MAJOR CHALLENGES FACED BY THE MEXICAN HEALTH CARE SECTOR

1. HEALTH POLICY AND FEDERALISM MAJOR CHALLENGES FACED BY THE MEXICAN HEALTH CARE SECTOR Forum of Federations / Forum des fédérations www.forumfed.org forum@forumfed.org INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO DR. EDUARDO VELASCO DR. ARMANDO ARREDONDO Presentado ante el Foro de Federaciones en México, 18 de octubre de 2001

2. HEALTH POLICY AND FEDERALISM OUTLINE • OVERVIEW OF THE MEXICAN HEALTH SYSTEM • CHALLENGES • HEALTH REFORM STRATEGIES • DECENTRALIZATION • INSTRUMENTAL STRATEGIES • POLITICAL ACTORS • GAPS • OTHER ISSUES INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

3. HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

4. HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

5. HEALTH POLICY AND FEDERALISM CHALLENGES • 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 INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

6. HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES • GUIDING FORCE: DEMOCRATIZACION • LEADING PRINCIPLE: CITIZENSHIP • VALUES: • JUSTICE • LIBERTY • REPRESENTATION OF CITIZENS’ INTERESTS • SOCIAL PARTICIPATION • ACCOUNTABILITY INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

7. HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES • SUBSTANTIVE STRATEGIES • Link health to economic development • Decrease backlogs of disease and healthcare • Respond to emerging problems • Crusade for quality • Financial protection • INSTRUMENTAL STRATEGIES • Federalization • Regulation (steering, stewardship) • Universal Health System • Freedom to choose provider and citizens’ participation • Advancement of knowledge INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

8. HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES • INSTRUMENTAL STRATEGIES • Federalization • - Complete decentralization • - Explicit formulation of resource allocation to states • - Interstate cooperation • -in public health services • - in high specialty areas and services INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

9. HEALTH POLICY AND FEDERALISM MODALIDADES DE DESCENTRALIZACION SEGUN GRADO DE INTERDEPENDENCIA DE LOS NIVELES DE GOBIERNO RESPECTO A FUNCIONES ESPECIFICAS ADMINISTRACION DE RECURSOS HUMANOS AUTORIDAD DECISION CAPTACION NECESIDADES NORMATIZACION FINANCIAMIENTO PLANEACION DESCONCENTRACION MODALIDADES DE DESCENTRALIZACION DELEGACION DEVOLUCION PRIVATIZACION GRADO DE INTERDEPENDENCIA MENOR - MAYOR + INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

10. HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE DECENTRALIZATION • Deconcentration to shift power from the central offices to peripheral offices • Delegation • Devolution shifts responsibility and authority from the central offices of the Ministry of Health to separate administrative structures still within the public administration • Privatization. Prospective payment health insurance with private providers; reversion of IMSS fees to banks who purchase health services elsewhere. ISES. • Overlap and duplication • Conditional and block grants • Unilateral and vertical decisions • Joint-decision making INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

11. HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE 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. INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

12. HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES • INSTRUMENTAL STRATEGIES • 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) INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

13. HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES • INSTRUMENTAL STRATEGIES • 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 INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

14. HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES • INSTRUMENTAL STRATEGIES • 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 INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

15. HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES • INSTRUMENTAL STRATEGIES • Strengthening knowledge • - Promotion of mission-oriented research • - Information system for decision making • - Human resource development INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

16. HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE Communication media Civil society: low incomes Civil sociaty: high and middleincomes States with high incomes Insured Population Entrepreneurs PRD Health Policies Health Care Reform Uninsured Population Health Researchers IMSS SSA Federal Government President States with middle and low incomes State governments PAN PRI Health Institution Unions Other Unions HIGH INFLUENCE on health policies MEDIUM INFLUENCE on health policies LOW INFLUENCE on health policies INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

17. HEALTH POLICY AND FEDERALISM GAPS IN HEALTH POLICY FORMULATION • 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 INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

18. HEALTH POLICY AND FEDERALISM OTHER ISSUES DECENTRALIZATION Symmetry of relationships between central and peripheral levels Formal intergovernmental bodies Decentralization to the municipality level HEALTH POLICY Evidence-based Financing allocation based on performance & health improvement Explicit caps and allocation of funds at central, state, and municipality levels INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO