THINKING

Analysis of the healthcare proposal put forward by Presidential Candidate Gustavo Petro

Gustavo Petro has named Jaime Hernán Urrego Rodríguez his Healthcare Advisor for the campaign. Urrego is currently a Professor of Public Health at the Medical Faculty of the Universidad del Rosario. He has also been Undersecretary for Public Health in Bogotá and managed the Territorio Saludable Program, the foremost primary care initiative in Colombia. His main task during Petro’s campaign has been to suggest new ideas for the creation of a healthcare program.

AGORA’s analysis has established that the Candidate has a mid to high level of interest in the healthcare sector. Notable actions during the electoral campaign include three political speeches and six appearances in the media specifically related to healthcare. When he was a Senator he proposed two laws, one of which, a law regarding a modification to the General Social Security and Healthcare Program, was passed.

The Candidate has announced a ‘Governmental Program for an Era of Peace’ with the following proposals for healthcare:

  1. Democratic and participative governability: a single public healthcare system would be created run by a National Health Council and regional councils with significant participation from indigenous communities and those of African heritage. The councils will be made up of healthcare authorities and delegates from different communities, workers, scientific groups, the private sector and academia. Their roles will be to direct healthcare policy and to administrate and coordinate public and private healthcare networks as well as communication with a Single Healthcare Resources Administration Fund. Administrative and financial intermediation in the healthcare sector will gradually be eliminated with the dissolution of the EPS and the ARL.
  2. A Single Healthcare Fund: This fund will guarantee transparency in the handling of resources and income will be handled by the administration while payments and resource management will be coordinated in association with national and regional councils, the Ministry of Health and Social Protection and healthcare authorities at departmental and municipal levels, as well as representatives from indigenous and African heritage authorities.
  3. Increased, sustainable public financing: financing shall continue to be sought from taxation and para-fiscal contributions at national and regional levels with the goal of increasing the general budget through a crack-down on tax evasion, increasing employment and formalization of jobs, ensuring that public health spending remains equal to or above 80% of the entire expenditure in the sector.
  4. A wellbeing-based healthcare model. A comprehensive healthcare model shall be implemented that places the emphasis on awareness and prevention, improving care and rehabilitation with a focus on human, intercultural and differential rights.
  5. The country shall be organized into healthcare regions to ensure wellbeing at street level in urban areas and municipal level in rural areas. Specialized teams shall be organized for different areas of healthcare to provide services and care throughout the country. These teams will visit families in their homes, children at schools and kindergartens, young people at university and workers and businesspeople at their workplaces, where the focus will be on the prevention of work-related accidents and deaths.
  6. So, the pillars of the Candidate’s public health policy are as follows:
    1. Comprehensive, universal prenatal and infant care.
    2. Zero deaths from hunger, combatting obesity and excess weight, a tax on sugary drinks and the promotion of the healthy food industry.
    3. Proper, comprehensive care for the victims of armed conflict.
    4. A reduction in pollution and improvement in the quality of water, air and food. Greater regulation of the use of toxic substances such as asbestos, mercury, lead and others.
    5. Prevention and comprehensive care for drug users with a focus on reducing the damage through strategies such as mobile centers to combat drug addiction.
  7. Healthcare services would be provided by a public-private network. Primary care will be provided by public hospitals in their different jurisdictions across the country with a focus on primary care and prevention, registration of the population, problem-solving, participation and technological advances. Medium and high complexity healthcare services shall be provided by both public and private hospitals.
  8. Public spending will finance all provision not excluded by the law: services covered by public financing will be all those that aren’t excluded by as provisions according to Statutory Law 1751 and thus there will be no administrative restrictions for any group of healthcare technology that has not been specifically excluded.
  9. Quality, equitable healthcare training: healthcare training at all levels and in every area will be strengthened to match general international medical indicators in specialties, nursing, dentistry and other areas both on average and in terms of equitable distribution across the country.
  10. Quality medications with universal access at a fair cost to the country: regulation and price controls will be increased, the declaration of public interest for the issuing of obligatory licenses, the use of ADPIC flexibility, revision of TLCs, public incentives for research and development of medications, rational use based on cost-benefit analysis, good practice, strict monitoring of drugs and the availability of information.

To ensure rational spending, all the existing tools for the improvement of quality, opportunity, medical autonomy, satisfaction, comprehensiveness, scientific certification and positive cost-benefit relationships will be maintained.

Conclusions and issues not addressed by the Candidate’s program  

The healthcare program of Candidate Petro is clearly opposed to the healthcare insurance model of structured pluralism that has existed in Colombia for the past 25 years.

If it is implemented, a major reform of the Colombian healthcare system would be required with unpredictable consequences. The main concerns are related to the legal mechanisms and financial resources that Gustavo Petro has available to bring about this reform. In addition, apart from announcing the creation of a national health system, like Candidate Duque, Petro does not address the issue of structural fiscal sustainability faced by the healthcare sector, and it is not clear where the resources will come from to pay for the healthcare system’s current debts.

In conclusion:

  1. Candidate Petro’s program proposes a comprehensive reform of the healthcare system with a switch to a completely different model. This generates uncertainty about the consequences of said reform but also how it will take place and where the necessary resources will come from.
  2. The proposal to create a national, highly de-centralized healthcare system aims to resolve the issues of efficiency, transactions and quality that the current model has been unable to resolve through competition between insurance providers but also may generate greater inefficiencies and, more worryingly, greater corruption given the history of public administration in Colombia.
  3. It is notable that Candidate Petro has made a priority of the need to improve the working conditions of healthcare workers and the strengthening of the public hospital network in his public agenda.
  4. The healthcare program places a special emphasis on controlling the price of healthcare technologies through strong regulatory mechanisms such as the declaration of public health interest. This could generate tension with the pharmaceutical industry and possibly raise barriers to entry for innovative technologies within the country.
  5. The proposal to eliminate insurers (EPS and ARL) is a very significant reform of the entire Colombian social security system, requiring i) significant political support, ii) a complex legal framework, iii) the financial resources to pay off accumulated debt, and iv) the creation of an enormous administration apparatus by the state, which currently does not exist. All this reduces the feasibility of the proposal, at least in the short term. The implications for the pharmaceutical industry are uncertain as the new healthcare system would have to develop a contractual and operational model for the acquisition, distribution and delivery of medications and medical devices. Given what has been observed of the Mayoral Administration of Bogotá, the unsettling prospect arises of significant trauma to pharmaceutical companies and reduced access for patients.
  6. Finally, the proposal for the unrestricted public financing of healthcare technologies not excluded by the Statutory Healthcare Law leaves open questions about the availability of financial resources to ensure existing provisions and especially would seem to contradict recent rulings by the Constitutional Court regarding the contributions of members to the healthcare system, limiting state subsidies in relation to their ability to pay.