Abstract
Background
Financing fragmentation in health systems refers to the coexistence of uncoordinated financing and payment control mechanisms that hinder the achievement of universal health coverage. This study aimed to identify the political and institutional determinants of the Colombian health system’s financing fragmentation, based on the experiences and perceptions of health sector stakeholders and policymakers.
Methods
An exploratory qualitative study was conducted. A total of 28 stakeholders and policymakers, including government officials, elected politicians, healthcare insurance and provider managers, and health-professional-association representatives, participated in semi-structured interviews. Initial coding and categorization (deductive analysis) were performed, followed by data clustering and content analysis (inductive analysis) using a framework analysis approach. Synthesis was graphical and narrative.
Results
From the interviewees’ perspective, the political determinants that may perpetuate the Colombian health system financing fragmentation were: governance issues, including corruption, armed conflict, poor debate and political polarization, decisions made by politicians without adequate knowledge of the health system, limited civil society participation, media influence, and lack of funding for the immigrant population’s healthcare. The institutional determinants were: corruption, underfunding of the system, poor information systems, limited research, resource management by insurers, vertical integration, and the medical-industrial complex’s role.
Conclusions
The results suggest that financing fragmentation in the Colombian health system has determinants rooted in social struggles, armed conflict, and state-society interactions. Addressing these determinants requires political commitment, stronger governance, civil society engagement, and technically skilled decision-makers to develop public policies that ensure integrated financing, robust resource monitoring, and interoperable information systems to achieve universal health coverage.
Patient or public contribution
To identify the political and institutional determinants of financing fragmentation in the Colombian health system from the perspectives of stakeholders and policymakers, this study included elected politicians, government members, health insurance and provider managers, and health professional association representatives involved in the formulation, regulation, implementation, or debate of healthcare reforms.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12913-026-14755-0.
Keywords: Financing fragmentation, Colombia, Health system, Political-determinants, Institutional-determinants, Health financing, Health governance
Background
Health systems financing fragmentation refers to the coexistence of multiple financing and payment control mechanisms in a country that operate without coordination [1]. This generates differences in terms of efficiency, quality, and equity in health system access among population groups, representing an obstacle to achieving universal health coverage (UHC) [1, 2]. This situation is common in Latin American countries [1], where this phenomenon has been associated with access inequities and worse health outcomes [1–3].
To characterize health systems financing fragmentation, Bossert et al. proposed a conceptual framework composed of six dimensions: (1) number of organizations offering financial coverage or insurance to a significant portion of the population; (2) existence of mechanisms for pooling or distributing financial risk among different groups or entities; (3) differentiated eligibility criteria for accessing coverage; (4) number of different benefit packages offered; (5) differentiated levels of contributions or premiums; and (6) diversity of payment mechanisms and number of payers for the main types of providers [1].
The Colombian health system exemplifies this fragmentation [1]. Established by Law 100 of 1993, it created the General Social Security System in Health (Sistema General de Seguridad Social en Salud, SGSSS) under a “structured pluralism” model [4–6]. This law enabled the creation of health insurance organizations (EPS) that manage risk through a capitation payment mechanism (Unidad de Pago por Capitación, UPC) and coordinate service delivery through healthcare provider institutions (Instituciones Prestadoras de Servicios de Salud, IPS) [6, 7]. The system operates through a centralized public entity (Administradora de los Recursos del Sistema General de Seguridad Social en Salud, ADRES), which manages financing sources, ensures timely resource flow, controls resource utilization, calculates and disburses the UPC, and transfers payments to the insurers and providers [6–8].
This institutional structure operates across three distinct regimes, each with different financing mechanisms and target populations: contributory (funded by mandatory payroll or individual contributions, covering employed workers, public servants, pensioners, retirees, and self-employed individuals); special, a form of contributory, (covering armed forces, education sector, and state-owned companies); subsidized (funded with public resources for those unable to pay) [9–11]. As of May 2025, Colombia had achieved 98.39% coverage across these regimes [12].
