[Politics] Why does the minister ask to lower resources for health? / Analysis of Ricardo Avila

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On August 26, the newly appointed Minister of Health, Carolina Corcho, invited Federico Gelli, the Italian doctor who treated then-presidential candidate Gustavo Petro in March while he was recovering, after being infected with covid-19 in Florence (Italy). After the conversation, two moments remained in the memory of the attendees.

The first is that the foreign specialist did not denigrate the Colombian health system, which has been branded by his hostess as "failed" on repeated occasions. "The indicators, compared to other Latin American countries, are good," stressed the European.

This affirmation, based on analyzes made by the university to which Gelli is associated, did not impress the official. The second moment of the talk occurred when, on the contrary, Corcho pointed out in his speech that "there has to be an explicit, clear crisis that allows society to understand that change is required."

Was such a statement a warning of the Government's intention to deliberately create a debacle to demonstrate that the current structure does not work? Recent events do not contradict that interpretation, beyond the fact that opinion is distracted by the tax reform, energy rates, peace or the pension proposal.

Without going any further, last Wednesday, in a debate in Congress, the minister was in favor of the resources allocated to the portfolio she is in charge of being for a much smaller amount than that proposed by the previous government. Specifically, of an increase of 8.1 billion pesos proposed by the Duque administration in the initial national budget project for 2023, now the request is for 3.8 billion, to which 1.3 billion would be added to move forward the preventive and predictive health model proposed in the campaign.

(She may be interested: 'Petro's pension reform would indebt governments and future generations': Eduardo Lora)

It is unprecedented, to say the least, that someone of that level arrives at the Capitol to insist that his area does not require more, but less money. And that is even more noticeable in a sector that suffers from a chronic lack of resources and not a few imbalances. "A minister does not have to throw in the towel when he is going to defend resources for the health system," says Denis Silva, spokesman for Patients Colombia.

Among the arguments put forward is mistrust regarding what has been done before: that the capitation payment unit, UPC (the amount that the Government transfers to the EPS for each affiliate), is poorly calculated; that the maximum budgets (the old recoveries, which finance the services not covered by the UPC) are “a very rare matter”; that tests for the diagnosis of covid-19 are no longer so necessary. Even, faced with the request for an item to finance the cost of care for the migrant po[CENSORED]tion, the health minister said that she is confident that the government of Nicolás Maduro will cover the amount indicated for the normalization of relations. between Colombia and Venezuela.

mislead
Given what happened, speculations arise. "Providing services in this area today is much more expensive than what was projected in December 2021, when the UPC was calculated," says former Vice Minister of Social Protection Diana Cárdenas. “Since this year costs have been higher than expected and people are using more services, one would expect that, by 2023, the government would try to correct the situation.”

For her part, Ana María Vesga, Vice President of Health at Andi – which brings together EPS, private providers and the pharmaceutical industry – believes that the reduction in the health budget for 2023 puts at risk the sufficiency of the UPC and the payment of the technologies that are financed through the mechanism of maximum budgets. "The defunding of the system has enormous consequences in the timeliness of care and affects users," says the union leader.

With similar surprise, the researcher in health systems Andrés Vecino pronounces himself, pointing out several contradictory aspects. One, that the reduction in insurance resources will particularly affect the po[CENSORED]tion with the lowest income. Two, that the country is emerging from a pandemic “and has a large burden of disease left behind.” Three, that this reduction "can affect the salaries of health workers, because the resources of the UPC end up determining their salaries." Four, that a reform is intended with fewer resources. And five, that so much money be allocated to the predictive and preventive program, "which has not been piloted and has not been evaluated at the national level."

Under the proposed scenario, there is a financial strangulation that will deepen the already existing problems. Given the growing complaints from users who will begin to protest the deterioration of the service, the ground will be fertilized for a counter-reform that will be formally presented next semester, but which in practice has already begun.

spinning fine
For that to happen, a key player will be the new Health Superintendent, Ulahi Beltrán. Doctor, trade unionist, university professor, former adviser to the Comptroller's Office and former hospital manager, the official came to office despite a couple of tax proceedings against him.

Convinced that the current structure favors "financial intermediation," he reiterates that he will honor the "mandate of the people." In his statements, he has made it clear that he will maintain the liquidation process of the EPS that do not meet indicators, but no longer under the slogan of purging the system.

Since Beltrán took office, two entities have ceased to operate – Comfamiliar Huila and Convida, which had more than a million members – and there seems to be no intention of giving new opportunities to another seven that have a special surveillance measure. Particularly important is what might happen in Antioquia with Savia Salud and its 1.7 million users, whose future will be defined before the end of the month.

