By Lorena Perdomo, GTS Unification Committee – Impulso Socialista
Health reform has had a great public debate, not only because it is one of the most sensitive issues for the working class and impoverished sectors in Colombia, but also because of the role of big business and companies that enrich themselves at the expense of an obsolete and inefficient health system.
The illness of Law 100
Since Law 100, the outsourcing of health services in the hands of intermediary companies called Empresas Promotoras de Salud (EPS) has meant the privatization of the health system, causing the gradual de-financing of public hospitals to the point of bankruptcy and disappearance of many of them throughout the country. A significant example is the former Hospital San Juan de Dios.
This has led to the fragmentation of the health system, which has deepened the inequality gaps, since it is made up of a set of institutions and markets that through special regimes, contributory regime, subsidized regime and a system of care through the supply of public hospitals for the non-affiliated population provides services in an inequitable manner. This means that, although there is massive affiliation to the different regimes, this affiliation is made to a private EPS that manages state resources to generate profits to the detriment of the provision of the right to health.
Under this type of health model, those who have greater purchasing power and can pay for better health services can have the privilege of not dying and receiving more comprehensive care, while the population of the subsidized or unaffiliated regime must submit to EPS with lousy services and underfunded public hospitals. In this regard, the Mandatory Health Plan (POS) is a mechanism imposed by these deathly businesses, which increasingly restrict the services that must be covered to save lives and exclude treatments in order to charge more for them.
An important fact is that 50.5% of Colombians, almost 26 million people, are in the subsidized regime, i.e. the most precarious, while 45.1%, more than 23 million people are in the contributory regime[1], a regime where most of the formal and informal workers who can contribute are, however, the services are terrible. Such is the crisis in the health system that avoidable mortality is a key indicator: during the period 1998-2011, a total of 2,677,170 deaths were reported in Colombia, 1,427,535 (53%) corresponded to causes classified as avoidable[2].
The government’s limited proposal
Faced with this tragic panorama that Law 100 has left, a change is urgently needed. However, the recent proposal filed in Congress by the Minister of Health and Social Security, Carolina Corcho, has as its main problem the policy of class conciliation promoted by Petro’s government, since, despite the Minister’s strong proposal to end the EPS and intermediation, the government met with representatives of the EPS with the aim of reaching an agreement that guarantees their profits.
The current government proposal implies a health model based on the social determinants of the health-disease process, since it intends to advance in a model that addresses the social causes of diseases and does not reduce the attention only to their treatment, thus it would be a more preventive model under the slogan of strengthening Primary Health Care with interdisciplinary teams in the national territory. Although this could be progressive, the problem lies in who and how this proposal will be implemented if the EPSs continue to exist and prioritize their profits over the right to health.
It also states the creation of a Single Public Health Fund administered by ADRES (Health System Resources Administrator) so that the resources would go directly to the Hospitals or health care institutions, which would be called CAPS (priority health care centers), in this case, people would no longer ask for appointments at the EPS but directly at CAPS without a moderating fee. This sounds pretty good, but what was the government’s negotiation with the EPS representatives? The agreement is that the EPSs can build and manage some of these CAPS, an issue that would keep the use of public resources in the hands of private parties whose purpose is to maximize their profits.
It is certain that with the new health reform the model would change and the EPS would not be what we know today, but it would not solve the historical problem of health as a business and not as a fundamental right. Although the reform proposes that the EPSs must pass their affiliates to the CAPS to be attended, what would happen to the affiliates of the EPSs that manage and build their own CAPS? Would it be a new way of maintaining intermediation?
On the other hand, recovering the country’s public hospital system in terms of infrastructure and technology implies a very high injection of resources, which is extremely necessary and urgent.
In this case, the reform bill proposes that the sources of financing of the new Single Public Health Fund be from the resources of the General System of Participations, the resources of an annual item of the General Budget of the Nation (PGN), the resources coming from the tax on the purchase of weapons, the resources coming from the contributions for social security in health corresponding to the salaries of the employees or dependent workers of the public health system, the resources from the social security health contributions corresponding to the salaries of employees or dependent workers, the resources from the social security health contributions of the self-employed or independent workers and capital rentiers, the resources from the contributions of pensioners and two percent (2%) of the contribution to the Family Compensation Funds (Cajas de Compensación Familiar). As we can see, there are several financing sources, the issue here is that, based on the tax reform, these sources of financing would be supported mainly by what the workers contribute and not on the weight of large capitalists and entrepreneurs, since the progressive and permanent tax on large fortunes was never proposed and it is the workers who support the tax system and the sources of financing of this new health model. A matter that continues to maintain inequality.
Finally, the reform says nothing about the labor guarantees of the health sector workers who have in the state institutions precarious service contracts (86%), temporary contracts, hourly labor contracts or contracts of free removal and appointment, which are no guarantee of job stability, they are synonymous with multi-employment. During the pandemic we were called heroes, but we were treated as disposable. Even taking into account that the sentence T-338 states that service contracts should NOT be given for missionary and permanent jobs such as those performed in the health sector.
Those who mobilize against the government, but in favor of health as a business
The pro-capitalist and business opposition, which even on behalf of Uribe promoted Law 100 and the privatization of the health system, mobilizes and calls in media to defend the EPS and the precarious health system. Definitely those of us who question the government for not taking deeper measures in favor of the people, must reject the political and mobilization expressions of this reactionary opposition that goes against our rights. We call on the popular and workers sectors that see this government as limited not to mobilize with this opposition sector that seeks to maintain the past, on the contrary, we propose a path of struggle with political and class independence.
The health system needed by the working class and the people
No matter how many good ideas, the government’s policy of class conciliation will not have the results we need. It is possible that we will see changes in the healthcare system, but it will not succeed in transforming business into law, since it continues to maintain the privileges of the health care businesses and companies that have brought us to the current crisis. This is why we revolutionaries must stand firm with the demands of the Colombian people against Law 100 and for the disappearance of the EPS, even proposing changes that go further to solve the health problem.
We revolutionaries propose for the Colombian people, to demand from this government:
To put an end to Law 100.
For a completely public, free and universal health system under control of workers and users.
Expropriation of the physical and technological spaces of the EPS and private IPS.
Strengthening of the public hospital system with high standards of technical, technological and human quality.
Increase of health services at the national level with guaranteed access to impoverished sectors of the cities, peasants, indigenous and Afro-descendants of the territories.
For a health system at the service of prevention and cure of disease. To implement processes of Primary Health Care in all the territories of the country with total democracy of the communities and workers.
For the transfer to permanent staff of all health workers who currently have contracts for the provision of services, hourly labor, temporary staff and free removal and appointment.
For the increase of health personnel with all labor guarantees throughout the national territory, to provide hospital and public health care in the territories. Strengthening of secondary and technical training in health, in all public universities and SENA.
February 16, 2023
[1] Data taken from: https://www.minsalud.gov.co/proteccionsocial/Paginas/cifras-aseguramiento-salud.aspx
[2] Taken from: Report 3. Avoidable Mortality in Colombia https://www.ins.gov.co/Direcciones/ONS/Informes/3.%20Mortalidad%20evitable.pdf