SeriesComprehensive reform to improve health system performance in Mexico
Section snippets
Background
The foundation of the modern Mexican national health system dates back to 1943 with the establishment of both the Ministry of Health (then the Ministry of Public Health and Assistance) and the Mexican Institute for Social Security (Instituto Mexicano del Seguro Social, IMSS). In 1959, the Institute of Social Security and Services for Civil Servants (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE) was created to cover public-sector employees and their families.
Challenges confronted by the reform
Like most middle-income countries, Mexico is undergoing inter-related processes of demographic and epidemiological transition. The fertility rate fell substantially from 6·8 livebirths per woman in 1960 to 2·1 in 2005. During the same period, life expectancy increased from 57·5 to 75·4 years. As a result, the composition of the population has changed dramatically. Whereas the under-5 age group has decreased in absolute numbers since 1994, the growth of the population group aged 60 years or more
Ethical basis
Although the social right to health protection was formally recognised by the Mexican Constitution two decades ago, in practice not all individuals had been equally able to exercise this right.12 As discussed above, half the population, by virtue of their occupational situation, enjoyed the protection of social insurance and thus faced fewer barriers to health care than the uninsured.
This type of occupational segregation is incompatible with the notion that access to health care is a human
Stewardship
The devolution and decentralisation of service delivery from the federal Ministry of Health to the states began in the mid-1980s and continued throughout the 1990s.3 This important step made it possible to focus the stewardship role of the Ministry of Health around coordination, regulation, monitoring, and evaluation. However, this process weakened the instruments that the Ministry of Health could effectively mobilise for steering the system and aligning incentives.
One of the key outcomes of
Advances and future challenges
The reform is producing positive results. The amount of public resources devoted to health has grown substantially; the number of insured families is expected to reach 5·1 million by the end of 2006, in line with the legal mandate to affiliate 14% of the uninsured population per year; and the set of health-care services to which every covered family is entitled has been greatly expanded.
Lessons
The Mexican experience offers potentially relevant lessons to other countries considering health reform under similarly challenging scenarios. Most developing countries face the combination of a rapid epidemiological transition with an underfunded and overwhelmed health-care system that is unable to respond accordingly. In this context, designing and implementing comprehensive reform proposals on the basis of the three pillars of public policy—ethical, technical, and political—is necessary.18,
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