Supporting Health Reform in Mexico
Experiences and Suggestions from an International Primary Health Care Conference
Background and aim:
Most countries experience major challenges to their health systems, and strengthening primary health care is a critical strategy to secure sustainable health care . Primary health care provides the ability to respond in a cost-effective way to the needs of individuals and communities by approaching health problems in a broad social, economic, political and cultural context , and this makes primary health care a core component of a sustainable health system. Mexico is an example of a country going through rapid socio-economic and health care developments. An important barrier for the country to move to a robust health system is the poor understanding amongst policy makers of the potential of primary health care for population health improvement, and an equally poor understanding amongst health science and academic leaders of the importance of research in the primary health care setting. Indeed, these are some of the major reasons why the country is struggling to meet the health needs of its entire population.
The Mexican College of Family Medicine is a leading medical-academic organisation in the country. It has the potential to guide health systems change, advocate the importance of a stronger primary health care and family medicine sector in Mexico and engage with stakeholders, including consumers in this process. Currently however, it lacks an established workforce capacity to head such a process.
This paper reports on an action plan developed during an international pre-conference meeting at the 2015 conference of the North American Primary Care research Group (NAPCRG) in Cancun. The meeting had been organised to support the Mexican College to build leadership capacity to reform the Mexican health system.
International Collaboration for the Implementation of Primary Care Policy.
Advocacy is an important driver of the process of health systems change, and has to be based on an understanding of the contribution of primary health care to population health. It also has to acknowledge the role of primary health care research in implementing change, and the value of constructive collaboration with other stakeholders, in particular patients/ service users, the world of research and science, insurers, employers, and community leaders. To achieve reform, it is important to articulate these points to these various audiences unfamiliar with the science of health systems.
There is substantial hands-on experience in the international community in implementing primary health care policy and direct health systems reform [2, 3, 4, 5, 6], with platforms for collaboration to develop methods, exchange experiences, and research to compare outcomes of care and critically appraise success and failures . Collaboration is directed at the translation of general principles of primary health care development to local circumstances and priorities. This has to result in a bottom-up process tailored towards the needs of the actual setting of the community and population for which changes are meant. A model to put this into effect, is capacity building of local leadership based on international experience.
Mexican Health and Health Care
The Mexican Health System (MHS) is in transition to universal health care, which is intended to remedy health inequality, mainly through addressing high out of pocket spending. Indeed over 35% of health spending in Mexico is paid directly by the consumer .  Like many low to middle income countries, Mexico faces an untenable burden of disease due to the demographic and epidemiological transition, increased life expectancy, an aging population and the increase in non- communicable chronic diseases . Diabetes Mellitus, with a prevalence in adults aged 20-79 of 16%, is a leading cause of death in men and women across the country and is the highest among OECD countries . At the same time, communicable diseases still prevail, and even coexist, in rural areas.
There are three relevant moments in the development of the MHS. In 1943, the Mexican Institute of Social Security (IMSS) became the first health care institution to fund care for workers; it was followed by several institutions providing health services for other sectors of the population. In 2014, efforts began to carry out what is considered the second health reform with the creation of the System of Social Protection in Health (SPSS)  and its operating arm, Popular Insurance (PI)  to increment health coverage. In 2015, the project of health care reform was launched by the Mexican President to provide full healthcare coverage.
Despite these reforms, the provision of services, health governance, and funding remain as independent functions for each institution. As a consequence, health services provision is vertical and fragmented. Further health governance is not yet fully exercised by the Ministry of Health and the health system remains a complex mixture of funding sources according to the population being served.
Public institutions, which most of the health care services are based on, rely on government contributions; however, in the IMSS and ISSSTE, fees paid by workers and employers also cover services, and supplementary payments as in the case of Popular Insurance, comes from the decile of the population with a higher income .
Each institution has a vertical financing system which increases administrative expenses of health care costs up to 40% .
Although the health reform is in its beginnings, some developments can be acknowledged such as the portability of benefits and convergence in the provision of services .
