This article was originally published online in The Lancet on August 7, 2023.
Assessment of health system performance is a complex task, especially amid major political change, structural reforms, and a global pandemic. The Health Policy paper by Felicia Marie Knaul and colleagues1 in The Lancet identifies many challenges to improving the performance of the Mexican health system in the 21st century. Their analysis seeks to illustrate how successful implementation of health reform requires continuous efforts at improvement and careful political management of key stakeholder groups.1–3 We highlight important aspects of this Health Policy paper and suggest three principles to improve the performance and equity of the Mexican health system.
Andrés Manuel López Obrador has been President of Mexico since his election in 2018 with 53% of the votes; his left‐of‐centre MORENA party also achieved a super‐majority in the Mexican Congress. Seguro Popular was the financing mechanism of the System for Social Protection in Health in Mexico’s 2003 health reform. This landmark reform created a voluntary public insurance programme that covered an explicit list of health interventions for the large population outside of social security health insurance. López Obrador campaigned on complaints about Seguro Popular’s incomplete achievements in universality, insufficient reduction in out‐of‐pocket health spending, and limited improvements in health outcomes, as well as reported corruption.2 Once in office from December, 2018, López Obrador’s administration pushed forward with a health reform that eliminated Seguro Popular and replaced it with a new entity called Instituto de Salud para el Bienestar (INSABI) at the start of 2020. INSABI (associated with the Ministry of Health) was then eliminated in 2023 and its functions absorbed by a newly created government agency IMSS‐Bienestar (associated with the Mexican Social Security Institute [IMSS]). Following a trial‐and‐error approach to system reform, as Knaul and colleagues point out, the Mexican Government under López Obrador has dismantled health policies and programmes introduced by previous governments, replacing some and ending others.
Seguro Popular achieved important advances in health system performance, especially its expansion of assured financing for 294 basic health interventions and 66 catastrophic health conditions by 2018, which expanded access to both basic and high‐cost health services. But Seguro Popular also confronted challenges, as Knaul and colleagues describe. The services financed by Seguro Popular were mainly provided in the existing health‐care facilities operated and regulated by Mexico’s 32 state ministries of health and the federal Ministry of Health. Consequently, the achievement of effective coverage through Seguro Popular was heterogeneous and dependent on local capacity to deliver services.4 As shown by Knaul and colleagues’ assessment and an independent systematic review in 2022,4 Seguro Popular had mixed results in its impacts on financial protection and treatment effectiveness.
Seguro Popular’s heterogeneous effects on health outcomes could have resulted from its focus on increasing enrolment and expanding the number of health services financed, without equal efforts to guarantee access to primary care services and diagnostic tests and to raise the quality of care across all levels of the health system. For example, although the number of Seguro Popular affiliates increased to 40 000 per 100 000 inhabitants between 2004 and 2018, there was no observed increase during this period in the number of primary care centres and only a small increase in the number of doctors (from 17 to 25 per 100 000 inhabitants).5
Health system performance can be measured by outcomes in population health, financial protection against the costs of ill health, and public satisfaction with health services and facilities, with intermediate measures of access, quality, and efficiency.6,7 Timely quality care is especially important for expanded access to improve health outcomes of chronic diseases. For example, despite increased access to breast cancer treatment through Seguro Popular, clinical stage distribution and stage‐specific breast cancer survival rates remained constant in Mexico between 2006 and 2016.8,9 Similar results of increased access to care but limited impact on survival were observed for childhood leukaemia and prostate cancer.10–12 Additionally, there were diﬀerences in outcomes between states and facilities.9–12 By requiring accreditation of the hospitals that could provide high‐cost health interventions, Seguro Popular created some important improvements in quality of care, especially in federal hospitals. Nevertheless, delays in referrals from primary care to diagnostic services and then to cancer centres remained a problem, and therefore most patients were treated at advanced disease stages.13
Knaul and colleagues argue that there were setbacks for Seguro Popular from 2012 to 2018 related to what they call reform ageing with a lack of continuing improvements to respond to policy shortcomings. However, their analysis shows that enrolment in Seguro Popular continued to increase between 2012 and 2016 with a small decrease thereafter and up to 2018.1 Additionally, access to treatment for breast cancer and childhood leukaemia did not show setbacks but rather a continued expansion of access.8,11 Furthermore, during these years Seguro Popular managers introduced policies to improve fiscal accountability, efficiency in resource transfers, and identification of duplicate enrolment with social security.14
The elimination of Seguro Popular has created considerable challenges for the Mexican uninsured population. A prominent example is the reduced access to high‐cost treatments previously covered.15,16 Moreover, today, even 4 years after Seguro Popular’s elimination, there has been limited formal evaluation of the impact of the new reforms on health outcomes, financial protection, and public satisfaction in Mexico. The studies done to date rely on periodic national household surveys (ENIGH17 and ENSANUT),18 which collect data on self‐ reported health problems, health services use, and health expenses. These reports show similar use of public services, and increased out‐of‐pocket and catastrophic health expenses between 2018 and 2022, as Knaul and colleagues confirm, although it is unclear how much was due to the impacts of COVID‐19 or a result of restructuring of the health system.19,20
Knaul and colleagues propose five recommendations to strengthen the Mexican health system. We welcome their suggestions but believe that the way forward should be based on broader principles of health system performance and public deliberation of possible solutions. We suggest the following three principles, based on our research and experiences,2,3,6,8,9,11–13 to improve health system performance in Mexico.
