In Latin America, since the early eighties from the last century and as part of the reforms to the State apparatus, several reforms to health policies have been carried out, which have been implemented following the proposals of international organisms specially the World Bank. In its application, these reforms have taken their particularities (according to the country) and have undertaken in two stages: the former with a sustainable decrease of the role of the State and the latter with an apparent recovery of its role but rearticulated with the market.
In the case of the health care sector, the reforms have been undertaken as part of the deep changes for transforming societies that have gone from historical moments with greater involvement of the State, to others where the market regulates the access to most of the goods and services.
In Mexico within this framework, reforms to health policies have also been made, stating with the change of the Political Constitution in 1982, which allowed generating the regulatory legal framework of the new government facing society as the repealing of the existing documents and the emergence of the General Health Law. The implementation of this law should be carried out in all spaces which give medical attention and by all health services providers.
Later in the 80’s and 90’s period, the health services were decentralized to the government of the States (federative entities), prioritizing to each local government the health needs of its population without social security through programs with essential interventions.
For this matter, the Health Sector Program was implemented having as its first objectives the promotion of the quality, the efficiency and wider its coverage. The decentralization process was too slow. In the federative entities the State Health Systems were created, modifying in that way the structure of the National Health System. The decentralization at first happened as an “operational de-concentration” exercise (López & Blanco, 1993), exclusively transmitting the responsibility to provide services, but not the financing and the decision taking. This situation had a negative impact in the lack of investment in the needed infrastructure in localities. In follow up and assessing meetings, staff from the Secretary of Health (SSA due to its abbreviation in Spanish) pointed out to the health specialists in local governments the kind of program that should be implemented (Portillo, 2007). The “decentralization” program was not carried out by all states at the same time, some of them presented some resistance when identifying this issue and in some other cases, it was not found workable, due to the infrastructure delay and the risk increase that public health would have in this population.
The establishment of new health policies stopped this strategy, reactivating itself by half of the nineties (López & Blanco, 2007). With the signing of agreements between the federation and the state governments, the process of decentralization was taken back, transmitting to the regional governments the obligation to address the health of the population.
It was already in the nineties that the private sector was boosted to meet the health needs, regulating for this matter the private capital inflow in the planned and completed activities by the government.
In virtue of social struggles in Mexico, the right to health protection is expressed in one of the former articles from the Political Constitution of the United States of Mexico (Chamber of Deputies of the Union Congress, 2017).
Derived from it, the General Health Law announces the right to the health protection as a mechanism through which the State must guarantee the effective, timely, quality access, with no disbursement at the time of use as well as without discrimination to the medical-surgical, pharmaceutical and hospital services which integrally care the population health needs (SSA, 2007). To achieve this, in the health services the combination of interventions in health promotion, prevention, diagnose, treatment and rehabilitation must be carried out, which are selected as a priority, thereby complying the criteria for security, efficiency, cost, effectiveness, adherence to professional ethical standards and social acceptability.
During the presidential term 2000-2006, the application of the Reform continued, creating the Social Protection System in Health, to which they generated the necessary field to its legalization, and promoting its operational form called Popular Health Insurance (SPS due to its Spanish abbreviation).
It was in 2002, when the Government of the Country introduces the SPS led to the population without social security being necessary to locate it as part of the reforms process to the policies of Mexican health, which have been applying since the early eighties and have taken part of a structured integral tactic of the new social policy; this, in coordination with the regional governments (state-owned).
Meanwhile; for the attention of health in all Mexican population, there is in the country the National Health System (SNS―due to its Spanish translation) which is constituted by the National Health System dependencies and entities, federal as well as local, by individual or legal entities from the social and private sectors, which provide health services and the coordination of the SNS oversees the Secretary of Health. This system is divided in two, the Private Subsystem and the Public Subsystem. The former, is aimed to the part of the population that, having the economic resources, makes the payment by the provided services and the Public Subsystem is aimed to two kinds of population: population with social security that represents 52% of the total Mexican population and the population without affiliation or “open” affiliation (48%), that is met in the health institutions with public financing (Contreras, 2014).
In the case of population with affiliation, through its institutions a follow up to the health status is provided, receiving the required attention in a continuous way, which allows to implement prevention programs with this “captive” population. In the case of the population without affiliation, their health attention is by means of specific institutions, where the population normally goes when they get sick and for the preventive programs, other strategies have to be used in order to achieve their implementation, where the health providers are the ones who approach the communities. The Popular Health Insurance is aimed to this group of people.