Applying the framework of Bossert et al., Colombia’s health financing fragmentation is manifested due to the presence of multiple organizations offering insurance to the population, the diversity in payers, and payment mechanisms for healthcare providers [1], and the presence of complementary plans and prepaid medicine schemes, offering enhanced benefits to individuals with greater purchasing power [6, 13].
Despite the impact of this kind of fragmentation in Colombia and other low- and middle-income countries (LMICs), this phenomenon has been little studied, particularly in these settings, where there are significant gaps in understanding the political and institutional determinants that perpetuate health system financing fragmentation [14–16]. In this study, political determinants are understood as the norms, policies, ideologies, governance arrangements, decision-making processes, power relations, and sociopolitical dynamics that influence the functioning of the health system [17, 18], while institutional determinants refer to the organizational structures, administrative capacities, interorganizational relationships, and coordination mechanisms that influence how the health system is organized and operates [19, 20].
The analysis of these dynamics is key, given that political and institutional decisions regarding the financing, organization, and governance of the health system are fundamental determinants of its fragmentation or integration [1]. This situation is particularly relevant in the Colombian case, given that the Colombian health system, under the government of President Gustavo Petro since 2023, is going through a stage of institutional transformation and great political polarization, as the sustainability and role of insurers in the health model are being questioned [21].
Given those gaps in knowledge and the topic’s relevance in the current context, this study aimed to identify the political and institutional determinants of Colombian health system financing fragmentation from the perspective of health system stakeholders and policymakers. Understanding such determinants can contribute to the development of public policies for health sector planning and financing in Colombia and other countries with similar characteristics.
Materials and methods
Design
This was an exploratory qualitative study. This type of study seeks to understand and interpret participants’ perspectives, addressing an understudied phenomenon [22]. The following specific objectives were proposed based on the study’s main objective: (1) to describe the sociodemographic characteristics of the interviewees; (2) to analyze the interviewees’ perceptions on the causes and consequences of the Colombian health financing fragmentation; (3) to identify the possible solutions and facilitators, and barriers to the solutions to the financing fragmentation.
Selection and description of participants
Participants were selected based on their background as elected politicians, members of the government, managers of health insurance and provider companies, and health-professional-association representatives. All of them were somehow involved in the formulation, regulation, implementation, or debate of reforms related to the financing or delivery of healthcare services in Colombia. Those with less than six months of experience were excluded. Convenience sampling was performed. Diversity was sought, including stakeholders and policymakers from different Colombian regions, perspectives, professional backgrounds, and sexes. Invitations were sent by email explaining the study’s aim and measures of confidentiality.
Information collection and storage
Information was collected through in-depth semi-structured interviews conducted in person or virtually from November 2024 to January 2025. The interview script was pilot-tested before the fieldwork, and appropriate adjustments were made (See Appendix A for the thematic interview guide).
The interviews were audio-recorded. A team member (NL) conducted the interviews and provided verbatim transcriptions to ensure data accuracy. The recordings and transcripts were stored in the platform REDCap [23] with restricted access to the research team. Anonymity and confidentiality were ensured through codes for each interviewee: Ei (Sex, background), where i was the interview number.
Information analysis
After the transcriptions were completed, familiarization was conducted by re-listening to the recordings and rereading the transcripts. Two researchers (NL and LS) conducted a framework-based content analysis [24, 25], for which a categorical analysis matrix was designed. The initial categories were established using a deductive approach based on the study’s specific objectives. Subsequently, the data were arranged and grouped into categories and subcategories that would give meaning to the findings using the interpretive inductive method. Finally, the final categories and subcategories were established through discussion among researchers and inter-branch triangulation (among subjects investigated, contrasting views of different actors according to their experience) and triangulation with the theoretical framework [26, 27]. The matrix structure is presented in Table B1 in Appendix B. This process was performed manually using Microsoft Excel. The synthesis of the results was both graphical (flow maps and word clouds using MAXQDA [28]) and narrative.
