Social Science & Medicine 187 (2017) 118e125

Contents lists available at ScienceDirect

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Work-related illness, work-related accidents, and lack of social

security in Colombia
María Teresa Buitrago Echeverri a, *, César Ernesto Abadía-Barrero b,
Consuelo Granja Palacios a
a
School of Nursing, Pontificia Universidad Javeriana, Bogotá, Colombia
b
Department of Anthropology and Human Rights Institute, University of Connecticut, United States

articleinfo abstract

Article history: The impacts of neoliberal or market-based social security reforms in health have been extensively
Received 3 February 2017 studied. How such reforms transformed employment-related insurance and entitlements, however, has
Received in revised form received significantly less attention. This study aims to understand how the employment insurance
20 June 2017 system operates in Colombia and to assess how the experience of workers seeking social security en -
Accepted 21 June 2017
titlements relates to the system's structure. We conducted an ethnographic study of the Colombian
Available online 23 June 2017
Occupational Risk System between May 2014 and March 2016, with two main components: 1) analysis of
the system itself through in-depth interviews with 32 people working in leadership positions and a
Keywords:
systematic review of the system's most important legislation, and 2) a study of people who experienced
Colombia
problems receiving entitlements and were challenging the assessment of their work -related illness or
Employment insurance
Judicialization accident. We conducted in-depth interviews with 22 people, followed up with half of them, and
Neoliberalism reviewed their case files. We found that difficulties accessing health care services, payments for medical
Social security leave, job reassignments, severance packages, and filing for pension benefits were common to all cases
Welfare systems and resulted from overwhelming bureaucratic and administrative demands. Regional and national
evaluation bodies dictate whether a given illness or accident is work-related, and establish a percentage
of Loss of Wage Earning Capacity (LWEC). People's disabled bodies rarely reached th e threshold of 50%
LWEC to qualify for disability pensions. The lengthy process that workers were forced to endure to obtain
work-related entitlements always involved the judiciary. The three competing for-profit financial sectors
(health insurance, pension funds, and Occupational Risk Administrators) actively challenged workers'
demands in order to increase their profits. We conclude that these for-profit sectors work contrary to the
principles that sustain social security. Indeed, they push sick and disabled workers to unemployment,
informality, economic dependence, and ultimately dire poverty.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction protected by social security. In theory, the country's entire popu-

lation had access to health care services through public networks.
In spite of the Colombian government's commitment to However, entitlements regarding maternity, disability, pension, and
expanding social security to all sectors of the population during the death were formulated as universal only with the advent of
twentieth century (Ruezga, 2006), rural populations and those who neoliberal reforms, specifically the advent of the General Social
lacked formal employment or were unemployed were not Security System implemented through Law 100 of 1993 (Acevedo,
2010). This reform, also known as market-based or privatization
reform, divided health care, pension, and occupational risk into
* Corresponding author. School of Nursing, Pontificia Universidad Javeriana. Cra. three independent but interconnected sub-systems, each protected
7. No. 40-62, Hospital Universitario San Ignacio, Facultad de Enfermería, Séptimo by a different insurance sector. The impacts of neoliberal reform on
Piso, Bogotá, Colombia. the health care sub-sector has received significant attention both
E-mail addresses: mbuitragoe@javeriana.edu.co, mtbuitragoe@gmail.com
in Colombia and across the globe. In general, research in
(M.T. Buitrago Echeverri), cesar_abadia@post.harvard.edu, cesar.abadia@uconn.
edu (C.E. Abadía-Barrero), cgranja@javeriana.edu.co, cgranjap@gmail.com Colombia indicates that while health insurance coverage offered by
(C. Granja Palacios). Health Promotion Companies (HPC) has improved significantly,

