Colombia: Between state violence, militarization, and the new authoritarian reform of the health system

Colombia is trapped between intensifying state violence, the criminalization of social protest, the COVID-19 epidemic, the deterioration of the financialized health system, job insecurity, the social and economic crisis, and arbitrary, authoritarian, inequitable, and unjust government policies..

The wave of systematic government repression, with a clear public policy of human rights violations by the Colombian government authorities, has been reflected in recent days in bloody figures that illustrate such repression: 37 people killed; 381 people who suffered personal injuries; 58 human rights defenders who suffered some type of violent aggression; 19 women who suffered gender-based violence, including rape; 1.180 people who were arbitrarily detained, some of whom were subjected to degrading treatment and/or torture; 239 who were detained and disappeared; and more than 500 people who reported abuses of power, aggression, or police violence related to the criminalization of social protest.

Official repression extended to the extreme militarization of cities like Cali and Palmira, which are at risk of running out of food and medicine; internet signals and social networks used by citizens and communities to denounce these forms of official repression were also blocked, and the possibility of declaring a State of Internal Disturbance was used as a deterrent to generate fear and uncertainty in the population.

This entire context was triggered by anti-government social protests due to the recent measures that the current president of Colombia, Iván Duque, attempted to implement in an arbitrary, authoritarian, inequitable, and unjust manner. One of the triggers was the attempt to implement a tax reform that imposed an income tax on a large number of people with low incomes; in addition, it increased the Value Added Tax (VAT) on essential products for most of the Colombian population. The discontent generated by this measure, coupled with the accumulated social dissatisfaction stemming from the negligent management of the Covid-19 pandemic, along with the deepening social and economic crisis in the country, precipitated a massive social protest. The criminalization of the protest by the Duque government led to an authoritarian and violent response from the authorities, with systematic violations of human rights. The following phrase from one of the many banners displayed in the public demonstrations clearly reflects the sentiment of the Colombian people who are demonstrating:

"If a people take to the streets to protest in the midst of a pandemic, it is because the government is more dangerous than the virus."

In the case of Colombia, violence is part of a substantive process of the social determination of collective health and life.

For many years, social and economic inequalities have been especially intensified and exacerbated by the Colombian armed conflict and the different forms of local and regional systematic violence, carried out by paramilitary groups and promoted by local, regional and national elites, with the primary aim of maintaining their privileges and benefits in a privatized democracy.

Social and community leaders who fight for the defense of territory and collective rights and common goods, who denounce and confront situations of injustice and inequalities based on social class, ethnicity and gender in various regions of the country, have been systematically targeted by this violence, including selective assassinations.

In this regard, it is also important to highlight that in recent years young people have become trapped in this systematic spiral of violence that permeates life in the country. Being young in Colombia represents a constant pressure to ask ourselves questions. What are young people dying from in Colombia? To answer this question, we must focus on two aspects. On the one hand, on symbolic forms of existence and the limits of daily life itself that threaten the dignified lives of young people, such as precarious education and employment, and media representations that discredit their voices; on the other hand, on specific forms of violence—extrajudicial killings and persecution—that account for what in the rhetoric of Colombian violence are known as “false positives.”

This context of violence, coupled with the non-compliance with the Peace Accords, has already led to 126 massacres, leaving 513 dead between 2020 and the beginning of 2021 (Indepaz). Furthermore, more than 900 women and men leaders have been murdered, along with more than 276 signatories of the peace agreement—former FARC combatants—since its signing in 2016 (Indepaz). In addition, in March of this year (2021), the bombing of a FARC dissident camp was reported, where children were found, described as “war machines” by the Colombian Minister of Defense.  

A new reform to the reform of the Colombian Health System

Amid this climate of discontent and massive social protests, of criminalization and systematic repression, of death and suffering among the Colombian people, President Duque's government seeks to push through a new reform of Law 100 of 1993, which had already resulted in the weakening, precariousness, fragmentation, privatization, and financialization of the Colombian healthcare system. Under the theoretical and conceptual framework of structured pluralism, as a state policy, a deregulated market for health insurance coverage, public-private partnerships, and the destruction of public health were promoted.

Currently before the Colombian Congress is Bill 010 of 2020, which seeks to deepen the insurance and financial intermediation model for healthcare, weaken the already fragile public health system, widen the gap between care in urban and rural areas, increase the corporate and business oligopoly of health insurers, emphasize citizens' responsibility for their own health, and ultimately, continue to violate the fundamental universal right to health. Additionally, this bill violates university autonomy, as it subtly proposes that some postgraduate training be moved out of academia and delivered by the same entities that act as healthcare intermediaries. 

Bill 010 of 2020 continues to be part of a strategy by Colombian elites to deepen the commodification of health under structured pluralism and the expansion of market goods within the health system itself.

The Colombian Health System is called the General Social Security System in Health finance Health coverage, pensions and occupational risks, is a case that perfectly exemplifies the geopolitical influence of organizations such as the World Bank, the IDB, PAHO-WHO and national and multinational corporations that represent the materialization of the neoliberal global health agenda.

The structuring of the Colombian reform institutionalizes sophisticated networks of pharmaceutical companies, multinational hospital corporations and private insurers, companies that purchase medical supplies and technologies, among others.

