'With Decree 0885, patients will face more access barriers': Augusto Galán

Former Health Minister and director of the Así Vamos en Salud think tank, Augusto Galán, lays bare President Petro's figures regarding his administration's three-year balance. Regarding the recently issued health reform decree , he states that experts are viewing more than ten points with concern.

How much truth is there in President Petro's health figures?

They are inaccurate and insufficient. Inaccurate because they are biased, contain half-truths, lack context, and lack traceability over time, which is very important for health indicators. Mortality due to malnutrition in children under 5 and perinatal mortality, for example, have been declining for 20 years thanks to sustained efforts by several governments. And the figures are insufficient because they do not present all the public health data. For example, they do not mention dengue fever figures, which reached the highest peak of cases in the historical record in 2024, with more than 320,000 people affected and nearly 3,000 cases classified as severe, potentially fatal.

How do you combat dengue?

With vector management. Climate change, particularly the El Niño phenomenon, does indeed have an impact, and possibly for those reasons it has worsened. However, vector control of the Aedes aegypti mosquito, the same mosquito that causes yellow fever, is needed. A declaration of a health emergency would have been required this year, because 93 cases is practically quadruple the number recorded in 2024. Based on the number we have in the series since 2010, which is official data, in many years there were zero cases of yellow fever. Nor did they present data on the number of tuberculosis patients, which increased by 6 percent in 2024 compared to the previous year.

But isn't tuberculosis supposed to be a preventable and curable disease?

It's re-emerging not only in Colombia, but around the world. It's a public health issue possibly related to the indiscriminate use of antibiotics, but it also has other causes related to poverty and overcrowding, for example, in prisons. Tuberculosis is highly contagious. He also didn't mention anything about AIDS.

They're changing the healthcare system model without adequate legal support. The only way to do this is with legal support. But they're bypassing Congress and violating several legal provisions.

And what is the AIDS situation?

There has been an increase in infections among young people in large urban centers. Nor does it mention that congenital syphilis and gestational syphilis remain an unacceptable scourge, with more than 9,000 cases expected in 2024. There hasn't been a significant decline in this regard, and these two figures are still preliminary. It doesn't mention, for example, that in 2024, nearly 2,000 women died from cervical cancer, which is preventable and avoidable with the human papillomavirus vaccine; but that vaccine coverage is below 60 percent, when it should be at least 90 percent, according to the World Health Organization's recommendation. And even less does it mention that the Ministry of Health or the National Institute of Health do not have updated vaccination records for measles, rubella, whooping cough, and hepatitis B, very important indicators of the country's public health situation. In the case of whooping cough, for example, cases have increased substantially in the country in the last year.

Can this delay in data be attributed to this government?

Well, that data was up-to-date; it was included in the country's vaccination plan, a very old program that had and continues to have permanent records that must be updated, because they are leading indicators worldwide in the area of vaccination.

I would like you to help us with your clarity, Dr. Augusto, to list the risks involved in this health reform that the government has begun to implement by decree.

Not only the group of former health ministers but also various stakeholders and agents in the health system generally view 10 or 11 points of concern. The first is that this decree, 0885, does not resolve the crisis facing the health system today; it does not address the requirements of the Constitutional Court regarding adequate financing of the health system; it also fails to heed the calls of the Comptroller's Office; and it does not validate the modifications that should be made to the calculation and methodology of the Per Capita Payment Unit to achieve more adequate financing.

So access to healthcare is going to continue to become more complicated, as is the availability of medicines?

Correct. There are several aspects to this. For example, it changes the healthcare system model without adequate legal support. The only way to do this is with legal support. But they bypass Congress and violate several legal provisions, such as Law 100, Law 1122, Law 1438, and the Statutory Law itself: we'll see what the Council of State says.

It does not expressly eliminate the EPS...

But it dilutes their functions as comprehensive risk managers and as the sole responsible for insurance, as is the case with the current model, and transfers these key functions to territorial entities, health secretariats, comprehensive territorial health networks, and the CAPs. In other words, it undermines the insurance model, which achieved universal coverage, financial protection, and comprehensive care for three decades.

The abrupt transition, with the decree coming into effect but lacking clarity about precise rules of the game and clear implementation, will generate a lot of confusion, and patients will be affected.

Dismantle the system, which could be improved, but it worked...

Absolutely. And the notion of a single person responsible for the patient is lost. Thus, there are multiple actors sharing functions that previously held the EPSs; there are the territorial entities, the networks, the committees they create, the providers. The EPSs are left with auxiliary functions and community teams. Users, citizens, and patients will face greater lack of coordination and more access barriers. Patients will be left without knowing who to turn to or who is responsible for their care. Because citizens will have to remain affiliated with the EPS and be registered as citizens in a mandatory health insurance program (Caps). But who is responsible for the patient's medical history? The health insurance programs? The EPSs? The Ministry of Health? Adres? The patient is scattered among several responsible parties.

