Clarice Sabogal, a 77-year-old mathematics teacher, was proud that Colombian teachers had a special health regime. So much so that that is why she was the only one in her family who defended former liberal president Ernesto Samper (1994-1998). “She gave us special health and pension regimes,” she told her son, Rodrigo Hurtado. Sabogal had participated in the union marches of the Colombian Federation of Educators (Fecode) so that the Government regulated this right, contemplated in a 1989 law. Three decades later, she has Alzheimer’s and is one of the patients suffering from the crisis of the special regime . President Gustavo Petro wanted to fix problems that had accumulated for years, but the improvised implementation of a reform turned into chaos. “If my mother was conscious, she would be very angry,” says Hurtado.
Sabogal’s family found out on April 20 about the new health model for teachers. José Hurtado, the teacher’s husband, read in Time that the Government and Fecode had reached an agreement to implement a reform starting May 1, Labor Day. The country would no longer be divided into ten regions, but rather into a single national network of providers. Fiduprevisora, a state trust, would no longer hire private operators to organize networks of medical centers and make payments, but would directly assume management of the system. The promise was that the 820,000 members would have more options to choose where to receive care and that corruption would be reduced by eliminating intermediaries. It was similar to what had been sought for all Colombians with the reform of the universal health system, which required a law that failed in Congress.
In the case of teachers, the old regime was far from perfect. The diagnosis that Sabogal received in 2007 was not in a system clinic, where a doctor simply said that he had “PU [la puta vejez]”. She obtained it at the Intellectus Memory and Cognition Center of the Javeriana University. Hurtado Sr. also filed a guardianship action a few years ago so that the teachers’ fund would cover his wife’s access to a nurse and diapers—he lost in the second instance. However, the family was generally satisfied: Sabogal received expensive medications and visits from doctors and therapists. Now, however, they feel uncertainty. “Change cannot consist of removing what more or less works and replacing it with what doesn’t even answer the phone,” says Hurtado Jr.
The anguish began at the end of April, when the orders for the medications that the teacher needs to calm the ailments of Alzheimer’s disappeared from the website. Nobody gave Hurtado Sr. reason about what to do. The clinic had warned him that the contract with the teacher scheme would soon end and the helplines were not working. The family chose to report the situation on their social networks, go to the Fiduprevisora headquarters in the north of Bogotá and contact friends in Fecode. They achieved new doses after several days of insistence, but uncertainty remains about other needs.
Eliminating the special regime and transferring teachers to the general system is not an option. “She fought for it, how many marches did she walk? We must respect the will of the teachers,” says Hurtado Jr. “They have a very strong sense of belonging: the system may be bad, but they value that it is theirs,” he adds. The priority, for the teacher’s son, is that the new problems are resolved as soon as possible.
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The claims
On the morning of Thursday, May 9, the Fiduprevisora headquarters in Bogotá is full of teachers. One of them is Ana Isabella Lombo, a dance and art teacher whose student tore the ligaments in her hand in an accident. A week has passed since a doctor from the Occupational Risk Administrator (ARL) told her that she needed urgent surgery. Since then, she has gone to several clinics. They all responded that they cannot operate on her without the authorization of Fiduprevisora, which in turn tells her every day that her request is under review and to wait a few more hours. “I tell them I can’t wait: I’m going to get gangrene, I could lose my hand,” she remarks.
Something similar is felt by Clara Inés Cruz, a 76-year-old retired teacher who is distressed because she has a high-risk illness and does not know when she will have her check-ups. With no one to answer her calls, she followed the advice a nurse gave her: go to Fiduprevisora. After several hours of waiting, she comments that the problem has been the accelerated execution of the change. The Teachers’ Fund (Fomag), with three members from the Government and two from Fecode, approved the reform on April 1 and gave Fiduprevisora just a month to implement it. “I think it’s good that it changes, but they should have planned it a year or two in advance,” says the teacher.
There is even more movement on the street. A few dozen members of the Boyacá Teachers and Education Workers Union (Sindimaestros) demonstrate, who arrived in the morning in several buses. “Long live the struggle of the Boyacá teachers,” exclaims the union’s health secretary, Luz Elena Benavidez, with a megaphone. “Live! Live! “Long live!”, the teachers reply. “We demand immediate hiring!” adds the union leader. “We demand! We demand! “We demand!” they respond. “We demand the immediate delivery of all medications!” “We demand! We demand! We demand!”
