Health Care Delivery System: Mexico

Health Care Delivery System: Mexico ROBERTO CASTRO National Autonomous University of Mexico

After the Mexican Revolution (1910–1917), the Mexican state adopted a political constitution which declared a deep social orientation towards the policies of education, work, and health. However, for diverse historical reasons, it was not possible for Mexico to adopt a unified and coherent health system. On the contrary, the Mexican health system is characterized by its heterogeneity and disparity, both in terms of its financial resources and concerning the population which it serves. However, in the last decade significant efforts have been made to correct some of the most manifest imbalances, as well as to reduce gaps in the universal coverage of health services and to improve the health of the population as a whole. Thus here we provide a brief review of the history of the Mexican health system, outlining its most important features and the main challenges it faces today.

A SHORT HISTORY The health service in Mexico can be considered to originate in 1943, when President Manuel Avila Camacho declared the establishment of three institutions which are all very important today: the Ministry of Health and Welfare or Secretaría de Salubridad y Asistencia (SSA), from 1982 onwards simply called the Ministry of Health; the Mexican Social Security Institute or Instituto Mexicano

del Seguro Social (IMSS); and the Mexican Children’s Hospital. The SSA is the agency which heads the government health sector and defines policies emanating from the federal department. It also provides health services to that sector of the population which has no alternative to social security. The IMSS provides health services and social security to all formally registered workers and employees within the private sector. And the Mexican Children’s Hospital was the first of the 13 National Health Institutes now in existence in Mexico, which typically offer highly specialized services, seek to increase knowledge through research, and have a high impact both nationally and internationally. In 1960 President Adolfo Lopez Mateos decreed the creation of the Institute of Security and Social Services for State Workers or Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado (ISSSTE). This has a similar mission to the IMSS but specializes in serving public sector workers, that is, those who work in government institutions. In 1983 the Mexican Political Constitution was reformed to include in its fourth article the recognition of health as a universal right, so that the state was required to coordinate both federal and state levels, ensuring access to health services for all citizens. It was the first of a series of very important legal reforms that gave legal standing to the regulatory role currently played by the Mexican state in public health and health services. Finally, in 2003 the General Law of Health was amended to create the Social System for Health Protection or Sistema de Protección Social en Salud (SPSS), whose operational

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2 arm is the Popular Health Insurance or Seguro Popular. This reform sought to institutionally accommodate a broad sector of the Mexican population (known as the “open population”), the poorest in the country, without formal employment, and not protected by either the IMSS or the ISSSTE, who only received “assistance” type care from the Ministry of Health. The 2003 reform sought to regulate the inclusion of this large group within the health care system, imposing a framework of rights (Frenk et al. 2006).

CURRENT STRUCTURE OF THE MEXICAN HEALTH SYSTEM According to the 2010 census, the Mexican population had reached 112.3 million people. Over the last 100 years, the population dynamics of Mexico have been characterized by a steady decline in the mortality rate, from 27 deaths per 1000 inhabitants in 1930 to 4.9 per 1000 in 2008; a decrease in fertility, from 7 children per woman in 1970 to 2.1 in 2008; and an increase in life expectancy, from 34 years in 1930 to 75.1 years in 2008 (CONAPO 2011). Currently, the Mexican health system is divided into two large sectors: the public and the private. The institutions mentioned above constitute the public sector: the Ministry of Health or Secretaria de Salud (SS) along with the decentralized departments of this ministry in the various states, called State Health Services or Servicios Estatales de Salud (SESA); the Mexican Social Security Institute or Instituto Mexicano del Seguro Social (IMSS); the Opportunities Program IMSS– Oportunidades, which focuses on the poorest sectors in the country and operates via the Program to Combat Poverty, also known as Opportunities or Oportunidades (involving the transfer of monetary resources to the poorest families in the country, together with

