Setbacks in the quest for universal health coverage in Mexico: polarised politics, policy upheaval, and pandemic disruption.

2023 marks the 20-year anniversary of the creation of Mexico's System of Social Protection for Health and the Seguro Popular, a model for the global quest to achieve universal health coverage through health system reform. We analyse the success and challenges after 2012, the consequences of reform ageing, and the unique coincidence of systemic reorganisation during the COVID-19 pandemic to identify strategies for health system disaster preparedness. We document that population health and financial protection improved as the Seguro Popular aged, despite erosion of the budget and absent needed reforms. The Seguro Popular closed in January, 2020, and Mexico embarked on a complex, extensive health system reorganisation. We posit that dismantling the Seguro Popular while trying to establish a new programme in 2020-21 made the Mexican health system more vulnerable in the worst pandemic period and shows the precariousness of evidence-based policy making to political polarisation and populism. Reforms should be designed to be flexible yet insulated from political volatility and constructed and managed to be structurally permeable and adaptable to new evidence to face changing health needs. Simultaneously, health systems should be grounded to withstand systemic shocks of politics and natural disasters.

Exploring system drivers of gender inequity in development assistance for health and opportunities for action.

Background : Deep-rooted and widespread gender-based bias and discrimination threaten achievement of the Sustainable Development Goals. Despite evidence that addressing gender inequities contributes to better health and development outcomes, the resources for, and effectiveness of, such efforts in development assistance for health (DAH) have been insufficient. This paper explores systemic challenges in DAH that perpetuate or contribute to gender inequities, with a particular focus on the role of external donors and funders. Methods: We applied a co-creation system design process to map and analyze interactions between donors and recipient countries, and articulate drivers of gender inequities within the landscape of DAH. We conducted qualitative primary data collection and analysis in 2021 via virtual facilitated discussions and visual mapping exercises among a diverse set of 41 stakeholders, including representatives from donor institutions, country governments, academia, and civil society. Results: Six systemic challenges emerged as perpetuating or contributing to gender inequities in DAH: 1) insufficient input and leadership from groups affected by gender bias and discrimination; 2) decision-maker blind spots inhibit capacity to address gender inequities; 3) imbalanced power dynamics contribute to insufficient resources and attention to gender priorities; 4) donor funding structures limit efforts to effectively address gender inequities; 5) fragmented programming impedes coordinated attention to the root causes of gender inequities; and 6) data bias contributes to insufficient understanding of and attention to gender inequities. Conclusions : Many of the drivers impeding progress on gender equity in DAH are embedded in power dynamics that distance and disempower people affected by gender inequities. Overcoming these dynamics will require more than technical solutions. Groups affected by gender inequities must be centered in leadership and decision-making at micro and macro levels, with practices and structures that enable co-creation and mutual accountability in the design, implementation, and evaluation of health programs.

Punt Politics as Failure of Health System Stewardship: Evidence from the COVID-19 Pandemic Response in Brazil and Mexico.

We present a new concept, Punt Politics, and apply it to the COVID-19 non-pharmaceutical interventions (NPI) in two epicenters of the pandemic: Mexico and Brazil. Punt Politics refers to national leaders in federal systems deferring or deflecting responsibility for health systems decision-making to sub-national entities without evidence or coordination. The fragmentation of authority and overlapping functions in federal, decentralized political systems make them more susceptible to coordination problems than centralized, unitary systems. We apply the concept to pandemics, which require national health system stewardship, using sub-national NPI data that we developed and curated through the Observatory for the Containment of COVID-19 in the Americas to illustrate Punt Politics in Mexico and Brazil. Both countries suffer from protracted, high levels of COVID-19 mortality and inadequate pandemic responses, including little testing and disregard for scientific evidence. We illustrate how populist leadership drove Punt Politics and how partisan politics contributed to disabling an evidence-based response in Mexico and Brazil. These cases illustrate the combination of decentralization and populist leadership that is most conducive to punting responsibility. We discuss how Punt Politics reduces health system functionality, providing lessons for other countries and future pandemic responses, including vaccine rollout.

