated to the Mexican Social Insurance Institute -IMSS- in 2000.Main results: Similarities with AMRO A subregion and Australia in first causes of burden, total DALY and years lost due to premature mortality; similarities withAMRO B and D subregions in disability live expectancy; highest socioeconomic development associated with highest magnitude of years lived with disability and disability live expectancyat federative entities level. Conclusion: An unexpective high burden of morbidity with disability was found in people affiliated to IMSS; in federative entities, the burden of morbidity is associatedwith socioeconomic level. These results permit to infer, ecologically, that this population is experimented low levels of mortality with an expansion of morbidity.

Estimou-se a carga de doença no IMSS em 2000. Resultados: semelhanças com sub-região AMRO A e Austrália nos primeiros diagnósticos, AVISAS Totais e APMP; maior semelhança em AVD com sub-regiões AMRO B e D; expectativa de vida total similar a sub-região AMROA; expectativa de vida com deficiência semelhantes às sub-regiões AMRO B e D; em entidades federativas, quanto maior desenvolvimento socioeconômico, maior AVD e expectativa de vidas com deficiência e menor APMP. Conclusão: Os filiados ao IMSS acumulam una cargade morbilidade superior à esperada e em entidades federativas associa-se diretamente com o desenvolvimento socioeconômico. Infere-se que, em 2000, os filiados ao IMSS experimentavam baixa mortalidade com expansão de morbilidade.

Una revisión de las formas de pago de los servicios de salud en el Distrito Capital / A review of the forms of payment for health services in the Capital District / A review of the forms of payment of the services of health in the Cardinal District

Este artículo es una presentación de la evaluación de las formas de pago a través de las cuales se reconocen los servicios prestados a la población pobre no afiliada en el Distrito Capital. Los resultados del presente trabajo se concentran principalmente en el análisis de una de las formas de pago, Pago Global Fijo prospectivo por actividad final, y tan sólo en dos de las actividades finales definidas por la Secretaría. Tales actividades son: la consulta de medicina general electiva y la consulta de medicina especializada electiva. Estas dos actividades representan, entre las dos, el 81,15% de las actividades finales realizadas por la red de hospitales y de ellas la atención médica general representa el 79,70%. El proceso metodológico para toda la evaluación desarrollo seis grande subprocesos: a) revisión bibliográfica, b) un marco conceptual y el diseño del plan de análisis, c) revisión de las especificaciones técnicas para la identificación de los registros de prestaciones de servicios de salud enviados, d) evaluación del sistema actual, e) construcción de escenarios de ajuste, y f) formulación de indicadores para el seguimiento de las formas de pago. A partir de los resultados se encontró que los actuales sistemas de pago del Fondo Financiero Distrital requiere ajustes que permitan un mejor manejo del riesgo financiero y la búsqueda de conciliación de los objetivos de política entre la Secretaría Distrital de Salud y los hospitales que prestan los servicios a la población pobre no cubierta con subsidios a demanda. Antes de pensar en migrar a otro sistema, se hace necesario entender que cada uno de los mecanismos genera diferentes incentivos los cuales se busca controlar a través del sistema de monitoreo y evaluación.

This article presents an evalution of the forms of pay that recognize services rendered to the poor population not housed in the capital district. The results of the present work are concentrated principlally in an analysis of one form of pay: Global fixed prospective pay for finished activities, and only in two of the finished activities as definined by the Secretary. Such work is: general elective medical consultations and specialized elective medical consultations and specialized elective medical consultation. These two activities represent, between the two, some 81.15% of the finished activites done by the network of hospitals, and of these the general medical attention represents 79.70%.This methodological process for a full evaluation creates six large subprocesses: a) bibliographic review, b) a conceptual framework and the design of a plan for analysis, c) review of the technical specifications for the identification of the registries for health services rendered, d) evaluation of the currents system, e) construction of adjustment scenarios, and f) formulation of indicators for the continuation of the forms of pay. From these results it was found that the current payment systems of the District Financial Fund require adjustments that permit better management of financial risk. The search must continue for the conciliationof political objectives between the District Health Secretary and the hospitals that serve the poor population not covered by necessary subsidies. Before thinking of moving to another system, it is necessary to understand that each one of the mechanisms generates different incentives which can be controled through the monitoring and evaluation systems.