It was a documentary investigation and an approach to the health policies, relating the content of documents with the undertaken actions in this field. To do so, issued documents in the scope were taken into consideration 1) national such as the Political Constitution of the United Mexican States, The General Health Law, the Agreements of Coordination between the Secretary of Health (national) and the government of State of Mexico and 2) regional as they were the official pages of Popular Insurance and the Health Institute from the State of Mexico. From the analysis of all these documents, it was only excerpted information about the affiliation process to the SPS as well as the services and medicines offered. Additionally, some statements made by the first person in charge of the implementation of the Popular Health Insurance in this region of the country were included and to know the materialization, two diseases that currently affect the population of the region and the country were taken into consideration.
3.1. The Popular Insurance in the Country
Popular Health Insurance is the name which was given to the testing pilot phase to the Social Protection System in Health. This stage was comprehended since December 2001 when the public notification was published, even though it started in February 2001, until December 2003.
In the country, the Popular Insurance started in 5 states of Mexico: Aguascalientes, Campeche, Colima, Jalisco and Tabasco. In 2002 some other states were incorporated, among them the State of Mexico. The actions provided to the population were 78 interventions listed in the Medical Benefit Catalogue (CABEME―due to its Spanish translation). By the end of that year, 295,000 families were affiliated and by the end of 2003, the number rose to 625,000 out of 24 states, out of 32 (Ortiz, 2006).
1The General Health Law is the regulatory document derived from the Political Constitution of the United Mexican States which has an obligatory application in all health services, either public or private located in the country, thus in the National Health System.
With the beginning of the validity of the regulatory framework in January 2004 its official name was changed; nevertheless, it was still regularly named as Popular Insurance. It was in May 2003 when the decree that reformed and added the General Health Law was published, which came into force on January1st 2004 due to its approval in the Senators and Deputies chambers (SSA, s/fa.). At this time, there was a period of great participation of the different actors since they were considered part of the public health policies just like institutional actors, political actors, business actors, social actors alongside academic actors and after 22 months of forums and debates, the new legislative structure started where the modification of the General Health Law1 was authorized for its incorporation.
For its implementation, the coordination agreements which were signed during the pilot stage (2002 and 2003) between the states governments and the Secretary of Health lasted a year and those that were already signed in the year 2005 had an indefinite validity. In these documents, the operative actions of the program and the competence to which both parties committed were established (SSA, 2002, 2005).
Finally, in May 2003 the President of the country signed the decree for the expedition of the reform, which was published two days after the signature and came into force until 2004. With this; regulations, operating rules and guidelines were issued so that the Popular Health Insurance was officially implemented. Furthermore, coordination agreements between the Secretary of Health and each of the governments of the states were signed for its implementation all over the country and it was essential taking it to debate in the legislative chambers so that the Popular Insurance could be contemplated in the General Health Law and that its application could be carried out obligatory by all the state services. Since then, the SPS is implemented all over the Mexican territory.
3.2. The Popular Health Insurance in the State of Mexico
In the State of Mexico (federative entity that adjoins the country’s capital), its introduction had other behaviors. Unlike the debate that existed in the Federal Legislative Chambers, here this exercise did not take place, accomplishing to avoid the existing regulatory procedures in the entity as it was at national level.
In this region of the country, it began as part of the testing pilot phase at a national level and the existing state structure was used as well as the same human and material resources (Contreras, 2014). This phase began in October 2002, by signing the collaboration agreement in the national government and the state-owned agreement until December 20th. It lasted only one year and the compromise from both parties to carry out the execution of the Popular Health Insurance were established, between them, the membership goals (Portillo, 2007).
In the second agreement already signed in the formal phase (January 2004) it was expressed that its validity was indefinite, as well as the bases, compromises, responsibilities from both parties to its execution, the creation of a state administrative unit responsible of the program and the coordination procedures with the federation (Contreras, 2014).
In the year 2004 and with the argument of functionally strengthening the Health Institute in the State of Mexico (organism in charge to offer health services to the population without social security), a series of structural modifications took part.
In session, the Internal Council from the ISEM itself (march 15th; 2015), approved as part of the Institution, the creation of the State Unit of Social Protection in Health, this adequacy was derived from the agreement ISE/134/007, which allowed to begin the institutionalization of the Popular Insurance Unit; therewith, the State Regime of Social Protection in Health and to its formalization an initiative was presented by the Head of the State Executive, using the faculties that the Political Constitution of the Free and Sovereign Mexican State provides. Thus, the Law that created the Decentralized Public Organization known as “State Regime of Social Protection in Health” was issued (SSA, 2005).