http://dx.doi.org/10.1016/j.socscimed.2017.06.030
0277-9536/© 2017 Elsevier Ltd. All rights reserved.
 M.T. Buitrago Echeverri et al. / Social Science & Medicine 187 (2017) 118e125
inequalities continued (Esteves, 2012; Ewig and Hernández, 2009;
Hurtado et al., 2011) and many people are still not receiving timely
and adequate access to health care services (Esteves, 2012). In fact,
new barriers to access proliferated (Abadía-Barrero and Oviedo
Manrique, 2009; Yepes et al., 2010), and corruption grew out of
all control (Robledo, 2012). These studies argue that having health
insurance has not always translated into access to health care ser-
vices. Indeed, the failures of the system have forced over a million
Colombians to initiate legal suits to make good on their right to
health, overwhelming the judiciary and requiring deliberations by
the Constitutional Court and the Inspector General (Chapman,
2016; Lamprea, 2014; Yamin, 2016). Human Rights scholars report
that Colombia is a prime example of how neoliberal social security
reform compromises the right to health care (Abadía-Barrero,
2015a,b; Chapman, 2016; Yamin, 2016).
The effect of neoliberal policies on pension and work-related
entitlements have, in contrast, received minimal attention.
Regarding the pension fund sub-system, Colombia (like most Latin
American countries) has promoted fully-funded individual pension
accounts in a private market offered by companies known as
Pension Fund Administrators (PFAs), in parallel with a reformed
public tier (Iriart et al., 2001; Titelman and Uthoff, 2005). The few
existing studies suggest that the partial privatization of pensions in
Colombia has failed to increase pension coverage due to increased
rates of labor informality (Vásquez-Trespalacios and Martínez-
Herrera, 2013) and has resulted in new income and gender in-
equalities. In terms of the so-called Occupational Risk System, in-
surance companies known as Administradoras de Riesgos Laborales
(Occupational Risk Administrators - ORA) offer insurance to cover
social security expenses associated with work-related illnesses and
injuries to both employers and independent workers. (Most ORAs
are private and only one is a public-private partnership.) Control
and oversight are in the hands of several state bodies. Legally
speaking, ORAs should offer insured employers and workers (with
contracts or working independently) preventative measures to
protect them from work-related illness and accidents, health pro-
motion, health care in cases of work-related illness or accident, and
disability pensions. However, the very high rates of informal labor
in the country (Ministerio de Trabajo, 2016) might explain the very
low rates of coverage by this system (32.5% of the workforce)
(Farné, 2002). Perhaps more worrisomely, the majority of the
workforce do not even know whether or not they are affiliated
(Farné, 2002). In addition, the system's market logic created a
perverse dynamic in which one must be severely disabled in order
to access any benefits (Moreno et al., 2011). This is the context for
our study of how the work-related insurance system operates in
Colombia and how the structure of that system affects the experi-
ence of workers in need of services after a work-related illness or
accident.
2. Methods
This is an ethnographic study of the Colombian Occupational
Risk System conducted between May 2014 and March 2016 with
two main components. 1) We conducted a series of interviews with
32 people working in leadership positions at different institutions
that make up the Occupational Risk System at the national level and
in nine cities. Our semi-structured interview protocol included
sections on their role and activities within the system, disputed
cases, ethical implications, and the system's normativity and
compliance with petitions from workers and other actors of the
system. We also conducted a systematic review of the most
important legislation relevant to the System, starting even before
the most known Law 100 of 1993 (General Social Security System)
and Decree 1295 of 1994 (General Occupational Risk System). (For
119
the full list of legislation that we reviewed, see the supplementary
electronic material.) [INSERT LINK TO ONLINE FILE Legal Docu-
ments]. 2) We interviewed workers who disagreed with the de-
terminations made by health and work-related institutions that
their illnesses or accidents were not work-related or that their
bodies had a lower loss of wage earning capacity (LWEC or in
Spanish, pérdida de capacidad laboral) than they themselves
thought. These 14 men and 8 women who agreed to be part of the
study challenged the “attribution of origin” and/or the percentage
of LWEC that had been determined in their cases, and petitioned
the Regional and National Evaluation Bodies (REB and NEB,
respectively) to reassess their cases. A full description of the cases
can be found as supplementary electronic material. [INSERT LINK
TO ONLINE FILE Descriptions of Cases]. Their possibilities for
rehabilitation, settlement (one-time compensation), and/or pen-
sions were at stake. We met them at the NEB's office. We randomly
approached men and women and told them about our research.
After signing the consent form, we conducted in-depth interviews
with them about their experiences with the system, filled out a
short survey with their sociodemographic information, and
reviewed their case files. In about half of these cases we were able
to conduct follow-up phone calls, and in some cases we conducted
follow-up visits to their homes. The data of the interviews with
people in leadership positions, with the workers, and the system-
atic review of the legislation were collected and analyzed following
an ethnographic abductive-iterative-recursive process, meaning
that we were particularly attentive to signs that emerged in in-
teractions with subjects and objects (in this research legislation and
case files), an approach that forces researchers to constantly
reevaluate concepts and realities (Agar, 2006). The data were
further analyzed independently by each researcher and then dis-
cussed together. Several readings of the material and ongoing dis-
cussions brought to light significant analytical categories. Threats to
validity were reduced by continuously contrasting cases and
triangulating among researchers (Maxwell, 1996). We also sought
validity via presentation of the results to different expert audiences.
The research project received ethics approval by the Pontificia
Universidad Javeriana and all participants signed consent forms.
3. Results
Interviews with people in leadership positions and workers
unveiled that obstacles to accessing care and filing for pensions,
overwhelming administrative demands from multiple institutions
and sub-sectors of the system, and failures to register the condition
of applicants as work-related were common practices of the
Occupational Risk System, which is largely described as malfunc-
tioning. Workers felt that they were being sent on a wild goose
chase, bouncing between Health Promotion Companies, (HPCs) and
Occupational Risk Administrators (ORAs), because ORAs commonly
failed to recognize the work-related origin of their conditions. In
addition, after a work-related illness or accident that resulted in a
permanent loss of functionality, applicants needed official LWEC
evaluations, which are performed by physicians from either the
HPCs or the ORAs. Often, people disagreed with their LWEC eval-
uation. According to the system's procedural mechanisms, they
could then challenge these evaluations at the Regional or National
Evaluation Bodies, which are private institutions in charge of
overseeing the evaluation of the functionality of peoples' bodies
and settling these kinds of disputes. Private lawyers or people
handing leaflets with information of close by lawyers surround the
REB and NEB offices and offer their services, which usually result in
people hiring them. Besides the judicialization of health, people
also used the judiciary to petition for reassessments of the origin of
