Why is the health reform promoted by Gustavo Petro so controversial?

On the street, in the media, among the government coalition parties and in Congress: health reform is the central issue of the debate in Colombia. The Executive of Gustavo Petro, the first left-wing president in the country, promised reforms at all levels from his campaign, including a shake-up of the health system. And despite criticism, including from within, he is determined to make it happen.

Petro and his Minister of Health, Carolina Corcho, defend that the main objective of this project is to make health stop being “a business” and become “a right”, after 30 years of a system managed by private entities with multiple corruption scandals and accused of putting their economic interests before those of their patients.

Filed before Congress on February 13, it is not the only reform promoted by Petro, which has also opted to rethink the pension, labor, educational and tax systems; this last project already approved. But the health reform has provoked intense debates, leaks, shake-ups and bitter controversies in recent days. Why is it so controversial?

Universal health under the pillar of primary care

One of the key points of this reform is that it proposes that thePublic resources are administered by the State instead of by the Health Promotion Entities (EPS), as is currently the case.

Today, it is the EPS – to which citizens must join and contribute to a mandatory plan for all those who work or contribute – that control the resources, manage and pay the Health Service Provider Institutions (IPS) , which run the services.

With the reform, the EPS would become only health service providers without administrative power. And it is that one of the main accusations against the current system is that the EPS have used State money to build their own facilities and that they refer their patients to them -preferentially- in order to have higher billings.

The reform also seeks to give a universal care throughout the national territory. One of the main shortcomings of the current model is the lack of coverage in rural areas and areas far from urban centers, for which citizens often have to travel long distances to be served.

Currently, according to official figures, there are 600 municipalities that do not have a health post in rural areas and 300 without a delivery room. The proposal contemplates the creation of about 2,500 Primary Care Centers (CAP) in which family doctors would be in charge of giving a first diagnosis and would refer to other specialists or hospitals if necessary.

Unlike the current model, in which patients can choose which care center treats them (within the possibilities of their EPS), and what some specialists call “freedom of choice”, with the reform citizens must be registered in a CAP of the municipality where they are registered and this would be a single gateway to the system.

Sergio Isaza Villa, president of the Colombian Medical Federation and one of the architects of the reform proposal, indicated in the podcast ‘A Fondo’ that this would initially limit the number of centers, but that this organization would allow users to go to a single care network in the country that will be able, in the long run, to provide a more complete response.

The new model would also seek strengthen preventive medicine with the creation of teams of doctors who travel the territory and who can treat and prevent ailments among the population. In addition, it would consider health as a pillar that is also considered by other ministries, such as Agriculture, or the Planning Department, in order to address problems such as water purification, the non-existence of which in various territories of the country is the cause of multiple infectious diseases.

Cascade of criticism of the health system reform

The radical change that the new system would entail has caused a tidal wave of concern and criticism. Although there is an almost general consensus between the health sector and in Congress regarding the need to increase the coverage of the system in remote areas and improve primary care, there are many buts surrounding the Corcho and Petro proposal.

The debate is heated and even caused a first crisis in the president’s cabinet. On February 27, Gustavo Petro announced that his Minister of Education, Alejandro Gaviria, would be removed from office. Gaviria, former Minister of Health (2012-2018) in the Government of Juan Manuel Santos, had expressed since the campaign his differences with Corcho over the idea of ​​relegating the EPS to an operational role.

But the tension increased when criticism of the project leaked in the local press. A document signed by him; the Minister of Finance, José Antonio Ocampo; the head of Agriculture, Cecilia López and Jorge Iván González, director of the National Planning Department, an entity in charge of managing State resources for infrastructures and public policies, was leaked by the magazine ‘Cambio’. This led to the almost immediate departure of Gaviria, who had already been warned of the consequences of not closing ranks around the project.

Senior officials pointed out blind spots in the reform that have been at the center of the debate in recent weeks and that other health voices such as the National Academy of Medicine have also highlighted.

Among the main fears is the questioning of that the State becomes the sole payer of the health systemsince the country has as antecedent the system prior to the current one, which worked until the 90s.

At that time, the only one in charge of managing health in the country was the Social Security Institute, for many a “giant of the bureaucracy” that was unable to solve the health needs of its 35 million users amid problems of supplies, operation and financial instability.

Another of the great fears is that what is known as “health insurance” will end. With the current system, established since the 1990s with what is known as Law 100, what is known in the country as a “solidarity system” was created, which is subsidized by paying people with higher incomes for the health service for people with minors. income. Some experts fear that with the new proposal this system will disappear.

“It becomes a territorial system where attention is guaranteed not by an insurance premium that is paid today to each Colombian and for which the EPS becomes responsible, but we have reached a public system where the budget will be the limiting factor. more important,” Fernando Ruiz, former Minister of Health and Corcho’s direct predecessor, told France 24.

Corcho has assured in repeated interviews that the new proposal will shield health insurance and “low out-of-pocket spending” for Colombians in the current system. According to the minister, “what changes is the way in which clinics and hospitals are paid” but she indicates that they would continue to care for patients as they have been doing.

But although Corcho assures that in the transition to the new model “no Colombian will be left undiscovered”, there are also doubts among experts about how this change is going to be guaranteed without jeopardizing the insurance of patients. It is estimated that several million citizens will go from being served by EPS to a hybrid company, the New EPS, about which there is no certainty if it will have sufficient response capacity.

“How will this progressivity in transmission be, how will it be done while the nearly 2,500 primary care centers that are necessary to care for the population are being built and consolidated. (…) The New EPS, which is the one that is going to receive that population of six million affiliates to 20 million affiliates, obviously does not have that capacity”, warns Ruiz.

The budget, in the crosshairs of critics and opponents

But if there is a crucial issue in the discussion of health reform, it is the budget. In the leaked letter signed by Minister Ocampo, one of the paragraphs indicates that the project, if sanctioned, would generate an “impact on the nation’s finances” and according to the local pressthe price of the reform could cost up to twice the value of the tax reform and would increase the budget for primary care by 2.5 trillion per year, on average.

Petro maintains that a good part of the budget of 9 trillion pesos that is expected to be allocated to health in 2024 will have to be dedicated to this sector whether or not there is a reform. And Carolina Corcho assures that various costs of the new management will be less than those generated by the system managed by the EPS.

However, the accounts do not seem to convince the opposition, which repeatedly requests that the Ministry of Finance not give its endorsement to the proposal and even calls for the resignation of the Minister of Health.

At the legislative level, there is also a debate on how this law should be processed. The opposition in Congress, but also Gaviria and the other members of the Cabinet who signed the letter, ask that the proposal be processed as a statutory law, a regulation that requires more debates and majorities in Congress than an ordinary law, a modality in which was presented. For some analysts, if the law is approved as ordinary, but it is determined that it should be statutory, the proposed law could end up being unconstitutional.

Shortly before Gaviria’s removal announcement on February 27, Petro also called on his coalition parties to contribute ideas to improve the project. Given the transversality of the health proposal and the multiple levels of the State that it affects, everything indicates that his debate in Congress will not be easy.

It will depend on the government’s ability to integrate criticism and contain fears about the reform that it does not become the biggest thorn in the side of the first left-wing president who promised reforms and structural changes in his four-year term.