Daniel Alzate Mora

Published September 23, 2014

This essay presents a critical view of the standard interpretation of the Constitutional Court of Colombia’s (the Court’s) role in health litigation. Although at first glance Colombia represents a successful case of health litigation, we argue that based on the Court’s judicial activism, and a more thorough analysis of health system dynamics, contradictions, and their development in the configuration of health rights, such litigation is reaching its limit, and the T 760/08 decision represents its peak.[1]

Colombia’s 1991 political constitution included a commitment to the development of a social security system. President Gaviria’s administration (1990-1994) accordingly developed the General Social Security System, but within the mandate of structural reform as promoted by the Washington Consensus. [2] The new health system, driven by neoliberal ideology that the market is the best mechanism to meet human needs, is based on the logic of a regulated health market, where the State would contract out health service provision to private institutions under an insurance scheme.[3]

Insurance companies have developed health oligopolies by incorporating corporate groups dedicated to health service provision, authorized by Law 100/1993 in a vertical integration model.[4] While stories of corruption in health service administration have been widely covered by the Colombian media since the beginning of the Santos Calderón Administration in 2010, corruption is not a new phenomenon; on the contrary, it has been present throughout the history of the health system.[5] For example, armed groups in certain parts of Colombia and their partnerships with regional elites showed the paramilitaries’ control over private insurance companies in 1998-2003.[6] The expressions “death trip” and  “Law 100 corpses” were frequently used in the Colombian media as a way to denounce the development of the health system, which failed to protect the right to health.[7]

Health litigation in Colombia progresses mainly through a mechanism called tutela action, a legal constitutional mechanism intended to protect and guarantee fundamental rights. By using tutela action, constitutional judges are able—in a relatively fast and unobstructed manner—to order the protection of fundamental rights that are being violated or threatened.[8]

According to a 2007 study by the Defensoría del Pueblo (Ombudsman’s Office), the number of tutela actions quadrupled from 1999 to 2005.[9] In 2008, the number of cases threatened to collapse Colombia’s entire justice administration system reaching its peak with 142,952 tutelas actions.[10]

As a result of the overwhelming number of cases and a major public health care crisis characterized by the worsening of public health indicators, the Court passed decision T 760/08 through their Segunda Sala de Revisión de Tutela, which is an Examination Room within the Court, presented by constitutional judge Manuel José Cepeda.[11] In this decision, the Court performed a thorough analysis on the right to health and the extensive court rulings up until that time.[12] They concluded that health is an autonomous fundamental right.[13]

However, the Court also considered that the health system suffered structural failures and that resolving each particular case would not repair those failures. On the contrary, the ongoing violations to health rights resulted in repeated use of tutela actions. Consequently, the Court decided to adopt a series of broader and more general structural rulings to resolve the health system failures, thus strengthening the guarantee to the right to health, and in turn reducing the volume of health litigation cases.[14]

Therefore, the Court considered that it should not be limited to particular cases, but it was necessary to look beyond the framework of individual violations and perform a comprehensive analysis of the health system. This analysis would identify the causes of repeated failure that resulted in the sharp increase in tutela actions. The Court grouped 16 general mandates into measures that: 1) related to the benefit plan; 2) related to the right to collect outside Plan Obligatorio de Salud, the set of medical services not covered in the benefits package; 3) to protect the right to health information through campaigns like the letter of rights, and the performance letter.[15] This set of general mandates is framed within the health model created by Law 100/1993. The Court verified that the health system and various providers were not complying with the law provisions.[16]

After decision T 760/08 was issued, a monitoring process of its general mandates became institutionalized. At the Plenary Chamber session on April 1, 2009, the Court decided to appoint a special chamber for this task, consisting of three magistrates, Jorge Iván Palacio Palacio, Mauricio González Cuervo, and Gabriel Eduardo Mendoza Martelo.

The Court’s monitoring process for “dialogic justice” seeking to construct jointly the way to overcome the hurdles of the health system has not been well accepted.[17] In 2009, the Uribe Administration applied “shock therapy” by declaring a state of social emergency in health, allowing it to legislate without congressional debate or approval to enforce the Court’s general orders, which were later declared unconstitutional.[18] In a detailed and sensible process, the Court collected extensive information, summoned two public hearings (July 2011 and May 2012), and agreed to enforce compliance with each of its general orders.[19] Nevertheless, observance of the decision has been inadequate. There is a persistent lack of information, delays of delivery, and actors and institutions that breach without grounds. This all occurs within a complex process where the Court has not yet established the contempt of its orders and has identified only a partial and limited compliance with its decisions.[20]