Results
Sociodemographic characteristics of the interviewees
A total of 28 participants (60.7% men, n = 17) participated in the study: 60.7% physicians (n = 17), 7.1% dentists (n = 2), and 3.6% (n = 1) from the fields: bacteriology, law, nursing, petroleum engineering, physiotherapy, accounting, and social sciences (Figure C1 in Appendix C). Some held multiple roles; the most frequent roles were: government officials (17.9%) and health-professional-association representatives (17.9%), followed by elected politicians (10.7%) and private-insurer managers (10.7%) (Table B2 in Appendix B). At the time of the interview, 67.9% (n = 19) of the interviewees were active in their positions, while 32.1% (n = 9) had left office. In terms of regions, most were from Bogotá (39.3%), Huila (28.6%), Nariño (7.1%), and Valle del Cauca (7.1%) (Figure C2 in Appendix C).
Colombian health system financing fragmentation
From the interviewees’ perspectives, eight categories were identified (perceptions of financing fragmentation, causes, political and institutional determinants, consequences, solutions to overcome fragmentation, barriers, and facilitators), along with 24 subcategories related to the Colombian health system financing fragmentation. These are described below. Figure 1 presents a flowchart of the main findings. Definitions, distinctive elements of each category differentiated by actors, and textual quotations for each subcategory are included in Table B3 in Appendix B, and word clouds (showing the most frequently used words by subcategory) are shown in Figures C3–11 in Appendix C.
Fig. 1.
Conceptual framework of the Colombian health system financing fragmentation
Perceptions of financing fragmentation
Divergent perceptions of financial fragmentation were identified. Some respondents believe that this phenomenon has diminished or is nonexistent, given the decrease in the number of insurers and the increase in direct payments from ADRES to healthcare providers. Other participants perceive financial fragmentation as a current structural problem, given the multiple sources of health system financing, payment methods, and contracts with healthcare providers, which create obstacles to timely, continuous, and quality access to healthcare services.
Causes of financing fragmentation
Political
Some interviewees believe that the Colombian health financing fragmentation began with the Law 100/1993, which allowed the creation of multiple health insurers to manage public health system resources and establish cost-containment mechanisms that hindered access to services. Other participants believe that financing fragmentation existed or was more pronounced before this law, given the decentralization of health services.
Institutional
It was found that the interviewees believe inadequate governance, prevalent in the face of poor state capacity to manage and provide services, contributed to the emergence of this phenomenon by delegating system administration functions to the private sector.
Economic
It was argued that the fragmentation arises from political and economic interests seeking to control health resources.
The management of resources allows for a number of practices that, at times, are not the best in public and private administration; there are political and economic interests involved, because everyone wants to make their own profit. E26 (Male, experience as health-professional-association representative)
Figure 2 presents the political and institutional determinants that may perpetuate the financing fragmentation of the Colombian health system, as perceived by the interviewees. Political determinants stem from governance issues, and corruption appears as a shared determinant across both political and institutional dimensions, while the other determinants are categorized as either political or institutional. These determinants are described in the narrative below.
Fig. 2.
Political and institutional determinants of the Colombian health system financing fragmentation
Political determinants of financing fragmentation
Governance
The Colombian health system is perceived as having weak governance, manifested in a lack of effective regulation, deficient oversight and control mechanisms, and poor institutional capacity. Government entities responsible for management, oversight, and control are criticized for failing to guarantee the system’s financial sustainability.
We don’t have an inspection, oversight, and control body that has fulfilled its true function during all this time. E4 (Woman, experience as health-professional-association representative)
Corruption
It was noted that the healthcare system organization allows its resources to be captured for clientelism. The interviewees reported that politicians and businesspeople divert funds intended for healthcare to finance electoral campaigns, buy votes, ensure their continued hold on power, and favor allied economic and political sectors.