Public health matters: why is Latin America struggling in addressing the pandemic?

This article examines how Argentina, Brazil, Chile, Colombia, Mexico, and Peru addressed the COVID-19 pandemic and the effectiveness of these policy responses from the date each country declared a sanitary emergency, between middle and late March 2020 to the most recent available measurement on 23 September 2020. To analyze how governments responded to the COVID-19 pandemic in these six Latin American countries, we use an index of government response, created by the University of Oxford. To explore the effects of these governmental mitigation policies on reducing social mobility, we use Google mobility reports. We also analyze how these policies may have influenced COVID-19 mortality rates. Overall, the results showed that both timelier and more stringent implementation of the public policies analyzed to address the COVID-19 pandemic seem to be associated with higher mobility reductions and lower mortality rates. We draw five policy lessons from the way each country implemented these mitigation policies. KEY MESSAGE: Timelier and more stringent implementation of these public policies may contribute to a higher mobility reduction in several public spaces and to lower mortality rates. The effectiveness of the closure and containment policies in each Latin American country seem to depend on the degree of compliance of their respective populations and to their socioeconomic living conditions. Economic and social policies of income support and debt relief provided by governments allowed people to comply with closure and containment policies. Health systems should maintain high levels of policy stringency together with effective surveillance through testing policy and contact tracing.

Loss of job-related right to healthcare associated with employment turnover: challenges for the Mexican health system.

BACKGROUND: The Mexican health system segments access and right to healthcare according to worker position in the labour market. In this contribution we analyse how access and continuity of healthcare gets interrupted by employment turnover in the labour market, including its formal and informal sectors, as experienced by affiliates to the Mexican Institute of Social Security (IMSS) at national level, and of workers with type 2 diabetes (T2DM) in Mexico City. METHODS: Using data from the National Employment and Occupation Survey, 2014, and from IMSS electronic medical records for workers in Mexico City, we estimated annual employment turnover rates to measure the loss of healthcare access due to labour market dynamics. We fitted a binary logistic regression model to analyse the association between sociodemographic variables and employment turnover. Lastly we analysed job-related access to health care in relation to employment turnover events. RESULTS: At national level, 38.3% of IMSS affiliates experienced employment turnover at least once, thus losing the right to access to healthcare. The turnover rate for T2DM patients was 22.5%. Employment turnover was more frequent at ages 20-39 (38.6% national level; 28% T2DM) and among the elderly (62.4% national level; 26% T2DM). At the national level, higher educational levels (upper-middle, OR = 0.761; upper, OR = 0.835) and income (5 minimum wages or more, OR = 0.726) were associated with lower turnover. Being single and younger were associated with higher turnover (OR = 1.413). T2DM patients aged 40-59 (OR = 0.655) and with 5 minimum wages or more (OR = 0.401) experienced less turnover. Being a T2DM male patient increased the risk of experiencing turnover (OR = 1.166). Up to 89% of workers losing IMSS affiliation and moving on to other jobs failed to gain job-related access to health services. Only 9% gained access to the federal workers social security institute (ISSSTE). CONCLUSIONS: Turnover across labour market sectors is frequently experienced by the workforce in Mexico, worsening among the elderly and the young, and affecting patients with chronic diseases. This situation needs to be prospectively addressed by health system policies that aim to expand the financial health protection during an employment turnover event.

Reforming the Mexican Health System to Achieve Effective Health Care Coverage.

