From the Tragedy of the Commons to Surgical Governance: Collective Action and Shared Resources in the Colombian Health System

Abstract

Surgical care depends on limited, interdependent resources whose use generates opportunity costs for other patients and system actors. This essay examines the conditions under which specific resources within the Colombian surgical system exhibit collective-action problems consistent with common-pool resource theory, and what Elinor Ostrom's governance principles contribute to their management. Four conditions are proposed to define situations as common-pool resource problems: a finite resource, subtractability, decisions distributed among multiple actors, and incomplete internalization of opportunity cost. These conditions are applied to operating-room time, intensive care beds, specialized human capital, financial resources, and technology adoption. The analysis locates the origin of the problem in the distance between whoever obtains the benefit of a use decision and whoever bears its cost, rather than in the impossibility of excluding users. Unlike prior applications carried out in public systems, this work is situated in a multi-insurer system, where contracting modalities, vertical integration, unpaid hospital receivables, and the judicialization of access determine who internalizes that cost. Ostrom's principles are regrouped into four governance dimensions, and the paper concludes that external recognition of local authority to establish allocation rules is the limiting condition, without which delimitation, participation, and monitoring produce non-binding agreements. Colombia's Organ Donation and Transplant Network illustrates the case in which that condition is explicitly satisfied.