The (de)regulated market for coverage with financial intermediation, a public-private provider market, geopolitically implies the establishment of a globally peripheral health capitalism in Colombia with the presence of United Health Group, a US multinational of insurance and health service providers; AUNA, the Peruvian multinational owner of a business conglomerate; Keralty (formerly Organización Sanitas Internacional), the Spanish multinational owner of a large network of insurance and health service providers (more than 200 in this country); Steward Health Care, a US multinational that integrates private providers and insurers; Christus Health, the US multinational owner of the health component of the Coomeva Group; Quironsalud, a Spanish multinational part of the German multinational Fresenius Helius; Fresenius Medical Care; and others.

In other words, Colombia implemented a hospital-centric and disease-focused insurance system, where the healthcare system itself institutionalized private interests and financial intermediation, reproducing fragmentation, segmentation, stratification, and especially inequities in the collective health of Colombian society. These objectives prevailed in the reforms undertaken in the country, deepening inequalities and, at the same time, radically worsening the working conditions of healthcare workers themselves.

In this specific aspect, it is crucial to remember that this precariousness disproportionately affects women, given the particularly feminized nature of the healthcare sector. The precarious working conditions of healthcare workers in Colombia reflect the prevalence of outsourcing, the erosion of labor rights and guarantees, which translates into relentless work, short-term contracts, and situations where healthcare workers essentially "give away" months of their time to secure these contracts, among other issues. This situation was exacerbated during the Covid-19 pandemic.

Mass protests, neoliberal reforms and the management of Covid-19

Colombia, like many other countries in the region, is currently experiencing an intensification of the epidemiological crisis and deaths associated with the COVID-19 epidemic in Colombian territory.

Indeed, according to official figures from the Ministry of Health itself, more than 76,000 deaths have been recorded to date, with nearly 400 deaths per day. In terms of vaccination, Colombia has one of the lowest rates in the region, primarily due to a vaccination plan that has prioritized political criteria over epidemiological or public health criteria, and secondly, due to the resulting monopoly on intellectual property rights (patents) for biological products, such as vaccines, held by large multinational pharmaceutical companies, supported by governments in the Global North. According to figures from the national government itself, since mid-February, just under 2 million people have been immunized with the two recommended doses. As has occurred in other countries in the region, the hospital system in the main cities is overwhelmed by the SARS-CoV-2 epidemic, and there is a significant shortage of medical oxygen.

As we have reiterated on several occasions, the effects of the Covid-19 epidemic are the result of social determinants that account for the health-disease-care process in the country, in its various territories.

Colombia is one of the Latin American and Caribbean countries with the greatest social and economic inequalities, with particularly significant local and regional disparities that disproportionately affect rural, Indigenous, and Afro-descendant populations, among whom women and girls are especially vulnerable. In many Colombian cities, informality and precarious employment, affecting more than 50% of the population between 18 and 64 years of age, are more the norm than the exception. Against this backdrop of profound social and economic inequalities, the pandemic, the measures adopted to control it, and the near absence of social protection measures have led to approximately 21 million Colombians falling into poverty in 2020. That year, poverty increased by 3,5 million people, and extreme poverty reached 7,5 million. 

From the Working Group on International Health and Health Sovereignty of the Latin American Council of Social Sciences:

• We categorically reject the systematic criminalization and repression of social protest by the Colombian authorities.

• We demand an immediate end to the violence and official repression against legitimate social mobilizations and protests, and the immediate implementation of legal mechanisms that allow for the clarification and prosecution of these violent actions and the human rights violations associated with this violence.

• We believe that the effects and consequences of the COVID-19 pandemic are the result of social determinants of a health-disease-care process shaped by social class, ethnicity, and gender, which accumulate in the lives of Colombians. The privatization, commodification, and implementation of corporate and business interests in the organization and management of the healthcare system are central to these determinants of collective health.

• We believe that universal social protection policies must be an integral part of the actions taken to respond to the Covid-19 epidemic in the country. Such policies must be equitable, redistributive, and contextually, territorially, and culturally relevant, paying particular attention to the specific needs of rural, Indigenous, and Afro-descendant communities and peoples. A gender perspective must also be an integral part of these social protection measures.

• We demand the immediate suspension of Law 010 of 2020 without any formal adjustments, and the implementation of spaces for social and community participation in health that, together with health workers, universities, unions, and social movements, make it possible to implement alternatives that truly allow us to begin a path towards the Refounding of the Health System in Colombia.

• We demand the implementation of regional integration strategies in health from a South-South Cooperation approach, to address the liberalization of patent rights for vaccines, so that each and every person living in the region can have access to Covid-19 vaccines as soon as possible.

• To leave behind the reform of Law 100 and the theses of structured pluralism, promoting a great debate in Colombia on the reconstruction of national health sovereignty for collective health and the well-being of Colombian society.

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May 7th 2021
CLACSO Working Group
International health and health sovereignty

This statement expresses the position of the Working Group International health and health sovereignty and not necessarily that of the centers and institutions that make up the CLACSO international network, its Steering Committee or its Executive Secretariat.