Abstract-Despite important progress in financial protection with the last health reform implemented since 2003 with Seguro Popular, effective access to health care in Mexico has not yet been fully achieved. The vision of the present Mexican health administration, 2012-2018, is to transform the Mexican health care system so that it ensures equitable and effective access to quality health care, regardless of the labor or socioeconomic status of the person who seeks care. This article is an overview of how we at the Ministry of Health plan to fulfill this vision. It analyzes three challenges that the Mexican health system currently faces to achieve effective access to quality health care and proposes specific strategies to address them. The first step to fulfill that vision is to strengthen the stewardship role of the Ministry of Health, through instruments such as new legal frameworks and better information for more effective regulation and permanent monitoring and evaluation of the health care system's performance, with a focus on quality of health care. In the short term, better coordination between institutions should be achieved by ensuring that resources follow the patient where she receives care through the instruments suggested above and by guaranteeing that resources are used efficiently and in a transparent manner. In the long term, Mexico's health care system should adapt its infrastructure and human resources to deliver primary care services to effectively meet the increasing demands for chronic disease prevention and management.

[How to reduce health inequities by targeting social determinants: the role of the health sector in Mexico]. / Cómo reducir las inequidades de salud actuando sobre sus determinantes sociales: el papel del sector salud en México.

OBJECTIVE: To study lines of action implemented in Mexico by the health sector from 2007 to 2012 in order to combat health inequities by targeting social determinants. To contribute to better understanding and knowledge of how health system inequalities in the Region of the Americas can be reduced. To formulate recommendations for designing a future public policy agenda to address the social determinants associated with health inequities in Mexico. METHODS: The policies and programs established in the National Health Program (PRONASA) 2007 - 2012 were reviewed, and those that met four criteria were selected: i) they affected the social determinants of health (SDH); ii) they developed specific lines of action aimed at reducing health inequities; iii) they set concrete goals; and iv) they had been evaluated to determine whether those goals had been met. Three programs were selected: Seguro Popular, Programa de Desarrollo Humano Oportunidades (PDHO), and Caravanas de la Salud. Once each program's specific lines of action targeting SDH had been identified, the monitoring and evaluation indicators established in PRONASA 2007 - 2012, along with other available evaluations and empirical evidence, were used to measure the extent to which the goals were met. RESULTS: The findings showed that Seguro Popular had had a positive impact in terms of the financial protection of lower-income households. Moreover, the reduction in the gap between workers covered by the social security system and those who were not was more evident. By reducing poverty among its beneficiaries, the PDHO also managed to reduce health inequities. The indicators for Caravanas de la Salud, on the other hand, did not show statistically significant differences between the control localities and the localities covered by the program, except in the case of Pap tests. CONCLUSIONS: These findings have important public policy implications for designing an agenda that promotes continued targeting of SDH and heightening its impact in terms of reducing inequities. Guaranteeing the effective exercise of social rights, without socioeconomic, employment, ethnic, or gender-based exclusion, will be key. Action to provide comprehensive, inclusive, equitable, effective, and quality coverage, supported by a preventive and remedial model of primary health care, are recommended. Strategies should be centered on primary health services, because at that level, more comprehensive care focusing on the person rather than the disease can be provided. It will also be necessary to include periodic monitoring and evaluation phases to offer the comprehensive social protection system scientific armor and guarantee its effectiveness.

Cómo reducir las inequidades de salud actuando sobre sus determinantes sociales: el papel del sector salud en México / How to reduce health inequities by targeting social determinants: the role of the health sector in Mexico