The notable absentee in the health system is primary care, which is based more on the public system, through institutions. In the IMSS, primary care is carried out by family physicians trained by the institution itself , the ministry of health (SSA) usually has general practitioners or noncertified family physicians, and the PI provides primary care through social service interns (8500)  and in less developed communities, through State services of SSA (SSa) units.
There is no single model of primary care in Mexico although in general, the outpatient clinic interview is short (15 minutes) and more often, curative in focus. Only 9.5% of interventions are preventive .
Primary care also does not feature in workforce development with family medicine accounting for only 4% of over 26, 000 training positions. .
Overall then, the current configuration of the system still does not respond to present and future demographic and epidemiological challenges. Health reform should focus on primary care, with health financing and investment according to primacy care principles such as integrated care for all health problems of the person, based on lasting, continuous relation and directed at the social environment in which people live.
Based on this overview, the group identified as the most compelling weakness, a lack of structure and organisation in the system leading to undue duplication of services, with no coordination between primary health care and hospitals. This causes problems in access, in particular for those from lower socio economic status and indigenous populations. Policy makers, educators and patients have no understanding of the specific role of primary health care and family physicians in the system and there is also no available definition of its role. This is amplified by the fact that undergraduate education and specialty training is not directed at health problems in the community. As a consequence, primary health care is used as a last, rather than first resort.
A substantial part of the population is uncovered for health care costs and with resources continuing to be directed to hospital services this threatens to further worsen the situation. Health reforms that have been attempted in the recent past have diminished physicians’ income, leading to a reduction in the already limited number of doctors practicing in the community.
Against these threats and weaknesses stand a number of positive points. Notably, Mexico has been successful in implementing preventive services in the community, in particular childhood vaccination. With the Mexican College there is a professional – academic organisation available to instigate change in the health system. An existing practice-based research network is able to generate real life data of the health problems in the community and a number of universities have departments of family medicine and provide family medicine residence programs.
The country has a history of policy- directed health reforms and has introduced compulsory health coverage for employees and their families and there is a safety net support for the lowest income groups to access basic health care. As the current economic situation makes it possible to spend more on health care, this should be seen as an opportunity to generate health system change.
International and local support
Ontario experience: The health system transformation that has taken place in Ontario, Canada is an example of lessons learned in transforming physician payment systems and implementing inter-professional teams [15, 16, 17]. The motivation for payment reform in Ontario lay with the decline and demoralization of family physicians in the late 1990s as scope of practice shrunk, isolation grew and reimbursement stagnated. Voluntary primary care models based on capitation blended with fee-for-service and pay-for-performance incentives also carried requirements for patient enrolment and after-hours office coverage. Blended capitation models rapidly became the most popular form of reimbursement and about half of participating physicians were supported with inter-professional teams. Other Canadian provinces implemented reforms involving many but not all of these elements.
The major success of the transformation and its most important lesson for other countries was that physician payment reform was accompanied by substantial increases in physician reimbursement and satisfaction. Medical student interest in family medicine almost doubled and close to 40% of Canadian graduates now choose family medicine. The major limitations and lessons for other countries about what to avoid included not adjusting capitation for health needs and not aligning primary care incentives with the needs of the rest of the health system.
Lessons from Honduras and the US: Mexico may wish to heed lessons from its Northern and Southern neighbours, in both geographic and fiscal terms. The US has demonstrated that health care investment does not lead to a return in health outcomes , when there is only marginal attention to and investment in the primary care function, which by some estimates receives 4-7% of total health care spending. Leaving the reins of its health care system in the hands of the marketplace and fee for service payments has created gross mal-distribution of the United States’ health workforce and infrastructure away from primary care specialties and urban/rural areas with high health needs, in favour of subspecialty and hospital-centric clusters in select areas.
