A Better Understanding of Reasons for the Failure of the Healthcare Reform in Colombia

The Colombian healthcare crisis is evidenced by obstacles to health service, diminished working conditions and medical autonomy, financial infeasibility, loss of leadership and legitimacy of the healthcare system. In the year 2013 twelve reform projects were presented to Congress, including a statutory law that defines health as a fundamental right which was approved and another ordinary one which sought a complete reform of the system but was rejected and criticized by different opinion leaders. For this study we have made an adaptation to Q methodology, which assigns quantitative values to the most frequent statement variables obtained from secondary sources (norms, articles, media, forums) giving objective information about the diverse positions in the proposals to healthcare reform. We analyzed from the most objective position and from academic independence the different views of the opinion leaders for a better understanding of the reasons for this failure in healthcare reform. There was a great polarization in the diverse statements which made an agreement with the government unlikely and, when added to a political moment in which the presidential election was being held, made the new reform non-viable. Although there is an agreement about the existence of a crisis, this has not been the case about the analysis of its causes or solutions. At the present time, the government is not presenting a new reform proposal and is focusing on some decree to create a model of healthcare in rural zones, define financial conditions for the EPSes (health providers), update norms for membership in a healthcare system and regulate biotechnological drugs. Even though to date there have been no opinions, plus taking into account the previous analysis, it is very possible there will be much criticism from those who demand a structural change in the system.


Introduction
The 1993 reform caused a great "big bang" in the Colombian healthcare system, based on structure pluralism.Its goal was universal insurance and participation of public and private service with regulated competition.
From the moment healthcare changed, there were benefits for the population such as increased coverage, diminished individual spending, better insurance equity and a small increase in prevention and promotion [1].
The crisis which has been increasing is manifested by barriers to the healthcare service because of the act of being insured.This does not imply access to healthcare service and even less to high quality service [2], deleterious labor conditions and medical autonomy with inconformity and diminishing quality of attention from the healthcare professionals.Financial crisis-as assured by the Health Minister-is caused by increased affiliations to the subsidy scheme (those who don't contribute), increased money recovery from the state, the fact that although the benefit plan is equal, the value per capita paid by the general system of health (Social Security) to each EPS is not equal [3] and finally the lost of legitimacy in the system and leadership by the Ministry of Health.
In 2013 Congress received twelve reform projects, including a statutory law and an ordinary law from the Ministry of Health.Of the twelve projects only the statutory law that defines health as a fundamental right was approved.The ordinary law included four great proposals consisting of a unique fund which would administer the total resources of the health system "Salud Mia", one sole benefit plan for the entire population "Mi Plan", the "Gestores" (health services providers) which would be the organizations in charge of healthcare and assessing citizens in the use of the health systems and a new system for organizing the services offered by areas of sanitary conduct [4].This total reform of the system was subject to strong criticism by the different opinion leaders and even though it was subject to various changes in searching for the necessary agreements, the critics continued and influenced directly or indirectly the rejection by Congress.
It is important to analyze from the most objective point of view and from the independence possible in academic work the different positions of the opinion leaders in order to understand correctly the reason for this failure and the next possible step to overcome the crisis.

Research Design
The data were collected using the methodology Q adaptation that assigns quantitative values to the most frequent variables of opinion.
There was a search based on secondary sources (articles, views, newspapers, magazines, forum), in the period from June to December 2013.From there, different statements were extracted which give objective information about the propositions for health reform.Initially, a first evaluator made the extraction of a total of 74 statements given by six different actors.

Sample
For defining the sample a second evaluator performed a new revision of the different statements and after filtering repeated opinions of those which didn't give enough information about what was being evaluated, 30 statements were obtained.

Procedure
The opinion leaders were clustered in six different groups, health providers (physician and other personnel), civil society (associations and representatives of the society), media, government, insurance companies (for this study the name insurance companies represents EAPB and similar for a better comprehension by the reader) and users (patient associations).
Four different variables were created which evaluate objectively each one of the 30 statements in the sample.As such, the four variables for the analysis of each one of the statements were closeness to the government reform, partial critics to the reform, unity between members of the same point of view, and changes in opinion.

Analysis of Data
Each one of the variables was evaluated by the authors with a score from −3 to +3.Afterwards, the significance

