The democratization of health in Mexico: financial innovations for universal coverage

Page created by Jonathan Miranda
The democratization of health in Mexico: financial innovations
for universal coverage
Julio Frenk,a Octavio Gómez-Dantés b & Felicia Marie Knaul c

    Abstract In 2003, the Mexican Congress approved a reform establishing the Sistema de Protección Social en Salud [System of
    Social Protection in Health], whereby public funding for health is being increased by one percent of the 2003 gross domestic product
    over seven years to guarantee universal health insurance. Poor families that had been excluded from traditional social security can
    now enrol in a new public insurance scheme known as Seguro Popular [People’s Insurance], which assures legislated access to a
    comprehensive set of health-care entitlements. This paper describes the financial innovations behind the expansion of health-care
    coverage in Mexico to everyone and their effects. Evidence shows improvements in mobilization of additional public resources;
    availability of health infrastructure and drugs; service utilization; effective coverage; and financial protection. Future challenges are
    discussed, among them the need for additional public funding to extend access to costly interventions for non-communicable diseases
    not yet covered by the new insurance scheme, and to improve the technical quality of care and the responsiveness of the health
    system. Eventually, the progress achieved so far will have to be reflected in health outcomes, which will continue to be evaluated so
    that Mexico can meet the ultimate criterion of reform success: better health through equity, quality and fair financing.

    Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. .‫الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة‬

Introduction                                                                                           Background
Institutional arrangements for sufficient, efficient, sustain-                                         In the mid-1990s, Mexico developed a system of national
able and fair financing are a major determinant of health                                              health accounts. This system showed, quite surprisingly, that
                                                                                                       more than half of the total national health expenditure was
system performance. Because of technical complexities, politi-
                                                                                                       out-of-pocket because approximately half of the country’s
cal sensitivities and ethical implications, the solution to the
                                                                                                       population lacked health insurance.8 By applying methods
main financing challenges faced by health sectors has been
                                                                                                       from The world health report 2000 to a series of national in-
elusive. It is therefore necessary to design and implement
                                                                                                       come and expenditure surveys, researchers were able to show
policies based on evidence about which arrangements work
                                                                                                       that these high levels of out-of-pocket spending were expos-
best, especially in developing countries. This paper seeks to
                                                                                                       ing Mexican households to catastrophic financial events. In
contribute to this aim by describing a recent example of suc-
                                                                                                       2000, an estimated 3 to 4 million Mexican families incurred
cessful reform.                                                                                        catastrophic or impoverishing health expenditures.9 As a re-
     In 2003, a large majority of the Mexican Congress ap-                                             sult, Mexico did very poorly on the international comparative
proved a reform to the Mexico’s Ley General de Salud [General                                          analysis of fair financing, even though it performed relatively
Health Law] establishing the Sistema de Protección Social en                                           well in other areas of health system performance designated
Salud [System of Social Protection in Health], which is                                                by WHO for The world health report 2000.10
increasing public funding to guarantee universal health-care                                                Mexico’s poor results led policy-makers from the Minis-
coverage. Poor families formerly excluded from traditional                                             try of Health (MoH) to focus on health system financing and
social security can now enrol in the Seguro Popular [People’s                                          triggered national and sub-national analyses that showed a
Insurance], a new public insurance scheme that assures legis-                                          concentration of impoverishing health expenditures in poor
lated access to comprehensive health care.                                                             and uninsured households.11 Careful analyses also identified
     In this paper we describe the financial innovations linked                                        the existence of five financial imbalances, documented later
with the expansion of health-care coverage in Mexico. Since                                            in this paper, that kept the health system from mobilizing
previous papers have described what led to the reform and                                              the additional resources needed to face the epidemiological
how it was implemented,1–7 we focus on its initial effects on                                          transition, with its increase in non-communicable diseases
the mobilization of additional public resources, the availabil-                                        and injuries requiring costly management.12,13
ity of health infrastructure and basic inputs, service utiliza-                                             The above evidence boosted the advocacy required to
tion, effective health-care coverage and financial protection.                                         promote a major legislative reform establishing the Sistema
Obstacles and future challenges surrounding the reform are                                             de Protección Social en Salud, whereby public funding is being
also discussed.                                                                                        increased by 1% of the 2003 gross domestic product (GDP)

  Harvard School of Public Health, Boston, MA, United States of America.
  National Institute of Public Health, No. 655 Colonia Santa María Ahuacatitlan, Cerrada Los Pinos y Caminera, CP 62100, Cuernavaca, MO, Mexico.
  Mexican Health Foundation, Mexico, DF, Mexico.
Correspondence to Octavio Gómez-Dantés (e-mail:
(Submitted: 15 March 2008 – Revised version received: 31 October 2008 – Accepted: 11 November 2008 – Published online: 25 May 2009 )

