The controversy of the Colombian health system
Gustavo Petro's new government in Colombia came into office with one overarching promise: reform. In office, this promise has manifested itself in his pledges like shying Colombia away from an extractive economy dependent on fossil fuels in favour of a renewable energy sector and implementing a national agrarian reform to redistribute productive land. As his term has progressed, Colombians have cheered and protested the adjudication of Petro's leftist and sometimes radical policies. Still, the most controversial reform which has managed to divide the country –even the ministerial cabinet– is the health system reform. However, why has it proven so divisive?
As the Constitutional Assembly signed the new magna carta for the country in 1991, they promulgated an unprecedented article on the document's second title, 'On Rights, Guarantees, and Duties'. "Public health and environmental protection are public services for which the State is responsible. All individuals are guaranteed access to services that promote, protect, and restore health." Access to the health sector was mandated as a right for Colombians. The government had to organise an effective, holistic and accessible health system for every citizen.
This obligation was formalised in the "Ley 100 de 1993", which created the General System of Social Security in Health (SGSSS for its initials in spanish). It overhauled the old system in favour of a public/private system. The first change was that Colombians now choose their healthcare insurer among companies called Health Promoting Enterprises (EPSs for its initials in Spanish). These companies would then hire Health Providing Institutions (IPSs for its initials in Spanish) to provide healthcare services to their clients. Both EPSs and IPSs could be public, private or mixed. In 2022 of the 41,427 registered IPSs, 61% were private and 39% public. Any member of the SGSSS had unrestricted access to the Health Benefits Plan (PBS for its initials in Spanish) that covered a wealth of essential healthcare services.
The system is also divided into two primary schemes, the "contributive" and the "subsidised". The former comprises all those who have "contributive means", determined mainly through employment and pension status. In 2021, the contributive scheme represented 48% of the population. This cohort had to pay 12,5% of its salary to the SGSSS. This money would go to the FOSYGA, a solidarity fund which provided resources for both schemes. On the other hand, participation in the subsidised scheme is determined by the sisbén; this entity classifies the Colombian population according to their vulnerability. The subsidised scheme represents 47% of the population. The remainder of the affiliated population is part of the special scheme, which includes the military, police forces and workers of the national oil company (and a couple of other exceptional cases). Nonetheless, wealthy Colombians could add on a private health plan offered by EPSs with access to exclusive IPSs that provided high-level treatments. However, this would be on top of the mandatory contribution. In 2000, 56.5% of the Colombian population held health insurance; by 2021, this number grew to 99%.
Figure 1: An overview of the Colombian healthcare system. Source
The restructuring of Colombia's health system has been considered by many one of the biggest successes sprung by the 1991 Constitution. On the "Health" pillar of the 2021 Legatum Prosperity Index, Colombia placed 32nd worldwide, above countries like Portugal and Canada and just one spot below the United Kingdom. In this index it was also 2nd in the Latin American region, only behind Cuba. In a study conducted by INVAMER –the biggest surveying company in the country– in January 2023, 73% of Colombians classified the health system between "excellent" and acceptable".
Notwithstanding, many recognise that there are still shortcomings. Some experts have coined the following phrase to describe the current state of the health system: "more coverage but less access". These critics understand that despite the new system being able to reach most Colombians, it does not ensure medical attention when required, especially in rural and impoverished areas. Additionally, there is still a notable disparity in access among Colombian departments. Other harsher critics express that EPSs have commodified healthcare. They believe that, despite only being a middle-man between user and service, they charge an unjustified fee.
Still, public opinion seems to back the current paradigm. INVAMER, in its latest survey, found that only 32% of Colombians want to get rid of EPSs. While 76% of Colombians agree that either the current structure needs adjustments but not reform or should remain the same.
As the Minister of Health, Carolina Corcho, prepares to present its bill to reform the health sector, many have started to worry it will undo the progress fomented by Ley 100. For now, Minister Corcho has presented three main points for the reform:
Bring all taxes collected to the SGSSS to the public domain. This seeks to avoid corruption and optimise costs from payment to service for citizens. This point translates to either eliminating EPSs or making all of them public.
Create an entity for civic participation in the health system. This would allow citizens to be a part of the process of health policy creation to help make it more equitable.
Ensure basic access for all Colombians: every health service provider must comply with some minimum requirements. This would help alleviate the lack of access to some aspects of the PBS in the most rural areas of Colombia.
Those worried about these proposals include the current Minister of Education, Alejandro Gaviria who was Colombia's longest-serving Minister of Health under President Juan Manuel Santos. Gaviria, on the first days of February, presented a four-page document in a ministerial meeting that posited why the reform as it currently stands could "do a lot of damage" to the system. For now, the Ministry of Health answered Gaviria by telling him, "all his doubts will be resolved in the final draft of the bill".
Nevertheless, general worry has not disappeared. On February 4th, Minister Corcho posted an Instagram post amidst all the scandal with the text "EPSs don't cure, EPSs charge!" which she promptly deleted after it sparked backlash. The post, for many, confirmed worries about the dismantling of EPSs.
As Petro deals with the tensions inside his cabinet, he will have to put Colombia's well-being before his ideals. Otherwise, the health reform might not only lead to a trench forming among his ministers but will also start to backslide his popularity. This move might be the first real test for Petro's government as he looks to balance his promises of reform with the reality of the country he now leads.
Update from the 10th of February 2023:
Interior Minister Alfonso Prada assured leaders at a Thursday night meeting with President Petro and representatives from the country's largest EPSs that EPSs will not be eliminated. In the new system outlined in the upcoming health reform bill, set to be presented on Monday, there will be a space for these institutions to continue providing their services. This statement dispels one of the primary concerns voiced by opponents of the reform. However, many remain cautious and will be awaiting Monday's presentation to verify the accuracy of Minister Prada's claims.
What should we expect to see in the future with the Colombian healthcare system?
We can expect Minister Corcho to release the bill for the healthcare reform next Monday February 13, painting a more accurate picture for the opposition to begin their fight against it.
After Minister Prada’s remarks, many want to see how truthful the promise to keep EPSs in the healthcare system is. Many are anxious to see if they will remain as fundamental to its functioning.
President Petro has made several remarks backing the reform, so he will likely go out on the defensive once the bill is out with Minister Corcho.
The reform might prove to be a pivotal point in Petro’s government, creating incurable divides within the cabinet, which might lead to the first resignations from Petro’s more moderate ministers.