HEALTH CARE system and policies
IC Social Policies: Welfare Policies Stefania Sabatinelli, PhD
HEALTH CARE system and policies in Colombia María Clara Restrepo Tirado January 31, 2010
Architecture and Society Faculty Politecnico di Milano 2010
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HEALTH CARE system and policies
Index I.
Introduction
II. General overview III. Legislation IV. Health care system : from theory to reality. V. Panorama 2010 VI. Conclusions VII. Annexes VIII.
Bibliography
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HEALTH CARE system and policies
INTRODUCTION The health care became a “problem” for the state since the cities grew after the industrial revolution, and the industrial accidents, the sickness caused by work and the healing of the people went out of the hands of families. The debate has been, as in the rest of the welfare spheres, if the provision should be given by the state or should be ruled, as in the most liberal states, by the market and the competition between private actors. The latest debates in the USA, caused by the proposal of the president Obama of a new model of health care system, or better, the creation of a system involving the state and the public funds for the provision of health, turned the eyes of the world to this “systems” that vary a lot around the world depending on the focus that every state has in terms of intervention in the welfare policies. A third world country with a very complicated context from the political, social and economical points of view, the violence that has characterized the history and present of Colombia, provides an even more acute “problem” when it comes to health. Even though the physicians say Colombians are one of “the healthiest” people, and it can be explained because of the strong race product of the mixing of all races, or by the hypothesis that people prefers not to get ill, just to not have to turn to the national health system. It is a good opportunity to get a bit of the reality of a very complex nation, to try to get to the bottom of the problem of the provision of health, to try to understand with a study case one of the multiple sides of the state’s faces. Maybe understanding one part will get us to understand the totality, and find some answers for the entire system of governing a in complex territoriality.
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HEALTH CARE system and policies
I. GENERAL OVERVIEW “… Colombia was one of the three countries that emerged from the collapse of Gran Colombia in 1830 (the others are Ecuador and Venezuela). A five‐decade long conflict between government forces and anti‐government insurgent groups, principally the Revolutionary Armed Forces of Colombia (FARC) heavily funded by the drug trade, escalated during the 1990s. The insurgents lack the military or popular support necessary to overthrow the government and violence has been decreasing since about 2002, but insurgents continue attacks against civilians and large areas of the countryside are under guerrilla influence or are contested by security forces. More than 31,000 former paramilitaries had demobilized by the end of 2006 and the United Self Defense Forces of Colombia (AUC) as a formal organization had ceased to function. In the wake of the paramilitary demobilization, emerging criminal groups arose, whose members include some former paramilitaries. The Colombian Government has stepped up efforts to reassert government control throughout the country, and now has a presence in every one of its administrative departments. However, neighboring countries worry about the violence spilling over their borders. “ *1 4
*Colombia on the maps. * The CIA Factbook, 2010, Colombia. 1
HEALTH CARE system and policies
Colombia could be described as a very MIXED country: mixed in races, in climates, in cultures. Colombia takes important part of the group called MegaDiverse countries of the world with Brazil, Indonesia, South Africa and Australia. It is one of the greatest strengths in the international field, and brings lots of good effects in tourism, economy and even national pride. But this special condition takes it all to a new level when it comes to management and control of populations, and finding common solutions and policies, from a central government. The physical territorial conditions are marked by a hard environment, sometimes unbreakable geography, that requires a very tough people to deal with it and survive. The presence of high risk conditions as volcanoes, high propensity to earthquake areas, up to 5500 AMSL mountains and the deep Amazon rainforest definitely put the health care issue on the table for every debate about the population’s welfare. Besides to the tendency to natural disasters and the wide presence of unhealthy climate in a large part of the territory, Colombians suffer mostly from heart diseases and strokes, respiratory allergies and diabetes. The increasing rates of road traffic accidents take also a big part of the causes of death in the country. All this combines with an historical poverty, initiated with the colonization processes, and an unfair and unequal state organization used to have complete control, because has never had a serious competitor or politically strong opponent. According to the annuals in health situation, the advances in technology, the high number of campaigns for promotion and prevention of diseases, especially in the most vulnerable areas: the unhealthy climates, the poor and “apart” regions (rural territories), has shown a decrease and sometimes disappearing, of lots of illness that in the past devastated the country as malaria, dengue, yellow fever. During the last decade, with the implementation