542                                                                                                              Bull World Health Organ 2009;87:542–548 | doi:10.2471/BLT.08.053199
Policy & practice
Julio Frenk et al.                                                                                        Democratization of health in Mexico

over seven years to provide universal               para la Comunidad [Fund for Commu-           health interventions that all citizens,
health insurance. Over a phase-in                   nity Health Services] is used to finance     regardless of their occupation or socio-
period of seven years, this will provide            public health services (health promo-        economic status, should receive and can
access to formal social insurance, to               tion, immunization and epidemiological       legally demand.14 The new Ley General
the 45 million Mexicans who had                     surveillance and the control of diseases,    de Salud clearly states that Seguro Popu-
been excluded from it in the past. A                including communicable ones such as          lar beneficiaries will have access to all
large proportion of this population                 HIV/AIDS, tuberculosis and malaria).         health interventions included in both
formerly received care at MoH care                  The rationale behind such funding is         packages and to the drugs required. In
centres on a welfare basis and benefits             the lack of spontaneous demand for           fact, upon becoming affiliated, families
varied enormously, from a relatively                public health services, known in eco-        receive a Carta de Derechos y Obligacio-
large package of services in the largest            nomics as positive externalities.            nes [Charter of Rights and Duties] that
cities of the wealthy northern states to                 In contrast, funding for personal       lists the health interventions to which
a basic set of preventive interventions             services is based on an insurance logic,     they are entitled.
for the poor in the rural south. The                which deals with uncertainty. The Se-              The FPGC, in turn, covers a pack-
new Seguro Popular scheme guarantees                guro Popular is the insurance instrument     age of services that are selected using
access to a package of 255 health inter-            devised to finance these services under      cost, effectiveness and social acceptabil-
ventions targeting more than 90% of                 the reform. For financing purposes,          ity criteria. To date, this fund finances
the causes leading to service demand                personal health services derive from         18 interventions, including neonatal
in public outpatient units and general              two sources: a package of essential          intensive care and the management
hospitals, and a package of 18 costly               interventions provided in outpatient         of paediatric cancers, cervical cancer,
interventions. Most interventions are               settings and general hospitals and           breast cancer and HIV/AIDS. 15 The
provided by the service networks of the             financed through a fund for personal         new Ley General de Salud stipulates
state ministries of health, which have              health services, and a package of high-      that both packages must be progres-
                                                    cost, specialized interventions financed     sively expanded and updated annually
their own outpatient units and hospi-
                                                    through the Fondo de Protección contra       on the basis of changes in epidemiologi-
tals, and hire their own salaried health
                                                    Gastos Catastróficos [Fund for Protec-       cal profile, technological developments
staff, including physicians and nurses.
                                                    tion against Catastrophic Expenditures,      and resource availability. Fig. 1 describes
These same networks provide services to
                                                    FPGC].                                       the resources allocated to the Seguro
the uninsured population. However, for
                                                         At present, 255 health interven-        Popular, including federal, state and
those affiliated with the Seguro Popular,
                                                    tions and their respective drugs are         family contributions.
services are free of charge at the time             included in Mexico’s Catálogo Universal            The Seguro Popular will offer cov-
of delivery and include the drugs pre-              de Servicios Esenciales de Salud [Univer-    erage to all Mexicans not protected by
scribed. By the end of 2007, 20 million             sal List of Essential Health Services],      any other public insurance scheme:
people in Mexico were Seguro Popular                designed to cover practically all the        the self-employed, those who are out
beneficiaries.                                      interventions in demand in outpatient        of the labour market and those in the
                                                    units and general hospitals of the           informal sector of the economy. Since
Financial innovations                               MoH. Some may ask why a package              it is a public insurance scheme, differ-
                                                    was developed, rather than includ-           ences in risk status are not considered
Central to the financial innovations
                                                    ing all interventions sought in these        for affiliation, so there is no danger
linked to Mexico’s recent health reform
                                                    health units. The reasons are three.         that low-risk families will be exclusively
is the separation of funding for personal
                                                    First, the intervention package serves       selected (“cream skimming”). The vast
or clinical health services and health-
                                                    as a blueprint to estimate the resources     aggregation of risks also eliminates the
related public goods. Such separation               required to strengthen health service        potential problem of adverse selection,
is intended to protect public health                provision through three master plans         which is common when risk pooling is
interventions within a reform frame-                for long-term investments in infrastruc-     not large enough.
work in which subsidies are granted                 ture, medical equipment and health                 Affiliation to the Seguro Popular
in response to the demand for health                personnel. Second, the package is used       is voluntary, yet the reform includes
care, to the potential neglect of public            as a quality assurance tool designed to      incentives for expanding coverage.
health services.                                    ensure that all necessary services are of-   States have an incentive to affiliate the
      In the Sistema de Protección So-              fered in accordance with standardized        entire population because their budget
cial en Salud, funds are allocated into             protocols. Under the new Ley General         is based on an annual, per family fee.
four components: (i) stewardship,                   de Salud, no facility providing services     Further, families not affiliated by 2010
information, research and develop-                  can participate in the insurance scheme      will still receive health care through
ment; (ii) community health services;               unless it is accredited, and accreditation   public providers but will have to pay
(iii) non-catastrophic, personal health             is given only if they have the required      user fees at the point of service delivery.
services; and (iv) high-cost personal               resources to provide the stipulated in-      The voluntary nature of the affiliation
health services. Stewardship functions,             terventions. Finally, the package is used    process is an essential feature of the re-
health research, the generation and                 to empower people by making them             form that helps democratize the budget
dissemination of information, and hu-               aware of their entitlements. According       by introducing an element of choice. It
man resource development are financed               to Brachet-Márquez, to make health           discourages adverse selection and pro-
through the regular budget of the MoH,              care a social right, what is needed,         vides incentives not only for universal
while the Fondo de Servicios de Salud               above all, is a definition of the set of     coverage, but also for good quality and

