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

2. OUTLINE OVERVIEW OF THE MEXICAN HEALTH SYSTEM CHALLENGES HEALTH REFORM STRATEGIES DECENTRALIZATION INSTRUMENTAL STRATEGIES POLITICAL ACTORS GAPS OTHER ISSUES HEALTH POLICY AND FEDERALISM 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 VariableSSAIMSS-ISSSTEPRIVATE INST. Funding type Funding source % total health expenditures Population coverage Basic principle Decentralization Invest in promotion in preventive care in curative care in rehabilitation Unipartite Federal & state govt. 15% 40% Citizenship & poverty Yes (1985) High Medium Low Tripartite Federal, employers & workers 43% 50% Corporative Yes (1995, 1999) Medium High Medium Unipartite Users 42% 10% Purchasing power No Very low Low Medium Very low THE MEXICAN EXPERIENCE INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

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

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

7. 1.SUBSTANTIVE STRATEGIES a)Link health to economic development b)Decrease backlogs of disease and healthcare c)Respond to emerging problems d)Crusade for quality e)Financial protection 2.INSTRUMENTAL STRATEGIES a)Federalization b)Regulation (steering, stewardship) c)Universal Health System d)Freedom to choose provider and citizens participation e)Advancement of knowledge HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO

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

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

10. HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE 1)Deconcentration to shift power from the central offices to peripheral offices 2)Delegation 3)Devolution shifts responsibility and authority from the central offices of the Ministry of Health to separate administrative structures still within the public administration 4)Privatization. Prospective payment health insurance with private providers; reversion of IMSS fees to banks who purchase health services elsewhere. ISES. 5)Overlap and duplication Conditional and block grants Unilateral and vertical decisions Joint-decision making INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO DECENTRALIZATION

11. HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE 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 DECENTRALIZATION

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

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

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

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

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

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

18. 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 HEALTH POLICY AND FEDERALISM INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO