Document(s) 9 of 14

Introduction

This chapter will analyze the Mexican Sistema Nacional de Salud (SNS, national health system) in two parts. The first will examine the socioeconomic and epidemiological characteristics of the population and the structure of health care services, with relation to expenditure, coverage, organization, and provision. The second will analyze the subsystems of the health care services, using the methodology proposed by the Organisation for Economic Co-operation and Development (OECD 1995). The section will look at the way the health care services have been modified since the beginning of the 1980s and discuss the tendencies within the system since 1995.

Structural Features

Social, demographic, and epidemiological aspects

According to the 1990 census, Mexico has a population of 81.25 million. The territorial distribution (Table 1) shows that the population is concentrated in a small number of cities and metropolitan centres.
 

Table 1. Socioeconomic index, Mexico, 1970, 1980, and 1990.
	1970	1980	1990
Population (thousands)*	48 225	69 655	81 250
Urbanization rate*	57.8	66.3	71.3
Literacy rate*	76.3	83	87.4
Per-capita GNP (US dollars)**	730	2 758	2 868
Life expectancy at birth**	62.21	66.22	69.69
Infant morality rate (per 1 000 live births)**	68.45	38.82	23.95
Mortality rate (per 1 000 inhabitants)**	10.07	6.24	5.21
Birth rate (live births per 1 000 inhabitants)**	44.23	34.85	33.71
Fertility rate***	7.0	4.5	3.4
Sources: *INEGI (1992). **Presidencia de la República Mexicana (1993). ***FUNSALUD (1994).

In 1990, about 47 million Mexicans were living in cities of 15 000 or more. Of these, almost half lived in the four largest metropolitan areas: Mexico City, Guadalajara, Monterrey, and Puebla. In contrast to this urban concentration, the remaining population is greatly dispersed, living in thousands of small rural centres. In 1990, about 28 million Mexicans lived in more than 155 000 small outlying towns or villages of fewer than 5 000 inhabitants (Secretaría de Hacienda y Crédito Público 1995).

There is a downward tendency in the growth rate of the population. Between 1930 and 1958, the annual growth rate was 2.5%, which resulted in a doubling of the population over this period. Between 1960 and 1970, the annual growth rate was 3.2% but it decreased to 2.3% between 1980 and 1990. The growth rate for 1992 was estimated at only 1.9%. Although the increase in population has slowed, there is still a significant increase in absolute numbers, and the most recent figure places the population at more than 90 million.

In general, the population of the country is young. An "aging" process can now be observed, however, as the proportion of the population below the age of 15 falls and the proportion of adults rises correspondingly. For those aged 65 and over, the proportional increase is most notable, with an annual growth rate of 3.8%. In 1994, the population distribution was: 57.87% below the age of 25; 36.02% between the ages of 25 and 59; and 6.09% aged 60 or more (Secretaría de Salubridad y Asistencia 1994a).

Fertility rates and death rates are closely related to the demographic changes in the country. In the case of fertility, it was not until 1970 that any reduction occurred at all. Between 1930 and 1950, there was a stable overall fertility rate of 6.5 children per woman. From 1950 to 1970, there was a slight increase, to 7 children per woman. From then on, the rate began to decline, to 4.5 children per woman by 1980 and to 3.4 children in 1990. There is an observable difference, however, by region and by poverty level of the mother, with the poorest states presenting fertility rates well above the national average. In 1990, for example, the overall fertility rate in states such as Chiapas or Oaxaca was more than 4.5 children per woman, whereas in the Federal District of Mexico City and other states of the central region, it was less than 2.4 (Frenk et al. 1994).

There has been a notable decline in death rates during this century. Between 1940 and 1994, the overall death rate fell from 25.1 to 4.7 deaths per 1 000 live inhabitants. There has been a corresponding increase in life expectancy: between 1940 and 1994, life expectancy for men increased from 40.4 to 69.4 years, and life expectancy for women from 42.5 to 75.8 years (Frenk et al. 1994).

In the last three decades, there has also been a change in the distribution of deaths by age group. From 1930 until the beginning of the 1970s, the prevailing pattern showed that 50% of deaths occurred in the under-5 age group and 25% among those 50 and older. Since then, the proportion of deaths during the early years of life has begun to fall. By 1992, only one death in six (14.4%) occurred in the under-5 population, whereas one out of two deaths in men (50%) and two out of three in women (61.3%) were among those over 50 year old (Frenk et al. 1994).

Another important aspect of mortality in Mexico is related to changes in the cause of death. There has been a considerable fall in death rates from infectious diseases, diseases preventable by vaccination, and from nutritional deficiency. On the other hand, there has been an increase in the number of deaths from cancer, ischemic heart disease, and accidents. Thus, in 1940, intestinal infections and pneumonia plus influenza were the two main causes of death, accounting for 491.2 and 381.4 deaths per 100 000 inhabitants, respectively. Although these were still the primary causes of death in 1970, their rates had dropped to 149.4 and 173.5 deaths per 100 000 inhabitants. By 1994, these causes had fallen to tenth and eighth place, accounting for 11.2 and 21.0 deaths per 100 000 inhabitants, respectively.
 

Table 2. Principal causes of mortality, Mexico, 1970, 1980, and 1990.
	1970	1980	1990
1st cause of death	Respiratory disease	Accidents	Accidents
2nd cause of death	Intestinal infection	Heart disease	Heart disease
3rd cause of death	Heart disease	Respiratory disease	Respiratory disease
Source: Presidencia de la República Mexicana (1993).

Heart disease and malignant tumours were in 12th and 18th places in 1940, with rates of 54.3 and 23.1 per 100 000, respectively. Diabetes mellitus, with a rate of 4.2 per 100 000 did not even feature among the first 20 causes of death. At that time, heart disease, malignant tumours and diabetes accounted for only 3.5% of recorded deaths in the country. In 1970, they were in third, fifth, and 15th places, with rates of 69.4, 38.1, and 15.5 per 100 000, respectively . Together, they made up 12.2% of the total number of deaths. By 1994, they were in first, second, and fourth places, with rates of 67.5, 51.5, and 33.7 per 100 000, and their joint relative weight was 32.8%, or nine times greater than that observed in 1940. Accidents and homicide moved from sixth and 13th places among causes of death in 1940 to third and ninth places, respectively, in 1994 (Secretaría de Salubridad y Asistencia 1996).

Mortality rates, like fertility rates, vary notably by region and income level. An analysis of mortality rates by region, for example, shows infant mortality rates for 1991 that varied between 22.4 and 43.3 per 1 000, with a national average of 31.9 per 1 000. Adult mortality rates varied from 2.9 to 3.9 per 1 000, whereas the national average was 3.3 per 1 000 (Frenk et al. 1994).

The distribution of deaths by age group and specific cause also varies according to socioeconomic level, which clearly shows that there are real conditions of inequality in the country in terms of the probability and cause of death.