Bull World Health Organ 2009;87:542–548 | doi:10.2471/BLT.08.053199                                                                        543
Policy & practice
 Democratization of health in Mexico                                                                                                             Julio Frenk et al.

efficiency. Families will not re-affiliate
                                               Fig. 1. Seguro Popular [People’s Insurance] budget by type of contribution, Mexico,
unless a minimum level of quality and                  2004–2007
responsiveness is guaranteed, while
wasteful care delivery would also limit                                   3 500
the ability to provide all the benefits                                           Federal   State    Family    Total
covered.                                                                  3 000

                                               Budget (millions of US$)
      Seguro Popular funding follows a
                                                                          2 500
tripartite logic of financial responsibili-
ties and rights, much like the funding                                    2 000
for Mexico’s two major social security
                                                                          1 500
agencies: the Instituto Mexicano del Se-
guro Social [Mexican Institute for Social                                 1 000
Security, IMSS] and the Instituto de
Seguridad y Servicios Sociales de los Tra-                                 500
bajadores del Estado [Institute of Social
Security for Government Employees,                                                 2004                2005                 2006                 2007
ISSSTE]. These agencies are financed
through social contributions, based            US$, United States dollars.
on the right of citizenship, obtained          Adapted from reference 23.
through (i) general taxes, (ii) the em-
ployer (with the government being the
                                              to fund the essential package of health                              absolute and relative terms. Nonethe-
employer in the case of ISSSTE), and
                                              services. State solidarity and family con-                           less, it has risen slowly but consistently
(iii) the employee (in the form of an
                                              tributions are collected at the state level                          over the last two decades. Expenditure
amount tied to income).
                                              and remain there, and they are also used                             for health increased from 4.8% of the
      The Seguro Popular has a similar
                                              to fund the essential package.                                       GDP in 1990 to 5.6% in 2000 and to
financial structure. It is financed, first,
                                                   Funding for the states is thus                                  6.5% in 2006.17,18 The increase gener-
through a social contribution from
                                              largely determined by the number                                     ated in this last period was due mainly
the federal government. Second, since
                                              of families affiliated with the Seguro                               to the mobilization of additional public
there is no employer, financial co-
                                              Popular and is thus demand-driven.                                   resources, mostly in connection with
responsibility is established between
                                              Formerly, federally-allocated state bud-                             the reform.
the federal and state governments to
generate the so-called federal and state      gets for health were largely determined                                    The substantial increase in public
solidarity contributions. The third con-      by inertia, the size of the health sector                            funding is closing the gap between pub-
tribution comes from families and is          payroll and political negotiations.                                  lic and private financing of the national
tied to income, as in the case of social                                                                           health system. Public health expen-
security institutions. Families in the two    Initial effects of the reform                                        diture as a percentage of total health
lowest tenths of the income distribu-                                                                              expenditure increased from 43.8% in
                                              The initial results of the reform are                                2002 to 46.4% in 2006.19 Given the
tion do not contribute. Annual family         promising. Public resources for health
contributions range from 60 United                                                                                 anticipated increase in funding linked
                                              have increased and are being distrib-                                to the expansion of the Seguro Popular,
States dollars (US$) for families in the
                                              uted more fairly; the number of Seguro                               public health expenditure is expected
lowest three-tenths of the income dis-
                                              Popular beneficiaries has reached 20                                 to continue to increase at a higher rate
tribution to US$ 950 for families in the
                                              million; availability of health personnel,                           than private expenditure. Projections
uppermost tenth.
                                              facilities and drugs has increased; access                           based on the annual growth in affilia-
      Funding for the Seguro Popular
                                              and utilization of health-care services                              tion stipulated in the law and on recent
is divided between federal and state
                                              have expanded; and financial protection                              trends in private expenditure suggest
governments. The FPGC equals 8% of
                                              indicators have improved. Most of the                                that public health financing will out-
the federal social contribution plus the
                                              data documenting this progress comes                                 grow private financing and that by
federal and state solidarity contribu-
                                              from the results of a comprehensive                                  2010 a much better balance between the
tions. Another fund, equivalent to 2%
                                              external evaluation that included a com-                             two sources will have been attained.20
of the sum of the social quota and the
federal and state contributions, is used      munity trial module.16                                                     A much larger proportion of the
to build health infrastructure in poor                                                                             additional public resources is currently
communities. A third reserve fund             Financial imbalances                                                 being allocated to institutions caring
worth 1% of the total was designed            Health expenditure in Mexico remains                                 for the population without access to
to cover unexpected fluctuations in           low when compared with the Latin                                     social security (including Seguro Popular
demand and temporarily overdue inter-         American average (6.9% of the GDP)                                   beneficiaries). The budget of the MoH
state payments. These three funds are         and in light of the demands gener-                                   increased 72.5% in real terms between
managed at the federal level to assure        ated by an epidemiological transition                                2000 and 2006, while the budget of
adequate risk pooling.                        in which non-communicable diseases,                                  the IMSS and ISSSTE grew 35% and
      The remaining social contribution       which are more difficult and costly to                               45%, respectively.19,21 This differential
and the federal and state solidarity con-     treat than common infections and re-                                 increase in the budgets of the major
tributions are allocated to the states        productive problems, are increasing in                               health and social security institutions