their illness or injury and to speed up the resolution of disputes,
120 M.T. Buitrago Echeverri et al. / Social Science & Medicine 187 (2017) 118e125
given that other rights such as the right to dignity, social security,
and work were being violated. Indeed, when questions arose
regarding disability pensions, workers entered into another cycle of
disputes between the Pension Fund Administrators (PFAs) and the
ORAs, given that a person filing for a pension would receive it
through the PFA if the health condition that prompted an early
pension was considered to be of “common” (not work-related)
origin, or through an ORA if the condition was assessed as work-
related.
The narratives that pointed to the complexity of the system and
the multiple competing actors helped us identify pieces of legis-
lation and key stakeholders to be interviewed from the different
sub-systems. The interviews with the people working in leadership
positions of the sub-systems and the review of the different laws
and regulations clarified that the problems people experienced
were the result of very complex structures composed of 1) three
principal for-profit financial sectors with conflicting economic in-
terests; 2) the Regional and National Evaluation Bodies and the
Judiciary, with intermediary roles to settle disputes among insurers
or between insurers and workers; and 3) government entities
tasked with the oversight and control of the process. In the
following table, we identify the principal stakeholders and their
participation in the system. Using a critical framework that marks
the Colombian Occupational Risk Subsystem within the global
neoliberal shift in welfare systems, we also present some of the
challenges, limitations, and conflicts facing each of the
stakeholders.
Next, we present a case synthesis for a worker named Jacobo in
order to better illustrate people's experiences with the Occupa-
tional Risk System:
3.1. Jacobo
Even though his technical qualifications allowed him a modest
salary, Jacobo considered himself lucky when he landed a secured
job with full benefits in 1992. He felt he was going to be able to
provide for his wife and his growing family. He and his wife had
seven children. During the twenty-one years that he worked as a
mechanic for a transnational mining company, Jacobo, 50 years old
at the time of the interview, suffered from six medical conditions
that he attributed to either his work-related duties or the ways that
the ORA had denied him several entitlements. His first work-
related health problem was diagnosed in 2002 when an audiom-
etry exam detected a hearing deficit at high frequencies, most likely
the result of a very loud pneumatic pistol that he frequently used to
repair machinery.
Jacobo experienced competing interests between the health
(HPC) and work-related (ORA) insurance companies first-hand.
While in 2005 the HPC considered his hypoacusis to be the result
of his work-related exposure to loud noise, in 2006 the ORA
considered the same condition to be a “common illness” and
petitioned the Regional Evaluation Body (REB) to settle the case.
What is called “attribution of origin” (common illness/accident
versus work-related illness/accident) results in different entitle-
ments, which affected most of the people we interviewed. Work-
related illnesses/accidents may entail severance packages and
result in better health services, longer paid medical leave, and
better pensions. Much to Jacobo's surprise, the REB concurred with
the ORA. Jacobo challenged the REB's ruling, however, which
resulted in his case being reevaluated by the National Evaluation
Body (NEB). Many months later, the NEB petitioned the ORA to
provide an assessment by an otolaryngologist and to perform
additional tests. Two medical reports arrived. The ORA physician
considered that the hypoacusis was most likely the result of
insufficient irrigation of the organ of Corti. In contrast, the HPC
physician considered the hypoacusis to be work-related and cited
the repeated use of the pneumatic pistol as its probable cause. The
NEB sided with the ORA physician and declared the hypoacusis to
be of “common origin.”
Jacobo subsequently used several legal strategies to have his
case reassessed by the judiciary, including both a constitutional
mechanism for the protection of fundamental rights and a regular
civil suit against the ORA. In the course of the lawsuit, the judge
received additional assessments, which also conflicted, and in 2014
finally ruled against Jacobo and in favor of the ORA. The judge also
ruled that the ORA was entitled to compensation by Jacobo for the
legal costs incurred by responding to his lawsuit.
Over these years, Jacobo developed other work-related health
problems that also required medical assessments and legal ma-
neuvers. In 2011, for instance, the origin of his lower back pain gave
rise to new discrepancies between the health and work-related
insurance companies. While this time the REB ruled the pain to
be work-related, the ORA challenged its determination. The NEB
again sided with the ORA and ruled the pain to be a common
ailment unrelated to Jacobo's employment.
Years later, Jacobo developed carpal tunnel syndrome and ro-
tator cuff syndrome, and in these cases the NEB did consider them
to be “work-related illnesses.” Interestingly, however, the physical
impairment occasioned by these conditions brought about the
involvement of a third institutional actor from the financial sector,
the Pension Funds Administrator (PFA), and with it another con-
tested process for the quantitative assessment of Jacobo's LWEC.
Depending on the severity of the impairment and the origin of the
illness, whether “common” or “work-related,” occupational health
dictates that workers should be either reassigned to other work
activities that do not further aggravate their health condition or
granted a pension by either the PFA or ORA. As shown in the long
version of Table 1 (supplementary material), an LWEC of 50% is the
threshold required to be awarded a disability pension. In illnesses
assessed as “common,” the PFA pays a pension equivalent to 45% of
base salary if the disability is assessed at 50e65.99% LWEC, or 54%
of base salary if it is over 66%. A pension through ORA, in contrast,
corresponds to either 60 or 75% of base salary for the same levels of
LWEC. Those receiving disability pensions through ORA, but not
those receiving pensions through PFA, receive pensions 15% larger
if they require permanent help with everyday life activities. Thus,
the determination of disability entitlements depends on a complex
process that requires both the identification of the entity respon-
sible and the quantification of the LWEC.
The processes required in Jacobo's new cases began to evince
the economic interests behind the assessment regime and the
uneven playing field in disputes between sick workers and several
for-profit entities. The PFA quantified Jacobo's LWEC due to carpal
tunnel syndrome at 10.68%, but since this malady was considered
work related, the ORA challenged the finding. The NEB increased
the LWEC, albeit minimally, to 10.78%. The PFA assessed the LWEC
resulting from Jacobo's rotator cuff injury at 7%. In this case, it was
Jacobo who challenged the determination, prompting the REB to
revise its assessment of his LWEC to 16.14%. The ORA challenged
both this new quantification and the “work-related” origin of his
rotator cuff injury. The NEB concurred with the work-related origin
of the condition but lowered the LWEC to 13.64%.
In addition to these ailments, Jacobo's clinical record lists a se-
ries of respiratory and other physical symptoms since 2002 that are
consistent with pneumoconiosis. Based on a 2010 lung tissue bi-
opsy that indicated the presence of coal and silica, the HPC physi-
cian diagnosed a form of pneumoconiosis found among coal
miners, and the work-related origin of the disease. Later that year,
Jacobo underwent a lung lobectomy. Not only did the ORA chal-
lenge the origin of the pneumoconiosis, but by legally challenging
 M.T. Buitrago Echeverri et al. / Social Science & Medicine 187 (2017) 118e125 121