First, Mexico needs to improve effective access to health services in the public sector. Enrolment is not enough to expand access, as shown with Seguro Popular. Stating that everything will be available to everyone for free, as the Mexican Government under López Obrador claims,21 does not work in practice. Primary health care in Mexico’s public sector has been neglected for decades. This neglect is reflected in the high use of doctors in private pharmacies and private health services, which are perceived as more convenient, inexpensive, and with shorter waiting times than both social security and Ministry of Health services.5,22 Primary health care in Mexico can be strengthened by expanding capacity, improving working conditions for primary health workers, and ensuring effective referrals to secondary and tertiary care hospitals.10,13,23 This strengthening will require substantial expansion of the government health budget plus effective collaboration and partnerships across distinct subsectors of the Mexican health system, including different social security institutes and between the public and private sectors.
Second, expanding access and improving quality should be sought together, in order to achieve impacts on health system performance outcomes. Experience with diseases that were covered under the high‐cost programme of Seguro Popular shows that efforts are needed to improve quality in health‐care provision across all levels of care.9–13 Improving health system performance in Mexico will require ongoing analyses of intermediate performance indicators and identification of problems to design and implement effective solutions that improve accessibility, ensure continuity of care for chronic diseases, and deliver good quality in process and outcomes.6 These efforts will need to include the private health sector (eg, doctors’ offices adjacent to pharmacies), along with effective monitoring and regulation of health‐service pricing, clinical practices, and health outcomes. Achieving improvements in quality of care will require sustained political commitment, effective regulatory organisations, and targeted incentives and sanctions across the entire health system in Mexico.
Third, continual monitoring and evaluation of Mexico’s health system is needed with public transparency and accountability. A core principle of health reform is the role of sustained monitoring and regular independent evaluation to ensure that public health goals are achieved.6 Without public transparency of monitoring and evaluation, it is difficult to determine whether health system reforms are being implemented efficiently and without corruption, and whether they are having the intended consequences. Mexico has a long history of mandated evaluations of public policy. The administration of López Obrador provided public access to excess mortality data during the COVID‐19 pandemic and has retained data collection for existing health indicators.24 However, one government evaluation of the reforms implemented since 2018 identified a number of important setbacks in health system performance indicators and confusion in operations.19 It is not clear how or whether the Ministry of Health responded to the concerns identified by the evaluation (and the report is not discussed by Knaul and colleagues), raising questions about accountability.
As Mexico approaches its next presidential election in 2024, it is time to consider how to effectively improve health system performance while increasing equity. We believe that Mexico would benefit from the creation of public spaces for open deliberative discussion about the health system. These spaces could bring together stakeholders from different backgrounds, including civil society, non‐profit providers, and the private sector, to discuss and decide on how to improve health system performance in Mexico’s complex reality for the future.
Author information: CONAHCYT‐National Cancer Institute, Mexico City 14080, Mexico (KU‐ S); Center for Research on Population Health, National Institute of Public Health, Mexico City, Mexico (ML); Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA (ML, MRR)
We declare no competing interests. The views and conclusions expressed in this Comment are our own and not necessarily those of the Mexican National Cancer Institute, the Consejo Nacional de Humanidades, Ciencia y Tecnologia (CONAHCYT), the National Institute of Public Health (INSP), and Harvard T H Chan School of Public Health. We thank Alejandro Mohar, Andrea Luviano, Sergio Bautista‐Arredondo, and other anonymous reviewers for their useful comments to improve this Comment.
- Knaul FM, Arreola‐Ornelas H, Touchton M, et al. Setbacks in the quest for universal health coverage in Mexico: polarised politics, policy upheaval, and pandemic disruption. Lancet 2023; published online Aug 7. https://doi.org/10.1016/S0140‐6736(23)00777‐8.
- Reich MR. Restructuring health reform, Mexican style. Health Syst Reform 2020; 6: 1–11.
- Campos PA, Reich MR. Political analysis for health policy implementation. Health Syst Reform 2019; 5:224–35.
