Alejandro Gaviria Uribe, Colombia’s minister of health and social protection, discusses the implementation of the Statutory Health Law, bridging the gap between healthcare coverage and access to healthcare, and the strategic priorities of the Ministry moving forward.
In our 2013 interview, your overarching sentiment was that the healthcare landscape was in a paradoxical time: indeed, as much as the sector was tired of reforms, it was demanding reforms at the same time. Your hope was for the then-upcoming reforms to be known as THE Reform – do you believe that the Statutory Health Law achieved his notoriety?
“Legal reforms are done with, implementation is now the name of the game.”
Yes, but not completely. My view now is that the system does not need another legal reform and that, with the Statutory Law and other minor laws that were approved during the past few years, we have already put in place all the required legal tools. In my public speeches, I like to use an expression, “legal reforms are done with, implementation is now the name of the game.” But some disagree. The private providers, for example, are asking for a big overhaul to the system.
One of the greatest challenges of the Statutory Health Law was its incompatibility with the POS (also known as the Benefits Plan), which ultimately created a greater financial burden on the system. How will the recent abolition of the POS advance the financial sustainability of the system?
I would not say that the POS was abolished, this can be a bit misleading. I would say that we now have a package of benefits that has two parts: a core, defined on an epidemiological and actuarial basis, that includes essential medicines and the most common procedures, and a complement, based on individual needs, that comprises new medicines and new procedures. In my opinion, the Statutory Law allowed us to give some order to a complex and chaotic situation. In the past, the judiciary defined the coverage of our system without clear criteria and with adverse financial implications.
What are the current measures under discussion as a viable alternative for the POS?
I will mention two measures. First, a formal procedure to exclude medicines that are either not effective or do not have much evidence of their effectiveness. This procedure was mandated by the Statutory Law. And second, the implementation of a new web-based application that allows doctors to prescribe medicines that are not in the core package of benefits but that, according to the prescriber, are required. This is also part of the implementation of the Statutory Law.
One of the reoccurring themes from the interviews we have conducted thus far is that while the Colombian healthcare system takes pride in its universal coverage (97 percent of the population), coverage does not necessarily equate to access. What are some of the measures to reconcile the gap between coverage and access in Colombia?
Coverage does not equate to access, but coverage increases access. There are many studies showing, in the case of Colombia, the causal link between greater coverage and greater access. Having said that, we must recognize that in rural and remote areas, access is a big challenge. We are implementing a new model that emphasizes the supply-side of the equation (public infrastructure, family doctors, primary care, etc.) in some of the remotest provinces of Colombia.
In June 2016, you signed a controversial decree declaring a drug as public interest. How has this been received by the key players in the healthcare sector?
It was controversial. As expected, it was saluted by some and denigrated by others. It was a difficult process, full of controversy and political pressures. Clearly this type of measure is not a substitute for price controls or traditional regulatory policies. They are exceptional and difficult to implement, but countries should be allowed to use them.
This year, Minister of Industry, Commerce and Tourism Maria Claudia Lacouture passed a decree modifying the conditions in which a drug can be declared as public interest. What do you believe is an optimal measure to achieve equilibrium between protecting the commercial interests of pharma companies while creating efficiencies in the healthcare system?
The decree made a small change: The Ministries of Industry and Planning can now participate in the technical studies that precede the declaration of public interest. Next time around there will be more internal controversy, no doubt about that. In general, it is difficult to find an equilibrium between commercial interests and sustainability, especially in judicialized system with an empowered citizenry. Our pharmaceutical policy, that combines price controls, biosimilar competition, HTA, and centralized bargaining, seeks just that.
Rafael Pineros mentioned to us that one of the key priorities in the sector is to find new sources of funding. How can this be achieved given the reality of the Colombian healthcare landscape today?
I agree. This is a key priority. We have had partial successes in that regard. The latest tax reform, approved by Congress last December, secured new sources of funding: half a percentage point of the national VAT tax and the entire revenue produced by the new tobacco tax, all in all, half a billion dollars annually. But we are not satisfied. This is an ongoing battle. In the next few years, the system will need additional sources of funding.
Our last report from Colombia was titled ‘Confidence in Uncertainty.’ You concluded your interview with the sentiment that your ultimate goal is to create more confidence with the stakeholders in the system. How do you believe you have achieved this goal?
Confidence is much higher than it was a few years ago, but we have a long way to go. The political economy is still complicated. Many agents have a zero-sum mentality. The financial troubles still loom large. But I am confident that the worst is behind us, and that the Colombian system will be an example for the region and a source of pride for the country.
How would you describe an optimal Colombian healthcare system?
A system that eliminates the regional and socioeconomic inequalities in outcomes and access, that is sustainable (i.e., it is based on a coherent social contract) and that is appreciated by the public at large. This is not easy. But we have the foundations in place already.
What are your strategic priorities for the Ministry moving forward?
My main priorities are the sustainability of the system, the implementation of the pharmaceutical policy and a new model of rural health for post-conflict areas.