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TOWARDS A NEW HEALTH MODEL:
BECAUSE WE COLOMBIANS ARE ENTITLED TO TIMELY AND QUALITY HEALTH SERVICES

Why is health reform needed?


Symptoms
•    Negative perception, distrust and lack of legitimacy in the system
•    Denial of services and access barriers
•    Problems with flow of resources


Causes
•    Disorderly growth of service coverage: increase of Services Not Included in the Mandatory Health Plan generated financial imbalance
•    Coverage increased, but it was unfunded:
•    Growth of local authority debt
•    Leveling of benefit plans without proper leveling of Capitation Payment Unit (UPC)
•    Crisis of the Health Promotion Entities (EPS): Coverage fell on many dubious quality Health Promotion Entities
•    Only now, Law 100 of 1993 entered full operation
¥    Market conditions were fully established with the increase of coverage and leveling of benefit plans
¥    It occurs at a time of liquidation of Health Promotion Entities and formalization requirements


Structural problems
¥    Operating: flaws in the flow of information and resources, and problems with corruption and transparency
¥    Lack of definition of the core of the fundamental right to health
¥    Incentives: there are no incentives for risk management, and supervision and control have been insufficient
¥    Offer: shortage of specialists, lack of beds and lack of response capacity of the first levels
¥    Decentralization and resources: formalization, fees, medicine and debt and structural deficit of State Social Enterprises (ESE)  

What it is: Statutory Law
With the Statutory Law, the what of the right to health is defined; that is, it establishes the framework that will help improve the health of Colombians.

This is the first statutory law issued in the country on social rights as of the Constitution of 1991.

The essence of the statutory law is that the fundamental right to health to which all Colombians are entitled is defined and ensured.

Among the items that can be highlighted are that the Statutory Law:
¥    Contains essential elements and principles with the clear purpose of guiding the interpretation and scope of the fundamental right to health.
¥    Provides that the Colombian State is responsible for respecting, protecting and ensuring the full enjoyment of the fundamental right to health.
¥    Regulates the rights and duties necessary for the full exercise of the fundamental right to health.
¥    States the right of people to participate in the decisions made by the agents of the health system that affect or interest them.
¥    Provides that health services should be fully provided, independent of the origin of the disease or health condition.
¥    Recognizes financing by the state of social determinants of health (that is, the circumstances in which people are born, grow, live, work and age), with resources other than those of health. However, for cases which affect or put the health of a community at serious risk, resources of the health system may be used.
¥    Protects access to health services by prohibiting the authorization for service.
¥    Ensures through an implicit Health Plan for all persons, the provision of services and technologies. This plan will be structured on a holistic concept of health, including promotion, prevention and care of illness and rehabilitation of its consequences. In no case may the Health Plan be interpreted as restricting the scope of the right.
¥    Services or technologies that do not meet the scientific or requirement criteria will be explicitly excluded by the competent authority, after a technical-scientific, public, collective, participatory and transparent process. In any case, the criteria of independent high level experts, of professional associations of the relevant specialty and patients that would potentially be affected by the exclusion decision should be assessed and considered. The decisions of exclusion should not result in the fragmentation of a previously covered health service or be contrary to the principle of integrity.
¥    Ensures the prompt resolution of conflict or discrepancies, through medical boards of the health care providers or medical boards of the network of health service providers.
¥    Respects medical autonomy and promotes self-regulation. Also, health professionals should contribute by participating in collective decisions of the Health System.

The how: Ordinary Law

Bill 210 of 2013
 The Ordinary Law defines the how, that is, it defines the stakeholders and the rules under which the health system will operate.

This bill aims for Colombians to have timely health service, with quality, and to regain trust in the health system.

It proposes a simpler and more efficient model, where no one is denied health services; it ends financial intermediation; and is more transparent.

The new model must continue the achievements of Law 100:

The draft Ordinary Law submitted to Congress maintains the achievements of Law 100: Health coverage for all Colombians and household financial protection so that no one will fall into poverty when suffering from a disease.


Four packages of measures to solve the main problems of the health system
1. To define the right to health and improve coverage
Mi-Plan: It will be a comprehensive benefits plan that will progressively move towards the inclusion of collection technologies and it will include all diseases.

This way, more coverage, quality and continuity of health services will be ensured. It will also not be necessary to resort to action for the protection of rights, or to technical and scientific committees to demand rendering of services.

With Mi-Plan, the potential of drugs which citizens can access will be greater, therefore people will not have the need for additional paperwork in order to receive treatments and medications.

Drugs, treatment and health service on the exclusion list will be those that are not approved for use in the country: those whose primary function is cosmetic or luxury; complementary treatments aimed not at the diagnosis or cure of a disease; which are not rated as health services or technologies by a competent authority; or for which there is no technical or scientific evidence of safety and efficacy or clinical relevance.

For health resources to suffice in financing Mi-Plan, the Ministry of Health and Social Protection will strictly control drug prices, applying the National Pharmaceutical Policy and tools.

2. To solve operational problems
Salud-Mía: a public entity to enroll in the system, and collect and distribute resources, under strict controls. With Salud-Mía, people will trust that health resources will be invested in their health.

Salud-Mia will be under the supervision and control of the Financial Superintendence of Colombia, ensuring transparency in the management of resources.

