Esta semana la Comisión Séptima del Senado de la República arrancó con una nueva mesa técnica fundamental para debatir uno de los pilares clave de la propuesta de reforma a la salud 2.0: la gobernanza y la rectoría del sistema de salud en Colombia. Este espacio reunió a actores del gobierno nacional, entidades del orden nacional, gremios de salud, expertos, exministros y exviceministros, además de organizaciones ciudadanas y comunidades territoriales.
La mesa técnica estuvo organizada en torno a varias preguntas rectoras, que abordaron los principales desafíos del sistema de salud propuesto, donde no solo se buscó construir insumos técnicos para la reforma, sino también ofrecer un foro de debate sobre las implicaciones políticas, sociales y económicas del nuevo modelo. Las senadoras Lorena Ríos y Norma Hurtado, coordinadoras de la mesa, destacaron la importancia de estos diálogos para que la reforma fuera construida con responsabilidad y técnica, asegurando que los colombianos pudieran entender claramente los alcances y limitaciones del proyecto.
Reforma a la salud: centralización VS autonomía territorial
Uno de los principales puntos de discusión giró en torno a la centralización del poder en la Administradora de los Recursos del Sistema General de Seguridad Social en Salud (ADRES) y la creación de nuevos fondos y entidades territoriales. Los representantes de los entes territoriales expresaron su preocupación por la recentralización del sistema de salud y el posible desajuste que esta podría generar en la capacidad de respuesta de los territorios. Según su visión, una concentración de funciones en Bogotá podría debilitar la autonomía de las regiones y complicar la gestión de salud en los niveles locales, creando un vacío de autoridad y recursos a nivel regional.
En respuesta, algunos voceros de comunidades autónomas solicitaron que la arquitectura institucional del nuevo sistema garantice autonomía y recursos suficientes para las entidades locales, asegurando que la gestión territorial no se viera limitada. Además, se subrayó que la reforma debe asegurar equidad en la distribución de recursos entre las zonas urbanas y rurales, evitando la centralización excesiva que podría generar una desarticulación del sistema.
Visiones divergentes sobre la viabilidad del modelo
Durante la jornada, las diferencias en la viabilidad del modelo propuesto fueron evidentes. El Dr. Jerson Bermont, Secretario de Salud de Bogotá, criticó la falta de articulación en el proyecto de reforma y explicó que, aunque la reforma debe ser un sistema articulado, no encontró esa conexión entre los elementos que deben estar interrelacionados. Para Bermont, esta desarticulación podría dificultar la garantía del derecho fundamental a la salud en el país, y expresó su preocupación de que la reforma podría “compartimentalizar” el sistema en lugar de integrarlo de manera efectiva.
El Dr. Iván González, exviceministro de Salud, fue aún más contundente al calificar la reforma como “totalmente inviable”. González destacó que la propuesta requiere articular a seis tipos de entidades, CAPS, ISEs, secretarías de salud, ADRES, entre otras, para que un paciente se mueva de manera eficiente por el sistema, lo cual, según él, sería imposible de coordinar en el contexto colombiano debido a las dificultades estructurales y operativas del sistema de salud.
Además, la Cámara Colomboamericana (Amcham Colombia) advirtió que el proyecto “no recoge adecuadamente las voces” de los diversos actores del sistema ni garantiza que el paciente continúe siendo el centro de la reforma. Insistieron en que una reforma de esta magnitud requiere de “una construcción participativa y técnicamente sólida”.
Las nuevas gestoras de salud y vida: ¿fragmentación del sistema?
Otro de los temas clave que generaron controversia fue la propuesta de eliminar las actuales EPS y reemplazarlas por las nuevas gestoras de salud y vida. El Dr. Juan Carlos San Pedro expresó su preocupación sobre el vacío de representación que esta figura podría generar. Señaló que las funciones asignadas a las gestoras, como organizar redes, gestionar riesgos y referir pacientes, no solo limitan la capacidad de gestión del riesgo, sino que también fragmentan el servicio y diluyen la responsabilidad sobre el paciente. Según San Pedro, la “superposición de funciones” crearía un “riesgo operativo considerable”, ya que se disgregaría la atención integral del paciente.
Por su parte, el Dr. Carlos Mario Ramírez, exdirector de ADRES, hizo hincapié en que la centralización de funciones en ADRES podría generar una “burocratización” en lugar de solucionar la fragmentación del sistema. Ramírez argumentó que, si bien ADRES tiene funciones clave como pagador único y recaudador, el modelo propuesto en la reforma no le otorga poder real a la gobernanza, ya que el Consejo Nacional de Salud tendría un papel solo de “recomendación” y no de decisión vinculante. En este sentido, la Sociedad Colombiana de Anestesiología y Reanimación (SCARE) propuso que el Consejo Nacional de Salud debería poder tomar decisiones vinculantes basadas en estudios técnicos independientes, especialmente en lo relativo al valor de la UPC.
El futuro del aseguramiento: retroceso en el goce del derecho a la salud
La eliminación de la figura del aseguramiento y su reemplazo por un “aseguramiento social” o sistema de pagador único fue una de las propuestas más criticadas. Algunos expertos, como un representante de la Vicepresidencia Sectorial, calificaron esta medida como “exótica” y argumentaron que, al eliminar la integralidad en la gestión del riesgo, se estaría retrocediendo en la garantía del derecho a la salud.
El Dr. Juan Carlos San Pedro también cuestionó la figura de las gestoras de salud y vida, señalando que “diluiría la capacidad de gestionar el riesgo de salud” y no resolvería los problemas estructurales del sistema. A su juicio, la reforma podría generar más fragmentación y riesgos operativos, ya que las funciones de las nuevas gestoras están demasiado dispersas y no ofrecen una solución integral al sistema de salud.
La viabilidad financiera: un sistema sin garantías claras de financiación
El tema del financiamiento fue otro de los puntos más álgidos del debate. El Dr. Juan Eduardo Guerrero, de la Federación Médica Colombiana, insistió en que la reforma, aunque necesaria, no tiene garantías claras de financiación. Señaló que las deudas acumuladas de las EPS y la insuficiencia de fuentes de financiación hacen que el modelo propuesto sea inválido financieramente.
El viceministro de Salud, Luis Alberto Martínez, defendió las proyecciones del gobierno, pero reconoció que la reforma debe incluir un plan de beneficios claro y asegurar la financiación sostenible del sistema. La Contraloría General de la República también subrayó la importancia de fortalecer los mecanismos de control fiscal para asegurar la transparencia en el uso de los recursos.
Atención primaria y los centros de atención primaria (CAPS): ¿un proyecto ambicioso?
La atención primaria en salud (APS) fue uno de los pocos puntos de consenso entre los participantes. No obstante, el Dr. Juan Carlos San Pedro alertó sobre la “hipertrofia funcional” que se asigna a los CAPS, señalando que las tareas que se les encomiendan, como la coordinación intersectorial y la articulación con gestoras, podrían tomar décadas en implementarse de manera efectiva. Esto contrasta con la visión de la Academia Nacional de Medicina, que celebró el enfoque en la atención primaria, pero advirtió que no se debe perder de vista el derecho individual a la salud.
La senadora Esperanza Andrade, coordinadora ponente, cerró la jornada reconociendo que la reforma es urgente, pero también destacó que el proceso de debate ha durado más de dos años y aún no ha alcanzado el consenso necesario para su aprobación. En su intervención, la Contraloría General de la República reafirmó su compromiso con la vigilancia activa del uso de los recursos, asegurando que se requieren herramientas adecuadas para garantizar la transparencia.
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