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Asa Cristina Laurell, MD, PhD, MPH

Asa Cristina Laurell is Minister of Health for Mexico City, Mexico.

Correspondence: Requests for reprints should be sent to: Asa Cristina Laurell, MD, PhD, MPH, Callejón de Chilpa 23-9, 04000 Mexico DF, Mexico (e-mail: claurell{at}prodigy.net.mx)

	ABSTRACT

TOP ABSTRACT INTRODUCTION MAINSTREAM HEALTH CARE REFORM... THE MEXICO CITY SOCIAL... References

 

Latin American social medicine (LASM) emerged as a movement in the 1970s and played an important role in the Brazilian health care reform of the 1980s, both of which focused on decentralization and on health care as a social right. The dominant health care reform model in Latin America has included a market-driven, private subsystem for the insured and a public subsystem for the uninsured and the poor.

In contrast, the Mexico City government has launched a comprehensive policy based on social rights and redistribution of resources. A universal pension for senior citizens and free medical services are financed by grants, eliminating routine government corruption and waste.

The Mexico City policy reflects the influence of Latin American social medicine. In this article, I outline the basic traits of LASM and those of the prevailing health care reform model in Latin America and describe the Mexico City social and health policy, emphasizing the influence of LASM in values, principles, and concrete programs.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MAINSTREAM HEALTH CARE REFORM... THE MEXICO CITY SOCIAL... References

 
The contemporary Latin American social medicine (LASM) movement arose in the early 1970s in different countries simultaneously. It was originally a critique of the dominant public health assumption that economic growth would automatically lead to improvements in the health conditions of the whole population. This proved to not be the case in most Latin American countries, which were experiencing a period of economic "miracles." As a result of a critical reflection on the facts of health in Latin America, it became clear that a conceptual reformulation was needed to explain the processes of health and disease, as well as those of health policies.¹

This emerging school of thought can only be understood in the political context of an upsurge in popular and student movements and the predominance of the Marxist intellectual tradition at universities. These factors led LASM to center its analysis on the effect of capitalist development and the work process on health and on class inequalities in health. For this purpose, the social sciences were used as an analytic tool, and the study of the role of social, political, economic, and ideological processes as determinants of health and disease and of health policy became LASM’s main focus.^2,3 Originally, social medicine was based in universities and expressed itself principally through research groups and training programs, particularly at the postgraduate level.

Social medicine’s first policy breakthrough was during the Brazilian health care reform of the 1980s, characterized both by the constitutional recognition of health care as a universal social right guaranteed by the state and by the organization of a decentralized, unified, and public health care system.⁴ This reform was clearly different from the health care reforms introduced in other Latin American countries by supranational financial agencies^5,6 and guided by what is still the conventional wisdom of health care reform.

	MAINSTREAM HEALTH CARE REFORM IN LATIN AMERICA

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The assumption underlying mainstream health care reform models is that health care is a private good for which demand should be satisfied through the family or the market. This thinking justifies a dual health care policy that consists of (1) a market-driven subsystem for the insured population that includes significant private involvement and (2) a public subsystem for the poor and uninsured.^7,8 This dual policy involves the transformation of the entire health care system; that is, mandatory social security health services, public services for the uninsured, and private services. Implementation of the market-driven subsystem requires direct state intervention to induce a process to commodify and, eventually, privatize service financing and provision. These processes "liberate" large mandatory social insurance health care funds to the private sector, which is then allowed to compete with public social security institutions for insured "clients" and is granted access to public hospitals through contracts.^8,9 This means that private insurance companies, usually linked to financial groups, are the emerging actors and forces in health care. Another characteristic of the implementation of these processes is the definition of a variety of health plans that did not usually exist in mandatory social insurance, as all insured people had the same rights regardless of their contribution.

Because mandatory health insurance is not universal in many countries, parallel governmental health services are necessary for the uninsured and usually exist but are less comprehensive. One of the purposes of the health care reform is to reorganize those services according to the principles of poverty programs; that is, targeting, decentralization, and cost-efficiency. To this end, central governments have decentralized services to the state, provincial, or county levels, retaining the responsibility to transfer funds only for an "essential health package" of 10–15 selected public health interventions and cost-efficient ambulatory clinical services, as recommended by the World Bank in 1993.⁷ This package usually contains substantially fewer services than those traditionally provided to the uninsured poor; the thought is that only those public health interventions and individual services that are highly cost-efficient, measured by disability-adjusted life years, should be included.

The dismantling of health services has become a fundamental concern to LASM, because it endangers governmental health institutions—which, although insufficient, nonetheless deliver services to hundreds of millions of poor Latin Americans. Quite a lot of effort has been dedicated to analyzing this reform and to demonstrating its effects in the middle and long term.^8–12 Discussion of health care reform has evolved into a debate over political definitions, in which LASM has played a role furnishing arguments against a dual, commodified health care system and in favor of a universal, public health care system.