Unfortunately, Central American countries such as Honduras, had proven highly susceptible to imitating this U.S. approach. Against this can be placed the power of decentralized, local ‘communities of solution’ in trying to achieve more with less resources, for example the Hombro a Hombro project in rural Intibuca, Honduras . This academic to rural community partnership emphasizes the need to start with community engagement through the growth of local ‘committees’ for health. Investment in such local empowerment rendered groups capable of determining the social determinants of health in need of greatest attention, prioritizing resource use for each, and crafting community-wide buy- in to projects dedicated to educating young girls, providing safe water sources and food stability, reducing respiratory pollutants in the home, addressing alcoholism, as well as providing clinical services focused on the most basic oral, behavioural, preventive and primary care needs.
In considering these two examples the group identified learning points from both, that had to be translated to the local Mexican context. The experiences from Ontario in particular were seen as relevant, as this had resulted in a blended payment with a strong emphasis on capitation. Important was the generation of knowledge of the main population health problems with their impact on the demand for care in the community and hospital. This stressed as well the importance of family practice specialty training in the community setting, directed at the development of competencies required for the specific needs. Another priority was gaining insight in the number and distribution of healthcare professionals in the country as a basis for workforce planning. The rural setting was seen as a priority here, where training in the rural context might help to retain family physicians practicing there.
Working with stakeholders
Contemporary experiences with primary health care delivery are founded on a multi-stakeholder approach. Experiences from both the US and Canada in engagement between care providers, patients and their care-givers, managers and policy makers at all levels has led to greater understanding of complex systems needs surrounding effective care provision [ 20, 21, 22, 23]. Furthermore, the emphasis on both patient-centered care and patient and community driven outcome measures has meant that, as both primary care providers and researchers, we have needed to build our clinical and academic capacity to effectively engage with those who ultimately will benefit [24, 25, 26]. This participatory process puts the patient and community at the center of the discussion, assuring that care appropriately meets their needs and that evidence-creation is asking the right questions. Meaningful engagement has been demonstrated to lead to more rapid uptake of evidence into practice, and more patient and community satisfaction with care provided [27, 28, 29].
In reflecting on these experiences the group acknowledged the importance of working with patients but identified a number of shortcomings in the current Mexican situation in this regard. There is no readily identifiable consumer organisation to work with, and patients are passive in their relationships with health care professionals. There is a poor understanding of primary health care and the role of family physicians. This makes the exploration of ways to engage the voices and views of patients a priority.
The group concluded to initiate action to work for health reform to improve the health of the Mexican population, based on a sustainable high quality health system. It was unanimously agreed that implementation of primary health care should play an integral role. The action was summarised in the Cancun Manifesto , urging the design of a long-term strategy for primary health care and family medicine development in Mexico. For the successful outcome of this, it was determined that the status of the Mexican College of Family Medicine be changed so as to make it an academic body that can legally represent the discipline of family medicine in medico-political decision making. The College was advised to convene a working party to guide the work for system change with addressing its legal status as a first priority.
A number of short term objectives were identified that could be advanced in the coming year with the view to informing the long term process of system change:
· Constructing the Ecology of Medical Care in Mexico , with the support of the existing research network.
· Collecting stories of patients of their experiences with their family physician and how they value this.
· Organising the definition of the role and function of family physicians and primary health care in the Mexican health system .
Continued mentoring and support to the Mexican College from the international primary health care community (NAPCRG, WONCA, IIRNPC) will be provided alongside the evolvement of this work. In evaluating the process of the meeting, it was concluded that the approach used here might be applied to other countries striving for health systems change to better integrate primary health care.
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Authors and affiliations:
Chris van Weel, Radboud University Nijmegen, The Netherlands; Australian National University, Canberra, Australia
Deborah Turnbull, University of Adelaide, Australia
José Ramirez, Autonomous University of Nuevo Leon in Monterrey NL, Mexico and Research Coordinator of Mexican Family Physician College.
Andrew Bazemore, Robert Graham Center Policy Studies in Family Medicine & Primary Care, Washington DC, USA
Richard Glazier, Institute for Clinical Evaluative Sciences, St. Michaels Hospital, University of Toronto, Toronto, Canada
Carlos Jaen, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
Bob Phillips, American Board of Family Medicine, Washington, DC, USA
Jon Salsberg, McGill University, Montreal, Canada