544                                                                                            Bull World Health Organ 2009;87:542–548 | doi:10.2471/BLT.08.053199
Policy & practice
Julio Frenk et al.                                                                                       Democratization of health in Mexico

is closing the gaps that existed in the                  These figures have improved. In        Health service utilization and
allocation of public health financing               2006 the population with social security    effective coverage
for different segments of the popula-               increased to 48.9 million and Seguro        Studies show that health service uti-
tion. The ratio of the per capita public            Popular beneficiaries reached 15.6 mil-     lization patterns have also improved
expenditure for people covered by so-               lion, while the number of individuals       in Mexico after health sector reform.
cial security agencies to the per capita            covered by private health insurance         One study that looked at data from
expenditure for the uninsured declined              rose to 5.3 million.18 As already men-      the 2005-2006 Encuesta Nacional de
from 2.5 in 2000 to 2.0 in 2006 and                 tioned, Seguro Popular beneficiaries had    Salud y Nutrición [National Health and
will continue to fall with the legislated           reached 20 million by the end of 2007,      Nutrition Survey] showed that Seguro
growth in the Seguro Popular.                       according to the most recent data from      Popular beneficiares are more likely to
     Inequities in the distribution of              the MoH. Most of these families were        use health services based on perceived
public resources among states are also              previously uninsured: 96.9% belong          need than uninsured individuals.6 This
declining. Between 2000 and 2006, the               to the two lowest tenths of the income      same study showed a link between af-
difference in the per capita allocation             distribution, 35.2% are rural families      filiation and service utilization: all else
of public resources between the state               and close to 8.2% are families from in-     being the same, a rise in affiliation to
receiving the largest allocation and the            digenous communities.23 Interestingly,      the Seguro Popular from 0% to 20% was
state receiving the lowest decreased                more than 23% are families headed by        associated with a rise in service utiliza-
by five to four times.19 In the reform              women. Thanks to the Seguro Popular,        tion from 58% to 64%. An increase in
period, there was also less variation               Mexico is on track to attain universal
in the states’ contribution to health                                                           service utilization was also noted based
                                                    health insurance by 2010, as stipulated     on MoH hospital discharge data.
care financing, as shown by a drop in               in the law that launched the current
the variation coefficient from 1.14 to                                                                According to a similar study based
                                                    reform.                                     on data from the 2006 National Sat-
1.11.19 Finally, public funding allocated
to investment in health infrastructure                                                          isfaction and Responsiveness Survey
                                                    Health infrastructure and drug              implemented in 74 hospitals nation-
has increased. In the MoH, the share                availability
of the budget allocated to such invest-                                                         wide, Seguro Popular beneficiaries are
ment grew from 3.8% in 2000 to 9.1%                 As previously mentioned, one major          more likely to seek hospital services
in 2006.19                                          objective of the reform was to increase     for elective surgeries, diabetes and hy-
                                                    investment in health infrastructure,        pertension than the uninsured.26 The
Insurance coverage                                  which had decreased consistently over       Seguro Popular has had an even greater
                                                    the two previous decades. The propor-       effect on service utilization for the
The mobilization of additional public               tion of the MoH health budget devoted       management of leukaemia in children,
resources for the Seguro Popular cre-
                                                    to investment increased from 3.8% in        one of the catastrophic interventions
ated the financial conditions required
                                                    2000 to 9.1% in 2006, and because of        covered by the FPGC. This effect was
to expand health insurance coverage in
                                                    this, the MoH was able to construct         also found in the study mentioned in
Mexico. As a result, the population with
                                                    751 outpatient clinics and 104 hospi-       the previous paragraph.6
social protection in health increased
                                                    tals, including high-specialty hospitals          Actual service delivery can be
20% between 2003 and 2007.
                                                    in the poorest states, between 2001 and     measured more precisely through ef-
      Because social security agencies
                                                    2006.24 In the public sector as a whole,    fective coverage, a metric that has been
lacked a nominal census, the size of
the population with health insurance                1054 outpatient clinics, 124 general        recently used in Mexico for key inter-
had to be estimated using several other             hospitals and 10 high-specialty hospi-      ventions.4,27 For 11 indicators (delivery
sources, including population censuses              tals were built in the same period.         of skilled birth attendance; antenatal
and surveys. When this was done for the                  The availability of basic inputs in    care; bacille Calmette–Guérin, diph-
first time in 2004, the results showed              the public sector has also improved.        theria–tetanus–pertussis and measles
that the number of beneficiaries of                 During the reform period, regular ex-       immunization; treatment of premature
social security agencies (mainly the                ternal measurements of the availability     neonates, diarrhoea and acute respira-
IMSS and ISSSTE, plus other smaller                 of drugs in public institutions were        tory infections; Papanicolaou screen-
entities for the armed forces, oil work-            carried out. In 2002, only 55% of the       ing for cervical cancer; management
ers and local government employees)                 prescriptions issued in MoH outpatient      of hypertension and mammography)
amounted to 47.7 million, or 45.4%                  clinics were fully filled. By 2006, this    it was possible to compare measure-
of the total population.22 IMSS and                 figure had increased to 79% in MoH          ments for 2000 and 2005–2006 using
ISSSTE beneficiaries comprised 80%                  outpatient clinics in general and to        data from the National Health Survey
and 16.7% of this figure, respectively.             89% in MoH outpatient clinics serving       and hospital discharge records. Results
During its first year of operation, the             Seguro Popular beneficiaries.25 In some     showed that national coverage has
Seguro Popular had already enrolled 5.3             states, 97% of the prescriptions issued     increased for most of the 11 interven-
million people, for a total of 53 million           in outpatient clinics serving Seguro        tions.4 Coverage for mammography,
insured individuals. If to this we add              Popular beneficiaries were fully filled.    cervical cancer screening, skilled birth
the 5 million people covered by pri-                In 2006, the percentage of prescrip-        attendance, management of premature
vate health insurance, many of whom                 tions issued in social security institute   birth and treatment of hypertension
were also social security beneficiaries,            outpatient clinics that were fully filled   showed important increases. Also, Se-
45 million Mexicans still lacked health             was consistently above 90, as opposed       guro Popular beneficiaries were found
insurance in 2004.                                  to less than 70 in 2002.                    to have significantly higher levels of

