1. HEALTH SYSTEM REFORM IN FEDERATIONS: CURRENT SITUATION AND PERSPECTIVES THE MEXICAN EXPERIENCE INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO DR. EDUARDO VELASCO DR. ARMANDO ARREDONDO HEALTH POLICY AND FEDERALISM Presentado ante el Foro de Federaciones en Sao Paulo, Brasil, 15 de octubre de 2001 Forum of Federations / Forum des fédérations  www.forumfed.org  forum@forumfed.org

2. INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE

3. INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO 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 in research Unipartite Federal & state govt. 15% 40% Citizenship & poverty Yes (1985) High Medium Low Medium Tripartite Federal govt., eployrs & workers 43% 50% Corporative Yes (1995, 1999) Medium High Medium Low Unipartite Users 42% 10% Purchasing power No Very low Low Medium Very low THE MEXICAN EXPERIENCE

4. INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE  Reform of the social security through pension reform to generate internal savings in the long run.  Financial restructuring to avoid bankruptcy of the social security system, including its health component.  Health reform formulation, legislation, and implementation is led by structural adjustment policies, through technocrats empowered to bring about policy change.  Efforts at reforming the IMSS health care provision have included decentralization and financial deconcentration to the local level.  Efforts to establish separation of the financing and provision functions.

5. INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO 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 fees to companies who purchase health services elsewhere. The center retains policy making and monitoring roles and the periphery takes operational responsibility for administration.

6. INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO 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.

7. INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE  link health to economic and social development  reduce health system gaps that affect the poor.  deal with emerging problems by establishing priorities  launch a national crusade for improving 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.

8. INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE  IMSS Financial restructuring Deconcentration and rationalization of the IMSS Institutional model for comprehensive health services (MIAIS) Medical areas for deconcentrated management (AMGD) Family health insurance (SSF) Family doctor eligibility and performance incentives in family health care centers Performance incentives Costing according to diagnosis-related groups (DRGs) Contracting-out of health services  SSA Extended Coverage Program (PAC)

9. INSTITUTO NACIONAL DE SALUD PUBLICA, MEXICO HEALTH POLICY AND FEDERALISM THE MEXICAN EXPERIENCE Health Policies Health Care Reforms 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

10. GUIDING FORCE: DEMOCRATIZATION LEADING PRINCIPLE: CITIZENSHIP VALUES: JUSTICE LIBERTY REPRESENTATION OF CITIZENS’ INTERESTS SOCIAL PARTICIPATION ACCOUNTABILITY HEALTH REFORM STRATEGIES HEALTH POLICY AND FEDERALISM

11. 1.SUBSTANTIVE STRATEGIES a)Linking 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

12. 1.SUBSTANTIVE STRATEGIES Linking health to development - Healthy policies - Intersectoral cooperation - Healthy communities - Women and health - Healthy fiscal policies (15% tax to medications) HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES

13. 1.SUBSTANTIVE STRATEGIES Decreasing backlogs of disease - Improving the package of basic interventions - Cost-effectiveness - Modernization of biotechnology, informatics and telecommunications - 100 essential medications for all HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES

14. 1.SUBSTANTIVE STRATEGIES Responding to emerging problems - cost-effective interventions for emerging or priority problems such as injuries, tobacco smoking, substance abuse, depression, diabetes, high blood pressure, obesity. HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES

15. 1.SUBSTANTIVE STRATEGIES Crusade for quality - Ethics codes - Patients’ rights - Ethics education and information - Performance appraisal of personnel - Standardized processes and monitoring outcomes - Certification of health personnel - Rationalization of regulatory structures HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES

16. 1.SUBSTANTIVE STRATEGIES Financial Protection - Improve financial equity and justice - Decrease catastrophic expenditure in 70-80% - Strengthen preventive care - Liberate resources for productive use - Incentives for formal work/employment - Six-year cumulative cost: 1.2% of GNP HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES

17. 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

18. 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

19. 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

20. 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

21. INSTRUMENTAL STRATEGIES Strengthening knowledge - Promotion of mission-oriented research - Information system for decision making - Human resource development HEALTH POLICY AND FEDERALISM HEALTH REFORM STRATEGIES