the provision of health services and access to schooling for children); the Institute for Social Security and Services for State Workers or Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado (ISSSTE), as well as the State Social Security Institute or Institutos Estatales de Seguridad Social; and the health services of the National Ministry of Defense or Secretaria de la Defensa Nacional (SEDENA), the Navy (Semar), and Mexican Petroleum or Petroleos Mexicanos (PEMEX). As for the private sector, it is constituted by a network of hospitals and private outpatient clinics (which are accessed either by purchasing health insurance to cover greater expenses, or through direct payments for each visit or service), and also by the private health insurance companies. The Mexican health system aims to provide universal coverage for the entire population within the public sector, even though many prefer to use private services. This is because health is seen as a right which the state is obliged to provide. Within the public sector, the IMSS, the ISSSTE, and the health services of SEDENA, SEMAR, and PEMEX serve those who are employed in the formal sector of the economy, whether they be the employees of private companies (served by the IMSS) or employees of public institutions (served by the ISSSTE, SEDENA, SEMAR, and PEMEX). In 2010, according to official statistics, the population covered by IMSS (workers and their families, as well as retirees) was 52.3 million people (IMSS 2011), the ISSSTE covered 11.9 million people (ISSSTE 2011), and other institutions (SEDENA, SEMAR, and PEMEX) covered nearly one million people (Gomez-Dantes et al. 2011). Meanwhile, the Popular Health Insurance or Seguro Popular covers a very large sector of the Mexican population consisting of selfemployed workers, informal sector workers, and the unemployed, along with their families

3 and dependants. Official statistics for July 2011 showed that 49.1 million people were affiliated (Calderon 2011) out of a possible 51.3 million. This would seem to indicate that health service coverage has reached almost 100 percent of the Mexican population. However, more specialized studies indicate that this goal is far from being achieved. There is still a very large number of Mexicans (in 2008 an estimated 30 million people) without access to any form of social security (Frenk and Gomez-Dantes 2008). The above figures are  misleading because the Mexican health system has serious shortcomings, most notably the existence of two or more systems of coverage for certain sectors of the population (for example, there may be workers who are affiliated to the IMSS and also have private insurance, or workers who are affiliated to both the IMSS and the ISSSTE because they have two different jobs, and so on), whereas other sectors remain without protection of any kind. It is estimated that 25 percent of the population has dual coverage (Oláiz et  al. 2006). Some critics attribute this inconsistency of official data to outright manipulation on the part of the institutions themselves or the federal government (Laurell 2010a).

BENEFITS Social security institutions (IMSS, ISSSTE, SEDENA, SEMAR, PEMEX) offer similar coverage to their members, consisting of sickness and maternity insurance, occupational risk insurance, disability and life insurance, insurance for retirement and old age, various social benefits, child care, and other benefits. The Popular Health Insurance or Seguro Popular, however, offers only one package of 260 health interventions with associated medications, offered by all the State Health Services, and 18 high-cost interventions

(pediatric cancers, cervical-uterine cancer, breast cancer, and others) where patients are cared for in more specialized units.

FUNDING The IMSS has tripartite funding: employers, government, and workers. In the social security institutions this tripartite scheme is usually maintained, unless the employer is the government itself. In IMSS–Opportunities, targeted at the poorest sectors, the funding comes entirely from the government; and in the Popular Health Insurance or Seguro Popular the funding comes from the federal government, the State Health Services, and the affiliated individuals themselves. Only 20 percent, from the poorest sector, are exempt from payments and receive fully subsidized services.

HEALTH EXPENDITURE Specialists in the field (Gómez-Dantes et al. 2011) show that total expenditure on health as a percentage of gross domestic product (GDP) increased from 5.1 percent in 2000 to 5.9 percent in 2008. However, spending on health as a percentage of GDP is below the Latin American average (6.9 percent); countries with better figures are Argentina (which spends 9.8 percent of GDP), Uruguay (8.2 percent), Costa Rica (8.1 percent), and Colombia (7.4 percent). There has been a similar trend in per capita spending on health, which increased from US$508 in 2000 to US$890 in 2008. However, there are marked inequalities in this area, as per capita health spending is much higher among people with social security than among people without. Whereas most health spending remains private, there is a tendency towards increased public spending on health, which in 2008 represented almost 47 percent of the total. Partly

4 as a result of the expansion of the coverage of the Popular Health Insurance or Seguro Popular, there has been a gradual perceived decrease in the percentage of households that incur “catastrophic” health costs, that is, excessive expenses which lead to their ruin.