Bull World Health Organ 2009;87:542–548 | doi:10.2471/BLT.08.053199                                                                       545
Policy & practice
 Democratization of health in Mexico                                                                                         Julio Frenk et al.

coverage for mammography, cervical          a health reform that made health care             ticularly in rural, dispersed and in-
cancer screening and management of          a legal right, as prescribed by amend-            digenous communities in Mexico’s
childhood acute respiratory infections      ment to the Mexican Constitution in               southern states. A large proportion of
and hypertension than the uninsured.6       1983. Through the new Seguro Popular,             the resources mobilized by the Seguro
                                            by 2010 high-quality health care will             Popular must be directed towards these
Financial protection                        have been extended to everyone in                 communities to strengthen health
Protecting the population against cata-     Mexico. Thus, the democratization of              infrastructure and the availability of
strophic health expenditures was one        health care – defined as the application          human resources and basic inputs.
of the key goals of the reform process.     of democratic norms and procedures                Another challenge facing the reformed
Several studies show that this objective    to individuals deprived of the ben-               system is how to achieve an adequate
is being met. According to a study          efits and duties of citizenship, such as          balance between additional investments
based on data from Encuestas de Ingresos    women, youngsters, ethnic minorities              in health promotion and disease pre-
y Gastos de los Hogares [National House-    or workers of the informal sector of the          vention, on the one hand, and personal
hold Income and Expenditure Surveys]        economy 29 – will have been attained.             curative health services on the other.
that traced trends in catastrophic and           This paper has provided evidence             Finally, the Seguro Popular has also
impoverishing payments for health           that the financial innovations linked to          been criticized for further segment-
care from 1992 to 2005, all indicators      the Sistema de Protección Social en Salud         ing the health system. We would like
of financial protection have improved       are improving insurance coverage, the             to stress that this is a temporary situ-
since 2000.5                                availability of health infrastructure and         ation. Given the financial restrictions
     Another study based on data from       basic health inputs, health-service uti-          the country faced in 2003, the national
the 2005-2006 Encuesta Nacional de          lization, effective health-care coverage,         Congress decided to phase affiliation
Salud y Nutrición showed that the Se-       and the levels of financial protection            to the Seguro Popular over a seven-year
guro Popular has had a protective effect    enjoyed by the Mexican population,                period. However, by 2010 the health
against catastrophic expenditures, both     especially among the poor. However,               system will be, in fact, less fragmented;
at the population level and in a sub-       Mexico continues to face important                three public insurance schemes having
group of households that reported hav-      challenges, mainly in connection with             a similar financial structure will provide
ing used outpatient or inpatient services   emerging diseases. Disease control ef-            services to the entire population.
in the two weeks preceding the survey.6     forts before the epidemiological transi-
                                                                                                    The new Ley General de Salud also
     Most importantly, a large commu-       tion yielded important improvements,
                                                                                              provides for the cross-utilization of ser-
nity trial developed to evaluate, among     but as immunization coverage increased
                                                                                              vices among beneficiaries of the differ-
other things, the effect of the Seguro      and deaths from diarrhoea, acute re-
                                                                                              ent health agencies. In fact, the Seguro
Popular on financial protection showed      spiratory infections and reproductive
                                                                                              Popular is already buying services for its
similar results. This evaluation, devel-    events dropped, non-communicable
                                                                                              beneficiaries from the IMSS-Oportuni-
oped by a group from Harvard Univer-        diseases began to take a proportionately
                                                                                              dades programme and will probably do
sity and Mexico’s National Institute of     larger toll. As a result, there is a critical
                                            need for additional public funding to             the same with IMSS and ISSSTE. In the
Public Health, showed that this insur-                                                        near future, this should culminate in the
ance scheme provides protection against     extend access to costly interventions for
                                            non-communicable health conditions                financial integration of the system.
catastrophic and impoverishing health                                                               Eventually, the progress achieved
expenditures in communities where the       not yet covered by the FPGC, such as
                                            cardiovascular diseases, adult cancers            so far in mobilizing additional re-
Seguro Popular is being implemented.28                                                        sources, insurance coverage, service
More specifically, the study showed         and the complications of diabetes. The
                                            benefits offered by the Seguro Popular            delivery and quality of care will be
an important decrease in catastrophic                                                         reflected in health outcomes. These will
expenditure among households affili-        in public outpatient clinics and general
                                            hospitals are very similar to those pro-          continue to be evaluated to ensure that
ated to this public insurance when two
                                            vided by comparable services in social            Mexico meets the ultimate criterion of
different thresholds for catastrophic
                                            security agencies. However, there is still        successful health reform: better health
expenditure were used (30% and 40%
                                            a need to extend the coverage of costly           through equity, excellent quality and
of disposable income). The same study
                                            interventions, which is still higher at           fair financing. ■
suggested that the protective effect
may be due to reduced hospitalization       IMSS, ISSSTE and other social security
expenditure in these households. The        agencies.                                         Competing interests: Two of the au-
study allows these changes to be reason-         The quality of care is also expected         thors were directly involved in the
ably attributed to the Seguro Popular,      to improve further, but not unless                design and implementation of the re-
an encouraging finding in light of the      several areas are further strengthened:           form, which is the subject of this paper;
short period (11 months) that trans-        the technical quality of care; drug avail-        one (Frenk) as Minister of Health of
pired between baseline and follow-up        ability, especially in hospitals; prescrip-       Mexico, and the other (Gómez-Dantés)
measurements.                               tion patterns; care availability during           as Director General for Performance
                                            evenings and weekends in outpatient               Evaluation at the Ministry of Health.
                                            clinics and emergency services; and               The third author (Knaul) also provided
Conclusion                                  waiting times for outpatient emergency            continuous external support to several
In Mexico, important strides have been      care and elective interventions.                  of the reform initiatives.
made in increasing people’s access to            Narrowing gaps in access to health
comprehensive health care, thanks to        services also remain a challenge, par-

