Colombia Health Reform Analysis: A bumpy road ahead

Colombia is set to undergo a major overhaul of its healthcare system as Gustavo Petro, the country’s newly inaugurated president, announced the finalized text of his much-anticipated comprehensive health reform on February 13. Petro’s election in March 2022 marked a major shift in the political landscape of Colombia and has been championed by Petro and allies as a reflection of the growing public discontent with the country’s current healthcare system.

The months leading up to the reform´s announcement were marked by uncertainty and skepticisms as Petro´s campaign announcement of eliminating EPS’s (Health Promoting Entities1), which are crucial to the way the Colombian healthcare system currently orks, increased tensions. Criticisms of the reform came from many quarters including patient groups, industry groups, scientific society, political opposition, and even the government’s own Minister of Education and former Minister of Health, Alejandro Gaviria. The majority of criticisms were on the lack of socialization of the reforms, uncertainty about the future of EPS’s and effects on healthcare access in a system that is broadly accepted.

Details about the health reform

The final text of the highly controversial reform was presented to the legislature by President Petro and Minister Corcho included four fundamental pillars:

1. Centralization of the public management of the health system resources that have been historically managed by private entities.
2. The implementation of a prevention-based primary health care program integrating existing EPS infrastructure to the Integral and Resolutive Primary Health Care Centers (CAPIRS).
3. The creation of the National Health Council to guide health policies.
4. Dignification of health workers and strengthening human capital.

Minister of Health Corcho announced that the government is “proposing, as in all the health systems of the world, to recover the public management of healthcare system resources.” The Government’s aim is to redirect the role of the General Social Security Health System Resources Administrator (ADRES), the public entity responsible for managing health system funds. Instead of allocating resources to EPSs for the provision of healthcare services, ADRES would act as a single unified fund providing funding to clinics and hospitals directly, eliminating the need for intermediaries like EPSs and marking a significant shift to the current system.

This change means that current EPSs in liquidation will roll-over their patients to existing EPSs during a transition period. EPSs that are not in the process of liquidation “will agree, based on the regulations established by the Government, on the rules for the healthcare delivery of the population affiliated to the new social health insurance”. This means that EPSs will cease to have covered patients and will become health service providers through their clinics and hospitals, as part of the Integral and Resolutive Primary Health Care Centers (CAPIRS) system.

Regarding the shift towards a primary care system, the reform proposes the creation of 2500 CAPIRSs -with public, private and mixed ownership– throughout the country to implement a “gradual and orderly transition process to the new model.” However, details on how existing EPS infrastructure and human capital will be integrated are still not clear. When announcing the reforms, President Petro explained that EPSs can, if they want to survive in the new system, start their survival through creating CAPIRSs. Petro went further and detailed that “in time this will result in a universal system with primary and preventive care, with CAPIRSs playing a central role.” The reform text does include some text with details on a transition period where EPSs and ADRES continue operating as usual until all patients from existing EPSs are transferred to CAPIRSs in their geographical area, but this is likely to be one the chapters with most discussion and will likely be modified and the transition period lengthened.

Another key aspect of the reform is the creation of a National Health Council, consisting of representatives from health system workers, medical unions, the business sector, indigenous and Afro communities, that will play a key role in guiding the development of public health policies. The council will not manage funds, but rather engage in discussions and hold health system actors accountable. This council model will be replicated at the departmental and municipal levels, empowering citizens to have a direct say in the management of their health system. Minister Corcho emphasized that active participation of the communities will be crucial to identify and address the most pressing public health problems and priorities.

The health reform encompasses a range of additional measures aimed at improving the system, including the establishment of a formalization and dignity in work program for health workers. According to Minister Corcho, there will be a consultation process with the Government to establish the salary scale of healthcare worker with a gradual application process starting at the primary level: the first beneficiaries will be nurses and auxiliary nurses, who have lower salaries.

Criticism of the reform and public views on the healthcare system

The health reform is facing significant push backs and criticisms from various actors in society. These actors include patient groups, industry groups, scientific society, political opposition, and even the government’s own minister of Education and former minister of health, Alejandro Gaviria.