The constitutional tutela action and the development of the Court decisions in health cases can be interpreted in various ways. First, tutela action has been deemed significant in the development of the new “aspirational constitutionalism” because it allowed people to enforce their constitutional rights through court action. Thus, rights developed from being simply aspirational or in name only.[21]

However, insurance companies have also made use of tutela actions, because according to the Court ruling, health service denial was due to a systemic failure, rather than a fault on the part of insurance companies. Treatments or procedures claimed through tutela action and ordered by the constitutional judge had to be paid by the State if those treatments and procedures were not included in the benefit plan.[22] Consequently, private insurance companies implemented a denial policy for health care procedures, forcing users to take a tutela action so that the insurance company could charge the State for services provided. This implied a swap of insurance logic because services were paid through the State, and not by the health insurance company. In fact, private insurance companies consistently deny the provision or payment of health services while waiting for a court decision to determine whether they can collect costs from the State for those services.[23]

The Constitutional Court approach to the health system crisis has mainly considered that the cause of the crisis lies in the lack of regulation as identified in T 760/08. While there is no denying there are failures in regulation and the health system needs to develop a set of procedures and rules, the crisis is also attributable to structural aspects of the health system as a result of Law 100 passed in 1993. The Colombian health system treats health as a commodity, with system actors driven by a profit motive, which is detrimental to the realization of the right to health.

The Constitutional Court has made emphatic decisions against perverse and corrupt practices by insurance companies on the basis that the right to health is not being realized.[24] However, in a recent 2014 ruling, number 104 by the Constitutional Court, it was noted there is a lack of surveillance and reporting mechanisms on Court orders. This has resulted in a lack of progress in defining insurance company obligations within the health system.

The T 760/08 decision by the Constitutional Court stated that the number of tutela actions based on the right to health would provide a measurement of the degree of compliance with general mandates. The last report by Defensoría del Pueblo–an analysis of the tutela action usage since 1999–stated that the number of tutela actions has increased after T-760/2008, but there has not been any reduction in health litigation. In 2013, according to last report of Ombudsman’s Office, every four minutes a tutela action is invoking the right to health.[25]

Despite the effort made by the Constitutional Court to make progress in compliance with the general orders of T 760/08, the levels of observance of the decision have been very reduced, and the trend of increasing health litigation has not diminished. Therefore, in conclusion, I suggest that Colombia is reaching the limit of health litigation because the Constitutional Court has adopted a series of structural decisions, but these decisions do not overcome the narrow definition of the right to health arising from Law 100 of 1993. There has been no progress in a deeper discussion on the right to health obligations of profit-driven health providers and insurers. Unless the public debate addresses the structural elements of the Colombian health system, individual health litigation cases will continue to increase without achieving the protection and fulfillment of the right to health.


Daniel Alzate Mora, PhD, is a lawyer, social activist in NGO “Salud al Derecho,” and Associate Professor of Law at Rosario University, Bogotá D.C., Colombia.


 

 References

[1] J. Lemaitre and K. Young, “The comparative fortunes of the right to health in South Africa and Colombia,” Harvard Human Rights Journal 26/1 (2013), pp. 179-216; C. Rodríguez, “Beyond the courtroom: The impact of judicial activism on socioeconomic rights in Latin America,” Texas Law Review 89/12 (2010-2011) pp. 1669-1698; E. Lamprea, “Colombia´s right-to-health litigation in a context of health care reform,” in C. Flood and A. Gross (eds), The right to health at the public/private divide, a global comparative study. (New York: Cambridge University Press, 2014), pp. 131-158.

[2] M. Hernández, “El debate sobre la ley 100 de 1993: Antes, durante  después,” in S. Franco (ed), La salud pública hoy: enfoques y dilemas contemporáneos en salud pública (Bogotá: Universidad Nacional de Colombia, 2002), pp. 463-479;  J. Estrada, Construcción del modelo neoliberal en Colombia. 1970-2004 Ediciones Aurora (2004), pp. 78-129 ; Congreso de la República de Colombia, Ley 100. Por la cual se crea el sistema de seguridad social integral y se dictan otras disposiciones (1993). Available at http://www.secretariasenado.gov.co/senado/basedoc/ley_0100_1993.html.

[3] D. Harvey, A brief history of neoliberalism (Oxford: Oxford University Press, 2005); F. Yepes, M. Ramíez, L. Sánchez et al., “Luces y sombras de la reforma de la salud en Colombia. Ley 100 de 1993” (Bogotá: Assalud, Universidad del Rosario, Facultad de Economía, Mayol Ediciones, 2010).