It was in the year of 2005 when the Popular Health Insurance was reflected in the State Health Program 2005-2011, document issued by the state executive specifying that the System would be boosted (SSA, s/fb). The State Program propound that in 2010 the State of Mexico joins the federal aims of affiliation through the extension actions of enrolment of all the population in the State of Mexico without being enrolled before so that they can count on the coverage of the Popular Healthcare Insurance, covering in that way the right to health of all population expressed in the Mexican Constitution.
In this way, since 2005 the State Regime of Social Protection in Health guarantees the effective, timely, quality and without discrimination access to the medical-surgical, pharmaceutical and hospital services, led to the population who doesn’t have social security throughout their enrolment to the Popular Insurance; thus, the ISEM functions were oriented to the administration resources, purchase of services to the providers, rights protection and accountability (ISEM, 2005).
In the State of Mexico, the Popular Insurance is propounded as an aim to offer medical-surgical, pharmaceutical and hospital services to the population who doesn’t have social security, the State Regime of Social Protection in Health has been established, through this regime it is intended to guarantee the effective, timely, quality and without discrimination access, to do this an incorporation to the Popular Insurance Program is required (SSA, s/fc).
To affiliate, the population should fill an application in the special modules located in specific places. The requirements are to reside in the State of Mexico, not to be beneficiary of any other institution which provides social security (for instance: IMSS, ISSSTE, etc.) (SSA, s/fd), to attach a photocopy of the Unique Population Registry Code, birth certificate, official identification with photograph and in the case, the proof of studies for the 18 to 25 years old members (SSA, s/fd).
At the time of affiliation to the Popular Insurance program, the users feature the benefits of:
1) Receiving comprehensive health services.
2) Equal access to care.
3) Respectful treatment and quality care.
4) Receiving the needed medicine corresponding to the health services contained in the (CAUSES).
5) Receiving sufficient, clear, efficient, timely and truthful information, as well as the needed guidance regarding health attention in addition to the risks and alternatives of the procedures, therapeutic and surgical diagnoses which are indicated or applied.
6) Having a clinical file.
The new affiliates to the Popular Insurance, once finishing their affiliation process, they receive their policy to ask for medical attention (SSA, S/FF); they attend to the primary healthcare service and request their ticket for medical consultation, after being evaluated, the doctor issues the prescription (or can provide a request for medical exams or send them to the secondary healthcare services) so that they go to the pharmacy and be given the medicine, all these in accordance with the CAUSES.
In the case of the medication associated to the interventions, in 2004, it was raised from 168 to 172 in 2005. For the year 2006, the CASES, was substituted by the Universal Catalogue of Healthcare Services (CAUSES―due to its Spanish abbreviation), with 285 medications (Contreras, 2014) and in the year 2017 it has 660.
About the medication topic, in the year 2002 the Medical Benefits Catalogue (CABEME―due to its Spanish abbreviation), already included 78 interventions in the formal phase (2004), it was substituted by the Essential Healthcare Services Catalogue (CASES―due to its Spanish abbreviation), which increased to 91 interventions and for 2005, CASES raised the interventions number, going from 91 to 15 and by 2016 the Universal Catalogue of Healthcare Services (CAUSES, its abbreviation, which changed its name again) added 287 interventions, which are classified in six groups: Public Health, General/Family and Specialty Medicine Attentions, Odontology, Emergencies, Hospitalization and General Surgery that treats 59 diseases.
In the State of Mexico the right to Health Protection of the population is taken up as it is established in the 4th article of the Constitution. This recognition is
Table 1. Diseases treated in General Surgery.
given in the Administrative Code from the State of Mexico and the Health Regulation from the State of Mexico; both documents agree and contribute in what is established in the General Health Law about the concurrency of the federation and the healthcare services decentralization to the federal states. There is equally a recognition that the Secretary of Health from the State of Mexico is in charge about the regulation of the services; however, it will be the Health Institute from the State of Mexico (ISEM―due to its Spanish abbreviation) who will be in charge to grant them, guaranteeing in such way the right to health protection.
The way in which the Popular Insurance was introduced in this region of the country was by arguing that it was a part of its “pilot phase” and it would refrain from following with the established legal procedure, embracing it, considering to this effect only the results that were the variables quite controlled.
Presently, the official website from the Popular Insurance for the State of Mexico indicates that it is “safe” since it provides the Families from the State of Mexico the certainty of knowing that if any member of the family got sick, they would not have to worry for the payment at the moment of the clinical attention as well as the medication and it is directed mainly to the low-income families that don’t have social security (which is granted to workers through the Mexican Social Security Institute or through the Social Security Institute for State Workers). Likewise, it points out that it is “popular” due to the fact that it includes all citizens, no matter whether they work, how much they make or where they live.