- Colchero MA, Gomez R, Bautista‐Arredondo S. A systematic review of the literature on the impact of the Seguro Popular. Health Res Policy Syst 2022; 20: 42.
- Colchero MA, Gómez R, Figueroa JL, Rodríguez‐Atristain A, Bautista‐Arredondo S. Increase in medical oﬃces in pharmacies in Mexico and health care in public health services between 2012 and 2018. Salud Publica Mex 2020; 62: 851–58.
- Roberts M, Hsiao W, Berman P, Reich M. Getting health reform right: a guide to improving performance and equity. Oxford: Oxford University Press, 2003.
- Papanicolas I, Rajan D, Karanikolos M, Soucat A, Figueras J, eds. Health system performance assessment: a framework for policy analysis. Geneva: World Health Organization, 2022.
- Unger‐Saldana K, Contreras‐Manzano A, Lamadrid‐Figueroa H, et al. Reduction in the treatment gap for breast cancer in Mexico under Seguro Popular, 2007 to 2016. Health Syst Reform 2022; 8: e2064794.
- Unger‐Saldaña K, Bandala‐Jacques A, Huerta‐Gutierrez R, et al. Breast cancer survival in Mexico between 2007 and 2016 in women without social security: a retrospective cohort study. Lancet Reg Health Am 2023; 23: 100541.
- Doubova SV, Knaul FM, Borja‐Aburto VH, et al. Access to paediatric cancer care treatment in Mexico: responding to health system challenges and opportunities. Health Policy Plan 2020; 35: 291–301.
- Munoz‐Aguirre P, Huerta‐Gutierrez R, Zamora S, et al. Acute lymphoblastic leukaemia survival in children covered by Seguro Popular in Mexico: a national comprehensive analysis 2005–2017. Health Syst Reform 2021; 7: e1914897.
- Torres‐Sánchez L, Hernández‐Pérez JG, Escamilla‐Nuñez C, et al. Disparities on prostate cancer survival in Mexico: a retrospective cohort study. Salud Publica Mex 2023; 65: 236–44.
- Unger‐Saldana K, Arroyo‐Valerio A, Turrubiates GS, et al. Time intervals to care and health service use experiences of uninsured cancer patients treated under public financing in Mexico City. Cancer Epidemiol 2023; 84: 102366.
- Chemor Ruiz A, Ratsch AEO, Alamilla Martinez GA. Mexico’s Seguro Popular: achievements and challenges. Health Syst Reform 2018; 4: 194–202.
- Villarreal‐Garza C, Aranda‐Gutierrez A, Ferrigno AS, et al. The challenges of breast cancer care in Mexico during health‐care reforms and COVID‐19. Lancet Oncol 2021; 2: 170–71.
- Agren D. Farewell Seguro Popular. Lancet 2020; 395: 549–50.
- Encuesta Nacional de Ingresos y Gastos de los Hogares (ENIGH). 2020 Nueva serie. https://www.inegi.org.mx/programas/enigh/nc/2020/#Documentacion (accessed July 18, 2023).
- Encuesta Nacional de Salud y Nutrición (ENSANUT). 2022. https://ensanut.insp.mx/index.php (accessed July 18, 2023).
- Consejo Nacional de Evaluacio´n de la Poli´tica de Desarrollo Social (CONEVAL). Evaluacio´n estrate´gica de salud. Primer informe. CONEVAL, 2022. https://www.coneval.org.mx/InformesPublicaciones/Documents/Evaluacion_salud_web.pdf (accessed July 18, 2023).
- Bautista‐Arredondo S, Vargas‐Flores A, Moreno‐Aguilar LA, Colchero MA. Utilización de servicios de salud en México:cascada de atención primaria en 2022. Salud Publica Mex 2023; 65 (suppl 1): S15–22.
- Secretaría de Salud de México. Programa Sectorial de Salud 2020–2024. Diario Oficial de la Federación, August, 2020. https://www.gob.mx/cms/uploads/attachment/file/570535/PROGRAMA_Sectorial_de_Salud_2020‐ 2024.pdf (accessed July 18, 2023).
- Pérez‐Cuevas R, Doubova SV, Wirtz VJ, Servan‐Mori E, Dreser A, Hernández‐Ávila M. Eﬀects of the expansion of doctors’ oﬃces adjacent to private pharmacies in Mexico: secondary data analysis of a national survey. BMJ Open 2014; 4: e004669.
- WHO, UNICEF. Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization, United Nations Children’s Fund, 2020.
- Dirección General de Información en Salud (DGIS), Secretaría de Salud, México. Datos abiertos.Información en salud. http://www.dgis.salud.gob.mx/contenidos/basesdedatos/Datos_Abiertos_gobmx.html (accessed July 18, 2023).
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