Factores determinantes y condicionantes de la accesibilidad a los servicios de salud por parte de la población afiliada al régimen subsidiado y participantes vinculados del nivel tres del Sisben de las localidades de Ciudad Bolívar, San Cristóbal, Usaquen, Suba, Usme y Rafael Uribe Uribe de Santa Fe de Bogotá, D.C., 1997 / Determining and conditioning factors of accessibility to health services by the population affiliated to the subsidized regime and participants linked to level three of the Sisben in the localities of Ciudad Bolívar, San Cristóbal, Usaquen, Suba, Usme and Rafael Uribe Uribe of Santa Fe de Bogota, D.C., 1997

Se plantean las siguientes hipótesis: Existen diferencias en el peso de los factores que intervienen en el fenómeno del acceso a los servicios de salud: algunos son condicionantes mientras otros son determinantes y se presentan de manera diferente entre los afiliados del régimen subsidiado y los participantes vinculados del sistema de salud. Se establece como objetivo general analizar el acceso a los servicios de salud por parte de la población perteneciente al régimen subsidiado y los participantes vinculados del nivel tres del Sisben de las localidades de Ciudad Bolívar, San Cristóbal, Usaquén, Suba, Usmey Rafael Uribe Uribe de Santa Fe de Bogotá, 1998, a través de la determinación y valoración de los factores condicionantes y determinantes que en él influyan. Los objetivos específicos son los siguientes: diseñar y probar una metodología que permita estudiar el acceso a los servicios de salud de la población afiliada al régimen subsidiado y de los participantes vinculados clasificados en el nivel 3 del Sisben; identificar los factores de orden geográfico, económico, funcional, social, cultural y de contexto condicionantes del acceso a los servicios de salud entre los dos grupos; determinar los factores de las administradoras del régimen subsidiado y las instituciones prestadoras de servicios involucradas en la generación o eliminación de problemas de acceso a los servicios de salud para la población del régimen subsidiado; determinar los factores de los prestadores de servicios de la red pública involucrados en la generación o eliminación de problemas de acceso a los servicios para la población de participantes vinculados: analizar la influencia de dichos factores en la generación de problemas o facilidades de acceso; definir cuáles son los factores determinantes (variables trazadoras) del acceso que permitan el seguimiento periódico y comparar el comportamiento de dichos factores entre los dos grupos de población del estudio. El estudio busca aportar a la Secretaría Distrital de Salud lincamientos conceptuales y metodológicos sobre los factores condicionantes y determinantes del acceso a los servicios de salud para la población de beneficiarios del régimen subsidiado y los participantes vinculados, que le permitan tomar decisiones para disminuir barreras de acceso y a la vez seguir los logros en materia de equidad del sistema de salud.

The following hypotheses are proposed: There are differences in the weight of the factors that intervene in the phenomenon of access to health services: some are conditioning factors while others are determinants and are presented in a different way between the affiliates of the subsidized regime and the participants linked to the health system. The general objective is to analyze the access to health services by the population belonging to the subsidized regime and the participants linked to level three of the Sisben of the localities of Ciudad Bolívar, San Cristóbal, Usaquén, Suba, Usmey Rafael Uribe Uribe of Santa Fe de Bogotá, 1998, through the determination and evaluation of the conditioning and determining factors that influence it. The specific objectives are the following: to design and test a methodology to study the access to health services of the population affiliated to the subsidized regime and of the participants classified in level 3 of the Sisben; to identify the geographic, economic, functional, social, cultural and contextual factors that condition access to health services between the two groups; to determine the factors of the health care administrators of the subsidized regime and of the participants classified in level 3 of the Sisben; determine the factors of the administrators of the subsidized regime and the institutions providing services involved in the generation or elimination of problems of access to health services for the population of the subsidized regime; determine the factors of the service providers of the public network involved in the generation or elimination of problems of access to services for the population of linked participants: analyze the influence of these factors in the generation of access problems or facilities; define the determining factors (tracer variables) of access that allow periodic follow-up and compare the behavior of these factors between the two groups of the study population. The study seeks to provide the District Health Secretariat with conceptual and methodological guidelines on the conditioning and determining factors of access to health services for the population of beneficiaries of the subsidized regime and the participants linked to it, which will allow it to make decisions to reduce access barriers and at the same time follow up the achievements in terms of equity of the health system.