16 years after it had begun and 14 after its formal launch, several critics have been made to the Popular Insurance both in its national performance as well as in the State of Mexico.
In this region of the country penetrated within the normative framework of the State of Mexico failing to comply the existent legislative procedures, which affected in changes such as the State Health Program 2005-2001 that since then, the Popular Insurance has been considered as strategy to support and strengthen the needed actions to reach the 100% of the population without social security that represents the 48% of the total population (Contreras, 2014).
Other strategy that was incorporated to the state regulations is the impulse and promotion of the private sector through the supplying of primary and secondary healthcare pharmacies and the services subrogation (Contreras, 2014).
At this time private business focused on health are reinforced since the services such as hemodialysis, nursery, laboratories, warehouses, research, surgeries, camilleri and cleansing and hygiene, clothing, maintenance, pharmacy and dietetics are subrogated because they are not covered by the State in the basic health package. All this with the signing of agreements with the insurance companies endorsed by the Secretary of Health benefiting the large pharmaceutical corporate groups (Leduc, 2016).
Ever since it began, it was framed that the Popular Insurance had 100 % coverage above the population without social security, nevertheless, this has not been reached and experts call it a great “national deception”. Their argument is based in saying that its coverage is absolutely minimum, due to the fact that it doesn’t include all the diseases, it limits the medical and hospitable attention, it does not have enough resources, it does not have the necessary infrastructure to respond to the national demand and it does not have resources (Manzano, Cervantes, Leal, & Tello, 2015).
Financially, the national budget cuts in the health sector, have diminished the programs that it includes, such as the breastfeeding promotion (O’Shea in Cázares, 2017 ). 13 years away from its formal beginning, the Popular Insurance presented in 2017 a deficit for about 8 thousand million pesos as well as the lack of personnel and infrastructure. In the case of the State of Mexico, 900 million pesos are added together (Cázares, 2017).
Other aspect to consider is the lack of transparency in the management of financial resources. In the case of the State of Mexico, in august 2017, 921 million pesos hadn’t been proven, they must have been proven in June 30th; 2016 (Chemor, 2017).
In recent conference, the Health Secretary Narro (2017) informed that from 2007 to 2016 the Popular Insurance covered the treatment of almost 24 thousand underaged children with cancer (Narro, 2017). Despite these numbers, the headmaster of the State-Owned Oncological Center from the State of Mexico (Centro OncológicoEstatal del Estado de México) recognizes that this is in the first place in the country of diagnosed cases of breast cancer, prostate and leukemiacancer cases in the country (Barrera, 2018). The people who live with HIV and who are treated with the Popular Insurances die faster since they do not have all the services being the fastest dead curve from all other institutions which provide health services, in addition to this, according to the OCDE, the Popular Insurance does not cover heart attacks in people older than 60 years, neither cardiovascular events, dialysis due to renal failure, multiple sclerosis and lung cancer (Castillo, 2016). It is noteworthy that, given the electoral times that are currently happening in Mexico, there is not enough information neither in the official sites nor in the National and State Secretary, which allows getting a better knowledge about the SPS.
It can be noticed that there is an intention in the attention for this disease in children while this actions are recognized. The inversion of the population pyramid has to be taken into consideration as well as the major quantity if adults and older adults in the country, consequently, it is required that the attention be also guaranteed to the older population, so the age as eligibility criterion to health attention inside the Popular Insurance must be changed (Moctezuma, 2018).
While looking through the documents that regulate the implementation of the Popular Health Insurance in the State of Mexico, it is noticeable that, in the State of Mexico, it surprisingly emerges by reflecting as part of the reforms to the public policies in health. It is from the State Health Program 2005-2011 that it is introduced thus capturing, the new proposed strategies by the vertical policies that currently regulate the country, without complying the legal procedure that are demanded in the regulations from the State of Mexico.
Regarding the coverage statistics from the SPS in the geographical space of study, it could not be recognized the percentage in the population coverage, since there is not available information.
Even though the present study was made in only one region of the country, at a national level, it is recognized that the Popular Insurance neither includes all the diseases, nor all the services, and it neither has the human, nor the material resources, nor the necessary infrastructure to provide the services, situation that is generating a selectivity in the attention.
About the most deeply felt diseases of the population such as childhood cancer, although it is being prioritized in the catalogue of services from the SPS with the participation of oncologists in tertiary spaces, the preventive actions are being pushed aside, not taking into account that these have a lower cost and a higher impact, providing these actions in the primary healthcare services.