In the area of poverty-related illness, there has been a considerable deterioration in the nutrition status of the population. This can be seen from the increase in preschool deaths due to nutritional deficiency, which have been rising since 1983, particularly in depressed rural areas (López and Blanco 1993). The national nutrition survey reports that about 23% of children under 5 years of age are below the normal height for age. In this case in particular, economic conditions play a fundamental role. The proportion of undernourished children in areas of extreme poverty in the south of the country is four times greater than in the poorer districts of Mexico City or in the northern states (Frenk et al. 1994).

To summarize, Mexico has undergone notable demographic and epidemiological transformation over the last three decades. On the one hand, there has been a change in the population pyramid. The width of the base has tended to diminish as the proportion of children under 5 years of age decreases. The middle of the pyramid has widened with the corresponding increase in the population over 15 years of age, particularly among those over 60. And, the upper point has remained very sharp. On the other hand, epidemiological tendencies show a drop in mortality rates, with notable changes in the distribution of deaths by age group and specific cause. The considerable differences between regional, social, and economic levels, however, indicate that the prevailing epidemiological pattern in Mexico is polarized as a consequence of social inequality.

With respect to another indicator of social welfare, education, significant gains have been achieved. In 1980, 17% of the population of Mexico was illiterate but this rate had been reduced to 12.6% by 1990. As with most of the socioeconomic indicators, there are notable regional differences. In the Federal District of Mexico City and in some of the northern states, the illiteracy rate is about 4%. Official figures give the average number of years of schooling for the population older than 15 as seven. However, there is a significant educational backlog in the country, because the official figures admit that about 2 million children have never been to school (Aboites 1997).

Expenditure

If expenditure on health care is analyzed by source of financing, an initial division can be made between public and private resources. Expenditures destined for financing public institutions fall into the first group, and household expenditure on health goods and services account for the second.
 

Table 3. Public expenditure on health, Mexico, 1970-90.
Year	Net health care expenditure (in millions)		Per-capita expenditure
	Mexican pesos (historical value)	US dollars	Mexican pesos (historical value)	US dollars
1970	8 342	667	173	13.84
1971	9 488	759	186	14.85
1972	11 810	945	219	17.49
1973	13 960	1 117	245	19.63
1974	18 617	1 489	319	25.54
1975	23 922	1 914	398	31.81
1976	32 106	1 607	518	25.93
1977	44 473	1 956	697	30.65
1978	54 954	2 420	837	36.85
1979	69 247	3 037	1 026	44.98
1980	90 735	3 899	1 303	55.98
1981	135 486	5 179	1 908	72.94
1982	217 757	1 459	3 013	20.19
1983	339 960	2 107	4 626	28.67
1984	544 821	2 595	7 296	34.75
1985	888 196	1 985	11 713	26.17
1986	1 464 036	1 601	19 024	20.80
1987	3 409 690	1 532	43 678	19.63
1988	7 814 842	3 494	98 748	44.15
1989	9 307 579	3 524	116 102	43.96
1990	12 721 636	4 319	156 574	53.16
Source: Valdéz (1991).

According to the Fundación Mexicana para la Salud (FUNSALUD, Mexican foundation for health), 29% of the total expenditure on health between 1992 and 1996 came from employers, 22% from the government, and the remaining 49% from households, with external resources amounting to less than 1% (Hernández et al. 1997). These resources were distributed among financing funds as follows: social security funds, 43%; funds for the uninsured, 13%; funds for private medical insurance, 2%; and private funds, 42%. These funds were chaneled into the institutions that provide health care services.

Given the importance of the public sector in addressing the need for medical attention in the country, and because more information is available on this sector than on others, some relevant aspects of financing within the integrated public model are given in detail. The indicators for this analysis include net expenditure on health care, per-capita expenditure on health care, and the health sector’s share of the gross national product (GNP), public expenditure as a whole, and social development expenditure. The distribution of resources is also briefly analyzed.

For the historical evolution of public sector financing, it is useful to use a characterization by Valdés (1991) that shows, in general terms, health care financing moving from expansion (1970-81), through crisis (1982-90), to signs of recovery at the beginning of the 1990s.

The proportion of GNP used for health care expenditure showed a constant upward tendency during the 1970s but decreased from 1983 (Table 4). The recovery of this indicator since 1992 has been consistent, with the share of the GNP used for health care maintaining an average of 4.5%.
 

Table 4. Social and health care expenditure in relation to gross national product (GNP), Mexico, 1970-90.
Year	Public expenditure as % of GNP*	Social expenditure as % of GNP*	Health** as % of GNP
			GNP	Public expenditure	Social expenditure
1970	16.44	4.86	1.89	11.52	38.98
1971	16.82	5.33	1.94	11.51	36.35
1972	18.72	6.30	2.09	11.17	33.17
1973	20.99	6.33	2.02	9.63	31.95
1974	21.74	6.66	2.07	9.52	31.08
1975	26.37	7.33	2.17	8.25	29.68
1976	24.49	8.05	2.34	9.56	29.08
1977	23.26	7.84	2.4	10.34	30.67
1978	24.19	7.91	2.35	9.72	29.72
1979	25.02	8.43	2.26	9.02	26.77
1980	25.95	8.06	2.03	7.82	25.20
1981	29.43	9.19	2.21	7.51	24.07
1982	26.98	9.13	2.22	8.24	24.35
1983	23.75	6.66	1.9	8.01	28.57
1984	24.23	6.70	1.85	7.63	27.60
1985	22.31	6.94	1.87	8.4	26.99
1986	21.72	6.66	1.85	8.51	27.77
1987	20.29	6.21	1.76	8.69	28.42
1988	19.01	6.08	2	10.53	32.94
1989	17.39	6.17	1.83	10.54	29.71
1990	17.06	6.47	1.85	10.86	28.64
Sources: *Presidencia de la República Mexicana (1993). **Valdéz (1991).

Figures for annual per-capita expenditure on health present a similar picture: the level reached in 1990 (US $53.16) is not very different from that of 1980, but less than that of 1981, when per-capita expenditure peaked at US $72.94. In 1970, annual per capita expenditure was US $13.84, in 1981 it was US $72.94, and between 1982 and 1987 it was less than US $40.00, even dropping as low as US $20.00. But it has now recovered, reaching a per-capita expenditure of US $54.30 in 1991 (Valdéz 1991).

The data on public sector expenditure, social development expenditure, and health care expenditure clearly indicate the pattern of expansion in the 1970s, crisis in the 1980s, and an apparent tendency toward recovery in the 1990s.

Moreover, there were considerable inequalities in allocating expenditure, in the form of great disparities between institutions. For example, 35.1% of public health care expenditure between 1992 and 1994 went to the Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security), while only 4.5% went to the Secretaría de Salubridad y Asistencia (SSA, department of health) (Hernández et al. 1997). The funds available for social security and those available for services to the rest of the population are clearly disproportionate. On average, between 1970 and 1990, of every 1 000 pesos invested in health, 742 pesos went to social security institutions and only 258 pesos to health care services open to the entire population (Valdéz 1988) -this gives the social security institutions an average advantage of 2.8:1 (Table 5). According to official figures for 1995, this difference has decreased, although it was still high, at 1.59:1 (Secretaría de Salubridad y Asistencia 1995).
 

