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Jeopardizing legitimacy and health policy implementation by excluding essential health reform stakeholders: A case from Colombia

Jeopardizing legitimacy and health policy implementation by excluding essential health reform stakeholders: A case from Colombia

By Cesar Vargas
on March 31, 2023

Last year, on June 19, Colombia elected its first leftist president, committed to sustainable peace and tackling social and economic inequality and corruption, in a historic result. The stewardship of the country’s health system, headed by the Ministry of Health (MoH), was henceforth going to be presided over by civil and political forces rooted in health activism. With the anti-establishment wave came the hope that ‘action on behalf of the causes of health equity, accessibility, and quality of care’ would be for everyone, starting with a reform of the country’s health policy.

But history is not going as expected. The hope for deepening participatory democracy in health and health equity, through an open and inclusive policymaking process, has been fading as many (crucial) stakeholders are currently being “left behind”. Indeed, unlike what was expected,  radical action seems to be lacking “for people, even patients, to gain a ‘voice’ and to have influence”.

But let’s first briefly introduce the Colombian health system before digging into the criticisms of the reform process.

The Colombian healthcare system is a mixed one, based on a ‘structured pluralism’ model. Among others, it features a combination of public and private financing; Health Promoting Entities (as per translation from Spanish), who manage the resources acting like insurance intermediaries; and medical and health services provision by public and private providers. The system serves just over 50 million people and has, since its implementation 30 years ago, made substantial progress in terms of performance, mainly by achieving Universal Health Coverage (99.6 %), at least officially, including financial risk protection (OOP: 15 %), and even coverage for the migrant population, to mention a few achievements. Despite these positive aspects, there are also challenges that need to be addressed. Access to healthcare services is not equitable, particularly in rural regions, leading to legal disputes, and service fragmentation. All these  are major worries for a big part of the population.

The health reform bill was filed on February 13 of this year with a  full of symbolism. The changes include the intention to transition toward a system in which the state manages the financial resources of health (with an average health expenditure per capita of 495 USD) instead of health insurers. In addition, lay the foundations for a primary health care system with a territorial rather than a population-based approach, reconfigure the labor relations for health workers & their employers, strengthen public policies around the social determinants of health (SDoH) and build a public online information system.

Whereas these are well-intentioned plans, as we all know even well-intentioned plans sometimes go wrong. Among others, the proposal is being criticized for its insufficient explanation of how the state will assume the management of resources without increased risk of corruption or how it will address the risk management of the population efficiently. But in this article, I want to highlight how the ones steering the system reform have been viewing stakeholder engagement, more or less throughout the policy-making cycle (starting with the problem identification), as a nuisance. This, in my opinion, jeopardizes the possibility of implementing necessary structural changes for achieving equity in health and social justice within the Colombian healthcare system. 

Stakeholder engagement implies “the practice of involving members of the public in the process of policymaking.” Although it is a complex process, it is considered an essential part of democracy to enhance transparency, accountability, and societal trust. It is expected to be inclusive (in terms of stakeholder group participants) as well as comprehensive (i.e. throughout the policy development cycle) to enable effective implementation of policies. At least three components of stakeholder engagement have been recognized: 1) public communication; 2) public consultation; and 3) public participation. All three have been insufficient in this case, I reckon. 

There is no reform in [Colombia’s] republican history that has been discussed more than the health reform”,  said the minister in a public speech. Discussed, yes, but as a proposal within an electoral process instead of as a public, democratic public policy. What has been seen is that after months (perhaps years) of engaging with a few preferred stakeholders, the content of the health care reform bill was made public only after having already been substantially developed. Meanwhile, a few stakeholder groups not close to the government were demanding to have their voices heard, but largely overlooked. Among others, patient associations, payers, scientific associations, some hospital associations, minoritarian communities and product makers.

In order to overcome this kind of tokenistic involvement, àll stakeholders, certainly including patients and communities, need to be able to influence the substance of the health policy instead of feeling that their contributions are being disregarded.  

To gain legitimacy, as a steward, the current health’s government, rooted in health activism, should recognize that grassroots pressure groups “from the others” can genuinely advocate against their reform attempts and (also be) in favor of health equity. They should not be treated merely as instrumental actors from alleged opponents, as have been said off-camera by the MoH.

The author wishes to acknowledge the kind editorial support of Kristof Decoster and Radhika Arora. 

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