No, the health system has not killed more people than the war: experts question the figure with which Petro defends his health reform

President Gustavo Petro has said in several scenarios that Colombia's health system “has killed” more people than the armed conflict. He repeated it a few days ago in Cali in front of hundreds of people when he proposed a national constituent assembly. “340,000 Colombians died while they could have lived if they had been cared for in a hospital or clinic, more than the armed violence in Colombia,” said the president. The people applauded. Petro insisted. “In Colombia, the commercial health system we have has killed more; it killed 340,000 Colombians in the last 10 years, while 15 million million pesos were stolen.” He has also written it in X.

The president has used that figure to support the urgency for Congress to approve his health system reform, which will return to public debate this week because the Senate's Seventh Commission finally faces the imminent decision to reject it.

María Paula Fonseca, head of communications for the Presidency of the Republic, explains to EL PAÍS that this is “a figure from the National Institute of Health (INS).” Fonseca says that during the period from 2010 to 2019, 2,160,686 deaths were reported in Colombia, of which 16.8%, or 364,113, are classified by the INS as “preventable deaths by the health system.” The conclusion is that of the president: “This means that 364,000 deaths should not have occurred if the health system had attended to or prevented them with the tools and medical knowledge available.” According to this information, the system would be responsible for 24,000 additional deaths than those reported by Petro.

However, three academic experts in health systems and two former ministers of the sector agree that the figure reported by the INS is different, and that it does not have the meaning that the Presidency suggests. In summary, they say that the concept of “deaths preventable by the health system” does not imply that they have occurred only due to failures in the health system.

Andrés Vecino is a professor and researcher in the health systems program at Johns Hopkins University, in the United States. The Colombian expert explains that the concept “refers to people who die prematurely, before the age of 75, due to conditions that technology and knowledge can already cure.” And he adds: “Everything comes in there, because almost everything can be cured, eventually.” Vecino assures that, for example, all deaths from colon cancer or melanoma are included, because there are health strategies, medications and technology to cure these types of cancer. The problem is that these treatments do not work for everyone. “Deaths from gunshot wounds, sharp weapons, falls, and injuries from traffic accidents are also included because they are potentially preventable.” Vecino summarizes that today very few things are absolutely untreatable. ”It is a very broad indicator of the state of health in a country, but many of these causes do not correspond directly to the health system.”

Vecino, a doctor from the Javeriana University and a doctor of medicine, insists that it is problematic that the president uses the figures from the report to promote a fundamental change to the system. “When Petro uses that indicator without nuance, he implies things that are not true. Basically, he is saying that the Colombian health system allowed the death of 340,000 people and that is not the case.” Vecino gives an example: “Death from leukemia is included, because in some cases it can be treated. But in many others not, it depends on a thousand reasons and variables. “Any person who dies from leukemia will be counted as a preventable death by the health system, even when everything humanly possible was done to prevent it.”

The INS document from which the data comes, called When death is avoidable, explains that of the total of 7,993,591 deaths reported in Colombia between 1979 and 2021, 19.7% (1,576,800) are considered preventable attributable to the health system. However, the same report contradicts the idea that the health system has been harmful. “There is a decrease in the rate of deaths preventable by health services of 35.8%, going from a rate of 136.9 per 100,000 inhabitants in 1979 to 87.9 per 100,000 inhabitants in 2021,” says the report. In other words, Colombia has been reducing its preventable deaths since there was solid data, 45 years ago. This drop occurred with the system prior to the current one and was maintained with this one, created essentially by Law 100 of 1993. That year the rate was 134.1 deaths per 100,000 inhabitants.

Another conclusion of the report reaffirms that the system has been improving because the portion of all deaths that the health system could, theoretically, avoid has decreased. “Regarding the proportion of deaths preventable by the health system of the total annual deaths, at the beginning of the period (1979) this value was 28.4%, while in 2019 it reached 16.4%.” That is to say, in those 40 years the health system has managed to reduce preventable deaths, to the point that many more are attributable to other sectors. “For every preventable death attributable to the health system, there are 1.6 additional deaths attributable to other public policies,” the report concludes.

Johnattan García Ruiz, senior researcher at the health systems innovation laboratory at Harvard University, remembers that these data are statistical estimates of possible system failures, they are not absolute certainties, as the president claims. “There is no investigation in which scientists say that 340,000 Colombians were denied health service or were not treated and that is why they died.” He explains that the Colombian health system, on the contrary, has notable achievements: “We have a system that works for our context, with good results despite inequity and few resources per capita. The resources invested in health in Colombia are 7 or 8 times lower than those of high-income countries, but our avoidable mortality rate is not 7 or 8 times higher, it is less.” García insists that the president does not mention the major conclusion of the INS report, that preventable mortality rates related to the health system have decreased. “Something is being done right, there are fewer and fewer deaths,” he says.

Alejandro Gaviria, former Minister of Health under Juan Manuel Santos and former Minister of Education under Petro, has also criticized the figure of 340,000 deaths. In his X account, he responded directly to whoever was his boss: “This tweet from President Petro is full of fallacious interpretations. It is sad that, a year and a half later, the debate on health reform continues to be based on these types of erroneous opinions. Preventable deaths are divided into preventable and treatable. For each category, what matters are the relative values ​​(the comparison), not the absolute ones. In comparison, Colombia is doing well. In contrast to what is said, the progress is undeniable,” reads the former minister's message. Gaviria takes up some graphs by researcher Ramón Abel Castaño, a health systems consultant, which show how Colombia “has been improving in avoidable mortality and is much better than the American average.”

Castaño had published a message about the data on preventable deaths: “I continue to insist on the president's mistake in saying that the health system has killed more people than the war in Gaza or violence. All countries have avoidable mortality, the important thing is to reduce it. And in this Colombia comes out very well compared to the region.” For the expert, these data lead to the opposite conclusion to that of the president: “Colombia has substantially improved its avoidable mortality indicators and today is better than the average for the region.”

Augusto Galán, former Minister of Health and director of the Así Vamos en Salud think tank, explains in dialogue with EL PAÍS his disagreement with the president's figures. The doctor states that a recent study by the Pan American Health Organization (PAHO) shows that in Colombia “there is a fairly pronounced decrease in the age-adjusted rate of potentially avoidable premature mortality for both men and women.” This is a different, and more precise, concept than that of preventable deaths. The data that Galán points out is that in 2000 there were 469 deaths per 100,000 inhabitants and two decades later, in 2020, the figure was 245. “This shows a sustained drop in the potentially avoidable premature mortality rate,” says the former minister.

Galán explains that the measurement of avoidable mortality is closely related to the Human Development Index, which involves factors beyond health systems. Economic growth, GDP per capita or the education rate influence that rate. “Linking deaths exclusively to the health system and indicating that the reform would prevent them is, to say the least, reckless,” says Galán. And he concludes: “That figure from the president is taken out of context and does not show what is really happening.”

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