Patient groups are concerned about being excluded from the debate surrounding the reform, and have called for their voices to be heard. They are worried that the proposed changes will negatively impact access to quality healthcare and leave vulnerable populations behind, particularly those suffering from rare conditions which require high-cost medicines. A coalition of patient groups has gone as far as proposing a parallel health reform in Congress, separate from the government’s own proposal. This new proposal seeks to address some of the concerns raised by patient groups and will include the participation of experts in the field.

Industry groups, such as the Colombian Association of Pharmaceutical Laboratories (AFIDRO), have raised concerns of how the proposed elimination of EPS´s will play out and how this could affect continuity of treatment for high-risk patients. Paula Acosta, executive president of Acemi (Colombian Association of Integral Medicine Companies) said that the current healthcare model without the EPSs would have serious consequences for citizens’ access to basic healthcare systems, and in addition, family expenses would have a significant increase as well as prepaid medicine rates.

Roy Barreras, president of the Senate of the Republic and ally to President Petro, himself criticized the country’s health reform and Minister Corcho, despite being a strong supporter of the administration. Barreras, who is a doctor, questioned the way the health reform has been discussed and the lack of clarity surrounding it. He also expressed concern about the possibility of the promotion of health services being transferred to territorial entities and the ability of the State to audit medical bills. Former president and leader of the Liberal Party, Cesar Gaviria, another short-term ally of Petro´s in the legislature, was also very critical of the proposed reforms and signaled that he would not support it as currently proposed. Gaviria called legislators to not vote “blindly” in support of the initiative which, in his opinion, can severely affect health access if not debated and socialized in an appropriate manner.

The reform’s detractors have even come within the President’s own cabinet. The Minister of Education and former Minister of Health Alejandro Gaviria has made several criticisms of the proposed health reform. He has stated that the reform lacks proper socialization and that the government has not taken the time to properly consult with stakeholders and experts in the health sector.

The public opinion on the health reform is similar. A recent national poll conducted by pollster INVAMER, and the ANDI (Association of Colombian Businessmen) showed that 63% of respondents reject the elimination of the EPS and 67% are not willing to give up their current service to move to a fully public one. Additionally, 54% of those surveyed are “very concerned” that the resources of the health system are administered only by public entities such as the Government or the Ministry, as opposed to 26% who are not at all concerned and 17% who are, but in a moderate way.

Despite this, the President has defended his reform and dismissed criticisms and the results of the poll conducted by ANDI. He believes that the poll does not represent the views of the population accurately and that the reform is necessary to ensure that everyone has access to quality healthcare services.

How likely is the reform to pass?

There is a great deal of uncertainty surrounding whether the government will be able to secure the necessary votes in Congress to pass the reform, with some opposition politicians indicating that they will not support the reform as it is currently written. In particular, the elimination of EPSs has been a major point of contention, with several opposition politicians arguing that this will negatively impact access to healthcare services in the country.

One of the main issues affecting the approval odds of the reform has been the lack of public engagement and discussion around the reforms. Critics have argued that the government has failed to adequately socialize the reforms and engage with key stakeholders, including patient groups, industry groups, and scientific societies. This lack of public engagement has led to a great deal of skepticism about the reforms, and many people are now concerned about the potential impact that the reforms may have on the quality of care that patients receive. This was seen in the responses to the ANDI poll which suggest that there is still a lack of information and understanding among the population regarding the proposed reform.

Despite these challenges, the government remains committed to pushing the reforms forward, and the formal presentation of the reform opens the door to work with opposition politicians and key stakeholders to address the concerns and questions that have been raised about the reforms. What is certain is that the debate likely to take several months and will result in the first major legislative hurdle the Petro government will have to overcome.

Having an acute understanding of how the health reform is advancing in congress and developing an advocacy plan to mitigate the negative effects of certain provision included in the reform will be vital for the healthcare sector in Colombia in the coming months. At Speyside we can assist global, regional and local policy teams understand and react to this local context.