Since he took office in December 2012, President Enrique Peña Nieto has achieved much in terms of the number of major reforms passed in Mexico. Besides the most expected change opening the long-time state-run energy sector to foreign investment, Peña Nieto’s government undertook an ambitious program of reforms aimed at cutting Mexico’s chronic levels of tax evasion, at spurring competition in sectors heavily dominated by oligopolies such as telecoms, broadcasting and banking, at allowing re-election of federal legislators and at toughening evaluation standards for teachers.
Healthcare is one of the next items on the government’s busy agenda. The objective: to move Mexico towards universal health coverage. The initiative was started at the beginning of 2000 by the National Action Party (PAN) with the vision of ensuring in the long term that “any Mexican – employed or unemployed – could go anywhere in the country and get quality healthcare at any institution,” as Maki Ortiz, president of the Health Commission at the Senate and former vice-minister for integration and development, explains.
The long way towards universal (effective) coverage
Historically, the Mexican health system has been fragmented among different providers and access to healthcare services was only offered to salaried workers and their families. At the beginning of 2000, the two main public healthcare providers – the Mexican Institute for Social Security (IMSS) and the Institute for Social Security and Services for Civil Servants (ISSSTE) – hardly covered half of the population, leaving more than 45 million Mexicans exposed to health-related expenditures.
Since then, Mexico has gone a long way down the three-step path towards the creation of a universal healthcare system. The first important milestone was laid in 2004 with the launch of Seguro Popular, a public insurance scheme offering previously uncovered Mexicans access to a package of basic health services. By 2014, a decade after its implementation, federal commissioner Gabriel O’Shea announced that: “57.3 million previously uninsured Mexicans are now enrolled in Seguro Popular.”
After universal enrollment – almost completed – the next step is universal coverage, which means access to a package of comprehensive healthcare services with financial protection. This is the stage Mexico is currently moving towards. As a matter of fact, over ten years the number of interventions covered by the program has increased threefold, the amount of drugs included more than 300 percent and the number of diseases included in the fund for protection against catastrophic expenditures has been raised from four to 59.
The last step is universal effective coverage, which implies services are provided with a level of quality that ensures a successful effect on the patient as well as on society. Because as Enrique Ruelas, president of the National Academy of Medicine, points out, “universal health coverage is about value, not only volume. If you don’t introduce quality to the equation, you risk doing more harm than good.”
A foggy landscape
The reform currently under discussion aims at creating a universal healthcare system under the concepts of portability of benefits and convergence of institutions. The idea is to give Mexicans the opportunity to be treated at any institution, independent of their affiliation – a measure already approved for obstetric emergencies a couple of years ago to face the dramatic number of maternal deaths in the country. This will soon include a limited number of chronic-degenerative diseases, such as heart failure, diabetes, kidney transplants and HIV, among others, before moving on to cover more diseases over time.
However, a number of challenges stand in the way to effective implementation of universal coverage. First, universal enrollment: while the Ministry of Health claims that full coverage is almost reached, Hector Valle, general manager for North Latin America at IMS Health argues that “studies carried out by the consulting company, the National Public Health Institute and INEGI (the National Institute of Statistics and Geography) indicate that around 20 percent of the population is still uncovered.” Second, healthcare expenditure. Currently only 3.2 percent of GDP is destined to health, up compared to the 2.7 percent of 2004, but severely below the average 7.7 percent of OECD members. Over the last decade the total expenditure on healthcare has meagerly increased from 6 percent to 6.2 percent, with nearly half of it still paid directly by patients.
A further hindrance is effective integration of the different healthcare providers. “The systems and processes they are using today are completely different and separate. If you want to build an integrated system, you first have to standardize and connect the existing ones – something which is not happening yet,” Valle points out. Last but not least, the participation of the private sector. As José Campillo, president of FUNSALUD (the Mexican Health Foundation) argues, “we support increased participation of the private sector in the health sector through outsourcing of services and public-private partnerships (PPPs). But there are still many questions about how this should happen.”
Undoubtedly Mexico is moving in the right direction. “When […] Seguro Popular was approved a decade ago, we were aware that this was a mid-term reform and that the next step to take was the integration of the public institutions providing healthcare services in Mexico and the possibility of interaction with private caretaking providers,” comments Julio Frenk, former minister of health and currently dean at the Harvard School of Public Health. However, the concrete methods to achieve effective integration, critical to creating a working universal healthcare system, still remain undefined.
Article by Manuela D’Andrea
Photo: ‘El pueblo en demanda de la salud,’ Diego Rivera
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