Mexico has been engaged in the process of health care reform for about a decade. Reform was formally announced in 1996 in the Program of Health Sector Reform¹³ but had some important antecedents as early as 1983, with the implementation of structural adjustment policies. It shares the basic characteristics of the health care reform described above, but the transformation of public social security institutions has been particularly slow because they are strong institutions that provide health care services to about 50 million persons, they own the most important medical facilities of the country, and they employ 550 000 persons, including 73 000 doctors and 102 000 nurses.¹⁴

Decentralization of the public health care system for the uninsured to state governments was completed in 1997. It provides, in theory, health care services to another 50 million persons, but in practice, only the so-called Essential Health Package of 14 interventions (basic sanitation at the household level; family planning; Papanicolaou test; prenatal, delivery, and postdelivery care; child nutrition and growth surveillance; immunizations; ambulatory care of diarrhea; family antiparasite treatment; ambulatory care of acute respiratory disease; prevention and ambulatory control of pulmonary tuberculosis; prevention and ambulatory control of hypertension; and diabetes; accident prevention and first aid; and community training for self-care) and the corresponding 19 drugs are granted free of charge to everybody. Remaining services must be paid for—if they are available. There are many private providers, mainly independent doctors and small clinics, but during the last 10 years, large for-profit hospitals have been established and private health insurance has emerged. However, social security funds are still 7 times the size of private health care funds.¹⁴

At present there is an emphasis on the separation of regulation, financing, and provision of services. To this end, the Ministry of Health has launched a new partially subsidized "popular health insurance" program for the uninsured population. There will then be 3 different types of health funds in Mexico: those of the Ministry of Health, that of social security, and the private ones. All 3 could, in principle, be managed by competing public or private agents who may contract with public or private providers.¹⁵

Despite the fact that health protection is a constitutional right in Mexico, the segmentation of health services causes large inequalities in access according to economic status and according to position in the labor force. Finally, it should be mentioned that health spending represents only 5.6% of the gross national product; 3.0% is private and 2.6% public, with 1.9% going to social security and 0.7% to the uninsured. This is the national context of the Mexico City health policy, which has a radically different orientation.

	THE MEXICO CITY SOCIAL AND HEALTH POLICY

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The 2000 elections were historic, as the "state" party (Partido Revolucionario Institucional), which had ruled Mexico for 70 years, lost both on the national level and in Mexico City. However, although the presidency was won by a right-wing party (Partido de Acción Nacional), the head of government in Mexico City was won by a left-wing party (Partido de la Revolución Democrática). The two most important political positions in the country are thus occupied by governments that represent different ideas of how to conduct public policy. The national government has embraced, by and large, a neoliberal policy, and the Mexico City government (MCG) has given high priority to a comprehensive and redistributive social policy. In the health field, this means that the national policy is a continuation of the previous health care reform, whereas the Mexico City government has adopted a progressive policy. Although the national health policy is the norm for the whole country, there is room for the MCG initiative because the Mexican Constitution (article 4) and the federal health legislation (article 35) mandate the right to health protection for all citizens, as well as universal coverage and free care through public institutions. There exists, then, a legal justification for the MCG policy, and as long as it can be financed, it cannot be challenged. The MCG executive office has the power to make policy decisions, which can then only be objected to by the state congress if they infringe on existing legislation. The congress can also act by denying the requested budget—however, this can be politically costly when the budget is for health care or for pensions.

The challenges Mexico City’s new administration faces can be summarized as follows: reducing inequality in health conditions between groups and geographic areas (some with differences that are 2- to 3-fold); ensuring public health protection in a city that is vulnerable to social and natural disasters despite public health actions that function fairly well (immunization coverage of 95% in children under age 5 years, a stable epidemiological surveillance system, and rapidly falling rates of diarrhea and acute respiratory infections); extending timely access to the necessary treatment and reducing inequality in access to services; and implementing a system of sufficient, sustainable, and equitable financing based on principles of solidarity between the rich and the poor, the healthy and the sick, and the young and the old.

The main obstacles to overcoming these challenges are (1) a fragmented public health system in which the local health authorities cannot intervene in the organization of social security and other federal services, (2) deteriorated local infrastructure—26 hospitals and 220 health centers—that have suffered a lengthy process of underfinancing as well as corruption, and (3) the idea that public institutions are incapable of offering appropriate services.

The influence of LASM can be seen in the values and principles that guide the MCG policy. Contrary to the prevailing ideology of health care reform that presents itself as an objective, technical solution to objective problems, the MCG decided to assert the moral value of its policy: the recognition of the intrinsic and equal value of all men and women, which obliges the government to honor and protect alike the life of all human beings. The concrete translation of this value is that health care is a social right and, therefore, is the responsibility of government as the guardian of the public interest.