Results
A total of 40 different documents were analyzed which resulted in finding 74 statements of which 30 were selected.It was seen that the majority of the actors distanced themselves from the government, criticizing partial aspects of the reform with disagreements inside the representative's (or representatives'?) points of view with a tendency to polarize their opinions.The users represented mainly by the patients associations distanced themselves from the start from the reform project presenting strong criticism and concern for the future of their health.The main concern is their access to specialists and the high cost of medicine.They questioned why the reform does not eliminate the assurance system pointing out that it is a barrier to the access of service.Due to the existence of different associations, there was no evident union between them but there was a homogeneous opinion about the reform.In general, there were not many changes of opinion among the associations during the debate (see Table 1).
Civil society, which corresponds to foundations, observatories, academy, and representatives of society in general, strongly disagrees with the reform, which focuses on the concerns about the quality of the services and the training of health professionals as well as the continuity of the assurance companies.It did not pronounce in a unified manner, but manifested similar concerns.In general there were no changes of opinion in civil society (see Table 2).
The health providers which pertain (or apply?) to physicians and other health professionals always disagreed with the reform as evidenced by the strong critical posture found and the disagreement with many of the proposals made by the government.In health personnel there was a strong cohesion against the reform by graduated physicians, residents and students that resulted in objections and letters directed to the Health Minister.There critics focused on the training of specialists by non-academic hospitals and the fact that the reform didn't improve the working conditions of the health staff.There were no changes in opinion, however.In general this group presented a unanimous opinion (see Table 3).
In the media there were diverse statements generating a median score because of the findings of critics and also closeness and support for the reform.Its critics manifested that partial changes would be made without any structural changes in the system and it was not focused on the needs of its users.There was no clear unity among the different media because of the diversity of statements and each type of media maintained its approaches during the time evaluated (see Table 4).
It was the government that proposed the reform in a way all its statements favored it, no evident critic was found except for some suggestions planned such as the suppression of controversial articles and specialist training by non-university hospitals.There is a clear unanimity within the government toward creating the reform so that changes of opinion were minimal (see Table 5).
The insurance companies defined as OPBPs (Organizations Providing Benefit Plans) presented diverse statements provoked by the association of the EPSes of the contributive regimen that moved from some criticism of certain aspects of the reform to a total disagreement with the project.Its critics focused on the changes of the functions of OPBPs which would change to their becoming "Gestoras" (providers) and the risks of cost increments.They agreed that the membership and money were to be government responsibility.Insurance association from the subsidized regimen and compensation funds show contrary opinions about this reform.Compared with the other opinion leaders this was the group with the most frequent changes in view points (see Table 6).Source: author's own.
Evaluating the different statements about the variable "Closeness to the government reform", there are tendencies of the majority of actors to be against the government proposal.It is evident that the tendency was nearly unanimous and the government was finally left alone (see Figure 1).

Discussion
Even though the reform project was led by the Health Ministry its failure shows a problem in one of the basic recommendations by WHO about the strengthening of the health system [35].
Each opinion leader expressed ideas about the convenience of the reform for his or her sector without mediating an analysis of the needs of the system as a whole and of making the users a priority.In other studies taking into account the system as a whole is recommended.It must be considered jointly by all agents involved in each health service [36].
The debate about reform has not considered the user as its center and the mechanisms to reduce inequities in the access to and results in health were also manifested in the study undertaken by the IDB [37].
Up to now Colombia maintains a segmented system even though intents have been made to search for mechanisms to increase social cohesion [38].The evidence of studies shows that reducing certain dimensions of fragmentation may be much more politically viable and acceptable than others [39].
The most frequent spaces for debate about the reforms in Latin America have been the Parliament and in "We agree for the state to assume total responsibility for insuring, through direct affiliation, resource charges and their administration and direct pay to the health providers, functions that up to now have been carried out by the EPSes." "The EPSes have always assured that they are not interested in managing the resources of the system and that they agree for the government to take care of this task."some cases commissions created by the Health Ministry with the participation of different leaders [40].The parliament does not seem the best space for seeking agreements among these leaders as was shown in the last reform attempt in Colombia.As a different factor, the influence of presidential elections as experienced in Colombia at that time has to be considered.During the reform project release, the Ministry of Health declared that "the election campaign was a Closeness to the government reform mortal event for health reform" [41].Furthermore, some speakers referring to the reform assured that even though it was necessary to improve the system for patient attention in Colombia, it was necessary to delete this topic from any electoral debate [42].The debate about the health system in Brazil was also affected by the elections in opinions such as: "For Lula's government, health was never a priority", given by the health economist Aquiles Mendez of San Pablo University [43].
In the United States, it is considered that unless there is a change in the way campaigns are financed, there cannot be a reform in the health system [44].

Conclusions
There is an agreement among the leaders about the acknowledgement of health as a basic right and the publicprivate participation in healthcare services.The users, health services, individuals and civil society advocate for a system administered by the state, without profit and free of intermediation.The government maintains agencies of private management even though it changes their functions, and about this topic the insurance companies do not agree.
In the 30 statements evaluated in this study it was found that the great majority of leaders distanced themselves from the government by being critical about partial aspects of the reform, with disagreement among the leaders and with a tendency to polarize their opinion.
Because of the collapse in government reform projects, four new decrees have been proposed to create a model of health in rural and remote areas, define financial conditions for the EPSes, update norms for membership in healthcare systems and regulate biotechnological drugs.It is important to perform another analysis to evaluate whether or not these changes will be relevant and improve significantly to be a solution to the health crisis in Colombia.
is explained for each one of the variables.▪ Closeness to the government reform: ▪ +3 Extremely agree with the reform ▪ −3 Extremely against the reform ▪ Partial critics of the reform: ▪ +3 Important critics of specific aspects of the reform ▪ −3 Scarce critics of specific aspects of the reform ▪ Unity among members of the same point of view: ▪ +3 The different members of the same view expressed similar points of view ▪ −3 The different members of the same view expressed different points of view ▪ Changes in opinion: ▪ +3 Many changes of opinion about the reform ▪ 0 No changes in opinion about the reform

"""
The rescue fund has a sole goal: save the hospitals.Those who say otherwise are lying."Some of the past reform articles are not subject to regulation because they argue with the basic postulates of the current model.Administrative ways are being sought to solve the gaps in these statements after the unsuccessful transaction of the ordinary law."

Figure 1 .
Figure 1.Closeness of the different health system groups regarding the proposal for a 2013 reform by the government.

Table 1 .
Statements from the users about the 2013 healthcare reform.

Table 2 .
Statements from the civil society about the healthcare reform of 2013.

Table 3 .
Statements from the health providers about the healthcare reform of 2013.

Table 4 .
Statements from the media about the healthcare reform of 2013.

Table 5 .
Statements from the government about the healthcare reform of 2013.

Table 6 .
Statements from the insurance companies about the healthcare reform of 2013.