Table 5. Distribution of public expenditure on health, Mexico, 1970-90 (pesos spent out of every thousand)
Year	Social security	Population in general	Ratio
1970	802	198	4.06
1971	811	189	4.28
1972	769	231	3.34
1973	758	242	3.13
1974	768	232	3.31
1975	760	240	3.17
1976	788	212	3.71
1977	749	251	2.98
1978	726	274	2.65
1979	707	293	2.42
1980	706	294	2.40
1981	706	294	2.40
1982	731	269	2.72
1983	745	255	2.92
1984	735	265	2.77
1985	724	276	2.63
1986	696	304	2.29
1987	712	288	2.47
1988	744	256	2.90
1989	738	262	2.82
1990	716	284	2.52
Source: Valdéz (1991).

During the period 1970-1995, the population covered by public health care institutions increased significantly, making these values all the more indicative of inequality in terms of access to and quality of health care. This situation is even more serious when one considers that the general living conditions of the population without access to social security are relatively unfavorable to begin with.

It is interesting to note that most of the IMSS contributions come from workers and employers, 85.2% of them on average, between 1970 and 1990. On the other hand, the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE, social security institute for civil servants), received 54.4% of its funding from public bodies and 37.2% from workers during the same period (Valdéz 1991).

To summarize, public health care financing has gone from a period of expansion, through one of crisis, to a period that, although it shows some signs of recovery, has still not reached levels comparable to the earlier period. As a result, it is hardly surprising that institutions making up the public health care system have faced and are facing numerous difficulties in terms of the growth, capacity, and quality of the services that they provide.

As mentioned earlier, there is insufficient information on the private sector. Some indicators exist, however, that reflect its financial importance in the system as a whole. Between 1982 and 1987, the private sector accounted for 44.16% of total health care as a percentage of GNP (Ruiz et al. 1988).

Coverage

Many difficulties arise in analyzing official data on health care coverage. A major difficulty is the lack of uniformity in the concepts used. According to the department of health (Secretaría de Salubridad y Asistencia 1995), information on coverage may be obtained in the form of nominal coverage (the number of people entitled to receive services), but only for social security institutions; potential coverage (the number of people who can be cared for with the resources available); and real coverage (the number of people who actually used the services in a given year). Other difficulties include the diversity of methods used for generating information, inconsistency in this information, and a lack of data on some of the sectors that provide services. Because of these problems, the values presented must be considered as approximations only.

Estimates of the total capacity for coverage show that, for 1978, social security institutions could cover 24.0% of the total population, institutions open to the population in general 18.4%, and private services 12.3%, leaving 45.3% of the population (about 29.63 million inhabitants) with no coverage (COPLAMAR 1985).

In an effort to extend coverage, numerous government initiatives were introduced between 1979 and 1982 to open more services to underprivileged sections of the rural and suburban population. The most widespread and complete of these was the program known as IMSS-COPLAMAR. IMSS stands for Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security), while COPLAMAR stands for Coordinación General del Plan Nacional de Zonas Deprimadas y Grupos Marginados, (COPLAMAR, national program for depressed areas and marginal groups). Since 1982, IMSS-COPLAMAR has been known as IMSS-Solidaridad (IMSS solidarity).

As a result of these programs, the proportion of the population with access to medical services has greatly increased. Some studies indicate coverage rates of between 75.0% and 82.2% of the population, reaching nearly 89% by 1990. This would mean that about 11% of the inhabitants of the country or 9.5 million people still had no access to any kind of medical services at that time (Frenk et al. 1994). However, official data on real coverage, meaning actual use of health services, was 55.8% of the population in 1990 and 70.1% in 1995 (Table 5).

It should be pointed out that data on the distribution of coverage does not make a distinction between services provided by the public sector and services provided by the private sector. It is assumed, however, that private medical insurance coverage is still minimal, estimated at 2% by some sources (Frenk et al. 1994).

Thus, the issue of coverage remains one of the most critical problems facing the system. During the process of reform, various strategies for extending coverage were proposed in the national health programs for 1984-88 (Poder Ejecutivo Federal 1984) and 1989-94, as well as in the social security reform bill and the Programa de Reforma del Sector Salud 1995-2000 (PRSS, health care sector reform program 1995-2000) (Secretaría de Salubridad y Asistencia 1996).

Subsystems

There are two basic dimensions to the structure of the Mexican health care system (Frenk et al. 1994): social groups and system functions. A fundamental distinction can be made between two social groups: those who are insured and those who are not insured. The vast majority of the insured are covered by social security, as the private sector covers only a very small section of the population. Those who are not insured fall into two groups: the poor, both urban and rural, who are excluded from social security because they do not participate in the formal sector of the economy, and the self-employed or professional middle class, especially urban middle class, who are not protected by social security and have not acquired private medical insurance.

The main problem that arises in relation to the functions of the system comes from the fact that the various social groups are segregated into different subsystems. The present system can be characterized as "vertically integrated" but "horizontally segregated." That is, each institutional group (social security, general population, or private sector) carries out its functions independently.

This system structure gives rise to many problems, especially the duplication and waste of resources and the establishment of monopolies for the respective clients. Perhaps the most serious problem, however, is the overlap in demand, because a large number of those with social security also use the private sector and the institutions run by the Secretaría de Salubridad y Asistencia (SSA, department of health). In these cases, the insured patient pays twice or even three times, resulting in what is known as multiple contribution.

The institutions in the social security group are the Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security); the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE, social security institute for civil servants); the Instituto de Seguridad para las Fuerzas Armadas Mexicanas (ISFAM, social security institute for the Mexican armed forces), and medical services provided by and for the national oil company (PEMEX), the Secretaría de la Defensa Nacional (SDN, department of national defense), the Secretaría de Marina (SECMAR, navy department), and the Sistema de Transporte Colectivo del Metro (underground transport system).

Services for the general public are provided for by the SSA, the Sistema Nacional para el Desarrollo Integral de la Familia (DIF, national system for the integrated development of the family), the medical services of the Departamento del Distrito Federal (DDF, the administration of the Federal District of Mexico City), and IMSS-Solidaridad (IMSS solidarity)

Organization and provision of health services

As mentioned earlier, the system separates the population into insured and uninsured. Within the first group, there is a wide range of options that are related to the way people are tied to the formal sector of the economy; in the second group, there is a distinction between the poor and those of the middle class, who for various reasons are covered by neither social security nor private insurance. This diversity is reflected in the large number of institutions that not only provide health care services, but also finance and administer those services. This organization of the system results in a duplication of supply, waste of resources, unfair costs to users, and serious problems of coordination (Frenk et al. 1994).