The goals that guide this health policy are to democratize health care, reducing inequality in disease and death and removing economic, social, and cultural obstacles to access; to strengthen public institutions as the only socially just and economically sustainable option granting equal and universal access to health protection; to attain universal coverage, dissolving the link between access and economic capacity or labor market position; to broaden services for the uninsured population; to achieve equality in access to existing services; and to create solidarity through fiscal funding and the distribution of the costs of disease among the sick and the healthy.

The city government has given the highest priority to a comprehensive social policy with 4 main characteristics: (1) it is based on the concept of social rights; (2) it is massive, with programs that reach tens of thousands of individuals and families, and it should, ideally, be universal; (3) it implies progressive income redistribution; and (4) it is territorialized to the 1352 city sections, classified according to their socioeconomic characteristics, which allows collective rather than individual targeting.

The first such large-scale social program—the Program of Food Support and Free Health Services and Drugs for Senior Citizens—is run by the local ministry of health and was started in February of 2001. It is conceived of as the first step toward a universal citizen’s pension. The proposal is to create a social institution that grants a new social right to all senior citizens. By October 2002, 328 000 persons aged 70 years or more, or 98% of Mexico City residents of this age group, were enrolled in the program; that is, it is now virtually universal. These citizens receive US $70 a month, the food cost for 1 person, and free health care at the city government health facilities.

The strategies in the health sector are more complex because they must address simultaneously the right to health care and the restructuring and expansion of existing but deteriorated facilities. The main strategy is to remove the economic obstacle to necessary care for uninsured residents by means of the Program of Free Health Care and Drugs. This program includes all collective public health activities and individual health care at the health facilities of the city government. An estimated 875 000 families are eligible for the program and, by December 2002, about 350 000 families had enrolled. This program complements public social insurance, which already grants free health care and drugs to the insured. Taken together, these 2 institutions raise the possibility of achieving universal, public coverage of health services in Mexico City by 2006. Another indicator of the achievements of this program is that the provision of services has increased steadily during the present administration, as can be observed in Table 1.

This new model requires a profound institutional reorganization and strengthening of services through the creation of public health teams that hold responsibility for the population of a defined geographical area. Primary care is being reinforced, concentrating human and technological resources, to increase the capacity to resolve problems close to people’s homes and to unburden hospitals. The mission of each hospital is being redefined, each of them viewed as complementary parts within the city hospital network. Once these objectives have been reached, a process of regionalization and deconcentration will start.

During the first year of the new administration, the provision of drugs and consumables was stabilized, which allowed better quality of services and legitimized the idea that a real change was underway. Additionally, an extensive training program has been launched that includes all health workers—from doctors to laundry workers.

These changes are possible because of the strong political and financial commitment of the government. The first year, a 67% increase in the health budget was authorized, which means that 12.5% of the Mexico City budget is dedicated to health. This was possible thanks to an austerity program that cut superfluous government spending with a 15% salary reduction for top officials, a reduction of their staff, elimination of certain expenditures, restrictions on traveling and per diem expenses, suspension of resources to decorate offices and to buy new cars for personal use, and so forth. These measures yielded savings of at least US $200 million in 2001 and US $300 million in 2002 that were transferred to social programs. A frontal attack on corruption was also initiated and made government purchases at lower costs possible. For instance, the Ministry of Health saved about 10% on its purchases.

Simultaneously, the government substantially increased its income through specific measures against both a widespread network of corruption at its treasury and tax evasion. These policies are likely to continue to be successful in the future, particularly as citizens are observing that their taxes are now used to increase benefits and services for the public. The credibility and benefits of government programs, resulting in popular support and a willingness to pay for them, are what makes them sustainable. In this context it should be mentioned that a large number of opinion polls show steadily increasing approval of the governor of Mexico City, reaching an unprecedented 80–85% approval rating in April 2003. The most recognized programs are the universal pension and the expansion of public services.

At present, the MCG is developing mechanisms for popular participation through the neighborhood assemblies of the 1352 city sections, which receive information concerning all social programs. Leaflets with the same information are also distributed to all households. This is a concrete way of making government action transparent. The assemblies also elect commissions to supervise specific programs. Some 800 health commissioners work with health personnel to diagnose local health problems and to create an action plan as the starting point for social control, based on specific and reliable information. These commissions are crucial for a qualitative evaluation of the programs.

The new policies are evaluated with a set of indicators that measure inequality in access—population coverage of services (number of families enrolled in the program of free services and their acceptance of promotion and prevention), redistribution of resources according to health need, and speed of change in quality of services. Household surveys are performed to detect problems in the application of the programs and to elicit user opinion. The effect on health of these programs is monitored and progress in health outcomes will probably be slow, but indicators of health inequality resulting merely from lack of or bad services should improve more rapidly.

	Acknowledgments

 
The section "The Mexico City Social and Health Policy" is based on the Programa de Salud 2002–2006 (Health Program 2002–2006) collectively elaborated by officials of the Mexico City Ministry of Health under the guidance of the author.

	Footnotes

 
Peer Reviewed

Accepted for publication June 29, 2003.

	References

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