Petro government presents an ambitious health reform in Colombia, which is criticized even among its allies

( Spanish) — The Government of the President of Colombia, Gustavo Petro, presented this Monday a health reform described as very ambitious and also as controversial by opposition sectors and within the Executive itself, whose purpose will be to transform the current health model to, according to the president, make health a universal right in the country, and not be, as he claims, a business.

As can be expected from any government reform proposal, the hint of a reversal in the current health system has generated public discussions due to concerns about the provision of the service. The Government has said that this reform seeks to bring a preventive health model to the vulnerable and, a key point, is that public resources are managed by the public sector and not by private ones, as is currently the case.

This Monday, the Colombian Minister of Health, Carolina Corcho, filed the health reform before Congress, where it will have to undergo debates and perhaps modifications, before final approval, if it occurs.

These are the three pillars of health reform.

1. Change of the EPS and direct payment to hospitals

The main objective of the health reform is for public health resources to be managed by a public entity. And here is a major entanglement related to the provision of health services.

To understand this point, you have to know a few things about the Colombian health system.

First: in the country there are figures of Health Promotion Entities (EPS). These are private entities responsible for the affiliation, registration and care of affiliates to the health system. They also collect money from contributions and its function is to “organize and guarantee the provision of the obligatory health plan”. That is to say: the EPS provide health services to people who pay social security.

The Government has said that many EPS are insolvent and have a financial deficit, which would lead to a liquidation of health care providers, which, upon declaring bankruptcy due to million-dollar debts, stop serving the public. Currently in Colombia, 16 EPS are in the process of liquidationaccording to data from the Superintendence of Health.

“The reality is that if any of these EPS is liquidated, a massive transfer must be made to the EPS that do meet the indicators and (if an EPS is recharged) the system collapses, they have to declare insolvency. That is, it is a house of cards that is not new,” Corcho said this week.

(Credit: Fredy Builes/Getty Images)

Second: the address

Once these EPS provide the health service (for example, an appointment with a general practitioner or a dentist), they issue a collection invoice to the Resource Administrator of the General Social Security Health System, address.

The Adres manages all the resources of the General System of Social Security in Health. In other words, all the money that enters both from the State (through taxes), and from parafiscal (which are the health contributions of individuals and companies) and resources from the General Participation System.

So the EPS pass the bills to the Adres for serving people. The Adres pays them the money and the EPS is in charge of paying the doctors, nurses, and everything related to the provision of health services. That is to say: public money is delivered to private ones. And that is the change that this health reform seeks.

“We have a system where the State lost control of millions of public resources. After these resources enter the Adres fund, which is the great collector, they go to a private administrator and from then on we don’t know,” pointed out the minister Corcho at the National Academy of Medicine of Colombia last week, when discussing the reform with a sector of the medical union.

What is the government proposing? That with the reform it is the Adres fund that pays directly to the clinics and hospitals. And from there to nurses, doctors and all health personnel.

A worker pushes an oxygen tank at a hospital, amid the COVID-19 pandemic, in Medellín on April 22, 2021. (Photo by JOAQUIN SARMIENTO/AFP) (Photo by JOAQUIN SARMIENTO/AFP via Getty Images)

The president said that the EPS that are currently in liquidation today will be eliminated and those with optimal financial statements will receive, in a progressive and orderly manner, your patients so they don’t go without coverage

This week, criticism of this point of the reform even came from sectors close to President Petro, such as his Minister of Education, Alejandro Gaviria, who in turn was Minister of Health during the government of President Juan Manuel Santos. Gaviria said that he does not agree that there is “a single payer who receives invoices, who does absolutely everything,” which is the proposal that ADRES be the only payer.

“That can be chaos”, Gaviria said on the La Tele Lethal program. He also expressed doubts about pharmaceutical management, and questioned the transition of the elimination of EPS, as well as criticism of territorial entities taking charge of payments for medical services in a country with high levels of corruption by politicians in the management of public money.

Gaviria He said that he exposed his differences with the reform in a meeting of ministers and that his commitment to the Petro government remains intact.

Alejandro Gaviria was Minister of Health of Colombia in the government of Juan Manuel Santos. In this photo he is paired with President Gustavo Petro, whose Minister of Education he is. (Credit: DANIEL MUNOZ/AFP via Getty Images)

What do the EPS say?