HOSPITAL INFRASTRUCTURE AND HEALTH PROFESSIONALS The most recent information on this subject dates from 2007. The fact that this information is so outdated indicates the difficulties faced by the Mexican health system in generating reliable and up-to-date statistics. During that year there were 23,858 health units (excluding private clinics), of which 4354 consisted of hospitals and the rest were outpatient units. Out of all these hospitals, 27 percent were in the public sector, while the remaining 73 percent were privately owned, mostly maternity units (SINAIS 2011; Frenk and Gomez-Dantes 2008). During that year there was a ratio of 0.75 beds per 1000 population (below the WHO recommendation of 1 bed per 1000). Likewise, the rate of doctors per 1000 inhabitants is 1.85 (below the WHO recommendation of 3 doctors per 1000). The rate of nurses nationwide is 2.2 per 1000 inhabitants, also below international recommendations. But apart from this deficiency, the Mexican health system also has a large imbalance in terms of the distribution of resources. There are cities with a high concentration of medical and paramedical staff, whereas it is still very difficult to supply doctors to rural and to more marginalized areas of the country. In Mexico there are about 80 schools of medicine, of which 44 are accredited by the Mexican Council for Accrediting Medical Education. There are also more than 600 training programs for nurses, few of which are accredited by an equivalent medical council.

MEDICINE Many drugs are still not regulated in Mexico, meaning that the customer can purchase them at the chemist. The private market is dominated by patented medicines, whereas the public sector mainly uses equivalent generic drugs, resulting in significant savings. Most public spending on drugs is undertaken by the IMSS (almost 48 percent), followed by the SSA, the SESA, and IMSS–Opportunities (almost 27 percent) which serve those people who have no insurance (Frenk and GomezDantes 2008). NATIONAL HEALTH INSTITUTES In addition to the health service structure described above, the Mexican health system has 13 national institutes which offer top-level services, are involved in cutting-edge research, and train specialists in different areas of medicine. These institutes are the pride of Mexican medicine. They consist of the Mexican Children’s Hospital and the National Institutes of Cardiology, Cancer, Nutrition, Respiratory Diseases, Neurology, Pediatrics, Perinatology, Psychiatry, Public Health, Rehabilitation, Genomic Medicine, and Geriatrics. Likewise, the IMSS has several research centers in different parts of the country. Overall, more than 1200 researchers working in these institutes and centers produce information and knowledge which is extremely important for Mexico. THE MINISTRY OF HEALTH The federal government agency heads the health sector and proposes and coordinates progress in terms of health policies, coordinates the various branches of the public health sector, and is responsible for epidemiological surveillance at a national level. In addition, the Ministry of Health is responsible for the

5 System for National Health Information or Sistema Nacional de Informacion en Salud (SINAIS), which collects and publishes statistics about all issues related to the health of Mexicans and their health services.

OVERVIEW: ACHIEVEMENTS, IMBALANCES, AND CHALLENGES IN THE MEXICAN HEALTH SYSTEM For many years, Mexico’s health system differentiated between those sectors which had social security related to their employment (with the IMSS serving workers in the private sector of the economy, and the ISSSTE and other agencies serving workers from the public sector) and those who were unable to formally participate in social security. The latter were called the “open population,” and their health care was the responsibility of the Ministry of Health, which provided welfare. With the law reform of 2003, the Mexican state recognized its obligation to treat everyone equally, and thus began to seek ways of incorporating all Mexicans within a framework of the universal right to health. This is perhaps the most important contribution made by the Popular Health Insurance or Seguro Popular. Similarly, several imbalances in the health system have been identified and since 2000 there have been attempts to correct them. First, the distribution of resources does not correspond to the epidemiological profile of the country: infectious diseases, although they have not disappeared altogether, have given way to chronic degenerative diseases. Second, the population continues to direct much expenditure towards solving their own health problems, with state participation only recently being improved. Third, social security institutions have taken responsibility for a much greater proportion of spending compared to institutions tending the uninsured population, where the contribution by different