[4] R. Castaño, “Integración vertical entre empresas promotoras de salud e instituciones prestadoras de servicios de salud,” Revista Gerencia y Políticas de Salud 3/6 (2004), pp. 35-51 ; J. Restrepo, J. Lopera, and S. Rodríguez, “La integración vertical en el sistema de salud colombiano,” Revista de Economía Institucional 9/17 (2007) pp. 279-308; R. Cruz, “Senador Robledo dice que Minhacienda recomendó en 2009 la integración vertical de Saludcoop,” Prensa senador Jorge Enrique Robledo (2011).

[5] Lemaitre (see note 1), pp. 195-197; S. García, “El Pulso: 13 años advirtiendo la corrupción en salud,” El Pulso (June  2011). Available at http://www.periodicoelpulso.com/html/1106jun/general/general-02.htm.

[6] F. Gutiérrez, “Colombia: reestructuración de la violencia,” in F. Gutiérrez and D. Peñaranda (eds), Mercados y armas: Conflictos armados y paz en el periodo neoliberal (Medellín: La Carreta Editores; Instituto de Estudios Políticos y Relaciones Internacionales, Universidad Nacional de Colombia, 2009), pp. 127-152; C. Medina, “El narco-paramilitarismo. Lógicas y procesos en el desarrollo de un capitalismo criminal,” in J. Estrada (ed), Capitalismo criminal: Ensayos críticos (Bogotá: Universidad Nacional de Colombia, Facultad de Derecho, Ciencias Políticas y Sociales, Departamento de Ciencia Política, Grupo de Investigación Theseus, 2008), pp. 105-141; M. Romero, La economía de los paramilitares. Redes de corrupción, negocios y política, Debate (Bogotá: 2011), pp. 245-325.

[7] G. Molina, I. Muñoz, and A. Ramírez, “Dilemas en las decisiones en la atención en salud en Colombia. Ética, derechos y deberes constitucionales frente a la rentabilidad financiera en el sistema de salud” Facultad Nacional de Salud Pública, Universidad de Antioquia; La carreta editores (2011); M. Hernández, “El derecho a la salud en Colombia: Obstáculos estructurales para su realización,” Revista Salud Pública 2/2 (2000), pp. 121-144; C. Abadía and D. Oviedo, “Bureaucratic itineraries in Colombia: A theoretical and methodological tool to assess managed-care health care systems” Social Science & Medicine 68/6 (2009).

[8] C. Botero, La acción de tutela en el ordenamiento constitucional colombiano (Bogotá: Consejo Superior de la Judicatura, Escuela Judicial “Rodrigo Lara Bonilla”  2006).

[9] Defensoría del Pueblo, La tutela y el derecho a la salud 1999-2004 (Bogotá, 2004); “La tutela y el derecho a la salud periodo 2003-2005″(Bogotá, 2007); “La tutela y el derecho a la salud. Periodo 2006-2008” (Bogotá, 2009).

[10] O. Moestad, L. Rakner, and O. Motta, “Assessing the impact of health rights litigation: A comparative analysis of Argentina, Brazil, Colombia, Costa Rica, India, and South Africa,” in A. Yamin and S. Gloppen (eds), Litigating health rights: Can courts bring more justice to health? (Cambridge, MA: Harvard University Press, 2011), pp. 273-302.

[11] Acciones de tutela instauradas por Luz Mary Osorio Palacio and Others v Colpatria EPS and Others (2008), (Colombia, Corte Constitucional, Sentencia T-760, July 31, 2008)

[12] Ibid., pp. 15-123.

[13] Ibid., pp. 17-27.

[14] Ibid., pp. 162-165.

[15] Ibid., p. 165.

[16] M. Hernández, “¿Derecho a qué? el debate sobre la sentencia T-760,” in La Sentencia T-760: alcances y limitaciones (Bogotá: Universidad Nacional de Colombia. Doctorado Interfacultades en Salud Pública, 2010) 27-44; O. Dueñas, “Observaciones alrededor de la Sentencia T-760/08,” in M. Villareal (ed), Revisión a la jurisprudencia constitucional en materia de salud: Estado de las cosas frente a la Sentencia T-760 de 2008 (Bogotá: Universidad del Rosario, 2009), pp. 15-25.

[17] R. Gargarella, “Dialogic justice in the enforcement of social rights: Some initial arguments, in A. Yamin and S. Gloppen (eds) (see note 10), pp. 232-245.