Table 1
Stakeholders, Roles and Obligations, and Challenges/Limitations/Conflicts of the Occupational Risk System. (A more detailed version of Table 1 can be found as supplementary
electronic material). [INSERT LINK TO ONLINE FILE Table 1, long version].

Stakeholder Roles and Obligations Challenges/Limitations/Conflicts

Workers
Employers
ORA e Occupational
Risk Administrator
HPC e Health
Promotion Company
PFA e Pension Fund
Administrator
Regional and National
Evaluation Bodies
Judiciary
Control Entities
If employed: Contribute to the Social Security System.
If independent: assume full insurance costs.
Implement the “Occupational Risk Management” Program.
Contribute to the insurance costs of employees.
Rehabilitate and reassign disabled workers.
Offer health networks for the comprehensive treatment and
rehabilitation of people with work-related illness or accidents.
(No exclusions.)
Determine whether the origin of the illness or accident is work-
related or common.
Determine the “date of structuration,” i.e. the date of the
accident or first medical evidence of a work-related illness.
Evaluate the LWEC.
Pay medical leave, severance, and disability pension.
Offer a provider network for services included in the National
Health Plan.
Determine whether the origin of the illness or accident is work-
related or common.
Determine the “date of structuration.”
Evaluate the LWEC.
Pay medical leave.
Evaluate the LWEC in cases classified as “common illness.”
Pay medical leave and disability pension
When requested by any party, determine:
-The origin of the illness or accident: work-related or common.
-The “date of structuration.”
-LWEC.
When formal petitions are filed:
-Rule on the fulfillment of individual rights.
-Settle disputes among parties.
Minister of Health and Social Protection: grant occupational
health licenses.
National Institutes of Health: Define occupational health
research priorities
Ministry of Labor: Supervise, inspect and enforce control. Unify
criteria, establish norms, and update manuals and lists of work-
related illnesses. Establish sanctions on any actors implicated in
violations.
National Superintendent of Health:
Inspect, control, and oversee ORAs regarding health services.
National Superintendent of Finance: Oversee and control ORAs
regarding endowments, investments, and handling of finances.
Sanction ORAs that fail to fulfill their economic responsibilities
to injured or sick workers.
ORAs challenge the work-related origin of workers' conditions
and the assigned percentage of LWEC.
Avoid official reports of work-related illnesses or accidents in
order to keep competitive work-related indexes and the costs of
ORA policies low.
In cases of job reassignment or prolonged medical leave, find
ways to create an inhospitable working environment and/or
nonrenewal of contract upon expiration.
ORA brokers use regulation gaps to offer incentives to
companies to keep their business.
Hire health care professionals and lawyers to produce evidence
contradicting work-related origins, dates of structuration, and
LWEC.
Deny and delay health services, severance payments, medical
leaves, and pensions.
Transfer obligations to HPCs or PFAs.
Use payment delays, administrative problems, and limited
coverage of the National Health Plan to negate services.
Work with insufficient network and cumbersome
administration that result in geographic and administrative
access barriers.
Deny and delay health services or medical leave payments.
Transfer obligations to ORAs.
Deny and delay medical leave payments and disability pensions.
Transfer obligations to ORAs.
Use the three-year reassessment of disability pension
requirement to reduce LWEC ratio and stop pension payments.
Limit reporting to what is petitioned, resulting in narrow
assessments.
Tension between limiting their ruling to what is petitioned and
the parties directly involved or use a pro hominem principle to
protect social rights in a comprehensive manner.
Notwithstanding their ineffectiveness, control entities insist on
using and producing norms and regulations to solve the
structural malfunctioning of the system. This process has been
discussed as the “fetishism of the law” under neoliberalism
(Comaroff and Comaroff, 2006).
Cooptation or corruption are the result of third parties
regulating the system, revolving door practices, and lack of
transparency in the use of the Occupational Risk Fund.