Benavidez tells this newspaper that the claim is not against the new system as a whole. “We have a good model: we came from operators who used health as a commodity and now they disappear. The problem was improvisation in the implementation.” He says that some providers were not hired on time and that some colleagues from Tunja appear registered in Chiquinquirá, 80 kilometers away. He is especially concerned about suspended treatments for cancer patients. However, he emphasizes that Sindimaestros does not hold the Executive responsible, despite the fact that the ministries of Education, Labor and Finance account for three of the five votes of the Fomag board of directors. “The problem is not the Government, but Fiduprevisora,” he emphasizes.
President Petro, for his part, argued during an event in Pereira (Risaralda) that the problems are limited to technical difficulties. “We want the teacher to be able to choose which clinic they want to go to. That must be achieved and we have not done it yet. He is trapped by softwarewhich takes them to the old operators, making fun of the change we are making,” he stated.
The fiduciary
Inside Fiduprevisora, which executes the fund’s orders, there is also unrest. A source in the entity points out that the financial entity is only “the visible face” and that the responsibility lies with Fomag, which approved the reform and ordered its implementation for May 1. He also claims that the trustee and Fecode told Petro that they could not make the changes so quickly, but that the president insisted that the date of Labor Day was non-negotiable. “He said that whoever did not agree defended corruption in Fomag,” says the source. He adds that they were given the pharaonic task of going from having 10 contracts with operators to thousands, direct, with clinics, hospitals and all types of medical providers: “I live in a Kafkaesque nightmare. “What part of the Colombian State can hire 3,000 companies in three weeks?”
The source at Fiduprevisora, who prefers to keep his identity confidential to avoid retaliation, has moderate expectations with the new system. On the one hand, he assures that the “operational” problems of these days will be resolved in two or three weeks: contracts will be formalized, bureaucratic requirements will be adjusted and there will be more call centers. He also values that a large part of corruption can be “eliminated” by removing intermediaries. The problem, according to the source, is the tariff manual that the Ministry of Finance formulated to negotiate the contracts. Clinics and hospitals rejected it, which led to the Government giving “a blank check” for the fees to be paid. Likewise, he recognizes that Fiduprevisora does not have experience in health. “Our business really is managing assets. And now they have us handle medications.”
Assurance role
Tatiana Andia, professor of sociology at the University of the Andes and health expert, comments by phone that the system incorporates some advances. She appreciates that, on paper, there is now “a health model.” “They want Fiduprevisora to have an assurance role, to investigate who gets sick and why, audit accounts and develop programs to prevent illnesses. We are light years away from developing that capacity, but in the lyrics it is fine,” she highlights. Likewise, she highlights the intention to expand the supply of providers to give more alternatives to teachers, who previously had smaller and closed regional networks.
But, for Andia, structural problems also remain. “There are fewer and fewer young teachers coming into the system and helping to finance it. The population is aging and the accident rate is high [el 49% son mayores de 50 años]. It is difficult to make insurance, you are condemned to a pool of risks,” he points out. Furthermore, he points out that teachers are a more dispersed population than the Health Promotion Entities (EPS) usually have in the general system and that the regime is more vulnerable to the politicization of Fecode. He believes there are unresolved questions about how to hire and what criteria to use to ensure financial sustainability and quality. “They did it in a hurry, in four months of dialogue, with political urgency,” he says.
The academic believes that the Government missed a great opportunity. Harmony with Fecode allowed it to test in this special regime several ideas that are proposed for the general system, such as the elimination of private intermediaries. But the first days of chaos and disorganization have left a negative image. “It is very recent, yes. And you have to be patient, yes. But those who suffer for their health cannot be patients. It is a crime that you ask a person for patience with life or death treatments,” she emphasizes.
Hurtado Jr. agrees with her, from the patient’s perspective. He criticizes the accelerated and improvised implementation of a reform that the Executive presents as a rehearsal of what it wants to replicate in the rest of the country with the health reform. “You feel like the guinea pig. And it is unfair that it is like this with those who have been most faithful to the president,” he comments, in reference to Fecode’s constant support for Petro’s projects.
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