(The politicians) arrive indebted to contractors, to friends… from the first day they are elected, they have to figure out how to keep that money or how to raise it… Corruption goes from top to bottom. E12 (Man, experience as private insurance manager)
Violence and armed conflict
The infiltration of illegal armed groups (guerrillas, paramilitaries, outlaw groups, and drug traffickers) into various administrative levels of the health system in some regions was described, from hiring and appointing managers to creating insurance companies.
Armed groups have taken over much of the politics in some regions, generating more inequality and more violence… they even manage the hospitals. E9 (Woman, experience as health-professional-association representative)
Debate and political polarization
It was identified that political polarization in Colombia, the lack of structured debate, and technical foundations on the part of certain political sectors affect the financial functioning of the system.
Decisions made by politicians and their knowledge of the health system
It was perceived that some politicians who make decisions about the health system in Colombia lack adequate technical knowledge about it, and there is a shortage of health experts within the legislature, which limits the design of public policies that benefit patients.
95% of politicians know nothing about health… they have a profound lack of understanding of how the health system works and the implications of those resources… the only thing they know about health is that it’s a magnificent business. E21 (Woman, experience as elected politician)
Civil society
It was noted that civil society participation in debates on health policies is scarce and passive, as citizens have limited knowledge of the system and may feel fear or believe they will not be heard by the government.
The majority of the population doesn’t talk about this (health)… I think that has a lot to do with our history of violence…. E9 (Woman, experience as health-professional-association representative)
Media
It was argued that traditional media, aligned with economic and political interests, defend the current financial approach to the health system through narratives that instill fear in citizens, hindering changes aimed at reducing financial fragmentation.
Specific policies for financing care for the immigrant population
It was described that mass immigration to Colombia has generated pressure on the subsidized regime, and adequate measures to serve the immigrant population without affecting the health system’s functioning and financing have yet to be implemented.
Institutional determinants of financial fragmentation
Corruption
It was mentioned that corruption practices are at multiple levels: insurers diverting resources to non-health infrastructure, creating “phantom patients” (fictitious members to collect payment for services not provided), and overbilling for services; providers participating in these irregularities; patients abusing legal resources guaranteeing rights to illegally market supplies; and people with economic capacity evading contributions, violating the system’s solidarity principle.
Underfunding of the system
There was a perceived lack of funding and resources for the health system, as well as an insufficient UPC.
Information system and research
Structural deficiencies in the interoperability of the health information system and medical records were described, including a lack of traceability of information between services, payments, and clinical outcomes; fragmented medical records across different entities; and limited information quality and transparency. These deficiencies hinder resource monitoring, research, and innovation, while also generating duplication of services, diagnostic delays, and increased costs.
There is no interoperability… There are many opacities that are difficult to identify for the regulator. E9 (Woman, experience as health-professional-association representative)
Resource management by insurers
Some participants blamed insurers for perpetuating fragmentation by mainly hiring their own healthcare providers and by using healthcare resources for private interests, which undermines the system’s sustainability and leads to non-payment to healthcare providers and workers, resulting in service closures and shortages. In contrast, other interviewees consider them essential for resource management and advocate for private participation with efficient state oversight.
Vertical integration
Vertical integration has been defined as the integration of insurance management and health service provision. It refers to the process by which two levels of the same production chain are grouped within a single organization [29]. In this study, it was argued that vertical integration allows insurers to prioritize payments to their own suppliers, establish favorable rates (in the absence of a unified rate system), and concentrate resources on private infrastructure.
Most EPSs have vertically integrated with IPS, clinics, because it’s a way to rationalize costs. E12 (Male, experience as a private insurance manager)
Medical industrial complex
The medical industrial complex has been defined as the network of private corporations responsible for providing healthcare services for profit [30]. According to participants, the pharmaceutical industry, as a key component, not only benefits from the system but also actively participates in its design, since the system is structured to favor the consumption of technologies and medicines.
Consequences of the Colombian health system financing fragmentation
According to the perception of the interviewees, health system financing fragmentation generates positive and negative consequences presented below (See Table B4 in Appendix B for more details).
