Colombia's health reforms: Shock Treatment

President Uribe tries to push through some much-needed changes

AS ALLIES of Barack Obama seek procedural tricks to slip his health reforms through a truculent Congress, his Colombian counterpart, Álvaro Uribe, is not bothering with such niceties. He has simply issued a set of decrees ordering a much-needed but equally controversial shake-up of his country’s health service. The Constitutional Court, whose earlier rulings have added greatly to the health system’s financial stresses, is examining the decrees. Mr Uribe has begun negotiating with doctors and other opponents over how they are implemented—but he remains determined to see them through.

There is little argument over the need to close the big deficit in the health service’s budget. Mr Uribe’s decrees include an increase in taxes on alcohol, cigarettes and gambling, and measures to cut losses from corruption and bureaucracy. But his critics accuse him of taking advantage of this financial emergency to make more profound changes to the way health care is provided, and with little public debate.

Doctors are especially angry at a decree limiting their autonomy to prescribe the best treatment for patients. Along similar lines to reforms introduced in Britain in the 1990s, it seeks to introduce a list of approved drugs and treatments. However, Mr Uribe at first sought to go further and impose fines of up to $13,000 for doctors who prescribe beyond what the list allows. Their strong objections prompted him to backtrack and promise that the new treatment standards will be only advisory, except in certain cases.

Another controversial decree, although unobjectionable in its fundamental aim, would equalise the benefits provided by Colombia’s two parallel health systems. In one of these, salaried workers and the self-employed have to contribute 12% of their earnings to health plans run by managed-care organisations similar to those in the United States. The poor and unemployed get care from a second, subsidised system with fewer benefits and generally deficient service. A study in 2008 found that a quarter of those supposedly covered by the subsidised regime did not receive medical attention when they needed it.

Things were set up so that the premiums paid by those in the contributory system would eventually generate a surplus sufficient to subsidise the system for the poor. But this was based on over-optimistic forecasts that unemployment would remain in single digits (it hit 12% in 2009) and the economy would grow by about 5% (economists expect 2.5% growth this year). Since the new taxes seem unlikely to raise enough money to fix the financial hole, the worry was that “equalising” the two systems would mean worsening the contributory system, not improving the subsidised one. Mr Uribe now says he is prepared to delay implementing this part of the reform if that is what it takes to maintain standards of care.

Besides the challenge in the Constitutional Court, Mr Uribe faces an attempt by two senators to block his reforms with a “patients’ bill of rights”. Trade unions are also planning to protest against them. The minister for social protection, Diego Palacio, says the president’s decrees have been “misunderstood”. But as Mr Obama could tell him, any health reform worth passing inevitably involves a struggle.