Photo: Diego Peña Pinilla
Draft articles on what could be a structural health reform bill have begun to circulate in recent days. At the same time, several associations are working on proposals for additional or alternative articles. The media, political leaders, academics and systemic actors are taking a stand, some more vehemently than others. (Read Will the health care system be defunded? A guide to making sense of the confusion)
Although in my opinion it is too early to analyze point by point the unofficial version of the bill which will be presented next year, I would like to contribute some elements to the debate that is in the making. Specifically, I would like to argue that the categories and numbers with which we from different shores talk about the health care system, its flaws and its virtues, are getting lost in translation.
On the one hand, has the posture that highlights the achievements of the system, especially compared to past pre-legislative 100. In this version, the achievements of the system include, among others, the sustained increase in health coverage to reach practical universality (99% of the population in 2022), the broad scope of the benefit plan (which includes 97% of the health technologies available in the country) and low out-of-pocket costs (16% of total health care costs, the lowest in Latin America). All this with very little money (only 7% of GDP, close to the regional average and well below the OECD average of almost 13%) and with very little money per person ($1,200 per year versus between $4,000 and $5,500 in European countries) ). The system thus presented is a complete success. That yes, with things to improve, including the working conditions of human talent, primary health care in many territories and the possibility of meetings with specialists.
second, there is a position that speaks of the health system as a complete failure. In this variant, it is unacceptable that the maternal mortality of the subsidized regime is higher than that of the insurance regime; that the maternal mortality rate, for example, in Riosucio is 8 times higher than that in Bogotá; that in some municipalities children under the age of 5 die from acute respiratory infection or acute diarrhea in proportions 100 times greater than in Bogotá (which has an ARI of 3.65 and an ADD mortality of 0.2 per 100,000 children under 5 years of age) and that the density of human health talent per 10,000 people is 6 times lower in Chocó than in Bogotá. All this while 13 EPS were liquidated in three years and the guardianship of access to health services continues to be the daily bread.
Both visions of the health care system are real and the evidence on which they are based is just as rigorous, but seems irreconcilable or simply lost in translation. In my opinion, this happens for three reasons. The first is that the population data of the system’s achievements, even if they positively affect lives every day, seem cold and abstract next to the image of children under 5 years of age and mothers dying of preventable causes. The second is that although we all talk about social determinants of health, it seems that we would like the health system to solve social problems that are beyond its scope. The third is that we have an obsession with EPS, as if they were the only actors responsible for either the successes or the failures of the last 30 years.
With or without EPS many of Colombia’s health problems will remain intact, as seen in the teachers’ health care system, which has no EPS and does not perform better than the insurance system. Actually with or without EPS, it will not change what I see as our country’s primary health challenge: the tension between the basic and individual right to health and the undeniable budgetary constraint on its funding. This fundamental and individual right, moreover, is at the expense of more collectivist conceptions of the right to health with an emphasis on the community.
In practice, this means that we want to cover for the entire population all the increasingly expensive technologies available for chronic diseases, the incidence of which increases as the population ages and life expectancy increases. At the same time, we want to offer cross-cultural and quality primary care throughout the national territory, with a special emphasis on territories that are difficult to access and have a dispersed population. Both represent basic right to healthboth of these things are very expensive and must be financed with a low and limited budget.
So far, the balance has tipped in favor of unlimited funding for the former. I agree that the balance sheet needs to be balanced to fund the latter, but I don’t see how this can be achieved without restricting access to certain expensive technologies or increasing the health budget significantly. Eliminating EPS does not solve the problem this basic problem. Instead of clinging to our own data, denying or qualifying that of others, we need to have this and other essential debates in an inclusive, honest and transparent way.
We all need to calm down too. As Jason Shafrin, the creator of the portal, says Health Economistthere are three universal laws of health systems in the world:
1. No matter how good your healthcare system is, people will complain about it.
2. No matter how much money is spent on health care, doctors and hospitals will find it insufficient.
3. The last reform will always be considered a failure.
*Associate Professor of Sociology at the Universidad de los Andes
Read it the latest health news in The Spectator.