Elsevier

The Lancet

Volume 368, Issue 9539, 9–15 September 2006, Pages 954-961
The Lancet

Public Health
Bridging the divide: global lessons from evidence-based health policy in Mexico

https://doi.org/10.1016/S0140-6736(06)69376-8Get rights and content

Summary

During the past 6 years, Mexico has undergone a large-scale transformation of its health system. This paper provides an overview of the main features of the Mexican reform experience. Because of its high degree of social inequality, Mexico is a microcosm of the range of problems that affect countries at all levels of development. Its health system had not kept up with the pressures of the double burden of disease, whereby malnutrition, common infections, and reproductive health problems coexist with non-communicable disease and injury. With half of its population uninsured, Mexico was facing an unacceptable paradox: whereas health is a key factor in the fight against poverty, a large number of families became impoverished by expenditures in health care and drugs. The reform was designed to correct this paradox by introducing a new scheme called Popular Health Insurance (Seguro Popular). This innovative initiative is gradually protecting the 50 million Mexicans, most of them poor, who had until now been excluded from formal social insurance. This paper reports encouraging results in the achievement of the ultimate objective of the reform: universal access to high-quality services with social protection for all.

Section snippets

New dynamics of poverty and health

The need for the Mexican reform stemmed from the growing pressures placed on the health system by the double burden of disease. This dynamic process has become familiar to most developing countries. In health we are victims of our own success. The improvement in basic health conditions fuels the epidemiological transition by enhancing the survival of children to reach ages at which non-communicable diseases are more prevalent. Because the rate of this change is unequally distributed between

Empowerment through evidence

The reform of the Mexican health system was designed to correct such a paradox. It did so by investing heavily in the generation and application of relevant knowledge, in what is probably a textbook case of evidence-based policy.8 Indeed, the combination of internationally adopted methods of measurement with national analysis revealed critical realities that required solutions. Thus, the calculation of national health accounts showed that more than half the total expenditure in Mexico was

From evidence to action

The careful interplay between national and international analyses generated the advocacy instruments to promote a major legislative reform to establish a system of social protection in health, which was approved by a large majority from all political parties in the Mexican Congress. Having come into effect on Jan 1, 2004, the new system will gradually expand to protect 12 million uninsured families (close to 50 million individuals) over 7 years, thus achieving universal coverage by 2010. The

Entitlements and priorities

The element that brings together the financial and the managerial reforms is a specific package of benefits, which has been designed with cost, effectiveness, and social acceptability as the guiding criteria. Apart from serving as a priority-setting method, the package is a means of empowering people by making them aware of their entitlements and is also a key instrument for accountability on the part of providers.

An antecedent to this approach was an innovative initiative implemented in the

Searching for the diagonal

The explicit package of benefits provides a means to bridge the divide represented by one of the artificial dichotomies mentioned previously—namely, between the vertical approach focusing on specific disease priorities, and the horizontal approach aimed at strengthening the overall structure and functions of the health system. To go beyond this false dilemma, we need to extend the geometry metaphor and search for what has been called the diagonal21—a strategy in which explicit intervention

Protecting investments in prevention

The benefits of the new system are not restricted to curative actions. For the first time in Mexico, the new system has created a separate Fund for Community Health Services, which protects the budget for health promotion and disease prevention interventions. A peril in financial reforms is that enhanced access to curative services might be achieved at the expense of the budget for community-based interventions, which often do not generate spontaneous demand by the public. The separate fund was

Healthy policies

Preventive actions should be part of a strategy to bridge yet another divide, in this case between sectoral and intersectoral policies. Indeed, a key component of the stewardship role that must be undertaken by ministers of health is to mobilise all instruments of public policy, not just the ones under their direct control. Health cannot be seen simply as a specific sector of public administration, but must be understood as a social objective. Therefore, to develop health policies in the strict

Global public goods for local decision-making

The assessment experience gathered by the Oportunidades programme is being applied to the current health-system reform. In addition to its technical aspects, rigorous evaluation has political value to assure the continuity of innovations through changes in administration. In the case of Oportunidades, scientific evidence persuaded the present government not only to continue with the programme, but also to expand it. The encouraging results shown by the continuing assessment of Seguro Popular

The ABCDE of successful reform

The Mexican experience provides a wealth of lessons that can be summarised in five elements (panel). It shows the possibility of bridging one more divide: between analysis and advocacy. As Donabedian has stated: “…the world of ideas and the world of action are not separate, as some would have us think, but inseparable parts of each other. Ideas, in particular, are the truly potent forces that shape the tangible world”.35

The path is clear: sound evidence must be the guiding light for designing,

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