It seems like an improvised transition...

Yes, because for now there are no rules or resources. The decree takes effect immediately, but its effective implementation depends on multiple future regulatory acts. This obviously creates institutional uncertainty, contractual and financial modifications that can paralyze or significantly modify the operations of providers and networks while regulations are defined.

If today, after the health decree, a citizen falls ill, what's the first thing they should do? Go to a Caps?

Not immediately, as the EPSs continue to operate. This decree is missing other decrees. So the abrupt transition, when the decree comes into effect, but with no clear rules of the game and clear implementation, will generate a lot of confusion, and patients will be affected, as, furthermore, they don't have a clear and operational route in this decree. How will this referral be? Will there be continuity of care? This uncertainty obviously jeopardizes timely patient care.

In other words, they dismantled our healthcare system by decree, but we still don't know how the new system will work...

Exactly. They're proposing other decrees and are circulating draft amendments that we're analyzing, but even though they're sending them for consultation, they don't address comments or suggestions. In the end, what will happen with the first decree will happen, and they approved it as it was. Despite the fact that several organizations, including us, had comments. But nothing was taken into account.

And how will that be, territorially speaking?

The organization of networks and the leadership of the model will primarily be the responsibility of the territorial health secretariats; however, this does not strengthen their capacities, neither financial nor technical.

Exactly. Another concern is the increased risk of territorial inequality, because the technical and financial capacities of many territories do not allow them to do what they are supposed to do.

I insist: prevention is important, but to improve quality of life, not to reduce the costs of a health system.

As they say, they're going to give mayors and governors a huge amount of money, who, traditionally, especially in small municipalities, have had very poor management of public finances. And they're going to give them responsibilities that who knows if they'll be able to handle, because they don't know what the issue is...

This point is very important because it takes us back to the way state resources were allocated before Law 100 in 1993, when public hospitals and health centers were allocated resources based on historical budgets. If the director of a hospital, clinic, or health center had a surplus budget, they would cut the following year's budget because they supposedly needed less. And for this whole predictive model issue, they're going to divert resources that are meant for providing care for chronic diseases and other conditions to preventative care, which will be inefficient, according to the way they're presenting it.

Another gap could widen between those who can afford private insurance or prepaid medicine and those who can't, who are condemned to remain tied to a health insurance company that will no longer take responsibility for the patient. No one opposes incentivizing preventive medicine, but it should coexist with efficient care for the treatment of ongoing illnesses...

Well, one of the great achievements of Law 100, over the years, was a transformation in that regard. Before 1993, 57 pesos for every 100 pesos were spent to cover 17 percent of the population. Thirty pesos of every 100 pesos covered 23 percent of the population with social security, primarily people who paid contributions but didn't cover their entire families. And the remaining 100 pesos, or 13 pesos, remained so that the public system, the public subsystem, could cover 60 percent of the population. That was transformed with Law 100, leading to a scenario in which 76 percent of funding is direct public spending or social security: that covers 99 percent of the population affiliated with the general system. And private spending was reduced from 57 pesos to 24. In the case of out-of-pocket spending, it dropped from 43 pesos to 15. This is the financial protection that the health system has achieved over these 30 years. They are putting that at risk. And we are already beginning to see an increase in the purchase of private services and a significant increase in out-of-pocket spending among the population. There are studies that are beginning to show how private insurance is growing by 18 percent. Prevention and promotion have always been carried out; they certainly need to be strengthened further, but with clarity about what they are for, which is the well-being of the population. But not to reduce the costs of a health system, much less when the population, a very important Colombian social achievement, has aged to today's levels. And, of course, chronic diseases have emerged more strongly—cancer, coronary heart disease, diabetes, hypertension, etc.—because they are part of the natural aging process, and that will continue to cost the health system. I insist: prevention is important, but to improve quality of life, not to reduce the costs of a health system.

According to President Petro, it's a lie that Colombia has, or at least used to have, one of the best healthcare systems on the continent...

There is no perfect health system in the world. Problems evolve because the social conditions of populations change. The Colombian system (they don't like us to say this, but it's a reality) has long been internationally recognized for achieving universal coverage in such a short time, as well as for its equity and solidarity, and for its efficient management of resources compared to other countries. In the Colombian health system, we offer and deliver a benefits plan equivalent to that of most European countries: there, the average annual per capita spending is $4,000, and we're barely reaching $1,000, but we offer a very similar benefits plan, competitive with theirs. So, no health system is perfect, but the Colombian one has been recognized not only in Latin American countries. Even Mexicans have told me: How is it possible that you want to end what we want to do in Mexico? I was told this several years ago, and it's been repeated recently, given everything that's happening. So, yes, it's absurd, and it's an ideological issue, unfortunately. Let's see if we can minimize the damage caused to the health system.