Three different types of institution provide social security to the population: the Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security), which basically covers industrial workers; the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE, social security institute for civil servants), which covers civil servants; and institutions that offer health care for specific employers. The uninsured population receives health care in institutions that are considered to be for the population in general, such as those of the Secretaría de Salubridad y Asistencia (SSA, department of health), Sistema Nacional para el Desarrollo Integral de la Familia (DIF, national system for the integrated development of the family), and IMSS-Solidaridad (IMSS solidarity). A tiny segment of the population (2%) uses prepaid services and an unknown number pay directly for the use of private services.

Since 1984, there have been attempts to bring some order to the sector, using the SSA in a regulatory role, but these attempts have been unsuccessful. The Programa de Reforma del Sector Salud 1995-2000 (PRSS, health care sector reform program 1995-2000) has taken up these proposals (Secretaría de Educación 1996), indicating the urgency of the need for organization. The reform program proposal also encourages social security institutions to separate the financing function from the provision of services function. There is also, for the first time, official recognition of the private sector and of the need for its extension through an increase in new kinds of insurance.

Resources for the provision of services

The personnel and material resources available to the institutions, and the development of provision of health care services (Tables 6-10) are discussed in this section.

Public sector

Over the past 25 years, there has been a notable increase, in absolute terms, of material and human resources in the health care system as a whole. A considerable difficulty for analysis arises from the complete lack of information on the private sector prior to 1991. Nevertheless, the data on the increase in resources in the public sector give an idea of the magnitude of the increase within the system as a whole. In the public sector between 1970 and 1995, the number of medical units grew by 279%, with more emphasis on ambulatory facilities than hospitals; the number of beds increased 102%; and the number of physicians increased more than 400%. From 1980 to 1995, the number of consulting rooms increased 121%.
 

Table 6. Medical health centres, Sistema Nacional de Salud, Mexico, 1970-95.
Year	Private sector: Voluntary with out-of-pocket payment or voluntary contract	Public sector: Integrated public
		Social security*	General population**
1970	N.D.	2 030	2 066
1975	N.D.	2 493	2 454
1980	N.D.	2 667	5 316
1985	N.D.	3 030	7 705
1990	N.D.	3 343	9 848
1991***	1 790	3 411	10 401
1992	2 705	3 453	10 719
1995	2 816	3 606	11 919
		Percentage increment in the public sector
		1970-95	279
		1970-80	94
		1980-90	65
		1990-95	17
Sources: 1970-1975: Valdéz (1991). 1980-1995: Secretaría de Salubridad y Asistencia (1994c, 1995). * Includes: IMSS, ISSSTE, PEMEX, SDN, SECMAR, and state-level ISSSTE. ** Includes: SSA, DDF, and IMSS-COPLAMAR (IMSS-Solidaridad since 1990). *** State-level units are included as from this year.

It is worth noting that the rate of growth in the public sector has not been constant over this period. The greatest increases occurred between 1970 and 1980: 94% for medical units; 57% for numbers of beds; 75% for number of consulting rooms; and slightly over 200% for total number of doctors. From 1980 to 1990, the increases were notably less for medical units (65%) and human resources (31%) and dramatically so for number of beds (only 5.8% in this period). Over the same period, the number of consulting rooms increased 75%, the same growth rate as between 1970 to 1980. Records for the first part of the 1990s appear to confirm a slowing in the growth in numbers of medical units and consulting rooms (17% and 25%, respectively, by 1995), whereas the increase in human resources and the number of beds has risen again (37% and 21%, respectively).

Within the public sector, the institutions open to the population in general have experienced greater growth than social security institutions in all areas except for the number of beds, where the increase has been similar.
 

Table 7. Consulting rooms and beds, Sistema Nacional de Salud, Mexico, 1970-95.
Year	Private sector: Voluntary with out-of-pocket payment or voluntary contract		Public sector: Integrated public
			Social security*		General population**
	Consulting rooms	Beds	Consulting rooms	Beds	Consulting rooms	Beds
1970				21 257		16 519
1975				29 497		14 641
1980			11 693	36 110	8 042	23 522
1985			13 631	36 968	13 795	22 282
1990			17 157	38 050	17 567	25 072
1991***	7 500	21 895	17 606	38 189	18 704	29 514
1992	8 349	31 062	18 536	39 181	19 485	32 319
1995	12 022	34 496	20 792	41 128	22 878	35 514
Percentage increment in the public sector
1970-95		102
1970-80		57.8
1980-90	75	5.8
1990-95	25	21.4
Sources: 1970-75: Valdéz (1991). 1980-95: Secretaría de Salubridad y Asistencia (1994c, 1995). Note: The data on private sector consulting rooms include both general practices and specialization. * Includes: IMSS, ISSSTE, PEMEX, SDN, SECMAR, and state level ISSSTE. The figure for 1980 includes information corresponding to Ferrocarriles Nacionales ** Includes: SSA, DDF, IMSS-COPLAMAR (IMSS-Solidaridad since 1990). The figure for 1980 includes information corresponding to DIF. *** State level units are included as from this year

Data for the last 5 years (1991-95) indicate a contraction of the public sector relative to the private sector, both in terms of facilities and human resources. In the private sector, there has been an increase of 57.0% in the number of medical units, 57.5% in the number of beds, 60.2% in the number of consulting rooms, and 440% in number of doctors, compared to 12.0%, 13.2%, 20.2%, and 23.5%, respectively, in the public sector. The information regarding doctors needs further analysis, however, because it is estimated that only 30% of doctors work full time in private practice, while the remaining 70% work in both sectors.

Public and private sector

The majority of physical and human resources are concentrated in the public sector. The share of the private sector has increased over the last few years, however. By 1995, 15.5% of medical units, 31.0% of beds, 21.6% of consulting rooms, and 36.6% of doctors were in the private sector.
 

Table 8. Office visits by patients, Sistema Nacional de Salud, Mexico, 1970-95.
Year	Private sector: Voluntary with out-of-pocket payment or voluntary contract	Public sector: Public integrated
		Social security*		General population**
1970		11 963		6 746
1975		17 450		10 076
1980		33 881		22 540
1985		37 642		23 542
1990		44 935		29 121
1991***	10 868	49 603		32 708
1992	33 626	49 875		36 612
1995	58 724	55 380		46 295
		Percentage increment in the public sector
		1970-95	443.45
		1970-80	201.57
		1980-90	31.25
		1990-95	37.29
Sources: 1970-75: Valdéz (1991). 1980-95: Secretaría de Salubridad y Asistencia (1994c, 1995). Note: The figures for private sector doctors do not separate doctors in contact with patients from those with other duties. They also include full- and part-time doctors and those who have legal contracts with health centres for the use of installations or sporadic attention to individual patients according to their specialties but who do not form part of the staff. These doctors represent almost 50% of those reported. * Includes: IMSS, ISSSTE, PEMEX, SDN, SECMAR, and state level ISSSTE. The figure for 1980 includes information corresponding to Ferrocarriles Nacionales ** Includes: SSA, DDF, IMSS-COPLAMAR (IMSS-Solidaridad since 1990). The figure for 1980 includes information corresponding to the DIF. *** State level units are included since this year

 An analysis of the distribution of resources in the public sector shows that the institutions that are open to the population in general have more medical units (3.3:1) and more consulting rooms (1.1:1) than the social security institutions, whereas the social security institutions have more beds (1.15:1) and doctors (1.19:1).