[18] “Colombia´s health reforms. Shock treatment,” The Economist (February 4, 2010). Available at http://www.economist.com/node/15469812#; Revisión constitucional del Decreto 127 de enero 21 de 2010, “Por el cual se adoptan medidas en materia tributaria” (2010) (Colombia, Corte Constitucional, Sentencia C-253, abril 16 de 2010)

[19] Convocatoria a AUDIENCIA PÚBLICA de RENDICIÓN DE CUENTAS en el seguimiento a las órdenes 16 (adopción de medidas necesarias para superar fallas de regulación), 17 (actualización integral del Plan Obligatorio de Salud), 18 (periodicidad en la actualización), 21 (unificación de planes de beneficios para niñas y niños de regímenes contributivo y subsidiado) y 22 (adopción de programa y cronograma para unificación de los planes de beneficios de regímenes contributivo y subsidiado) de la sentencia T- 760 de 2008. (2011) (Colombia, Corte Constitucional, Auto 110, 27 de mayo de 2011); Seguimiento a la orden décimo novena de la Sentencia T-760 de 2008 (2012) (Colombia, Corte Constitucional, Auto 043, de 5 de marzo de 2012); Seguimiento al cumplimiento de la orden vigésima de la sentencia T-760 de 2008. Reiteración de parámetros para la elaboración del ranking de EPS e IPS que de manera frecuente vulneran el derecho a la salud de los usuarios del sistema. (2012) (Colombia, Corte Constitucional, Auto 260, 16 de noviembre de 2012); Seguimiento al cumplimiento de la orden vigésimo tercera de la sentencia T-760 de 2008. Regulación del trámite interno que debe adelantar el médico tratante para que la EPS autorice directamente servicios de salud o medicamentos no incluidos en el POS que se requieran con urgencia. (2012) (Colombia, Corte Constitucional, Auto 066, 29 de marzo de 2012); Seguimiento a la Sentencia T-760 de 2008. Verificación del grado de cumplimiento de las órdenes vigésimo cuarta y vigésimo séptima de la Sentencia T-760 de 2008. (2012) (Colombia, Corte Constitucional, Auto 263, 16 noviembre de 2013); Seguimiento a las órdenes vigésimo quinta y vigésimo sexta de la sentencia T-760 de 2008. (2011) (Colombia, Corte Constitucional, Auto 256, 6 diciembre de 2011); Seguimiento al cumplimiento de la orden vigésimo octava de la sentencia T-760 de 2008. Valoración del grado de cumplimiento de la orden vigésimo octava de la sentencia T-760 de 2008. (2012) (Colombia, Corte Constitucional, Auto 264, 16 de noviembre de 2012); Seguimiento al cumplimiento de la orden vigésimo novena de la sentencia T-760 de 2008. Cobertura universal en salud. (2012) (Colombia, Corte Constitucional, Auto 068, 29 marzo de 2012);  Seguimiento a la orden trigésima de la sentencia T-760 de 2008. (2012) (Colombia, Corte Constitucional, Auto, 6 de junio de 2012).

[20] C. Gianella, O. Parra, A. Yamin et al., “¿Deliberación democrática o mercadeo social? Los dilemas de la definición pública en salud en el contexto del seguimiento de la sentencia T-760 De 2008,” in La Sentencia T-760: alcances y limitaciones (Bogotá: Universidad Nacional de Colombia. Doctorado Interfacultades en Salud Pública, 2010); Hernández (2010, see note 16) .

[21] Rodríguez-Garavito (see note 1), pp. 1671-1672.

[22] Abadía-Barrero (see note 10), p. 1154.

[23] “Recobros en salud, un desfalco anunciado,” Revista Semana (Mayo 3, 2011). Available at http://www.semana.com/nacion/articulo/recobros-salud-desfalco-anunciado/239227-3.

[24] J. Gañan, Los muertos de la Ley 100: prevalencia de la libertad económica sobre el derecho fundamental a la salud. Una razón de su ineficiencia. Caso del plan obligatorio de salud régimen contributivo (Posc) PhD thesis (2010); D. Alzate, D. Oviedo, L. Velosy et al., “Derecho lucro-destructivo: vivencias de la ideología posneoliberal en salud,” in C. Abadía, M. Melo, C. Platarrueda, and A. Góngora, Salud, normalización y capitalismo en Colombia, (Bogotá: Universidad Nacional de Colombia. Facultad de Ciencias Humanas. Centro de Estudios Sociales (CES). Grupo de Antropología Médica Crítica. Ediciones Desde Abajo. Universidad del Rosario, 2013), pp. 345-369; V. Currea, El Derecho a La Salud En Colombia: Diez Años De Frustraciones (Bogotá: ILSA, 2003).

[25] Defensoría del Pueblo, La tutela y los derechos a la salud y a la seguridad social 2013 (Bogotá: 2014).

 
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