of social programs of the state, and the undeniable help of some organizations and NGOs, lots of advances have been made in the prevention and promotion of health care against preventable by immunization diseases and other serious public health problems. All this due to those who believe that hygiene and education are the best medicines. But the market doesn’t seem to think so, or maybe they also do, but there is no business in prevention. On the other side, the worsening of the armed conflict in the 90’s and beginning of the XXI century, have kept the health matter tilted to the problems of urban and rural mass homicides, the risk of minefields in apart rural territories, displacement of entire communities, violence against the woman and child in the war. For 2009 violent death is still one of the main death causes, even if the situation seemed to get better in the last 10 years, with the “demobilization” of paramilitary groups and the diminish of the armed guerrillas, as much in number of “soldiers” as in political and social power. The old conflict, a politically and socially based fight against an unequal society with a very strong oligarchy, degraded because of the lack of a real and solid political proposal, and the “interference” of narcotraffic to finance the struggle, into a senseless war against the civilians. It is impossible to deny the deeply enrooted problems Colombian society has – and will have‐ to deal with due to the last 50 years of history. Still with all this internal conflicts, the people that survives, tries the best to change the image and the atmosphere around, in order to find the light at the end of the tunnel of this challenging everyday situations. The solutions proposed are always under the world’s eye and that’s why the policies are always changing, implementing all kind of experiments, struggling with all the adverse, but counting with very compromised citizens looking for development, dreaming with equality.
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HEALTH CARE system and policies
“…Colombia is experiencing demographic changes as well as changes to its epidemiological profile typical of transitional societies. Examples of demographic changes include population aging, decreasing fertility, rapid urbanization, while the change in the epidemiological profile emphasizes the persistence of communicable diseases with a concomitant increase of non‐communicable diseases.” *PAHO – WHO, Health situation analysis and trends summary, 2008
II. LEGISLATION *Time line in legislation about HealthCare.
The actual national constitution was raised in 1991, based on the principles of “… peaceful coexistence, work, justice, equality, knowledge, freedom, and peace within a legal, democratic, and participatory framework…”, and coming from a 1886 constitution that by the time was already too old. The following period saw as many changes as the new national rules permitted. During the presidential period of Cesar Gaviria, and his very liberal team, the economical liberalization, self called “apertura económica” was enable as a Latin‐American trend after seeing the case of Chile and its arise successfully, once the “socialism” was – literally – erased from the government. Colombia could not go behind, and so the decision was made. By 1993, the turn was for the health care system. By the year 1990, the National Health Care System was based on the governmental assistance and characterized by its vertical organization (General Social Security System on Health Care). There was basically one public system (the Social Security Institute, in charge of all the public infrastructure for health) besides an open, growing, no regulated private sector of health provision. This system had an important development between 1975 and 1982, when there was a big increase in the number of infrastructures and functionaries in the sector : the main public medicine faculties increased the number of students and other faculties permitted the education of new physicians as well as nurses and dentist.
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HEALTH CARE system and policies
A mayor crisis in 1982 reduced the state contributions to health care from 8 % of the national budget to less than 4%. The effective coverage reached 27% of the population but could not grow further. By 1985 Colombia had one of the lowest rates in Latin America in health care covering, having only 15% of the population covered by the Social Security Institute, 10% of the population able to pay for private insurance and 5% covered by the special systems for state workers and their families. The remaining 60% was considered to have no accessibility to proper health care services. In December 1993, the Law100 was expedited and the Social Security Institute, was restructured having reduce his functions to the management of the regime of pensions subsidized by the state. The new system called General System of Social Security in Health ( better known as SGSSS) was completely detailed in the 4 books of the Law 100: a first book about pension regulations, the second book about the general system of healthcare, the third book about occupational safety and health and a fourth book about complementary social services. The reform basically has shifted the burden of subsidy from providers to users, and had 3 main goals: to avoid the statal monopoly in the health provision, incorporating private enterprises into the market , and the creation of a subsidiary system to cover all the poorest population, before left outside. The system also defines a special regime for teachers asociations, national police, national armed forces and ECOPETROL (National Petroleum Company) workers.