546                                                                        Bull World Health Organ 2009;87:542–548 | doi:10.2471/BLT.08.053199
Policy & practice
Julio Frenk et al.                                                                                                              Democratization of health in Mexico

Démocratisation de la santé au Mexique : innovations financières en faveur de la couverture universelle
En 2003, le Congrès mexicain a approuvé une réforme instaurant                        de disponibilité des infrastructures de santé et des médicaments,
le Sistema de protección social en Salud (Système de protection                       d’utilisation des services, d’efficacité de la couverture et de protection
sociale de la santé) et conduisant à une augmentation du                              financière. L’article évoque les défis à surmonter dans l’avenir, et
financement public de la santé de 1 % du produit intérieur brut                       notamment les besoins en fonds publics supplémentaires pour
de 2003 sur sept ans pour assurer la mise en place de la sécurité                     élargir l’accès à des interventions coûteuses contre des maladies
sociale universelle. Les familles pauvres jusque là exclues de la                     non transmissibles pas encore couvertes par le nouveau schéma
sécurité sociale traditionnelle peuvent maintenant bénéficier d’un                    d’assurance et pour améliorer la qualité technique des soins et la
nouveau schéma d’assurance publique, appelé Seguro Popular                            capacité de réponse du système de santé. Enfin, les progrès réalisés
(Assurance du peuple), qui garantit un accès régi par la loi à un                     jusqu’à présent devront se refléter dans les résultats sanitaires, qui
ensemble complet de présentations de santé. L’article présente                        continueront d’être évalués de manière à ce que le Mexique puisse
les innovations financières qui ont permis cet élargissement à                        remplir l’ultime critère de succès de la réforme : une meilleure
tous les Mexicains de la couverture par les soins de santé, ainsi                     santé grâce à l’équité, à la qualité et à la justice dans l’affectation
que leurs effets. Certains éléments attestent d’améliorations en                      des fonds.
matière de mobilisation de ressources publiques supplémentaires,

