Dr. José Angel Cordova Villalobos shares his experience as former Minister of Health and illustrates how the unification of today’s fragmented healthcare system is the only way to provide effective healthcare to the Mexican population and how prevention is key to tackle the increasing challenges the country is facing due to a changing epidemiological profile.
It has now been two years since you left the position of Minister of Health in 2012. What kept you most busy during this time?
I live with my family in León, in the state of Guanajuato, but have never stopped coming back to Mexico City, as I am still working as a doctor and need to follow my patients every Thursday, Friday and Saturday for consultations, operations and endoscopy studies. Beside this, I dedicate half of my time to advising private pharmaceutical enterprises on their operations, I am part of the board for the Centros de Integración Juvenil (CIJ), a private organization lead by Kena Moreno with 120 centers dedicated to helping young people with addictions to alcohol and other drugs. I also act as senior advisor to the World Federation for Medical Education (WFME) having spent time in the past teaching at the university. Last but not least, I am also working for Speakers México, a company organizing events and conferences. As a matter of fact, last week I was in San Luis Potosí conducting a conference – so I have been pretty busy!
When we met you in 2008, the Mexican pharmaceutical market saw the presence of innovative products, generics and similares, drugs which did not undergo bioequivalence tests. And we spoke about the fact that starting in 2010, all drugs would have to be re-registered every five years. On this regard, you said that “by 2010 quality will not be a variable in the Mexican market anymore”. How do you feel quality evolved since we last met you?
When I was deputy of the Mexican congress in 2005, we modified the article 376 of the General Health Law to implement the obligation for all enterprises producing generics to pass the test for bioequivalence. It was a very good initiative because it completely changed the perception of public institutions. Ironically, even doctors used to doubt the effectiveness of generic drugs and would usually prescribe branded medicines instead of those provided by the government. This image has changed dramatically since then, there has been a huge acceleration of product registration and the penetration of generics in terms of volume increased from 15 to 85 percent of the market by 2012. The population’s expenses used to be one of the most significant factors of poverty and many cases saw people not able to afford the appropriate treatment. We worked hard to make sure a prescription of three medications would not cost more than MXN$ 200 (USD 13), which the majority can afford. Today, all medication available in Mexico is of good quality and there is more confidence towards institutions. Also, having physicians present at the point of sale is great because it is fundamental to have a competent person responsible for the medicine people purchase.
Drug access is one of the most important issues here in Mexico. Despite the work of COFEPRIS (the Federal Commission for the Protection against Sanitary Risk), according to IMS Health it takes up to 4.3 years for a new treatment to be listed in the public healthcare sector in Mexico – way too long when compared to the 2 years it takes in the UK and in Japan or even the 3.4 years of Brazil. What other challenges is Mexico facing today?
When I was minister of health our strategy was to ensure the quality of the products available on the Mexican market and decrease the very high out-of-pocket expense in medications by pushing the use of generics. What definitely was a very important move to start also brought drawbacks, because the majority of companies have decided to go for the ‘easier’ generics market instead of investing in R&D. Another challenge is also coming with the increasing need of biotechnology, which we are slightly unprepared for. In fact, the only organization focusing on this area in Mexico is Probiomed, producing substances such as insulin, which we are in great need of. With the rise of chronic diseases, biotechnology gets increasingly relevant and now that the government has managed to push for more biomedicine, it is imperative to become much more competitive in this sector.
With an increasingly urbanized Mexico, the profile of its population is also changing rapidly, moving from infectious diseases to a burden typical of developed countries, with diabetes and obesity as some of the important issues. As the President of the Ministers’ Club for the EPODE International Network, the world’s largest obesity-prevention network, what would you say is the major impact of such trend on the Mexican healthcare system?
First of all, the demographics of Mexico are changing, with the fecundity index decreasing. We currently have fewer children between the age of zero and five compared to those between the ages of five and ten. In other words, the base of the pyramid is narrowing and predictions are that 25 per cent of the population will be above the age of 65 by 2050. Secondly, the problem of obesity is very severe now as opposed to the 1980s. We have been putting all our efforts into the fight against infectious diseases only to find out that we had 70 percent of the total population and a third of all children dealing with the problem of obesity.
For this reason during my tenure as minister of health we started a strong government program aimed at promoting prevention with a change in the alimentation, lifestyle and physical habits of Mexicans. This is a big challenge for our health system because the expenses are doubling every ten years. If we were spending MXN $70,000 million – nearly USD 5 billion – in 2008 to treat these types of disease, we calculated that by 2017 the expenses would go up to MXN $170,000 million. A further example is dialysis. We currently have 150,000 people in need of continuous dialysis but predictions are that we will have 1 million Mexicans needing dialysis in the next ten years. Considering that each individual case costs the system approximately USD 10,000 per year, it is natural to conclude that the only way to go is prevention.
In 2009 you had to face the A/H1N1 influenza crisis. What would be your best piece of advice for the current minister of health?
The influenza crisis has been a great lesson for all of us on the importance of allocating more resources to healthcare. The big challenge the current minister of health Dr Mercedes Juan is facing is definitely represented by chronic diseases. The Mexican health system is very well prepared to face extraordinary crises such as ebola. However, chronic diseases are a question of changing habits and mindsets and it is important for people to understand that obesity is not only a problem of aesthetics, but a real health issue and a huge expense for society in the long run.
What are the key priorities for the Mexican healthcare sector for the next five years and what would be your piece of expert advice to executives of the pharmaceutical industry?
The key goal to achieve within the coming years is to ensure Mexicans have access to universal health coverage. Today, many people subscribed to the national insurance scheme Seguro Popular are not even aware they are entitled to this insurance. A recent survey revealed that nearly 25 percent of the population has no health coverage, though it was later found out that people actually did not know they were affiliated. Mexico also needs to optimize its resources amongst its three main healthcare providers, IMSS (the Mexican Social Security Institute), ISSSTE (the Institute for Social Security and Services for State Workers) and Seguro Popular. Today an estimated 10 percent of Mexicans are affiliated to two or more of the above-mentioned institutions, so in order to avoid redundancy and increase efficiency electronic patient records are the way to go for the future. Unification of the systems is key.
Clinical guidance for medical attention is outstanding in the country, as the National Academy of Medicine, different boards of medical specialties, IMSS, ISSSTE and Seguro Popular all came together in the past years to create the clinical guidelines to treat disease such as diabetes, for instance. We currently have 620 guidelines; now what is left to do is applying them. Having all physicians follow these guidelines will homologate the different practices, bring down expenses and increase efficiency. Last but not least, we need to push for the formation of more nurses and doctors, whom we lack in the first level of attention.
To executives of the pharmaceutical industry I would say that although half of the population is below the age of 30 in Mexico, we are growing fast and are facing the great challenge of chronic diseases –this will definitely be the most important market growth driver for the next years. We are also in need of more biotechnology, which offers outstanding market opportunities to companies willing to venture in this still very open field.