OBJETIVO: Analizar las vías de acción implementadas en México por el sector salud entre 2007 y 2012 para atender las inequidades en salud, incidiendo en sus determinantes sociales. Contribuir a mejorar la comprensión y el conocimiento sobre cómo incidir en la reducción de las desigualdades de los sistemas de salud en la Región de las Américas. Formular recomendaciones para definir una agenda futura de política pública que permita atender los determinantes sociales asociados a las inequidades en salud en México. MÉTODOS: Se revisaron las políticas o programas definidos en el Programa Nacional de Salud (PRONASA) 2007 - 2012, seleccionando aquellos que cumplieran con cuatro criterios: i) que incidieran en los determinantes sociales de la salud (DSS); ii) que formulasen líneas de acción específicas para reducir las inequidades en salud; iii) que definieran metas concretas y iv) que hubieran sido evaluados en cuanto al cumplimento de dichas metas. Se seleccionaron tres programas: el Seguro Popular, el Programa de Desarrollo Humano Oportunidades (PDHO) y Caravanas de la Salud. Una vez identificadas las líneas de acción específicas de cada programa -dirigidas a incidir en los DSS- se evaluó el cumplimiento de las metas trazadas a partir de los indicadores de seguimiento y evaluación definidos en el PRONASA 2007 - 2012, así como de las evaluaciones y la evidencia empírica disponibles. RESULTADOS: La evidencia encontrada sobre el Seguro Popular mostró efectos positivos en la protección financiera de las familias de más bajos ingresos. Más aún, la reducción de las diferencias fue más evidente entre los trabajadores afiliados a la seguridad social y los no afiliados. El PDHO, al incidir en las condiciones de pobreza de sus beneficiarios, ha logrado también reducir las inequidades en salud. Los indicadores correspondientes a Caravanas de la Salud, en cambio, no mostraron diferencias estadísticamente significativas entre las localidades control y las localidades cubiertas por este programa, salvo en el caso de la prueba de Papanicolaou (PAP). CONCLUSIONES: Estos hallazgos tienen implicancias de política pública que resultan relevantes para diseñar una agenda que permita seguir incidiendo en los DSS y potenciar su impacto en la reducción de las inequidades. Es clave garantizar el ejercicio efectivo de los derechos sociales, sin que nadie sea excluido por razones socioeconómicas, laborales, étnicas o de género. Se sugiere realizar acciones destinadas a brindar una cobertura integral, incluyente, equitativa, efectiva y de calidad, sustentada en un modelo preventivo y resolutivo de atención primaria de la salud. Las diversas estrategias deben estar focalizadas en la atención primaria de la salud, porque en este nivel se puede brindar una atención más integral y con una perspectiva que haga hincapié en la persona y no en la enfermedad. Será necesario también incorporar etapas de evaluación y seguimiento que proporcionen al sistema de protección social integral un blindaje científico para garantizar su eficacia.

OBJECTIVE: To study lines of action implemented in Mexico by the health sector from 2007 to 2012 in order to combat health inequities by targeting social determinants. To contribute to better understanding and knowledge of how health system inequalities in the Region of the Americas can be reduced. To formulate recommendations for designing a future public policy agenda to address the social determinants associated with health inequities in Mexico. METHODS: The policies and programs established in the National Health Program (PRONASA) 2007 - 2012 were reviewed, and those that met four criteria were selected: i) they affected the social determinants of health (SDH); ii) they developed specific lines of action aimed at reducing health inequities; iii) they set concrete goals; and iv) they had been evaluated to determine whether those goals had been met. Three programs were selected: Seguro Popular, Programa de Desarrollo Humano Oportunidades (PDHO), and Caravanas de la Salud. Once each program's specific lines of action targeting SDH had been identified, the monitoring and evaluation indicators established in PRONASA 2007 - 2012, along with other available evaluations and empirical evidence, were used to measure the extent to which the goals were met. RESULTS: The findings showed that Seguro Popular had had a positive impact in terms of the financial protection of lower-income households. Moreover, the reduction in the gap between workers covered by the social security system and those who were not was more evident. By reducing poverty among its beneficiaries, the PDHO also managed to reduce health inequities. The indicators for Caravanas de la Salud, on the other hand, did not show statistically significant differences between the control localities and the localities covered by the program, except in the case of Pap tests. CONCLUSIONS: These findings have important public policy implications for designing an agenda that promotes continued targeting of SDH and heightening its impact in terms of reducing inequities. Guaranteeing the effective exercise of social rights, without socioeconomic, employment, ethnic, or gender-based exclusion, will be key. Action to provide comprehensive, inclusive, equitable, effective, and quality coverage, supported by a preventive and remedial model of primary health care, are recommended. Strategies should be centered on primary health services, because at that level, more comprehensive care focusing on the person rather than the disease can be provided. It will also be necessary to include periodic monitoring and evaluation phases to offer the comprehensive social protection system scientific armor and guarantee its effectiveness.