Democratización de la salud en México: innovaciones financieras para implantar la cobertura universal
En 2003, el Congreso de México aprobó una reforma por la que                          medicamentos; el uso de los servicios; la eficacia de la cobertura, y
se creó el Sistema de Protección Social en Salud, en virtud del                       la protección financiera. Se analizan algunos retos futuros, entre ellos
cual se aumenta la financiación pública de la salud en un uno por                     la necesidad de financiación pública adicional para ampliar el acceso
ciento del producto interno bruto de 2003 a lo largo de siete años                    a intervenciones costosas para enfermedades no transmisibles aún
a fin de implantar el seguro médico universal. Las familias pobres                    no cubiertas por el nuevo sistema de seguro, así como para mejorar
hasta entonces excluidas de la seguridad social tradicional pueden                    la calidad técnica de la atención y la capacidad de respuesta del
ahora integrarse en un nuevo sistema de seguro público conocido                       sistema de salud. A la larga, los progresos conseguidos hasta ahora
como Seguro Popular, que garantiza por ley el acceso a un amplio                      deberán reflejarse en los resultados sanitarios, que seguirán siendo
conjunto de prestaciones de salud. En este artículo se describen las                  evaluados para que México pueda cumplir el criterio último de éxito
innovaciones financieras que han permitido expandir la cobertura                      de la reforma, esto es, el logro de una mejor salud mediante una
sanitaria en México a toda la población, así como sus efectos. Los                    mayor equidad y calidad y una financiación justa.
datos disponibles muestran mejoras en la movilización de recursos
públicos adicionales; la disponibilidad de infraestructura sanitaria y

                                                          ‫ املبادرات التمويلية للتغطية الشاملة‬:‫إضفاء السامت الدميوقراطية عىل الصحة يف املكسيك‬
‫ واالنتفاع‬،‫ وتوفري البنية التحتية للصحة واألدوية‬،‫إضافية من القطاع العام‬               ‫ صادق الكونغرس املكسييك عىل إصالحات يف نظام الحامية‬2003 ‫يف عام‬
‫ وقد نوقشت التحديات‬.‫ والحامية التمويلية‬،‫ والتغطية الف َّعالة‬،‫بالخدمات‬                 ‫ ووفقاً لذلك سيزداد متويل القطاع العام للصحة مبقدار‬،‫االجتامعية للصحة‬
‫املستقبلية ومن بينها الحاجة إىل متويل إضايف من القطاع العام لتوسيع‬                    ‫ سنوات لتوفري الضامن الصحي‬7 ‫ من الناتج املحيل اإلجاميل عىل مدى‬1%
‫اإلتاحة للتدخالت العالية التكاليف لألمراض غري السارية التي مل تتم تغطيتها‬             ‫ وقد أصبح مبقدور األرس الفقرية التي كانت مستبعدة من الضامن‬.‫الشامل‬
‫ ومدى‬،‫ ولتحسني الجودة التقنية للرعاية‬،‫بعد بالخطة الجديدة للضامن‬                       ‫االجتامعي التقليدي أن تستفيد من الخطة الجديدة للضامن االجتامعي‬
‫الـم ْح َرز حتى‬
           ُ ‫ ينبغي أن ينعكس التقدُّ م‬،‫ ويف النهاية‬.‫استجابة النظام الصحي‬              ‫واملعروفة بالضامن الشعبي؛ وهو أمر يضمن اإلتاحة املرشوعة ملجموعة شاملة‬
‫ والتي سيتواصل تقييمها حتى تتمكن املكسيك يف‬،‫اآلن عىل الحصائل الصحية‬                   ‫ وتصف هذه الورقة مبادرات متويلية‬.‫من االستحقاقات يف الرعاية الصحية‬
‫ الوصول إىل رعاية‬:‫نهاية األمر من تحقيق املعايري القصوى لنجاح اإلصالحات‬                ‫ وما يؤدي إليه‬،‫تدعم التوسع يف الرعاية الصحية يف املكسيك لتشمل الجميع‬
                         .‫صحية أفضل من حيث الجودة والعدالة والتمويل‬                   ‫ وقد أظهرت الب ِّينات جوانب التحسني يف استجالب موارد‬.‫ذلك من تأثريات‬

1.   Frenk J. Bridging the divide: global lessons from evidence-based health policy   3.   González-Pier E, Gutiérrez-Delgado C, Gretchens S, Barraza-Llorenz M,
     in Mexico. Lancet 2006;368:954-61. PMID:16962886 doi:10.1016/S0140-                   Porras-Condey R, Carvalho N, et al. Priority setting for health interventions in
     6736(06)69376-8                                                                       Mexico’s System for Social Protection in Health. Lancet 2006;368:1608-18.
2.   Frenk J, González-Pier E, Gómez-Dantés O, Lezana MA, Knaul MF.                        PMID:17084761 doi:10.1016/S0140-6736(06)69567-6
     Comprehensive reform to improve health system performance in Mexico.             4.   Lozano R, Soliz P, Gakidou E, Abbot-Klafter J, Feehan DM, Vidal C, et al.
     Lancet 2006;368:1524-34. PMID:17071286 doi:10.1016/S0140-                             Benchmarking of performance of Mexican states with effective coverage.
     6736(06)69564-0                                                                       Lancet 2006;368:1729-41. PMID:17098091 doi:10.1016/S0140-

Bull World Health Organ 2009;87:542–548 | doi:10.2471/BLT.08.053199                                                                                                     547
Policy & practice
 Democratization of health in Mexico                                                                                                                 Julio Frenk et al.

