the health strategist
institute for strategic health transformation
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Joaquim Cardoso MSc.
Chief Research and Strategy Officer (CRSO),
Chief Editor and Senior Advisor
November 23, 2023
What is the message?
The article explores the rise and fall of Mexico’s flagship public insurance program, Seguro Popular, over the past two decades.
It emphasizes the program’s initial success in achieving universal coverage and improving health outcomes but highlights its subsequent dismantling by the current administration in 2020.
The article serves as a case study, demonstrating the challenges of sustaining health reforms in politically polarized environments and the negative consequences of abrupt policy reversals, particularly during crises like the COVID-19 pandemic.
What are the key points?
Origins and Success of Seguro Popular:
- Seguro Popular, established in 2003, aimed to provide health coverage to self-employed individuals and those without formal employment, achieving universal coverage by 2012.
- The program significantly reduced out-of-pocket spending, medical bankruptcies, and improved vaccine coverage, leading to substantial improvements in well-being from 2000 to 2018.
Systemic Issues and Lack of Ongoing Reform:
- Over the years, Seguro Popular faced challenges in adapting to evolving health needs and technologies.
- The program’s budget stagnated after 2015, and many initial gains were not sustained through 2018, indicating the need for ongoing and intensive reform.
Political Reversal and Negative Consequences:
- In 2020, the current Mexican administration abandoned Seguro Popular, alleging inadequacy, corruption, and private interests.
- The abrupt dismantling of the program without a replacement led to a sharp decline in population coverage, longer waiting times, increased out-of-pocket expenses, medicine shortages, and a reversal of key health indicators, especially during the COVID-19 pandemic.
Opportunity in Crisis and Recommendations:
- The article suggests that the pandemic crisis could be an opportunity for Mexico to implement systemic, well-designed, and sustainable health reforms.
- Recommendations include increasing health system expenditures, consolidating segmented health-care financing and delivery systems, and institutionalizing reforms for increased resilience.
Lessons for Reformers:
- The Mexican case offers both positive and negative lessons for reformers elsewhere, emphasizing the importance of sustained reform efforts, political stability, and crisis resilience.
- Governments must set priorities, strategically plan reforms, involve all stakeholders, and design systems capable of continuous improvement rather than making sweeping promises.
DEEP DIVE
The Rise and Fall of Seguro Popular: Mexico’s Health Care Odyssey
Unraveling success, lessons learned, and the quest for sustainable health equity
Think Global Health
by Tim McDonald, Michael Touchton, Felicia Marie Knaul, Héctor Arreola-Ornelas, Julio Frenk
November 14, 2023
This year (2023) marks the twentieth anniversary of Mexico’s flagship public insurance program Seguro Popular, which covers fifty million Mexicans who previously lacked access to conventional, employment-based social security, doubling the number previously covered. By publicly financing health care with innovative programs and building new hospitals and clinics, Mexico dramatically improved the health and economic well-being of the entire country. In the years since, Seguro Popular has become a widely studied model for evidence-driven health reforms across the globe.
In June 2020, however, the current Mexican administration abandoned its successful program, closing Seguro Popular and dismantling parts of the system without an adequate replacement designed or in place. Thus far, this reversal appears to have disrupted health care and increased health vulnerability for many Mexicans. This demonstrated the precariousness of reforms in polarized political environments, even those with a track record of success.
53 Million
Mexico’s government worked with civil society institutions to enroll more than 53 million people in the first ten years
Seguro Popular originated in a 1983 amendment to Article 4 of the Mexican Constitution that read “every person has the right to health protection,” but which for two decades the government struggled to realize. The system behind Seguro Popular slowly took shape as evidence accumulated about the economic and medical hardship of the uninsured, who made up nearly half the country. After the program was enacted in 2003, Mexico’s federal and state governments worked with civil society institutions to enroll more than 53 million people in the first ten years of the program, achieving universal coverage in 2012. It was an important affirmation of the principle that social protections should be expanded to all Mexicans, not just those with formal employment.
In a recent paper in The Lancet, we summarized some of Seguro Popular’s achievements: the program reduced out-of-pocket spending and fewer medical bankruptcies, improved vaccine coverage and expanded treatment for many diseases, and produced massive improvements in well-being. Between 2000 and 2018, infant mortality in Mexico fell by half and maternal mortality by even more.
But these decades have witnessed tectonic shifts in health needs and technologies, and Seguro Popular needed intensive, ongoing reform as it aged. Mexico increased the program’s budget to match population growth through 2015, then ceased to do so, and many of the earlier gains of the program were not sustained through the most recent data in 2018.
Perhaps it opened the door for a new round of systemic, rigorously designed, and well-implemented reforms
At a time when segmented health systems served salaried employees in Mexico’s private and public sectors, Seguro Popular created an additional system to cover self-employed workers and their families who were left out of these systems, as well as those who are unemployed or out of the labor force. But it did not find ways to achieve one of the original goals of the framers of the reforms, to coordinate and integrate across these systems.
Then in 2019 the new administration—which had campaigned against Seguro Popular by characterizing it as inadequate, corrupt, and driven by private interests—promised health-care benefits without limits and began dismantling the program without a replacement in hand.
The percentage of the population covered declined sharply between 2018 and 2020, by 16.8 percent. Patients are waiting longer to see doctors, paying more out of pocket, and encountering shortage of medicines. Funding for certain types of specialized care—such as childhood cancers—has fallen. Improvements in key indicators such as maternal mortality have reversed. During the COVID-19 pandemic, the country had among the highest levels of excess mortality of any country.
In crisis is opportunity. The pandemic brought into sharp relief how individual and population health and health systems are interrelated with all other areas of society, from education to the economy. Perhaps it opened the door for a new round of systemic, rigorously designed, and well-implemented reforms.
Several key steps need to be taken to improve the Mexican health system. First, Mexico must undertake financial reforms to raise its health system expenditures. The country spent 5.4 percent of GDP in 2019, relative to the Latin American and Caribbean average of 7.4 percent.
Second, the country needs to consolidate its segmented systems of health-care financing and delivery with instruments that help coordination across the systems, such as universal health coverage and common reimbursement processes for providers across all public insurance schemes.
Third, the arc of Seguro Popular demonstrates the need to institutionalize reforms as a way to increase their resiliency. Health systems should be built and managed in ways that are structurally permeable and adaptable to harness innovations needed to meet emerging health challenges. They need to incorporate new evidence and technologies to promote equity, and to be anchored in ways that allow them to withstand systemic shocks.
Governments face real capacity constraints and the most important and challenging aspect of health system reforms is to set priorities rather than promising everything to everyone, and to undertake the reforms strategically rather than trying to do them all at once. The real work lies in designing and implementing viable systems to achieve transparent objectives, while putting in place the mechanisms for continuous improvement. These goals cannot be achieved by decree and must involve all stakeholders and actors across the system.
Mexico is a study in contrasts: once a model for how to do health system reform, now a model of what not to do. This case thus offers both positive and negative lessons for reformers elsewhere. The rise, plateau, and elimination of Seguro Popular is a story about how the reform of large, important systems unfolds over time, as well as their vulnerability to political setbacks and reversals made worse during a time of crisis such as a pandemic.
Originally published at https://www.thinkglobalhealth.org