“ The general principles of the law determine the healthcare is a public service, which must be granted in conditions of proficiency, universality, social solidarity and participation. The article 153 of the law determines that the health insurance must be compulsory, the health providers must have administrative autonomy, and the health users must have free choice of health provider.” El SGSSS : una visión doce años después, Álvaro de J. Tirado Correa, 2005. Medellín. 7 The system was immediately recognized as very ambitious, but as a very intelligent and visionary one as well. The goals for 2001 were to be able to cover 100% of population (divided into 70% in the contributory regime and 30% in the subsidiary regime) and even up the scopes of the compulsory health plans for all the population . All the financial and regulation issues that seemed to be too complex to understand or maybe even unfinished, were supposed to be resolved on the way, in a Planning by Doing manner, on the way, the same that in the case of Chile, again a model for the Colombian system. In 2007, after the non accomplishment of the goal for 2001, the system and his regulators decided to modify in part the Law100, or adjust it, looking to solve some of the problems that by the date all ready where visible: financing, control and surveillance, number and quality of hospitals, relation between patients and doctors, information, corruption, and others. As a conclusion made by more than one analyst, this “important modification”, didn’t modified at all the central problems, but created a wide debate about the law and the entire system.
HEALTH CARE system and policies
III. HEALTH CARE SYSTEM: FROM THEORY TO REALITY The system has 5 basic actors that interact with each other for the health care provision and use of the service. This are 1. the direction‐surveillance‐control organisms, 2. The management and financial organisms, 3. The health providers institutions (IPS) public, private or mixed, 4. The employers and employees, 5. The beneficiaries of social programs of the state. * THE STATE
8 The Nation‐State, in the head of the President elected democratically, who elects a council of ministers, is in charge of the social protection and social security , terms commonly used to refer to health care provision, work conditions, pensions system and general welfare in the country. In the case of the health, the Law100 proposed two basic organisms to control, supervise and organize the system and the rest of the actors: the SNS and the CNSSS (replaced by the CRES in 2007). Also a CONPES is made in the name of HealthCare every year to define the distribution of resources for all the statal social programs
HEALTH CARE system and policies
* THE REGIMES
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HEALTH CARE system and policies
* THE COMPULSORY HEALTH PLANS
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* THE HEALTH ADMINISTRATORS
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The most “innovative” element of the SGSSS was the creation of intermediate organism between the health providers (hospitals – doctors) and the patients, better known as users of the services (not to mention the consumers as in any other business) and this organisms became the centre of activities through which all difficulties and solutions must pass by: the EPS. Furthermore, they became the origin also of most of the troubles both for the state and for the users.
HEALTH CARE system and policies
* THE PROVIDERS
* THE CONTROLLERS
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HEALTH CARE system and policies
* THE FINANCING
.1.
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This accounts are the heart of the entire SGSSS. If this accounts are going well, it means everything is going well, and if there’s any complication in them, the entire system falls down as a house of cards.
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One of the main problems normally seen in the finances is the fact that this 4 accounts are managed separately, but at the same time, are all part of the national budget. It is necessary to create a relationship between them of “transferences” : from the national budget to the FOSYGA, and from this account to the territorial entities depending on the needs in each one of them.
HEALTH CARE system and policies
.2.
.3.
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HEALTH CARE system and policies
.4.
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+ … a social security system, or a secure society? The SGSSS must be understood as a net of institutions, rules and procedures, each one equipped of an specific function, aiming the insurance in health risks, the equalitarian access to a minimum, but high quality, package of health services, promotion and prevention of a healthy life and it’s benefits, for the whole population over the national territory. This universality is the main objective of all health policies in the last 30 years in Colombia, and the reason why the old system was converted, and still today the reason why the opponents of the SGSSS call it inefficient and a fraud. The Law100 , and the actual SGSSS has been a big step towards the recognition of health as a fundamental right, given the fact that in a complex environment as “the third world”, the human basic rights are words on paper, but efforts are being made to turn them into real. But reality shows the state is always one step beyond the reach of the population in need. There is still the lack of a specific public policy for health, coming and protecting the citizen, by the state. Financing, covering and equity were the problems in 1975, and are still. Who should be covered? What kind of services should be given?
HEALTH CARE system and policies
IV. PANORAMA 2010 Even though the system was supposed to reach the goal of universality by 2001, in 2007, which was considered the best year in the last decades, the covering reached the 78%, including also the linked population (not affiliated to any regime, but counted by the SISBEN), so there are approximately 10 million person outside the system, therefore in inappropriate health conditions. For the common citizen, affiliated to both regimes, but with an obvious harder situation for the ones in the subsidiary regime ‐due to the lack of funds to get a better treatment, or the pity of not knowing “anyone inside” to help them‐ the EPS are widely known as expensive, inefficient and a wall between the sick and the cures. The lack of information and education about the way the system actually works, the bureaucracy in the organism, the low qualification‐ low payment of the personnel, makes the “follow of the regular conducts” a not so “followed” practice. The common user of the services, that usually is in need and even desperate, tends to think that anyway the EPS won’t work, so even before approaching to it, goes directly to legal actions (“writ of protection of civil rights” called tutela) to get access to the service, but leading to a misuse of this tool. The Colombian known “Tutelitis” is the tendency to lodge tutelas to the state, and it’s a “trend” in today’s normal life. This conducts ended by 2008 in the decision of the Constitutional Court of obliging the government to study and re‐define the POS, because of the prevision of a “high congestion in the legal fields” ( Sentences C463 and T‐760 2008). The amount of corruption in the Colombian state is directly proportional to the amount of money moving inside a system, and there’s no novel in the fact that health one is full of open cases of corruption, from the EPS, to the IPS passing off course through the financial and control organism. It is one of the main reasons of the “disequilibrium” of the system. Contrary to this, or not, all the parts coincide in the idea that if corruption could be eliminated or at least diminish, half of the problems in the system that are consider “structural” would disappear.
+ In December 2009, the social emergency state was decree, because of the lack of funds in the FOSYGA account and the debt of more than € 300 million ( ! ) to the EPS. In response, the government has proposed 10 emergency policies, to “restablish normality”. th EMERGENCY POLICIES, January 19 , 2010 Decree 126, 127, 128, 129, 130, 131, 132, 133 ,134, 135, 136
TO REGULATE THE RIGHT TO HEALTH AND LIBERATE FUNDS TO PAY THE DEBT
1.
To liberate about € 200 million from the accounts of ARS and pension funds.
2.
Increase the cost of SOAT (insurance for traffic accidents)
3.
The services not covered by the POS are extraordinary and won’t be covered under any circumstance. The funds for this procedures, medicines or treatments must be paid by the patients, with their personal assets, savings or even bank loans. The legal actions “writ for protection of fundamental rights” will be blocked.
4.
Disciplinary measures for doctors prescribing out of the POS.
5.
Higher taxation over liquors and cigarettes (from 10 to 14% over the total sells)
6.
Creation of a national lottery, to liberate at least €80 millions.
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HEALTH CARE system and policies
V. CONCLUSIONS Health has to be seen from inside a territory. The Colombian state and the definition of regions and territorial entities, is still a little bit blurry, even more when seen from the rural “apart territories” and from the point of view of the populations. The role of the state is not clear enough for the health provision, as much as is not clear for the rest of the interventions. The decentralization is a process still ongoing in the practice, and requires mayor efforts to reach 100% of the population, before being covered by health insurance, being covered by the nation and the benefits of being a citizen. The role of the state in the welfare of a liberal economy. The extreme liberalization of the societies are finally being understood as a not‐sustainable behavior, and even more in such unequal basic conditions for a third world society. The population, half under the poverty lines, still claims for the statal intervention in the business of such a dedicated matter as health, in a hard environment of war and extreme climatic conditions. The social construction of a model: a real participative system. In order to get to know what the population desire and need, but even more to find a place in between those two, that can actually be financed and subsidize by the national budget and the richest segment of the population. A real participation of the people and an effective method of socialization is required. The amount spend in promotion and prevention is definitely less cost and high benefit, for everybody. As any other national scale system, has to be based on a communitarian construction, where all participate and there’s no paternal relationship: it has to be “paid” by everybody, so we can all appreciate the work “we did”. Changing the mentality, more that the systems. The popular notion in Colombia of the public goods, public policies or any public element, is an idea created by the pressure of the market – who can be read as north‐american‐culture ‐ over the idea that liberalization and privatization are the saviors of our nation, communism is devil and the more you pay for something, the high quality you get. The bureaucratic state lead and supports this idea of public equal bad management, out of control, and finally, public equal corruption.