Negative consequences
Healthcare providers
It was described that multiple payment methods, payers, and payment delays have forced healthcare providers to take on debt or close services, leaving hospitals without sufficient capacity, medications, and supplies. Inequalities in payment and contracting times that favor vertically integrated providers were also highlighted.
Public providers are perceived as inefficient due to corruption, clientelism, low competitiveness compared to the private sector, and procurement systems based on political relationships rather than competencies. They also face greater limitations in investment for infrastructure and technology, which further affects their financial sustainability.
Health personnel
It was argued that healthcare personnel work under inadequate conditions, including labor outsourcing and service contracts without benefits, prolonged shifts, delayed or absent payments, low remuneration, job instability, and differential payments between the public and private sectors. These conditions have led to migration of healthcare personnel in some cases, representing a loss of highly trained human capital.
Patients
Financing fragmentation was identified as facilitating corruption, reducing resource efficiency, affecting the guarantee of the right to health by delaying or denying services, and hindering diagnoses and treatments for patients. This disproportionately affects economically vulnerable individuals, those covered by the subsidized healthcare system, residents of remote rural areas, informal workers, and patients with high-cost chronic illnesses.
Positive consequences
Health insurers
It is argued that insurers have obtained financial advantages from public resources and used vertical integration to concentrate resources.
Health service providers
It is explained that some providers have developed profitable business models based on the health system.
Medical industrial complex
It was identified that multinational pharmaceutical companies find Colombia to be a favorable market with few barriers to entry and lax regulations. The costs of medicines and supplies represent one of the main sources of resource drain in the system.
Politicians
Some politicians consider the health sector to be highly attractive because of the job opportunities in small municipalities, where hospitals are the main employers, using it as a resource for patronage, personal enrichment, or financing political campaigns.
Patients
It is argued that the principle of solidarity allows equal access, and fragmentation has stimulated competition among actors, driving technological development and service quality improvements.
Solutions to overcome the financial fragmentation of the Colombian health system
The participants propose that the government assume a more active role in oversight and regulation, strengthening its institutions, preventing the politicization of regulatory bodies, and establishing severe penalties for those who abuse the system. Regarding payment for services, some propose that ADRES be the sole administrator to eliminate intermediaries, i.e., insurers, and guarantee the timely flow of resources, while others point out that ADRES lacks sufficient infrastructure and that centralizing resources could exacerbate corruption, suggesting an independent technical entity or a mixed model. They propose adjusting the UPC to risk variables and maintaining diverse sources of financing given the threat posed by an exclusively fiscal model, as well as implementing robust databases, integrated systems with interoperability of medical records, online electronic billing, and strengthening health research to optimize spending and improve decision-making.
Barriers to overcoming the financial fragmentation of the Colombian health system
The interviewees believe that corruption, the prioritization of political and private interests over collective ones, political polarization, ADRES’ operational limitations, weak billing controls, a lack of auditing and regulation, and the system’s underfunding are barriers to overcoming financial fragmentation. Furthermore, there are conflicting views: some consider private sector involvement in public resource management to be the biggest obstacle, while others reject centralization in the public sector.
Facilitators to overcome the financial fragmentation of the Colombian health system
It was argued that civil society and healthcare personnel are key actors in oversight processes and strengthening the system. The use of technology to improve financial and operational management, the support of individuals with technical knowledge and scientific evidence for decision-making, and the political commitment of the national government are fundamental facilitators for overcoming fragmentation.
Discussion
This qualitative study used semi‑structured interviews to identify the perceptions of some stakeholders and policymakers on the political and institutional determinants of Colombian health system financing fragmentation. Some interviewees claim minimal fragmentation, blaming policy changes under President Gustavo Petro for the financial crisis, noting that fragmentation benefits patients via service guarantees. Others see fragmentation as a structural problem from Law 100/1993 that fuels the crisis, benefiting insurers, the medical‑industrial complex, private actors, politicians, and some providers while harming patients, workers, and other providers. The split reflects Colombia’s longstanding political polarization, intensified during Petro’s reform agenda [21].