the HPC finding, it also blocked Jacobo from filling for job reas-
signment and made it difficult for him to prolong his medical leave
and assure his medical leave payments. Even though consistent
tests and medical findings from the HPC pointed to the work-
related origin of his pneumoconiosis, the ORA produced the
finding of a foreign pulmonologist, presented as an expert on
occupational health, who said that the patient's X-rays were
consistent with bronchial asthma. From April 2011 to June 2012, the
ORA used different technical arguments to challenge the work-
related origin of Jacobo's condition and the quantification of his
LWEC. In December 2012, the NEB upheld the work-related origin
of Jacobo's pneumoconiosis and assessed his LWEC at 26.2%.
Besides the emotional toll of these prolonged battles with the
ORA and his “de facto disentitlements” (Lopez, 2005) to social
benefits, Jacobo incurred an unpayable debt. His house was seized
and he could no longer pay for his children's higher education nor
adequately support them, even with food. He began to express an
understanding of why some people pushed into situations like his
think of suicide as their only remaining option. After five years of
treatment for major depression, the HPC found this mental illness
to be work-related. Then there was another round of challenges and
reevaluations requested by the ORA, until the NEB concurred with
the work-related origin of his depression. The ORA finally accepted
that his maladies were work-related and offered him a severance
payment of around US$30,000, which included compensation for
the pneumoconiosis, the carpal tunnel syndrome, and the rotator
cuff syndrome only.
Jacobo petitioned for a global assessment of his LWEC, knowing
that the totality of his work-related pathologies would reach at
least the 50% needed to file for a disability pension, if not more. The
REB, however, assessed his LWEC at 29.75%, because it included
only the pneumoconiosis and the major depression. Desperate,
Jacobo filed for a disability pension. The HPC sent him to the PFA,
which found that Jacobo had an LWEC of 80.14%, but that his
pension application should be filed through the ORA because his
most recently diagnosed pathology, the depression, was classified
122 M.T. Buitrago Echeverri et al. / Social Science & Medicine 187 (2017) 118e125

as work-related. At the time of the interview, Jacobo considered this Table 2

report, which finally took all his conditions into account and Loss of Wage Earning Capacity discrepancies depending on the classifying entity and
the attribution of origin. ORA (Occupational Risk Administrator), PFA (Administrator
demonstrated that he should have been granted pension a long of Pension Funds), REB (Regional Evaluation body), NEB (National Evaluation body).
time before by the ORA, to be a cruel joke. Even though he knew
Attribution of Origin Loss of Wage Earning Capacity
that the ORA pension would be larger, he did not feel that he had
enough energy to apply for the ORA to assume his pension. If the ORA PFA REB NEB
PFA offered him the lower pension he would accept it, just to stop Work-related accident 4.39% 10.18% 10.18%
fighting and for his peace of mind. What he didn't know was that if 22.62% 20.58%
the ORA did not fulfill its responsibility, he would have to sue them 0% 23.29% 23.29%
17.30% 34.38%
again through the judiciary.
Common accident 42.40% 47.90% 47.90%
Work-related illness 31.20% 31.20%
3.2. Other cases 12.50%
7% 16.14% 13.64%
In all other cases people also reported prolonged interactions 52.85%
18.63% 29.18% 26.38%
with the different institutions involved in the Occupational Risk
19.20%
System. In order to organize the specificities of the cases, we Common illness 43% 55%
categorized them into groups according to their rulings on the 29.03% 45.73% 45.73%
origin of underlying injuries or illnesses: work-related accident, 39.10% 33.93% 38.85%