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VI. BIBLIOGRAPHY ‐
Ley número 100, 23 de Diciembre 1993, Congreso de la Republica de Colombia (Law 100, December 23, 1993, Republic of Colombia Congress) Bogotá.
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Ley número 1122, Enero 9 de 2007, Congreso de la Republica de Colombia (Law 1122, January 9 2007, Republic of Colombia Congress) Bogotá.
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CONPES 122, document of the National Council for Socio Economical Policies, January 29, 2009. Bogotá.
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“Indicadores básicos 2008, Situación de Salud en Colombia” Ministerio de la Protección Social Republica de Colombia y Organización Panamericana de la Salud. (Basic indicators report 2008, Health situation in Colombia, Ministry of Social Protection Republic of Colombia and PAHO) Bogotá.
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“La ley 100 en la visión de un salubrista: una aproximación en el concepto de la salud como empresa social” Luis Fernando Cruz G, apart from ColombiaMédica magazine, vol.27 n.1, 1996. Bogotá.
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“El seguro de salud en Colombia: cobertura universal? “Jairo Restrepo Zea, apart from Gerencia y Politicas de Salud magazine, n.2, September 2002. Bogotá.
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“La salud en Colombia: abriendo el siglo y la brecha de las inequidades” Esperanza Echeverry López, apart from Gerencia y Politicas de Salud magazine, n.3, December 2002. Bogotá.
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“El SGSSS : una visión doce años después” Álvaro de J. Tirado Correa, 2005. Medellín.
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“Fuentes de financiación del SGSSS”, Gustavo Ortiz Gómez, 2006. Pereira.
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“A propósito de la Ley 1122 del 2007 Reforma del Sistema General de Seguridad Social en Salud en Colombia: esperanza, mito y realidad” Román Restrepo Villa, National Faculty of Public Health magazine, vol.25 no.1, January ‐ June 2007. Medellín. “Knowledge, opinions and experience from applying health participation policy in Colombia”, María E. Delgado Gallego y María L. Vázquez Navarrete, Salud Pública magazine, vol.8 no.3 September ‐ December 2006, Bogotá. “Evaluación de Políticas de Salud en Relación con Justicia Social”, Román Vega Romero, Salud Pública magazine, vol.8 no.3 September ‐December 2006, Bogotá. “Lo mejor y lo más débil del sistema de salud Colombiano” Maria Teresa Ronderos, apart from Semana magazine, July 6th 2009. Bogotá.
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HEALTH CARE system and policies
Informational Web sites
https://www.cia.gov/library/publications/the‐world‐factbook/geos/co.html
http://www.paho.org/English/DD/AIS/cp_170.htm
http://www.supersalud.gov.co/index.asp
http://www.fosyga.gov.co/
http://www.pos.gov.co/Paginas/default.aspx
http://ley100.com/portal/
http://www.etesa.gov.co
http://www.eltiempo.com.co
http://www.elcolombiano.com.co
http://www.semana.com
Online documents:
http://www.eltiempo.com/colombia/politica/la‐emergencia‐social‐practicamente‐elimina‐ los‐servicios‐no‐pos_7019270‐1
http://en.wikipedia.org/wiki/Health_care_in_Colombia
http://www.saludcolombia.com/actual/reform.htm
http://www.semana.com/wf_ImprimirArticulo.aspx?IdArt=125943
http://www.paho.org/English/DD/AIS/cp_170.htm http://www.revmed.unal.edu.co/revistasp/v3n2/v3n2e1.htm
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