According to the interviewees’ perception, as a political determinant of financing fragmentation, we found that weak governance in Colombia may undermine the health system through limited institutional capacity, ineffective regulation, and poor oversight, echoing Restrepo and Zapata (2022), who identified that the Colombian health system had a weak governance, characterized by corruption, a lack of transparency and accountability, and precarious inter-institutional coordination [31].
Our study shows corruption as a financing fragmentation’s political and institutional determinant, affecting all actors in the system. This finding is consistent with news reports from 2016 to 2022, which showed 94 corrupt acts reported in the health sector, costing roughly US$411.1 million and harming patients, vulnerable groups, children, ethnic communities, and conflict victims [32]. Restrepo‑Zea et al. similarly found that 72% of 141 surveyed health‑system actors identified corruption as the chief problem [31].
Violence emerges as a political determinant that may undermine financial health, population well-being, and staff welfare. The Truth Commission (a state entity that seeks to clarify the patterns and causes of the internal armed conflict in Colombia) and related studies have shown that armed conflict diverts health resources, with armed groups controlling funds and facilities [33], and that residents and workers in conflict areas suffer physical and mental harm and loss of life [34, 35].
Political polarization may also perpetuate fragmentation, stalling dialogue and policy design, thereby damaging the system’s financial architecture. This situation is aggravated by the limited knowledge that elected politicians have of the health sector, hindering structural reforms. Our findings align with the Edelman 2023 report, ranking Colombia among the most polarized of 28 nations [36], and with Mehdi et al., who linked polarization to reduced economic growth in developing countries [37].
Limited civil‑society participation and the influence of traditional media act as political determinants that may drive and entrench financial fragmentation in the Colombian health system. Flamand et al. found that media coverage creates uncertainty, fear, and political polarization, hindering decision‑making while civil society and the media play key roles in shaping public policy [21]. Furthermore, the lack of specific financing policies for immigrants may exacerbate fragmentation, as immigration strains the subsidised regime without adequate support. Bojorquez et al.’s case study of Mexico, Colombia, and Peru confirms that, despite inclusive pandemic‑era initiatives, migrant access barriers persist and the system has failed to develop sustainable financing mechanisms [38].
Regarding institutional determinants, this study found that corruption, underfunding, and a deficit in UPC calculations may significantly worsen the health system’s finances, while late or non-payments from insurers to providers lower care quality and threaten sustainability. These findings echo Granger‑Castaño et al.‘s identification of rising fiscal demands due to new workers’ laws, benefit plan equalization, immigration, and shifting demographics [39].
A deficient information system, marked by inadequate monitoring of billed services, poor health outcome tracking, and a lack of medical record interoperability, may have perpetuated financial fragmentation and impeded health research. This is consistent with the findings of Eslava-Rincón et al., who noted that the health sector information system is fragmented and presents problems of quality, technical interoperability, and infrastructure hindering inspection, monitoring, and data control [40].
Our analysis also identifies vertical integration and the medical‑industrial complex as institutional determinants that may sustain financial fragmentation for some actors. This aligns with Cifuentes dos Santos, who found that vertical integration alters health‑technology prices, creating variability in diagnostic and therapeutic costs across providers [41].
The interviewees perceive financial fragmentation of the health system as having both positive and negative consequences. According to them, the insurers have obtained financial benefits from using public resources from the health system, a finding corroborated by EPS statements, media investigations, and National Health Superintendency reports that confirm campaign financing and corruption cases identified by the regulator [42, 43]. On the other hand, the participants identified mixed consequences for the healthcare providers; according to the interviewees, some of the providers profited from the system and developed profitable models, while others suffered payment delays from insurers and the government, forcing them to take loans to cover debts or shut down services, as confirmed by media reports such as Moreno’s [44].