work-related illness, or common illness. As of March 2016, the

average duration of the process to reach a final resolution was 58.9
months, 59.7 months, and 59.2 months, respectively. In the case of
one accident eventually ruled to be work-related, the process lasted
for 300 months, during which time the person aged to the point
that he was able to file for retirement benefits. The last time we
spoke with Jacobo, he was already into his 149th month and his case
file consisted of 1200 folios. (For all 22 cases, we have included
relevant socioeconomic, clinical, work-related information, in
addition to some characteristics of their legal petitions within the
occupational risk system, as supplementary electronic material.)
[INSERT LINK TO ONLINE FILE Descriptions of Cases].
We learned that work-related accidents were challenged less
often and less successfully by ORAs. It became evident that ORAs'
greatest efforts were to push workers into the “common illness/
accident” path, which translated into profits since in such cases
HPCs and PFAs had to assume the costs of workers’ health care,
medical leaves, and pension benefits. In our sample, 3 out of 7
work-related accidents were challenged by ORAs. The REB assessed
two of these accidents as work-related and one as common, but the
NEB determined the latter case to be work-related. Challenges to
work-related origins of illnesses were more common and resulted
in longer “bureaucratic itineraries,” usually reaching the NEB. In our
sample, 10 out of 11 cases determined to be work-related were
challenged by ORAs and 9 of them reached the NEB. Claims for the
protection of constitutional rights were filed in all these cases, and
civil suits against ORAs were filed in 2 cases.
14 out of the 22 people interviewed had already received a final
attribution of origin and date of structuration, which was a
requirement to start the LWEC evaluation process. Table 2 shows
the differences in LWEC determination in these 14 cases by
different institutions.
Table 2 reflects that people do not need to wait for official ORA
or PFA assessments to petition the evaluation bodies to assess their
LWEC. The biggest differences in the LWEC evaluation are between
the insurance sectors and the evaluation bodies. Interestingly, the
regional and national bodies are autonomous, resulting in the
notable lack of coordination and consistency of their reports.
We present Table 3 to convey the impact of these lengthy pro-
cesses on of work-related entitlements. The table considers work-
related outcomes such as work reassignment, severance payment,
disability pension, treatment for the illness or injury while
employed, or loss of employment.
The total number of outcomes is higher than the number of
cases because as we learned, applicants transited through different
categories. Hence, one applicant could report multiple outcomes
over the course of his or her process. For example, people who had
suffered work-related illness/accidents underwent treatments and/
or rehabilitation. Then, the result of the LWEC evaluation and
subsequent disputes led to job reassignment while receiving
severance packages or filing for pensions. However, we also learned
that workers could be terminated at the end of a period of legal
protection, or simply be told that their contracts had not been
renewed at the end of their work period, which usually resulted in a
lack of employability, severance payment, and pension. Some in-
terviewees, not only workers, even reported that legal advisors
helped the companies in their efforts to avoid renewing the con-
tracts or offer severance packages to workers who began to show
impediments. Even though this was legal, some interviewees felt
that workers were unjustly “fired” because of the economic
advantage to both the company and the ORA: while the company
saved expenses associated with having a “disabled worker,” the
ORA avoided any further obligations in a case that had started to
represent losses. We also learned that job reassignment can push
people to “voluntarily” resign and lose all their benefits, given a
scenario of workplace harassment promoted by the company or,
sadly, their peers.
4. Discussion
One of the main threads captured in the interviews was how
after a work-related accident or illness, component institutions of
the Occupational Risk System denied people's claims, refused to
provide them with much needed health care, or produced unfair
assessments that impeded them from filing for disability pensions.
Similar to previous research on health care in Colombia, workers
conveyed frustration with complex “bureaucratic itineraries”
(Abadía-Barrero and Oviedo Manrique, 2009). As has been
described previously for Colombia (Abadía-Barrero and Oviedo
Manrique, 2009; Echeverry López and Arango Castrillón, 2013;
Lamprea, 2014), workers in our study also had to resort to the
courts and use legal mechanisms to demand the provision of ser-
vices needed for their health care, a process known as the judici-
alization of health (Gonçalves and Machado, 2010). Protracted
delays in resolving legal disputes and winning approval of health-
related petitions also resulted in extremely painful accounts. Af-
ter several analytical sessions, however, we understood the struc-
ture of the Occupational Risk System to be more complex than had
previously been described for the health care system. Accessing
health and work-related benefits depended on the interaction of
many more actors than in the health sector and affected not only
 M.T. Buitrago Echeverri et al. / Social Science & Medicine 187 (2017) 118e125
Table 3
Outcomes based on attribution of origin.
Number of cases according to attribution of origin Outcome of cases
Labor reassignment Severance payment
Work-related accident: 7 4 5
Common accident: 1 0 0
Work-related illness: 11 3 2
Common illness: 3 1 0
Total: 22 8 7
the right to health care, but also larger constructs involving social
security and labor rights.
The results presented above offer a window through which to
understand the consequences of the neoliberal conceptual frame-
work known as Social Risk Management (SRM) as applied to wel-
fare systems. Promoted by the World Bank, SRM encourages States
to refrain from providing welfare services and promotes an insur-
ance market in which private insurance companies will offer risk
protection to the population through individual insurance
(Holzmann and Jorgensen, 2000). Employers and workers (both
under contract and those working independently) are encouraged
to purchase health and employment insurance and contribute to
pension funds based on parameters established for the assessment
of each individual's risk and their capacity to pay (Sojo, 2003).
Given that the system's funding relies on the employers and
workers' purchase of insurance (Rofman, 2015), its sustainability
depends on high rates of employment. Neoliberal projections of job
growth in Colombia were flawed, however, as they were in other
Latin American countries (Fraile, 2009). Official data for 2016
indicate that only 38.37% of the economically active population is
enrolled in the system. Furthermore, 47.2% of Colombians work in