Liquidating EPS gives the appearance of ruthlessness and generates applause, but, in general, each hole that is closed opens up others. The closures leave unpaid debts with providers and, by forcing the transfer of users to other entities, forces the latter to capitalize and attend to patients with repressed needs that usually trigger the accident rate once they are diagnosed. “This is not about transporting cattle from one place to another, but about treating people well,” recalls Denis Silva.

As things stand, only a handful of institutions would have the ability to survive from a financial strength standpoint, since multiplying in size overnight is nothing short of impossible. To make matters worse, voices are already beginning to be heard against alleged oligopolies, since the administration would frown on a small number remaining at the end, since that would go against the principles of competition.

Consequently, in addition to the financial suffocation, comes the approach of the inconvenience of leaving the activity to a reduced number of actors. Paula Acosta, president of Acemi, a union that brings together the ten EPSs that affiliate the majority of the po[CENSORED]tion, thinks that the Government "has placed the EPSs as the exclusive cause of the problems that have been arising and, under that scenario, a kind of de facto reform has been proposed, without going through the Congress of the Republic”.

In fact, many parliamentarians defend what exists now, among other reasons because surveys show that people value a system that handles more than two million queries and procedures a day. In this sense, and to avoid the opposition of the Legislature, there are those who say that the strategy is to come up with the issue when the emergency is of such magnitude that the only way is eviction.

Change yes, but like this?
And, finally, how is the new health system that the Government wants? The question does not yet find an official answer. It is true that it has

There have been pronouncements from high officials, while drafts of the articles of a bill whose paternity no one assumes circulate through the networks.

It is known that the administration aspires to a public model, with the presence of state and private hospitals and without intermediation, something that would respond to the intention of ending the EPS. The scheme would incorporate a strong preventive component, while the provider networks (clinics, hospitals, laboratories) would be organized by territory.

Within each one there would be primary care posts close to citizens' homes, and from there users would be referred to more complex centers, but without leaving a certain area. Apart from that, there would be extramural groups that would go to homes to assess health conditions.

Until then, the issue does not generate much discomfort, since no one disputes that it is urgent to strengthen primary care. Potential problems appear when it is mentioned that the Administrator of the Resources of the Social Security Health System (Adres), apart from being the only collector, would be the only payer, which would turn directly to the providers, who in turn would have the obligation to attend to what is presented.

In this regard, connoisseurs issue warnings about the dangers. On the one hand, there is the supreme power of an entity that would manage sums of the order of 70 billion pesos a year. On the other, fear arises in the absence of a figure genuinely interested in avoiding unnecessary spending, with which the money would run out faster.

It is no secret to anyone that most of the links in the chain do not show a vocation towards containment: more services and more sales, more income. In a context of rights without barriers, the possibility of excesses occurring and the corrupt doing their thing –and more so in those territorial entities where professional capacities are limited– would increase exponentially.

Thus, the serious risk of making a clean slate consists of going back. Putting an end to an architecture whose coverage is practically universal and which limits families' out-of-pocket expenses is only justified if there is a notable improvement. After having shown its strength during the pandemic, when the network responded adequately without anyone having to put a weight for the attention received, there are many who believe that it would be more logical to make corrections to what exists.

No one denies that there have been EPSs that have not fulfilled their task and have well earned their disrepute. But that does not mean that the figure lacks validity. After all, to make a system viable with limited resources, some agent must ensure that waste is avoided. And that is avoided thanks to the figure of insurance, making smart purchases and looking for efficiencies.

Not to mention that it would also be a waste to end the networks of providers developed over almost three decades. Starting from scratch can come at a very high price. The planned transition – especially if it is traumatic – is not exempt from leaving patients adrift, something that would be measured in the lives and well-being of many.

"All the objectives proposed by the current government are easier and faster to achieve with the EPS than without them," insists Elisa Torrenegra, executive director of Gestarsalud, the EPS union of the subsidized regime. She warns that "giving local governments these functions is exposing health to the dynamics of local politics."
"Today's panorama is one of discouragement, restlessness, polarization, where the citizen is in the middle," adds Denis Silva. "That's why each side should show their cards in order to come up with viable solutions," he stresses.

"To finish with what was built would be a monumental mistake," warns the president of Anif, Mauricio Santamaría. “What has been achieved is impressive in terms of coverage, access and equity, so risking going back to a pre-1993 country is very dangerous,” he says.

Such alarms, however, do not find an echo in a Ministry of Health that gives the impression of wanting to accelerate an "explicit crisis" and irreversible, before which it can propose another solution. The only alternative so that the chronicle of a self-fulfilling prophecy is not written is for users to defend what they have, which is not a small thing. Otherwise, they will attend the third-class burial of a system that deserves repairs and not have the death certificate issued.

https://www.eltiempo.com/economia/sectores/sistema-de-salud-analisis-sobre-posible-crisis-propiciada-para-una-reforma-703253