Table 9. General office visits versus hospital admissions, Sistema Nacional de Salud, Mexico, 1970-95 (values in thousands).
Year	Private sector: Voluntary with out-of-pocket payment or voluntary contract		Public sector: Public integrated
			Social security*		General population**
	General consultations	Hospital admissions	General consultations	Hospital admissions	General consultations	Hospital admissions
1970			44 298	907	9 147	306
1975			56 023	1 372	12 345	348
1980			47 943	1 815	19 518	485
1985			63 108	2 301	25 404	696
1990			67 773	2 234	32 574	1 035
1991***			66 641	2 297	34 296	1 073
1992			68 327	2 320	34 535	1 147
1995	3 192	887	82 508	2 491	42 929	1 665
Sources: 1970-80: Valdéz (1991). 1985-95: Secretaría de Salubridad y Asistencia (1994c, 1995). * Includes: IMSS, ISSSTE, PEMEX, SDN, SECSMAR, and state level ISSSTE. The value for 1980 does not include information corresponding to the SDN. ** Includes: SSA, DDF, IMSS-COPLAMAR (IMSS-Solidaridad since 1990). The value for 1980 includes information corresponding to the DIF. *** State level centres are included as from this year

 If, however, these resources are analyzed relative to population served, the institutions open to the general population clearly have fewer resources. For either potential or legal populations, for every 100 000 inhabitants, institutions open to the general population had 111.0 doctors, 183.6 nurses, 47.7 consulting rooms, and 83.7 beds; whereas social security institutions had 121.1 doctors, 218.4 nurses, 45.5 consulting rooms, and 89.9 beds. During 1990, the social security institutions had almost double the resources of public institutions (Secretaría de Salubridad y Asistencia 1995), indicating a serious disproportion in the distribution of resources.

It is clear that although the government has attempted to strengthen public health care institutions, it has not yet succeeded in providing the services required by the population in terms of quantity and, especially, quality.

Similarly, strengthening the institutions for the general population has not rectified the basic inequity in the distribution of resources throughout the country. For example, in 1992, only 13 of the 32 states reached the national average for the number of beds, only eight states reached the national average for the number of consulting rooms, and only 13 attained the international standard for the number of doctors per inhabitant. In fact, this last standard is only satisfied by eight states with respect to institutions open to the general population and by 17 states for social security institutions. In the case of the Secretaría de Salubridad y Asistencia (SSA, department of health), responsible for health care services in the poorest states, the data show that the areas of most need are those with the fewest resources, especially doctors. For example, in Chiapas there are only 51.7 doctors per 100 000 inhabitants, compared to the national median of 95.2 per 100 000. Of these, about 50% of the doctors who care for the general population are interns or have not yet obtained their full professional qualifications (Secretaría de Salubridad y Asistencia 1994b).

Table 10. External office visits at health centres versus hospitalization health centres, Sistema Nacional de Salud, Mexico, 1980-95.
Year	Public integrated sector
	Social security*		General population**
	External consultation	Hospital­ization	External consultation	Hospital­ization
1980	2 371	296	5 140	176
1985	2 705	325	7 467	238
1990	2 925	421	9 554	294
1991***	2 988	423	10 052	349
1992	3 030	423	10 309	410
1995	3 081	437	11 046	360
Source: Secretaría de Salubridad y Asistencia (1994c, 1995). Note: The external consultation centres cover first level care, hospital centres include secondary and tertiary level care. * Includes: IMSS, ISSSTE, PEMEX, SDN, SECMAR, and state-level, ISSSTE. ** Includes: SSA, DDF, and IMSS-COPLAMAR (IMSS-Solidaridad since 1990). *** State-level health centres are included as from this year.

Between 1980 and 1995, there was an 86% increase in the number of general consultations in the public sector, and an 80% increase in the number of hospital admissions, with the greater part of the increase occurring in institutions for the general population. There were, however, still notable differences in 1995 in the number of services provided. Social security institutions provided 65.7% of general consultations and 59.9% of hospital admissions, which can be explained by the lower number of doctors, beds, and economic resources available in the public health services for the general population.

When the public sector is compared to the private sector, official information shows that 97.51% of general consultations occur in the public sector, as well as 82.4% of hospital admissions. But, these values obviously underestimate the private sector’s real share. In fact, the government itself recognizes that the private sector provides about 32% of medical consultations, and that this proportion is higher for the lowest income groups, where about 41% of contacts with doctors are in the private sector (Secretaría de Salubridad y Asistencia 1996).

To summarize, there has been an increase in health resources in absolute terms. In the public sector, this growth has focused on strengthening public institutions, especially in the areas of primary care and ambulatory services, and primary health personnel. Nevertheless, these measures do not appear to have solved the many problems that exist in the public sector. As a result, there is room for growth in the private sector, especially in the area of hospital services.

Changes in the Health Service System

This section will analyze the changes that have occurred in the subsystems within the Mexican health care system over the last 25 years by describing the health care subsystems prevalent from 1970 to 1995 and the changes that they have undergone. Two different periods are considered: first, the 1980s, when organizational and administrative changes were made that led to the formation of the Secretaría de Salubridad y Asistencia (SSA, department of health); and, second, the most recent period since the reform of the social security system. Tendencies will be identified, the most important of which is the emergence of the public contract subsystem.

Two initial observations must be made. First, the aspects considered relevant in characterizing the subsystem are financing, provision, methods of payment, relations between the different participants in the system, and regulation. This approach fundamentally considers the first two aspects -financing and provision. Second, because of the historical process in which it has developed, the health care system in Mexico has been characterized by the coexistence of a wide variety of means of access, types of organizations, provision, and even financing, so that any attempt at grouping is very complicated. For this reason, the analysis considers the most representative options.

When analyzing the Sistema Nacional de Salud (SNS, national health system), with particular reference to financing and provision during the period from 1970 to 1995, the various options for health care can be grouped into four models: the integrated social security subsystem, the integrated public subsystem, the voluntary contract subsystem, and the public contract subsystem.

The integrated social security subsystem is characterized by compulsory financing through income-related contributions. Provision is by public institution. Payment of providers by users is indirect through public financing bodies that provide wages and, in the case of institutions, prospective budgets.

The integrated public subsystem for the population in general is funded by the state through general taxation. Payment to institutions and workers is based on prospective budgets and salaries, respectively. These institutions also charge for services based on the economic capacity of the user. However, these charges have had a minimal economic impact.

The voluntary contract subsystem is made up of so-called prepaid private services. Financing in this subsystem is voluntary and services are provided by independent professionals and institutions. The method of payment is indirect, through insurance companies on a fee-for-service or per-capita basis.

The public contract subsystem is the model that is considered to have emerged as a result of changes in the social security system since 1995. Under this model, financing is based on compulsory income-related contributions, services are provided by public or private institutions, and medical services are contracted from the private sector on a return-of-contributions basis. Although regulations have not yet been established to standardize payment to companies, it is already known that employers will be able to retain up to 40% of health insurance contributions, which they will then be able to use to contract for the kind of service they choose.

Organization of the health service system

Traditionally, the health care system in Mexico has been based on a clear differentiation between two sectors, public and private. Within the public sector, both subsystems correspond to the integrated public model, because there is no separation between financing and provision. Nevertheless, there are differences in financing and in the population covered that make them independent of each other.

In the integrated social security subsystem, social security institutions are financed by compulsory income-related contributions. At present, these institutions cover about 51% of the population. Public institutions provide the health care services and doctors are salaried.

The institutions grouped in the integrated public subsystem for the population in general are financed out of general taxation, through funds that are specifically allocated at the central level, both for national and state institutions. Theoretically, these institutions cover 49% of the population but, because there is no compulsory affiliation, it is estimated that about 11% of the population is without any kind of medical coverage at all. The definition of priorities and the distribution of resources all takes place at the central level, and depends very much on the prevailing political environment.

The voluntary contract subsystem, which has only been identified as recently as the second half of the 1980s, is made up of a great number of private hospitals that offer service by contract. These hospitals are complementary to the social security subsystem, since they generally handle only emergencysituations. Although these services cover only 2% of the population, the speed with which they have increased over the last decade indicates that this is an option that will play an important role in the future. Financing is by prepayment and doctors are paid on a fee-for-service or per-capita basis.

The public contract subsystem is in a period of gestation, but it will be the first institutionalized experience of the public-private mix.

Relationship between payers and providers

For the integrated public social security subsystem, the allocation of resources to providers has been very centralized, even in states that were decentralized in the 1980s. The only decentralized Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security) program was IMSS-Solidaridad (IMSS solidarity). Allocation was provided through a yearly budget. The Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE, social security institute for civil servants) and other smaller institutions that provide social security have bipartite financing (workers and the federal government). The IMSS has tripartite financing, from workers, employers, and the federal government. The percentage paid by each party varies from institution to institution. Doctors are paid fixed salaries that are defined on a sliding scale (Barreiro 1997).

Doctors are organized into unions. The union of IMSS workers provides some of the best benefits for its members. This body has been very active in opposing the changes proposed by the reform since the mid-1980s. The ISSSTE workers also have an organized union but it is corporate in nature, and represents its members through direct negotiations with the state. In general, all institutions in this part of the sector are regulated in a similar way, but each institution defines the specific points as to amounts, forms of payment and benefits for its workers according to criteria resulting from its individual history and dynamics.

The amount of work has been determined to date by demand and there have been no incentives to economize. As in most other state-supported institutions, incentives for punctuality and productivity have been introduced in recent years. There has been little control over the prescribing of pharmaceuticals in the past, but this is now very strictly controlled. The purchase of pharmaceuticals is regulated by the state on the basis of what is known as “consolidated purchase bidding,” with each institution having an official list of approved medicines for use in public health institutions, that of the IMSS being the most complete.

Before decentralization in 1986, the allocation of resources in the public subsystem was very centralized, like that of the social security model. Since then, 14 of the 32 states have been decentralized. Decentralization has resulted in better services in the more affluent states, but deterioration of services in the poorer ones, accentuating the differences between them. Between 1983 and 1987, state governments received only about 9.7% of all the resources allocated to the integrated public subsystem (Ruíz et al. 1988). There have been several decentralizing initiatives since 1990, but these have not been very efficient. Examples are the Sistemas Locales de Salud (local health care systems) and the Programa de Apoyo a los Servicios de Salud para la Población no Asegurada (PASSPA, support program for health care services for the uninsured). This latter program was applied in the four poorest states of the country and its effect tended toward centralization rather than decentralization (González-Block et al. 1997).

Hospitals receive payment through annual budgets. Fixed salaries are paid, which are independent of productivity. The workers in this part of the sector are also union members, but their working and economic conditions are not as good as for those working in the social security sector. There are few incentives for improving the efficiency or productivity in these institutions.

Although ambulatory services do not provide drugs, the Secretaría de Salubridad y Asistencia (SSA, department of health) has an official list of approved medicines through which prescriptions are regulated both outside hospitals and, especially, within them. This list is based on the programs of the institution and makes a priority of using mono-pharmaceuticals, that is, medications with a single active ingredient. The volume of work is determined by demand and there are no incentives for efficiency or economy, although it must be said that the present conditions of austerity and deterioration make such incentives unnecessary.

The voluntary contract subsystem is composed of prepaid services that provide health care on a profit-making basis. Financing is voluntary. Unfortunately, there is a lack of data as to the resources handled by the subsystem, although there is no doubt as to its importance within the health care system. Services are provided by private professionals and institutions. Providers receive payment from insurance companies on a fee-for-service or per-capita basis.

Relationship between patients and providers

Within the integrated public social security subsystem, service providers, professionals, and institutions belong exclusively to the public sector, although important changes are sure to result from the modifications to the social security act. Social security institutions, particularly the Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security), absorb a high proportion of the resources in this sector. The last 15 years of financial austerity, however, have caused a considerable deterioration in the services that these institutions provide.

These institutions offer ambulatory and hospital services, including primary-, secondary-, and tertiary-level care. The general health law stipulates that these institutions should participate in national health campaigns, and they play an important role in this area.

The family doctor is the gatekeeper to the subsystem, with the power of referral to secondary or tertiary levels as necessary. Patients cannot choose their doctor, who is assigned by the institution.

There is no out-of-pocket payment. Nevertheless, the lack of medical supplies means that patients often have to buy their own. The social security institutions, especially the IMSS, are still in the forefront of medical and hospital technology, although specialized services are being used to full capacity, so access to complex technology is not easy.

The services of the integrated public subsystem for the population in general are geographically separate, and access is defined by this characteristic. They provide ambulatory and hospital care. The Secretaría de Salubridad y Asistencia (SSA, department of health) is responsible for health policy and is, therefore, responsible for creating programs for the sector as a whole. In this capacity, it is the primary promoter and provider of preventive health care, such as vaccination, diagnosis and detection of disease, and care of healthy children. The services do not include the provision of drugs through walk-in consultations.

Initial contact with the system is through a general practitioner, who may refer the patient to secondary or tertiary level. There are no mechanisms in these institutions either, for the patient to choose his or her doctor. An out-of-pocket co-payment is usually charged for walk-in consultations. Although this is generally quite small, it has been increasing since the mid-1980s. This co-payment is not regulated in any way, and each institution fixes the charges and the way in which they are set. The amount of co-payment for hospitalization is based on a socioeconomic evaluation of each user.

Most public hospital services for the population in general (public decentralized SSA organizations, some national institutes, the Sistema Nacional para el Desarrollo Integral de la Familia (DIF, national system for the integrated development of the family), the Departamento del Distrito Federal (DDF, administration of the Federal District of Mexico City), and some states and municipalities have co-payment charges. The amount paid and payment conditions vary from institution to institution (COPLAMAR 1985).

As a whole, the integrated public system has been characterized by the impossibility for the user to choose a particular provider. This, together with various deficiencies in the quality of services provided, has justified a tendency to lay blame for the deterioration in services on the professionals and to call for the introduction of user choice of provider. This evaluation does not take into consideration, however, the role that serious under-financing has played in the deterioration of public institutions. Given the prevailing economic conditions, it is doubtful that the selection of doctor would result from free choice or need, but rather would depend on the purchasing power of the individual. Access would be differentiated on the basis of wealth.

Although there is insufficient information, some studies have found that the voluntary contract subsystem is used mainly to provide obstetrics and gynecology, surgery, and psychiatric services. The market available to the private sector is not large enough to permit the use of advanced technology or sub-specialties that are becoming increasingly refined and expensive. This subsystem has, therefore, tended to provide less-expensive services (COPLAMAR 1985). Nevertheless, in recent years, the sector has grown into a sizeable industrial-medical complex that uses high technology and is concentrated in large urban centres. Payment is indirect, through prepaid premiums, but in most cases an initial down payment must be made for each service. This out-of-pocket expense, which is often beyond the means of the user, discourages the use of this option.

Relationship between population and payers

At present, the integrated public social security subsystem covers about 51% of the population of Mexico, both those directly insured and their dependants. Financing is tripartite with contributions from employers, the state, and workers. It should be pointed out that, in the case of the Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security), workers’ and employers’ contributions cover most of the financing (85.2% on average between 1970 and 1990), whereas in the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE, social security institute for civil servants), a greater proportion of the contributions come from public bodies (54.4% versus 37.2% from workers and employers in the same period). Access is determined by affiliation, which in turn depends on being part of the labour market, for the most part in industrial activities, although some groups of workers from state-supported organizations are also affiliated. Medical benefits are also provided to workers’ families. The subsystem is geographically divided according to users’ place of residence. Nearly all institutions of this type provide additional benefits such as prescription medicines, child-care centres, retirement pensions, recreational facilities, and insurance against occupational hazards.

Theoretically, all those who are not covered by social security, mainly low-income people who are not involved in the formal labour market, have access to institutions in the integrated public subsystem for the general population. There is a small sector of the middle class that uses the integrated public services, especially those high-quality specialized services available at the institutes. In this case, access is through out-of-pocket payment and the cost is based on a socioeconomic evaluation of the user, although it can be similar to the most expensive of private services.

As was mentioned earlier, only about 2% of the population are covered by the voluntary contract subsystem. More detailed analyses show some interesting facts. Because of regional income differences, the acquisition of private medical insurance is more common among the urban population and in the north of the country. In the urbanized areas of the north, 5% of the population has private health insurance and, in Mexico City, about 3% has (Knaul et al. 1977). On the other hand, recent data show that about 42% of the population use private services, both ambulatory and hospitalization. This includes those who pay for such services directly out-of-pocket.

The emerging model

Modifications to the Ley del Seguro Social (social security law) and, more generally, legislative changes with respect to health care services, are very recent The social security law came into effect only in July 1996. Thus, this section will be limited to an observation of possible tendencies resulting from the changes to the Sistema Nacional de Salud (SNS, national health system). These will no doubt be significant, but are not yet clearly defined. Therefore, the following statements are provisional, and some aspects of the relationships between the participating parties can only be sketched, because it is not yet clear how they will develop in the future.

In general terms, the characteristics of the subsystems that have already been described will continue in the future. Perhaps the most important changes, those that will define the different relationships between the parties involved in health care services, will be the emergence of the public contract subsystem and the expansion of the voluntary contract subsystem.

Public contracting has been allowed under the law governing the Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security) for several decades, but it has had a limited impact and played practically no role in the general orientation of the Sistema Nacional de Salud (SNS, national health system). Nevertheless, the reforms that were advanced in 1995, both for social security and within the institutions for the population in general, make feasible a considerable increase in the use of public contracting for services. This will be the first institutionalized experience of a public-private partnership in Mexico.

In general, we believe that the emergence of this subsystem and the expansion of the private contract subsystem will shape new relationships between the public and private sectors. The relationships between the different parties are presented below, with emphasis on the changes that may take effect in the future.

Relationship between payers and providers

In the integrated public subsystem, the priority among the changes proposed by the Programa de Reforma del Sector Salud 1995-2000 (PRSS, health care sector reform program 1995-2000) is decentralization. As has been seen, the first initiatives in this respect appeared at the beginning of the 1990s in programs for decentralizing public health care services to the state level. But by 1994, only 13 of the 32 states in the country had decentralized health care services. In a government report of September 1997, the President of the Republic indicated that the decentralization process was nearly 100% complete. This is evidence of the importance that the present administration places on decentralization. But given the speed with which it has been brought about, it seems reasonable to suppose that its achievements will be limited in the immediate future.

In the most recent reform initiatives, the decentralization process has concentrated on setting up state and municipal health care systems through the Municipio Saludable (Healthy Municipalities) program, which proposes the participation of local communities in defining priorities, and drawing up, implementing, and evaluating local health care programs. Another important change will be the decentralization of IMSS-Solidaridad (IMSS solidarity) and its transfer to state health care systems.

Of course, the decentralization process is intended to allocate federal resources to the states in a more equitable manner, and also to mobilize greater effort by state and local authorities in collecting funds destined for health care services. In general, however, other aspects of the relationship between payers and providers will remain unchanged.

In the emerging public contract subsystem, which is closely tied to the integrated public social security subsystem, financing will be compulsory, with resources coming from the existing social security systems, using the mechanism of return-of-contributions that was described earlier. Contributions will continue to be made by the state, employers, and workers. The return-of-contributions mechanism will relieve problems resulting from the inability of institutions to respond to the need for care by the insured population. From the financial point of view, however, the withdrawal of workers with higher contribution rates, about 31%, will mean the loss of valuable resources. In fact, if all high contributors move to the private sector, the Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security) will retain 70% of the users but only 49% of the resources (Laurell 1996).

Also, because of the financial crisis in sickness and maternity insurance - the result of the growing imbalance between the population covered (workers and dependants) and the contribution scheme - a new model for contributions has been proposed in addition to the return-of-contributions scheme. In the case of maternity insurance, workers’ and employers’ contributions will be reduced by about 33% and this reduction will be covered by an increase in the federal contribution. For workers who earn less than three times the minimum wage, there will be a fixed payment made only by employers and the government. For workers who earn more than this, an additional 6% will be paid, again, by the employers and the state.

There is insufficient information at present to indicate what level of economic relationship will exist between the IMSS and companies. The only mechanism that is clearly defined is that the companies choosing to take advantage of the return-of-contributions system will retain about 40% of their total contributions to use for establishing contracts for medical services covered by the sickness and maternity insurance.

The IMSS is, therefore, in a difficult situation because of the possibility of losing those groups that pay the most and being forced to depend, to a great extent, on government efficiency in tax collection for its revenues, the government being one of the highest contributors since the reform. At the same time, the IMSS will be forced to improve as a service provider in order to compete with the private sector for the provision of services to the informal sector of the population, which will be incorporated through the new family insurance program.

In the public contract subsystem, providers will be paid indirectly through company sickness funds or public financing organizations. The latter, if they are established, will pay on a fee-for-service or per-capita basis, with the parallel introduction of incentives to encourage productivity. A high proportion of social security doctors are expected to work also for those private establishments that provide services through the voluntary contract scheme, once it becomes established.

Finally, there are plans to reorganize public institutions with regard to negotiating collective agreements for workers, on the basis of the new institutional reality and of a possible cut-back in the numbers of workers.

Relationship between patients and providers

Theoretically, the integrated public subsystem for the population in general will be reorganized to increase user choice. The reform program also envisages the introduction of incentives for good service. Although the providers in this model remain the same, it should be mentioned that services will be based on “packages” that will be defined according to cost-effective parameters based on the socioeconomic conditions of the population to be served. To increase efficiency, the unit cost of each intervention will be calculated. Also, it is expected that the current prevalence of direct payment will be increased.

An evaluation has shown that users prefer private over public sector consultation when they can afford it. Constant complaints are made about waiting time and the treatment received in the institutions that make up the integrated public model, both those of the social security and those open to the population in general. This has to do with the critical financial situation in the sector. Secondary- and tertiary-level services in the public sector have a better image; those who can generally make use of them, especially since the cost of such services in the private sector is a real obstacle to access.

This is the reason why there will be a combination of public and private institutions and public and private professionals in the public contract subsystem. The kind of institution or professional used will depend, among other things, on the kind of service to be provided. Thus, users will be expected to turn to independent professionals and institutions for primary attention, while relying on public sector professionals and institutions for hospital care.

Diversification of insurance plans is also expected both in the public contract subsystem and in the voluntary contract subsystem because, at present, most of these only cover extreme situations.

Relationship between population and payers

The most important change in the relationship between the population and payers affecting the integrated public subsystem has to do with the introduction of a basic care package. Adoption of the package was encouraged during the 1980s and has become especially important under the Programa de Reforma del Sector Salud 1995-2000 (PRSS, health care sector reform program 1995-2000). Apparently, the intention is to concentrate the greatest effort on the poorest urban and rural areas, in such a way as to avoid duplication of effort in covering this population.

The basic care package is defined as “the minimum number of health care interventions that must be provided to any population with respect to priority needs (risk factors, injuries, and sickness)” (Secretaría de Salubridad y Asistencia 1996). The package will include clinical, public health, and health promotion interventions that are easy to implement at low cost and with high impact. It will cover areas such as basic family health; family planning; maternal and child health; oral rehydration therapy; antiparasite treatment; management of acute respiratory problems; prevention and control of pulmonary tuberculosis; prevention and control of high blood pressure and diabetes mellitus; accident prevention and first aid; and community training in personal health care. The package is to be applied in 380 extremely poor municipalities in 11 states, where 4 million people live, 30% of whom have no access to any regular source of medical attention.

Traditionally, the extension of coverage under the social security subsystem, particularly the Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security) has been based on expanding eligibility to additional sectors of the population. The latest initiative along these lines has been the creation of family health insurance, which is directed at workers in the informal sector.

More particularly, changes that have been put into effect in this subsystem indicate different reforms for different insurance plans, specifically sickness and maternity insurance, and disability, old age, retirement, and life insurance.

The central proposal for sickness and maternity insurance concerns defining a package of services to be covered by this insurance, opening up coverage to workers in the informal sector by means of the family health insurance, allowing the option of contracting with the private system, and subcontracting certain services. To this end, a single, uniform, indexed contribution will be established, which, unlike the contributions that have been made in the past, will not be proportional to salary.

Contributions and benefits for disability, old age, retirement, and life insurance will be strictly correlated, with a system of individual accounts and the opening of the insurance plan to unsalaried sectors of the population. In other words, this will be a compulsory retirement insurance plan with individual capital funds. The main purpose of this change is to make the various branches of the insurance plan viable without increasing (in fact, decreasing) worker and employer contributions, and by complementing payroll deductions with general fiscal resources and including new kinds of worker. This measure actually favours various Asociaciones de Fondos para el Retiro (AFORES, associations of retirement funds) that will be responsible for providing workers’ retirement pensions in the future.

Lastly, the public contract subsystem is expected to absorb about 30% of the population covered at present by the IMSS, mainly those groups paying the highest contributions, as mentioned earlier. Since the changes to the social security law have come into effect, there have already been cases of medical services being contracted through the return-of-contributions option in the northern part of the country.

The voluntary contract model is likely to increase in the future because its target population is the workers in the informal economy who are to be incorporated into the IMSS. Fierce competition is expected between the IMSS and private insurance companies over the provision of this kind of service.

Regulation

The regulation of health care services in Mexico has been identified as one of the greatest challenges for the Sistema Nacional de Salud (SNS, national health system). The state has always predominated in health policy-making, and it would be true to say that civilian society has not participated in any way in the definition of health care policy. There is, therefore, vertical decision-making, with the state as main protagonist. The principal aspects of health care services regulation may be found, therefore, in the legal documents referring to health care that were summarized in the previous section.

Various authors believe that regulation is very weak and unresponsive to the needs and challenges arising from the changes taking place within health care institutions. One of the challenges for the future is considered to be the formation of a regulatory body with the capacity to establish standards and regulations for the whole sector (Frenk et al. 1994).

Traditionally, the Secretaría de Salubridad y Asistencia (SSA, department of health) has been assigned the role of regulator, but in practice the Instituto Mexicano del Seguro Social (IMSS, Mexican institute for social security) has become more important in the general dynamics of the system, diminishing the effectiveness of ministerial initiatives. Perhaps one of the most typical aspects of the regulation of the Mexican health care system concerns its structure. Because the system is segmented by population group and because each segment carries out its functions independently, regulation might be said to apply autonomously within each subsystem.

The institutions in both public subsystems have similar regulatory mechanisms with respect to their relationships with doctors, because in both cases the doctors are considered to be state employees. The practices and procedures for carrying out the work come under the regulations on general work conditions. But many aspects of professional behaviour, such as prescribing, are defined by practice and are not contained in any procedural documents. Because private practice has only been explicitly incorporated into the sector in recent years, there has been no regulation of its activities. With the changes in force since the reform of social security in 1995, however, greater emphasis on regulation is expected, both in the private and the public sectors.

Document(s) 9 of 14