the informal sector, and only 5% of these workers are enrolled in the
system (Ministerio de Salud y Protección Social, n.d.; Ministerio de
Trabajo, 2016). Hence, our data not only unveil how the complex
and perverse Occupational Risk System negatively affects those
who are enrolled in the system, but also raise additional concerns
regarding the plight of most Colombians, who still lack any
employment-related entitlements. How to understand ORAs'
controversial and contrasting evidence around the origin of
worker's illnesses? We see this practice as an effort to “dump”
patients onto competing insurers, since disentitling workers in the
insurance world is profitable. According to our data, state control
mechanisms are virtually inexistent while the evaluation bodies
serve only as mandatory intermediaries, which support discussions
about the important role of the “absent” state during neoliberalism
in furthering the profits of the private financial sector. Nonetheless,
people believed that the judiciary and the control entities would
evaluate their LWEC according to their expectations. Disappoint-
ments were frequent, however, as applicants' LWEC percentages
rarely reached the 50% required to qualify for pensions and they
were forced to go back to their employers and demand special
accommodations, job reassignments, or extensions of medical
leave.
As a whole, our results are consistent with the literature that
reports that the commodification of social security and
employment-related entitlements shifts care and the provision of
services in ways that benefit for-profit interests (Parrish and
Schofield, 2005; Roberts-Yates, 2003). Similar to our study, a set
of articles from Australia and Canada show how neoliberal reforms
have resulted in new challenges and obstacles to worker evalua-
tions, rehabilitation, job reassignment, compensation, and
disability pensions after an injury or accident (Gribich et al., 1998;
Guthrie and Barnes, 2008; Holley et al., 2015; MacEachen, 2000;
123
Disability pension In treatment Lose one's job
0 1 4
0 0 NA
2 5 2
1 1 0
3 7 6
Parrish and Schofield, 2005; Roberts-Yates, 2003). The ambigu-
ities involved in the assessment of responsibility in an
employment-related illness or accident allow for the “benefit of the
doubt” to take a primordial role (Gribich et al., 1998; MacEachen,
2000), meaning the impossibility to know whether the worker's
labor or home activities caused the injury, which can, ultimately,
blame workers for negative health outcomes (MacEachen, 2000;
Parrish and Schofield, 2005; Roberts-Yates, 2003). Just as in our
study, keeping “damaged” workers out of the system involve
lengthy, bureaucratized, and unfair evaluations and assessments
(Gribich et al., 1998). The data indicate that the judiciary might have
a limited role, given that the overall framework of the law responds
to the fragmentation and market principles of the system. Judges
rule over attributions of origin and LWEC controversies, but only
with respect to competing evaluations. That is, judges have to rule
based on the evidence produced by competing parties and in
keeping with the legal structure of the system, a process that has
been coined “neoliberal justice” (Abadía-Barrero, 2015a). However,
judges can also be proactive in setting up mechanisms to protect
rights, for example in one case where a judge ordered a PFA to start
paying the pension of a man who reached a 50% LWEC despite
ongoing disputes between a PFA and an ORA that questioned
whether he had any pension entitlements at all. Thus, the judiciary
in Colombia and elsewhere can be effective in protecting people's
entitlements (Yamin, 2014). The time, bureaucratic demands, and
expenses involved in the judicialization process, however, produce
a “harsh” process that can produce only “tardy” justice. These re-
sults support new insights on how delayed and painful processes
required to receive much needed support and entitlements under
neoliberalism harm people, drive them to insanity, and increase
death and inequality (Adams, 2013; Povinelli, 2011; Berlant, 2007).
This research also supports the claim that the suffering and death
that occur under neoliberal social welfare schemes facilitate capital
accumulation and is orchestrated by a close relationship between
state and for-profit sectors (Adams, 2013).
Our data indicate that the attribution of origin and LWEC
quantification are subjective processes, hence the common dis-
crepancies between determinations by different institutions and
the experiences of people. Furthermore, Colombians in our study
suffer the consequences of this system's bureaucratic need to
distinguish people's health conditions as expressions of working
bodies or aging bodies, and to establish quantitative evaluations of
those bodies' deterioration as a result of accidents or illnesses.
Despite the existence of specific guidelines and trained physicians,
these discrepancies can be read through anthropological studies of
biomedicine that critique efforts to reduce human complexity and
indeterminacy to fit into fixed parameters which, besides being
inexact representations of “rational reality,” exclude several do-
mains of people's experiences and political interactions (Adams,
2016). Furthermore, the 50% LWEC required in Colombia to be
awarded a disability pension is the lowest in comparison to other
Latin American countries that have adopted similar LWEC assess-
ment mechanisms (Grushka and Demarco, 2003), which might
124 M.T. Buitrago Echeverri et al. / Social Science & Medicine 187 (2017) 118e125
correlate with equal or even greater difficulties in receiving
employment-related entitlements in other countries in the region.
It is also worrisome that the system's fragmentation and the
specific technical requirements for classification leave sectors of the
population unprotected. For example, a construction worker who
worked intermittently, sometimes for a company and sometimes
through informal agreements, suffered a severe cut on his left wrist
that affected the mobility of his hand. Since at the time of this work-
related accident he was not “under contract,” he was denied
employment-related entitlements and pushed into unemployabil-
ity. In addition, he eventually lost his health insurance and found
himself unable to file for a subsidized health insurance policy given
the intricate bureaucratic process required. His case points to the
limits to schemes based on individual private insurance in which
people fall through technical cracks and are disentitled (Correa
Moreno et al., 2015; Lopez, 2005).
Furthermore, discrepant LWEC percentages and the almost
impossible 50% threshold to qualify for a disability pension should
not be read as technical challenges calling for improved classifica-
tion parameters. Rather, they represent “policies behind numbers,”
one of the ways in which numbers, rather than representing con-
crete facts, are tools used by powerful actors to construct norms
that separate human groups and differentiate populations as
deserving or undeserving of entitlements (Adams, 2016). Indeed,
