Elsevier

The Lancet

Volume 368, Issue 9546, 28 October–3 November 2006, Pages 1524-1534
The Lancet

Series
Comprehensive reform to improve health system performance in Mexico

https://doi.org/10.1016/S0140-6736(06)69564-0Get rights and content

Summary

Despite having achieved an average life expectancy of 75 years, much the same as that of more developed countries, Mexico entered the 21st century with a health system marred by its failure to offer financial protection in health to more than half of its citizens; this was both a result and a cause of the social inequalities that have marked the development process in Mexico. Several structural limitations have hampered performance and limited the progress of the health system. Conscious that the lack of financial protection was the major bottleneck, Mexico has embarked on a structural reform to improve health system performance by establishing the System of Social Protection in Health (SSPH), which has introduced new financial rules and incentives. The main innovation of the reform has been the Seguro Popular (Popular Health Insurance), the insurance-based component of the SSPH, aimed at funding health care for all those families, most of them poor, who had been previously excluded from social health insurance. The reform has allowed for a substantial increase in public investment in health while realigning incentives towards better technical and interpersonal quality. This paper describes the main features and initial results of the Mexican reform effort, and derives lessons for other countries considering health-system transformations under similarly challenging circumstances.

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,

References (34)

  • E González-Pier et al.

    Priority setting for health interventions in Mexico's System of Social Protection in Health

    Lancet

    (2006)
  • J Frenk et al.

    Health transition in middle-income countries: new challenges for health care

    Health Pol Plann

    (1989)
  • Programa Nacional de Salud 2001–2006. La democratización de la salud en México. Hacia un sistema universal de salud

    (2001)
  • J Frenk et al.

    Fair financing and universal protection: the structural reform of the Mexican health system

    (2004)
  • F Knaul et al.

    Evidence is good for your health system: policy reform to remedy catastrophic and impoverishing health spending in Mexico

    Lancet

    (2006)
  • Salud: México 2001. Información para la rendición de cuentas

    (2002)
  • FM Knaul et al.

    Preventing impoverishment, promoting equity and protecting households from financial crisis: universal health insurance through institutional reform in Mexico. Working Paper

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