June 2000 39 ENHANCING THE POLITICAL FEASIBILITY OF HEALTH REFORM: THE COLOMBIA CASE Enhancing the Political Feasibility of Health Reform: The Colombia Case Alejandra González-Rossetti, M.Sc., M.P.A. Harvard School of Public Health Patricia Ramírez Harvard School of Public Health June 2000 This publication was produced by the Data for Decision Making (DDM) project, which is funded by the U.S. Agency for International Development under Cooperative Agreement No. DPE-5991-A-00-1052-00 with the Harvard School of Public Health. It was done in collaboration with the Latin America and Caribbean Regional Health Sector Reform Initiative, funded by USAID under Contract No. HRN-5974-C- 00-5024-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development. TABLE OF CONTENTS ACRONYMS AND GLOSSARY.......................................................................................................................III SPANISH............................................................................................................................................................ III ENGLISH ........................................................................................................................................................... III INTRODUCTION................................................................................................................................................ 1 POLITICAL ECONOMY CONTEXT.......................................................................................................................... 2 POLICY PROCESS ................................................................................................................................................ 3 THE CHANGE TEAM AND OTHER POLITICAL STRATEGIES..................................................................................... 4 I. POLITICAL ECONOMY CONTEXT............................................................................................................. 6 INSTITUTIONAL CONTEXT................................................................................................................................... 6 GOVERNMENT ............................................................................................................................................... 6 POLITICAL PARTIES........................................................................................................................................ 8 OTHER GROUPS IN SOCIETY ......................................................................................................................... 10 GENERAL FEATURES OF THE POLICY PROCESS................................................................................................... 11 THE LEGISLATIVE PROCESS.......................................................................................................................... 11 POLICY MAKING AND DECISION-MAKING WITHIN THE EXECUTIVE ................................................................ 12 A BRIEF ACCOUNT OF POLITICS IN COLOMBIA SINCE THE 1950S ....................................................................... 14 THE NATIONAL FRONT (1958-86)................................................................................................................. 15 THE POST-NATIONAL FRONT PERIOD (1986-90) ........................................................................................... 17 THE GAVIRIA ADMINISTRATION (1990-94)........................................................................................................ 20 ELECTORAL PROCESS AND GOVERNMENT FORMATION.................................................................................. 20 THE FIRST STRUCTURAL REFORMS............................................................................................................... 21 THE 1991 NATIONAL CONSTITUTIONAL ASSEMBLY (ANC)........................................................................... 23 POLITICS AFTER THE ANC AND THE REMAINING STRUCTURAL REFORMS ...................................................... 25 THE SAMPER ADMINISTRATION (1994-98) ........................................................................................................ 27 CONCLUSIONS.................................................................................................................................................. 29 II. THE POLICY PROCESS ............................................................................................................................. 31 BACKGROUND.................................................................................................................................................. 31 THE PROBLEM ............................................................................................................................................. 31 THE ORIGINS OF THE REFORM...................................................................................................................... 32 LAW 100, 1993............................................................................................................................................ 33 PROBLEM DEFINITION AND POLICY FORMULATION............................................................................................ 35 A NEW CONSTITUTION ................................................................................................................................ 35 THE NATIONAL DEVELOPMENT PLAN ........................................................................................................... 36 THE SOCIAL SECURITY COMMISSION ............................................................................................................ 37 THE POSITIONS AROUND THE REFORM ......................................................................................................... 38 THE HATOGRANDE PROPOSAL...................................................................................................................... 40 LEGISLATION ................................................................................................................................................... 43 AGREEMENT IN THE COMMISISIONS.............................................................................................................. 45 NEGOTIATIONS IN CONGRESS – PLENARY SESSIONS ...................................................................................... 48 SECONDARY LAW FORMULATION................................................................................................................. 50 THE IMPLEMENTATION PROCESS....................................................................................................................... 51 THE TRANSITION PROCESS ........................................................................................................................... 53 FIRST STEPS TOWARDS REFORM CONSOLIDATION......................................................................................... 55 CONCLUSION: KEY POLICY NODES AND ACTORS............................................................................................... 55 ii Enhancing The Political Feasibility of Health Reform: The Colombia Case III. THE USE OF CHANGE TEAMS AS A POLITICAL STRATEGY.......................................................... 57 INTRODUCTION ................................................................................................................................................ 57 CHANGE TEAM CHARACTERISTICS.................................................................................................................... 58 THE CHANGE TEAM’S CONFIGURATION........................................................................................................ 60 CHANGE TEAM IDEOLOGY ........................................................................................................................... 65 CHANGE TEAM NETWORKS............................................................................................................................... 66 VERTICAL NETWORKS WITHIN THE STATE .................................................................................................... 66 HORIZONTAL NETWORKS WITHIN THE STATE................................................................................................ 68 POLICY NETWORKS ACROSS STATE-SOCIETY................................................................................................ 70 CHANGE TEAM POLICY STRATEGIES ................................................................................................................. 72 STRATEGIES USED DURING THE LEGISLATION PROCESS................................................................................. 73 STRATEGIES USED DURING THE SECONDARY LAW FORMULATION ................................................................. 74 GENERAL STRATEGIES TOWARDS THE REFORM............................................................................................. 77 CONCLUSIONS.................................................................................................................................................. 79 ANNEX I. POLICY TRACER: REFORM IMPLEMENTATION (1995-97) .................................................. 81 INTRODUCTION ................................................................................................................................................ 81 MAIN RESULTS OF