The Colombian Association of Comprehensive Medicine Companies (Acemi), a union that associates the EPS, defended the work of the EPS ensuring that “with limited resources they make efficient use of resources so that all Colombians are covered in health, regardless of the treatment that is needed.”

They also say that they contract the appropriate services for treatment and, unlike a hospital, they coordinate a network of health providers so that people are cared for: “Of course there are delays, but the access rates compared to other countries are very acceptable”, Acemi wrote when expressing concerns about the possibility that the EPS will end due to lack of solvency, as the government maintains.

President Gustavo Petro met this Thursday with representatives of the EPS, a meeting that rated as “excellent” and said that they “assess the need to implement the model of preventive health and primary care throughout Colombia.”

2. Establish a primary health care model

The reform proposes to establish a primary health care model in which all Colombians can have access to primary health care, which includes emergency consultation, general medicine care, and a delivery room.

This is especially important for the rural sector, the most remote areas of the country and in the poorest neighborhoods of the cities, since, according to government figures, in Colombia of almost 1,100 municipalities, there are 600 without health centers in rural areas. . And 183 municipalities with a single health center in rural areas.

“We are going to strengthen the health system by creating a preventive health system. That people try, with the preventive system, to avoid disease as much as possible,” President Gustavo Petro said this week when discussing the reform that poses.

The health reform will bring doctors to every home in Colombian territory to prevent disease or cure it before it is too late.

Your home and that of the farmer will receive routine visits from the family health team for your care.

— Gustavo Petro (@petrogustavo) February 1, 2023

“That we can arrive with doctors to that farmer’s house where the pregnant woman is… Why can’t we deploy a service where it is the hospital that goes to people’s houses and not people who arrive dying to seek an appointment? at the hospital”, Petro said when talking about the objectives of the reform.

This point would seek a preventive health strategy, with primary care to avoid diseases. This strategy will seek to formalize health workers and give them an incentive to go to work in scattered and rural areas, said Minister Corcho. In addition, an epidemiological profile must be established in each department and municipality to establish what is needed for primary care in each place, the official added.

3. Labor dignity

Another flank that the reform points to is the “dignification” of health workers. In other words, pay better wages to this entire sector, because according to the Government, “the personnel who take care of life cannot be precarious.”

According to Minister Corcho, for this point there will be a consultation process with the Government to establish the salary scale of the employment contract for nurses and doctors, so that they work without exclusivity. The priority to apply this “will be gradual” and “at the primary level”: the first beneficiaries will be nurses and nursing assistants, who have low salaries.

The Government has summoned demonstrations in favor of the reforms on February 14 in all the public squares of the country. The opposition called for marches against the reforms for February 15.

The critics

In principle, the Government received criticism of this project because for some there was a lack of debate and socialization, also because in principle the final text of the initiative was not known. The final text was presented this Monday and filed before Congress.

The Minister of Health said that if there are critics, it is because the reform project is known, however, she clarified that the text of the reform had not been public because the final drafting of the provisions and budget issues is being carried out together with advisors. of the Ministry of Finance to establish the financing.

Meanwhile, although a first proposal was to eliminate the EPS, this generated rejection since for many, health care would remain in the hands of large hospitals that, they say, would not have the capacity.

A survey on the health system carried out in February by the National Association of Businessmen of Colombia (ANDI) revealed that 63% of respondents disagree with the elimination of EPS and that its function is executed by a public entity only. And 67% of those surveyed say that they would not be willing to give up their current health service (provided by an EPS) and transfer to a public system.

Other criticism came from the president of the Senate, Roy Barreras, another great ally of Petro, who did not agree to end the EPS. Barreras said that although there are abuses by the EPS, there are other services that they provide that cannot be finished.

“That must be improved, corrected,” Barreras told the magazine Week on the errors of the EPS that must be improved. “But it is not done by destroying a 30-year-old information, quality, risk management system.”

“What do the EPS do today, in addition to providing the service? They do many other things: they audit two million bills a month. There are 1,000 million services a year. If you disrupt all that, who is going to review the bills?”, said Barreras to Week.

In this regard, Alfonso Prada, spokesman for the Petro Government, said this thursday that the reform will not eliminate the EPS and that these entities have the possibility of adapting to the new health model and being part of what the new system would be. Prada said that the Government recognizes the 30 years of experience of the EPS in information management and service provision, and it is hoped that this will be put at the service of the health of Colombians.

— With information from en Español’s Melissa Velásquez.