It will collect, manage and transfer public health resources; that is, $ 26 trillion pesos from 16 funding sources that include contributions from the Contributory System, resources of the National Budget and of payroll and other taxes for health.

With Salud Mía collection processes will be streamlined, the flow of resources will be improved, there will be direct control, and operation costs of the system will be greatly reduced.

Salud-Mia will promptly and directly pay health service providers and suppliers.

Salud-Mia will deliver a robust information system to ensure that health resources efficiently reach citizens.

Likewise, it will be easier for citizens to switch between Health Promotion Entities.

Health Service Managers

Health Service Managers (GES) will accompany people through the health system and will not handle money. Thus, they will respond and will be measured by the health of their members and not by resources. With the managers, the health system will be closer to the people.

Managers will be held accountable for the health of their members, so they must focus on their dependents being sick less, through promotion and prevention activities, and those who are ill receive appropriate, timely treatment and continuously, in order to recover their health.

Part of their remuneration will depend on their health outcomes.

Each manager will be assigned to an area of health management with a minimum number of members to ensure sustainability.

Health Service Managers will form networks of Health Service Providers to ensure timely care in the areas of Management.

They may not integrate vertically, that is, that managers may not own points of health service delivery.

They can operate both systems (contributory and subsidized) and may be public, private or mixed, provided they meet the requirements set by the Government:

Local Entities may be managers if they meet the requirements.

The Health Promotion Entities that are current in their obligations to hospitals and satisfy strict requirements (qualification) may become Health Service Managers.

The National Health Superintendence is responsible for monitoring and control of the Health Service Managers, for which more and better control tools will be delivered.


Service provision
People will not have to travel far to receive the comprehensive and continuous care they need, because the health system will be closer.

Public health and individual health
The provision of health service includes public health actions and individual benefits.

Public health actions will be the responsibility of the Local Authorities (Offices of Governors and Mayors). Individual actions will be the responsibility of Health Service Managers (GES) and they are those referred to in Mi-Plan.

Emphasis on local provision

The proposed Health model emphasizes local provision because it includes Health Management Areas where the Health Service Managers and their network of service providers will operate, ensuring that all the services and technologies included in Mi-Plan can be provided. Patients should be moved to other areas for provision of service only for highly complex procedures that are not available in all regions.

This new organization will end the current problem of patients having to go from one region to another to receive part of a treatment that the Health Promotion Entity cannot provide near the patient.




For areas with special geographical and social conditions, there will be a model of differential attention, to guarantee the proper provision of services.

 

Emphasis on care

Service provision will emphasize the care of people. Like the Health Service Managers, providers will be measured by health outcomes so they will improve performance in health promotion, disease prevention and quality of care.

Similarly, the Health Service Managers will form their networks with providers who will present health outcomes.

Strengthening of Public Hospitals (State Social Enterprises, ESE)


Managers or directors of State Social Enterprises (ESE) shall be appointed by the Local Authorities (governors and mayors); they shall be appointed and removed freely and they will have to pass a qualifying examination by a national authority.

So, the mayors and governors will be accountable for the good administration of public hospitals.

The Boards of Directors of State Social Enterprises will have terms of three years and the members may not be reelected. They will be formed by the head of the province, district or municipal government, the health director of the local agency, a representative of beneficiaries and two representatives of public employees of the institution, democratically elected.

Likewise, the Ministry of Health is granted extraordinary powers to issue rules on the labor system of the State Social Enterprises (ESE).


3. To improve health service offerings
Train more specialists for areas where they are needed: It is necessary to increase the number and distribution of physicians and specialists. The proposal is to work in coordination with the Ministry of Education and universities to create more places in the specialties that the country needs, and a single system for physician access to the quotas for medical specialist training that is fair and transparent.

Support medical residents: The National Board of Medical Residency will be created and working conditions of the residents will be improved with the support of monthly educational aid of no less than two minimum wages in force.
 
New employment regulation will be created for workers in public hospitals (State Social Enterprises, ESE), for which special powers are being requested. This statute will define job classification, the procedure for hiring and removal and overall labor regime for public servants that provide services in the State Social Enterprises at the national and local level, in order to ensure quality, humanization and efficiency in the provision of public health and make the social enterprises of the state sustainable.

4. To solve the financial crisis in the sector:
Clear debt: The Health Service Providers (IPS), the Health Promotion Entities (EPS) and local authorities must correct, conciliate and pay their debts.

The surplus of the General Revenue Sharing System will be used for the payment of debts and fiscal and financial clearing of the State Social Enterprises.

Mechanisms to buy portfolio and provide guarantees will also created.

Create a Guarantee Fund for the health sector

Salud-Mia will have a fund for the administration of the financial mechanisms necessary to preserve the financial sustainability of the Social Security System in Health.

This fund will help the Managers of Health Services and Health Service Providers have sufficient liquidity to ensure continuity of service delivery; to strengthen them in capital, so that they can access credit and financing; to support them financially in processes of intervention, liquidation or reorganization; or to buy or assign portfolio.

Not a single day without health

While the draft ordinary law is discussed and the new model is implemented (2 years), Colombians will remain protected by the current health system, without stopping health service provision, even for a single day.