MAJOR CHALLENGES FACED BY THE MEXICAN HEALTH CARE SECTOR

MAJOR CHALLENGES FACED BY THE MEXICAN HEALTH CARE SECTOR

INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

DR. EDUARDO VELASCO

DR. ARMANDO ARREDONDO

HEALTH POLICY AND FEDERALISM

Presentado ante el Foro de Federaciones en México, 18 de octubre de 2001

Forum of Federations / Forum des fédérations www.forumfed.org [email protected]

OUTLINE

• OVERVIEW OF THE MEXICAN HEALTH SYSTEM

• CHALLENGES

• HEALTH REFORM STRATEGIES

• DECENTRALIZATION

• INSTRUMENTAL STRATEGIES

• POLITICAL ACTORS

• GAPS

• OTHER ISSUES



HEALTH POLICY AND FEDERALISMTHE MEXICAN EXPERIENCE

Diagram 2

Insured and uninsured population by income level

Insured UninsuredP

riva

te I

nsur

ence

Soc

ial S

ecur

ity

IMS

S &

IS

SS

TE

Min

istr

y of

hea

lth

IMS

S S

olid

arid

ad

No

acc

ess

to h

ealt

h se

rvic

es

47 26 9 10

High income Low income

Populationin millions

Institutions

Coverage

Source: Ministry of Health, 1995 INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO


Variable SSA IMSS-ISSSTE PRIVATE INST.

Funding type

Funding source

% total health expenditures

Population coverage

Basic principle

Decentralization

Invest in promotion

in preventive care

in curative care

in rehabilitation

Unipartite

Federal & state govt.

15%

40%

Citizenship & poverty

Yes (1985)

High

High

Medium

Low

Tripartite

Federal, employers & workers

43%

50%

Corporative

Yes (1995, 1999)

Medium

Medium

High

Medium

Unipartite

Users

42%

10%

Purchasing power

No

Very low

Low

Medium

Very low

THE MEXICAN EXPERIENCE



link health to economic and social development

reduce health system gaps that affect the poor.

deal with emerging problems by establishing priorities

improve the quality of services

build a new cooperative federalist health system

strengthen the leading role of Secretaria de Salud ( SSA)

advance towards an Integrated Healthcare Model

strengthen investments in human resources, research, and infrastructure

promote community participation in health and the free choice of medical care provider

provide financial protection against catastrophic expenditures

CHALLENGES


GUIDING FORCE: DEMOCRATIZACION

LEADING PRINCIPLE: CITIZENSHIP

VALUES: • JUSTICE• LIBERTY• REPRESENTATION OF CITIZENS’ INTERESTS• SOCIAL PARTICIPATION• ACCOUNTABILITY

HEALTH REFORM STRATEGIES



1. SUBSTANTIVE STRATEGIES

a) Link health to economic developmentb) Decrease backlogs of disease and healthcarec) Respond to emerging problemsd) Crusade for qualitye) Financial protection

2. INSTRUMENTAL STRATEGIES

a) Federalizationb) Regulation (steering, stewardship)c) Universal Health Systemd) Freedom to choose provider and citizens’

participatione) Advancement of knowledge

HEALTH POLICY AND FEDERALISMHEALTH REFORM STRATEGIES



Federalization

- Complete decentralization- Explicit formulation of resource allocation to states- Interstate cooperation

-in public health services- in high specialty areas and

services




MODALIDADES DE DESCENTRALIZACION SEGUN GRADO DE INTERDEPENDENCIA DE LOS NIVELES DE GOBIERNO RESPECTO A FUNCIONES ESPECIFICAS


++ ++ ++ ++ ++ ++

- + - - + - - -

+ - - - - - - - -

- - - - - - - - - - - -

GRADO DE INTERDEPENDENCIA MENOR - MAYOR +

DESCONCENTRACION

DELEGACION

DEVOLUCION

PRIVATIZACION

MO

DA

LID

AD

ES

DE

DE

SC

EN

TR

AL

IZA

CIO

N

NO

RM

AT

IZA

CIO

N

AU

TO

RID

AD

DE

CIS

ION

FIN

AN

CIA

MIE

NT

O

CA

PT

AC

ION

N

EC

ES

IDA

DE

S

PL

AN

EA

CIO

N

AD

MIN

IST

RA

CIO

N D

E

RE

CU

RS

OS

HU

MA

NO

S



1) Deconcentration to shift power from the central offices to peripheral offices

2) Delegation

3) Devolution shifts responsibility and authority from the central offices of the Ministry of Health to separate administrative structures still within the public administration

4) Privatization. Prospective payment health insurance with private providers; reversion of IMSS fees to banks who purchase health services elsewhere. ISES.

5) Overlap and duplicationConditional and block grantsUnilateral and vertical decisionsJoint-decision making


DECENTRALIZATION


DECENTRALIZATION COMPONENTS:

-Competitional. Devolution to the states, of the direction, coordination, and operational implementation of medical care, public health, and sanitary control of concurrent general health services.

-Administrative. Creation of a structure to operate State Health Services.

-Patrimonial. The federal infrastructure was transferred at no cost to State Health Services.

-Occupational. Workers were protected under the labor and social security scheme and the employers’ individual faculties were delegated.

-Financial. A co-financing system was set up with federal and state contributions.

-Logistic. A mechanism was established to provide technical and logistic support required by decentralized services for their culmination and better development.


DECENTRALIZATION


Stewardship

- Liaisons:• intersectoral (Consejo de Salud

General)• sectoral (Comisión Federal de

Políticas de Salud• territorial (Consejo Nacional de

Salud)• Through popular representatives

(through Oficina de Vinculación del Congreso de la Unión and citizen groups)





Universal Health System

- Gradual elimination of population selective access to health care services- Interinstitutional master plans for high technology investments- Compensation fund among federal and state institutions





Freedom to choose health provider and citizens’ participation

- Free choice of healthcare provider- Free choice of family physician- Citizen health committees at all levels of health care





Strengthening knowledge

- Promotion of mission-oriented research

- Information system for decision making

- Human resource development





Health PoliciesHealth Care

Reform

Entrepreneurs

Federal Government

SSA

President

IMSS

PRI

PAN

PRD

State governments

States with high incomes

States with middle and low

incomes

Insured Population

Uninsured Population

Communication media

Health Institution Unions

Other Unions

Civil society: low incomes

Civil sociaty:

high and middle incomes

HIGH INFLUENCE on health policies

MEDIUM INFLUENCEon health policies

LOW INFLUENCEon health policies

Health Researchers


• REGIONAL DIFFERENCES

• HIGH LEVELS OF POVERTY

• SELECTION OF RISKS AND IMPERFECT HEALTH MARKET

• STAKECHALLENGERS IN POLICY FORMULATION

• PRIVATIZATION ?

• IMPOPULAR POLICIES (TAXES, FINANCIAL RESCUES)

• PERFORMANCE APPRAISAL

GAPS IN HEALTH POLICY FORMULATION



OTHER ISSUES

DECENTRALIZATIONSymmetry of relationships between central and peripheral levelsFormal intergovernmental bodiesDecentralization to the municipality level

HEALTH POLICYEvidence-basedFinancing allocation based on performance & health improvementExplicit caps and allocation of funds at central, state, and municipality levels



MAJOR CHALLENGES FACED BY THE MEXICAN HEALTH CARE SECTOR

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