Some participants consider that healthcare personnel experience precarious working conditions due to fragmentation, including outsourcing, instability, salary delays, lack of benefits, and low pay, which also affect mental health and increase migration. These findings align with media reports and González et al.’s study on poor working conditions [45, 46].
Regarding patients, some interviewees consider that administrative barriers and inequities persist, especially in the subsidized system, although the Colombian health system has broad coverage. This aligns with the study of Serván-Mori et al., which linked fragmentation, social inequities, and higher maternal mortality in Mexico [2]. Although our study found no reported negative consequences for actors such as the medical‑industrial complex or politicians, these actors appear to benefit from the fragmentation model.
According to our findings, financing fragmentation in the Colombian health system may be mitigated through stronger governance. The impact of weak governance, corruption, violence, and armed conflict on financial fragmentation may be significant. The State must actively regulate, supervise, oversee, and control the system while strengthening institutional capacity to prevent politicization. An effective information system that records all health‑sector transactions and maintains interoperable medical records will improve monitoring, curb corruption, and strengthen investigative processes, thereby supporting informed public decision‑making.
This study’s strengths include tackling an underexplored issue by drawing on the perspective of diverse political and social actors involved in policy formulation, regulation, implementation, and debate, and by linking health problems to structural and territorial inequities from a bioethical and political perspective. A limitation is the absence of patient or patient-representative voices. Future research could explore how geographic and cultural differences, territorial inequalities within the country, and contextual factors such as armed conflict have influenced fragmentation dynamics and health system functioning. It would also be relevant to assess the hidden costs of fragmentation for patients and society, its consequences for health personnel, and its implications for health inequalities and outcomes. Mixed-methods approaches, or quantitative studies, may help to integrate these dimensions and provide a more comprehensive understanding of these issues.
Conclusion
Our findings suggest that financing fragmentation in the Colombian health system has a complex combination of determinants rooted in the country’s history of social struggles, a long-lasting internal armed conflict, and dynamics of state-society interactions. Addressing the identified determinants requires political commitment, stronger institutions, and active engagement from civil society, technically knowledgeable politicians, and health staff. Equally, to secure equitable, high-quality patient care and optimal working conditions for health workers and advance toward universal health coverage, integrated, sustainable financing plans, robust controls and monitoring for health resources, and interoperable information systems that track health resources and outcomes must be implemented.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We are deeply grateful to the stakeholders interviewed who generously shared their time, experiences, and perspectives for this study. Their contributions were essential to the development of this research. During the preparation of this work, the authors used Trinka AI to improve language and readability. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.
Author contributions
NL-T, CG-H, JE-S and LAS-A contributed equally to the conceptualization and methodology of the study. NL-T led the data curation, formal analysis, investigation, and drafted the original manuscript. CG-H and JE-S contributed to the supervision and revision of the manuscript. LAS-A contributed to the data curation, formal analysis, supervision, and validation of the study. All authors contributed to the writing, review and editing, and approved the final version.
Funding
This research was funded by the NIHR (NIHR150067) using UK international development funding from the UK Government to support global health research.
Data availability
The interview transcripts and recordings are not publicly available due to confidentiality agreements with participants who were assured that only the research team would have access to these sources. Anonymized excerpts from the interviews are presented throughout the manuscript and in the supplementary material in a manner that protects participant identities.
Declarations
Ethics approval and consent to participate
The Ethics Committee of the Universidad Nacional de Colombia approved the project on September 12, 2024 (B.FM.1.002-CE-133-24). This study complied with Colombian regulations and the Declaration of Helsinki. All participants provided written or verbal informed consent.
Consent for publication
Not applicable. All data presented in this manuscript are fully anonymized, and there is no individual person’s data in any form that could lead to the identification of participants.
Disclaimer
The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK government.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The interview transcripts and recordings are not publicly available due to confidentiality agreements with participants who were assured that only the research team would have access to these sources. Anonymized excerpts from the interviews are presented throughout the manuscript and in the supplementary material in a manner that protects participant identities.