states to health expenditure is also very uneven, with some states participating substantially and others having very marginal involvement. Finally, health spending has become increasingly focused on the payroll and less oriented towards investment. Recent reforms to the General Law of Health have tried to balance these issues. However, several experts have identified a number of important deficiencies which characterize the Mexican health system. The first is that the Popular Health Insurance or Seguro Popular has further fragmented the population, when there should be a tendency towards unification of the population and the provision of health services under a single, universal framework of services. This fragmentation leads to greater inefficiency in health spending, as well as reinforcing the existence of services that differ in quality, accessibility, and the population that they serve. Another difficulty already mentioned relates to the existence of overlaps between the various segments of the population. Whereas some sectors have access to more than one type of coverage, there are still many millions of Mexicans who do not have any health protection. A third problem concerns the quality of health services. Although by 2001 continuous monitoring and evaluation of the quality of health services had been established, there are still large gaps in this area, and there is growing unease on the part of the user population about the kind of services being offered. An additional problem relates to the conservatism of the health sector unions, who are reluctant to permit any radical transformation of the system for fear of losing their corporate privileges. This labor arrangement causes an enormous loss in financial resources as these are channeled to the unions, instead of providing improvements to population health. Finally, the opposition has denounced the demagoguery of the Popular Health Insurance

6 or Seguro Popular on the grounds that it offers coverage but its facilities and infrastructure are insufficient to provide adequate care. Thus thousands of members are left without the possibility of exercising their right to basic treatment, simply because there are no services near to where they live. It has also been questioned whether the affiliates of the Popular Health Insurance, apart from the poorest people, should be charged a fee when supposedly health service coverage should be universal and free (Laurell 2010b). Moreover, Mexico is still a country with profound internal inequalities. Whereas the most forward looking municipalities may offer health provision similar to that in advanced countries, the most backward areas continue to have an epidemiological profile of poverty, with high rates of maternal mortality and child malnutrition. Also, given the enormous difficulty of structuring a unified and coherent health system, efforts have been made to introduce structured pluralism, which seeks to accommodate all players within the current health system, including those from both public and private sectors, but at the same time to regulate its scope and to structure its development, in order to cover the entire population. SEE ALSO: Health Care Delivery System: Brazil; Health Care Services, Cross-Border; Latin Americans, Health of REFERENCES Calderón, F. 2011. Quinto informe de gobierno. http://quinto.informe.gob.mx/archivos/

informe_de_gobierno/pdf/3_2.pdf. Accessed April 12, 2013. CONAPO. 2011. Indicadores demográficos básicos 1990–2030. http://www.portal.conapo.gob. mx/index.php?option=com_content&view=ar ticle&id=125&Itemid=230. Accessed April 12, 2013. Frenk, J., and Gomez-Dantes, O. 2008. Para comprender el sistema de salud de México. Mexico: Nostra ediciones. Frenk, J., González-Pier, E., Gomez-Dantes, O., Lezama, M. A., and Knaul, F. M. 2006. “Comprehensive Reform to Improve Health System Performance in Mexico.” Lancet 368: 1524–1534. Gómez-Dantéz, O., Sesma, S., Becerril, V. M., Knaul, F. M., Arreola, H., and Frenk, J. 2011. “The Health System of Mexico.” Salud Publica Mexico 53 suppl. 2: S220–232. IMSS. 2011. Memoria estadística 2010. http://www. imss.gob.mx/estadisticas/financieras/Pages/ estadisticas2010.aspx. Accessed April 12, 2013. ISSSTE. 2011. Anuarios estadísticos. http://www. issste.gob.mx/issste/anuarios/. Accessed April 12, 2013. Laurell, A. C. 2010a. “La simulación y la mentira no protegen la salud.” La Jornada, April 8. http:// www.jornada.unam.mx/2010/04/08/opinion/ a03a1cie. Accessed April 12, 2013. Laurell, A. C. 2010b. “Fracaso del seguro popular y un nuevo paso en la reforma privatizadora.” La  Jornada, August 4. http://www.jornada. unam.mx/2010/08/04/ciencias/a03a1cie. Accessed April 12, 2013. Oláiz, G., Rivera, J., Samah, T., Rojas, R., Villaplando, S., Hernández, M., and Sepúlveda, J. 2006. Encuesta Nacional de Salud 2006. Cuernavaca: Instituto Nacional de Salud Pública. SINAIS 2011. http://www.sinais.salud.gob.mx/ infraestructura/index.html. Accessed April 12, 2013.