the varying size and duration of disability insurance benefits in
different countries has been deemed as arbitrary (Grushka and
Demarco, 2003, p. 10). In addition, the establishment of specific
LWEC percentages necessary to qualify for entitlements based on
evaluation by outside experts represents a fetish of truth-making
behind numbers (Adams, 2016). In the case of severance pack-
ages, the quantitative assessment of what applicants “deserve”
does not consider the quality of a future to be lived with disabilities
and lacking employment. People who received severance packages
frequently used that money to pay off debts or to start small
businesses with minimal returns which, in addition, were not going
to provide them with long-term welfare benefits. In the case of
pensions, oftentimes the pension was so low that it put them below
the poverty line.
5. Conclusions
The Colombian health care system became fragmented as a
result of neoliberal reforms applied to social security, and an
additional fragmentation of the employment-related health,
pension, and disability system is proving to be a failing approach as
well. For-profit companies turn out to be the winners of an indi-
vidual insurance system such as that implemented in Colombia,
based on market forces rather than social solidarity. This is reflected
in their very healthy business reports. Injured or disabled workers,
on the other end, struggle for their meager right to social security.
The Occupational Risk System in Colombia appears convoluted
and cruel, given the competing interests of three for-profit insur-
ance sectors: the HPCs, ORAs, and PFAs. The narratives of our in-
terviewees challenge the very idea of “social protection” under SRM
principles and the “efficiency” of the private actors that sustain the
system. Indeed, other research has shown that the system's in-
efficiencies and multiple bureaucracies add to people's suffering
after employment-related illnesses and accidents (Gribich et al.,
1998; Guthrie and Barnes, 2008; MacEachen, 2000). The implica-
tions extend from the right to health (obstacles and delays result in
a progressive deterioration of people's health status) to other do-
mains of social security, namely medical leave, job reassignment,
rehabilitation, and disability pensions. Injured and sick workers are
not met with solidarity; rather, they face a lack of support from the
system embodied in the employers and the bureaucrats of the
different financial sectors (Holley et al., 2015; MacEachen, 2000;
Roberts-Yates, 2003).
People suffering from work-related illnesses or accidents see
their health deteriorating at the same time that they face work-
related disentitlements. The State has played a fundamental role
in deepening the crisis of its social security system by establishing
ineffective control mechanisms and passing legislation that further
entrenches the SRM principles of that system (Hernández and
Tovar, 2010). Something similar is happening to the Workers’
Compensation system in Australia (Guthrie and Barnes, 2008;
Holley et al., 2015), which argues against proposals to improve
the control exerted by governing bodies without altering the
overall SRM structure of social security. Indeed, this research aligns
with critical proposals that see the origins of the problem in the
new neoliberal fragmentations and multiple for-profit interests
(Holley et al., 2015; Parrish and Schofield, 2005; Roberts-Yates,
2003). In addition, this research argues against a system in which
“common illness/accident” and “work-related illnesses/accidents”
have been separated into conflicting domains with different sets of
benefits. This fragmentation “legalizes” inequalities, i.e. depending
on technical assessments of origin, LWEC quantifications, and dis-
putes among different for-profit companies, sick or disabled people
receive greater or lesser benefits, including severance payments
and pensions.
These SRM-based proposals invert the purpose of welfare: to
grant social security to all members of society. Thus, this research
supports bold counter-reform proposals that argue for integral and
comprehensive social security guided by collective risk pools and
solidarity-based financing (as it was structured in the European
Welfare System and the socialist republics after world war II) based
on progressive taxing systems, which effectively delink social
benefits from individualized risk assessments and complex systems
of classification to fulfill the administrative demands of insurance
companies (Birn et al., 2016; Hartmann, 2016). Furthermore,
moving away from individual approaches based on SRM/for-profit
insurance sectors can significantly reduce the differences in le-
gally established and perceived social benefits that characterize the
Colombian system and largely depend on a contrast between
formal and informal employment (Cuesta and Olivera, 2014).
Indeed, in proposals based on universal social welfare, everybody is
protected regardless of employment status, income classifications
for subsidies, or tendentious assessments of origin of illness or
LWEC. In a unified, public, single tiered, and comprehensive social
welfare system based on collective risk pools and solidarity-based
financing, costs are likely to be reduced with the elimination of
financial sectors engaged in a competition for profits (Birn et al.,
2016). Moreover, a streamlining of the burdensome, bureaucra-
tized, and fragmented structure can significantly reduce adminis-
trative costs (Holley et al., 2015; Parrish and Schofield, 2005;
Roberts-Yates, 2003).
It is recognized that social security is a fundamental aspect of
social well-being and economic prosperity, but that only one third
of the world's population has any kind of social protection (Ghai,
2015; Internationales Arbeitsamt, 2014; Hurtado et al., 2011). Our
research adds to this worrisome scenario, given the many obstacles
and disentitlements that insured populations face in Colombia.
While our data represent people who fought for justice within the
system, it is likely that many Colombians who suffer from work-
related illnesses or accidents simply are not part of that system,
have abandoned it, or have been expelled from it. Thus, our data
suggest that besides failing the uninsured, market-based social
security systems also fail to provide participants who have suffered
from work-related illnesses or accidents with the protection,
rehabilitation, or pensions that they require. We conclude that the
for-profit institutions that drive the Colombian system actively try
 M.T. Buitrago Echeverri et al. / Social Science & Medicine 187 (2017) 118e125
to disentitle workers from work-related social security benefits.
Furthermore, they push sick and disabled workers to unemploy-
ment, informality, economic dependence, and ultimately dire
poverty.
Acknowledgements
The current research received financial support from the Pon-
tificia Universidad Javeriana (project ID 6005). We want to thank all
the participants of the study and those who provided feedback.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2017.06.030.
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