The Gustavo Petro government in Colombia is experiencing turbulent weeks. This after suffering “his biggest political defeat” since he has been in the presidency.
The health reform, one of the biggest bets of his program, was shelved in Congress after 14 months of political and public debate.
The reform contained several highlights, but none caused as much division as the proposal to transform the role of the so-called Health Promotion Entities (EPS), questioned public-private insurers that compete with each other and mediate between the patient and the health service. .
“Petro considers that these entities receive public resources that they capture for themselves and that they are not necessary,” Johnattan García Ruiz, a global health systems researcher at Harvard University in the United States, tells BBC Mundo.
After the legislative setback, Petro's administration has two options left: appeal or present an alternative when the halfway mark of his term is already running out and time is running out.
Meanwhile, in a movement that critics and opponents interpret as a test of strength in the face of the collapse of its original reform, the government “forcibly intervened” two of the largest EPSs in the country due to “financing problems” and for “putting at risk” services to users.
Although the National Health Superintendence assures that these measures are intended to “save the system” and do not imply “closing of services or dismissal of workers”, they generate uncertainty and raise a series of questions about the Colombian health system that we at BBC Mundo try to answer.
Ramón Abel Castaño Yepes, a doctor at the CES University in Medellín, defines the Colombian health system, in force since 1993, as “a model of managed competition.”
García Ruiz explains how the current model works from three aspects: financing, management and service provision.
In financing, in Colombia there is an entity, the Administrator of the Resources of the General Social Security Health System (ADRES), which collects resources from taxes and subsidies.
Every person with formal employment contributes mandatory taxes from their salary. Other citizens are covered by a subsidized regime from taxpayer and State funds.
By February 2024, 23 million people were affiliated with the contributory regime compared to 26.5 million under the subsidized regime. In total, there are 51.7 million members, according to the Ministry of Health.
The National Administrative Department of Statistics (DANE) says that in Colombia there are 52.3 million inhabitants. That is, the health system has coverage of 98.46%.
In the management part come the controversial EPS, whose prominence divides the government and the opposition.
“The ADRES gives the EPS a per capita amount for each member it has,” Castaño Yepes explains to BBC Mundo.
Added to the EPS are the so-called compensation funds, attached to large companies, and the excepted regimes, alternative systems for the Armed Forces, universities and the state oil company, among others.
The EPS contract a network of providers, public or private hospitals, and through these they offer health services.
For example, if a person needs the health system, they go to their EPS, request their needs and, searching their own network or other providers, the EPS authorizes access to services, such as picking up a medication at the pharmacy or going to to a medical appointment.
No Colombian pays directly to the EPS and, from birth, they automatically have an identity number and must be included in the health system.
“In general, our health system works as we have just explained, but there are also private insurance companies that offer services like in other countries,” warns García Ruiz.
In the Colombian case, the specialist estimates, at least 8% of the population pays for private insurance.
Despite this, this insurance would be additional to what is already obtained through the State.
“One, in theory, cannot renounce one's affiliation with the EPS even if one has private insurance. If one has a job, the employer, by law, will take part of that salary and send it to the State,” explains García Ruiz.
In short, the two systems coexist and are not exclusive.
Broadly speaking, the experts consulted by BBC Mundo consider that the system does need a transformation beyond political positions.
Although they also believe that Petro's proposal does not in itself guarantee the solution to several of the challenges of Colombian healthcare.
In this country with high rates of inequality and serious problems with access to health, it would be necessary to invest in development in marginalized areas.
One of the questions asked by those who question the system is why have the EPS if the State can contract the providers directly.
For many years, these entities have also been criticized for access issues, such as delays in medical appointments for months, or for people needing medications or procedures not covered by the system.
The EPSs also accumulate debts with providers, “so Petro argues that these entities are inefficient and that these debts end up bankrupting hospitals and clinics,” explains García Ruiz.
“Petro also says that these entities have put more pressure on urban areas than rural areas, which has caused wide gaps in infrastructure and services,” continues the expert.
García Ruiz considers that the EPS, regardless of Petro's criticism, are going through a critical financial situation, with resource flow problems that lead to service problems because the service providers do not want to have more debts.
“This system, in general, spends more than it collects and that is not sustainable,” adds Castaño Yepes.
As a criticism of the Petro reform, he says that it did not address the need to “prioritize and make decisions about the finitude of resources and promises an unrealizable mirage that all people will have unlimited access to all highly complex services.”
For Andrés Vecino, from the Center for Digital Health Innovation at Johns Hopkins University in the United States, a differential care system must be created for rural areas and improve how it is provided in urban areas.
“The Petro reform proposed a single and non-differential system, and that is a clear problem that the current health system has that wants to change,” he argues for BBC Mundo.
Castaño Yepes, who also has a master's degree in health policy management at Harvard, says that no system in the region has a model of managed competition like Colombia's.
In Chile, for example, the service is made up of a mixed care system made up of public insurance, the National Health Fund (FONASA), and another private one called Pension Health Institutions (ISAPRE), according to the Superintendency's website. of Chilean Health.
Unlike in Colombia, in Chile it is not possible to be affiliated with both systems. In practice, ISAPRE membership is reserved for high incomes.
In Brazil and Costa Rica, other examples, a public system prevails, “although Costa Rica's is more prevalent and in Brazil up to 25% of people opt for a private, voluntary supplementary system to complement coverage,” explains Castaño Yepes. .
In Mexico, as in other Central American countries and others in South America such as Bolivia, Paraguay, Peru or Ecuador, “there is a social insurance system that is responsible for people in the formal sector who pay taxes from their salaries,” adds the expert.
In parallel, he adds, there coexists a public system financed by the ministries of Health that finance public hospitals to care for low-income and informal people.
An interesting system is that of the Dominican Republic, which recently adopted one similar to the Colombian one, with insurers competing with each other and receiving amounts distributed by a large fund.
However, unlike Colombia, this only works for the formal sector of the economy.
“The informal or low-income sector is in a subsidy scheme directly managed by the government,” says Castaño Yepes.
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