5.    Knaul FM, Arreola-Ornelas H, Méndez-Carniado O, Bryson-Cahn C, Barofsky J,     16. Mexico, Secretaría de Salud. Sistema de Protección Social en Salud:
      Maguire R, et al. Evidence is good for your health system: policy reform to        estrategia de evaluación. Mexico, DF: Secretaría de Salud; 2006.
      remedy catastrophic and impoverishing health spending in Mexico. Lancet        17. Organisation for Economic Co-operation and Development. OECD reviews of
      2006;368:1828-41. PMID:17113432 doi:10.1016/S0140-6736(06)69565-2                  health systems: Mexico. Paris: OECD; 2005.
6.    Gakidou E, Lozano R, González-Pier E, Abbott-Klafter J, Barofsky JT,           18. Mexico, Secretaría de Salud. Programa Nacional de Salud 2007–2012. Por
      Bryson-Cahn C, et al. Assessing the effect of the 2001-06 Mexican health           un México sano: construyendo alianzas para una mejor salud. Mexico, DF:
      reform: an interim report card. Lancet 2006;368:1920-35. PMID:17126725             Secretaría de Salud; 2007.
      doi:10.1016/S0140-6736(06)69568-8                                              19. Vázquez VM, Merino MF, Lozano R. Cuentas en salud en México 2001-2005.
7.    Sepúlveda J, Bustreo F, Tapia R, Rivera J, Lozano R, Oláiz G, et al.               Mexico, DF: Secretaría de Salud; 2006.
      Improvement of child survival in Mexico: the diagonal approach. Lancet         20. Mexico, Secretaría de Salud. Sistema de Protección Social en Salud:
      2006;368:2017-27. PMID:17141709 doi:10.1016/S0140-6736(06)69569-X                  evaluación financiera. Mexico, DF: SS; 2006.
8.    Frenk J, Lozano R, González-Block MA. Economía y salud: propuestas para el     21. Gómez-Dantés O. 10 mitos sobre el Seguro Popular de Salud. Nexos
      avance del sistema de salud en México. Informe final. Mexico, DF: Fundación        2008;362.
      Mexicana para la Salud; 1994.                                                  22. Mexico, Secretaría de Salud. Salud: México, 2004. Mexico, DF: SS; 2005.
9.    Mexico, Secretaría de Salud. Programa Nacional de Salud 2001-2006. La          23. Comisión Nacional de Protección Social en Salud. Informe de resultados,
      democratización de la salud en México. Hacia un sistema universal de salud.        2007. Mexico, DF: CNPSS; 2008.
      Mexico, DF: Secretaría de Salud; 2001.                                         24. Presidencia de la República. Sexto informe de gobierno. Mexico, DF: PR;
10.   The world health report 2000. Health systems: improving performance.               2006.
      Geneva: World Health Organization; 2000.                                       25. Mexico, Secretaría de Salud. Evaluación del surtimiento de medicamentos
11.   Knaul F, Arreola H, Méndez O. Protección financiera en salud: México 1992-         a la población afiliada al Seguro Popular de Salud. In: Secretaría de Salud.
      2004. Salud Publica Mex 2005;47:430-9. PMID:16983988                               Sistema de Protección Social en Salud: evaluación de procesos. Mexico, DF:
12.   Frenk J, Knaul F, Gómez-Dantés O, González-Pier E, Hernández-Llamas H,             SS; 2006. pp. 59-78.
      Lezana MA, et al. Fair financing and universal protection: the structural      26. Mexico, Secretaría de Salud. Utilización de servicios y trato recibido por los
      reform of the Mexican health system. Mexico, DF: Ministry of Health; 2004.         afiliados al Seguro Popular de Salud. In: Secretaría de Salud. Sistema de
13.   Knaul FM, Frenk J. Health insurance in Mexico: achieving universal coverage        Protección Social en Salud: evaluación de procesos. Mexico, DF: Secretaría
      through structural reform. Health Aff 2005;24:1467-76. doi:10.1377/                de Salud; 2006. pp. 39-57.
      hlthaff.24.6.1467                                                              27. Mexico, Ministry of Health. Effective coverage of the health system in Mexico,
14.   Brachet-Márquez V. Ciudadanía para la salud: una propuesta. In: Uribe M,           2000-2003. Mexico, DF: MOH; 2006.
      López-Cervantes, eds. Reflexiones acerca de la salud en México. México, DF:    28. Mexico, Secretaría de Salud. Evaluación de efectos. In: Secretaría de Salud.
      Médica Sur, Editorial Panamericana; 2001. pp. 43-7.                                Sistema de Protección Social en Salud: evaluación de efectos. Mexico, DF:
15.   Seguro Popular de Salud [Internet site]. Available from: www.seguro_popular.       Secretaría de Salud; 2007. pp. 21-68. [accessed       29. O’Donnell G, Schmitter P. Transiciones desde un gobierno autoritario. Buenos
      on 19 May 2009].                                                                   Aires: Paidos; 1991.

548                                                                                         Bull World Health Organ 2009;87:542–548 | doi:10.2471/BLT.08.053199
You can also read