Science will play a critical role in the expansion and improvement of global health. We must be able to apply what we learn about technology, drugs, communicable and noncommunicable diseases, personal hygiene, feeding habits, sexuality, and child rearing to policymaking on health care. Similarly, social science evaluations of the impact of health care policies and their implementation are crucial to the development of better health policy.
Cooperation among research and advocacy organizations has helped to create an international infrastructure to measure the burden of disease, analyze the cost-effectiveness of health interventions and develop broad plans and budgets to address national health care concerns. The application of these advances catalyzed the far-reaching structural reform in 2003 of the Mexican health system called Seguro Popular.
In the early 1990s, a calculation of national health accounts by the Fundación Mexicana para la Salud revealed that more than half of total Mexican health care expenditure was individual, out-of-pocket payments. Families and individuals were paying from their own incomes or savings for health care procedures, including emergency care. In other words, half of the population lacked health insurance.
The realization that households—the poor, in particular—had been paying catastrophic, out-of-pocket sums changed public perceptions and provoked public discussion of the need to expand public health coverage. Policymakers suddenly began to look at how financial issues affected the provision of health care and levels of poverty among Mexican households.
Another contributor to the reform was the realization that Mexico compared poorly with other nations, as measured by the World Health Organization in 2000, in providing full health care to its citizens—a direct result of its high levels of out-of-pocket spending. Mexican analysts concluded that poor households were driven into greater hardship by crushing health care expenditures.
The evidence sparked a broad coalition to establish a system of social protection in health. The legislative reform, approved by the Mexican Congress in 2003, led to a major overhaul of the country’s public health infrastructure and an increase in public funding for health care by a full percentage point of GDP over seven years. The eventual goal: to provide universal health insurance.
The vehicle for change was Seguro Popular, a publicly managed health care system funded predominantly through federal and state expenditures. In December 2009, more than 30 million of the 50 million Mexicans without traditional public health insurance were enrolled in the insurance system.
Microlevel management reform has accompanied this sweeping reform in public funding and organization of health care. The goal of the management reform was to strengthen the delivery capacity of the state through long-term planning of new facilities; implementation of efficient schemes for drug purchase and distribution; establishment of information systems; and performance benchmarking among states and organizations.
The reform has been subject to a rigorous external evaluation using a randomized design that takes advantage of the phased rollout of Seguro Popular. That rollout involved extending coverage to 14 percent of the uninsured each year from 2004 to 2010. The evaluation plan examines treatment and control communities (those communities that were originally included in the plan and those that were not) in a sample of around 36,000 households. Those data served as a baseline to collect information on several expected outcomes, most of all the financial protection of the poor in health care expenditures. After 10 months, the first follow-up measurement demonstrated a reduction of expenditures for catastrophic and emergency health care.
Mexico’s experience in launching and implementing its reforms provides some valuable lessons. First, cross-border learning is important. Public health experts and domestic policymakers should use global databases and evidence—for advocacy and the design of policies—to develop well-performing, broad-based health systems.
Second, long-term, effective reform requires investment in management capacity. Mexico’s reform process has benefited from efforts to establish and nurture organizations such as the Instituto Nacional de Salud Pública and the Fundación Mexicana para la Salud whose research has enriched the quality of information. In addition, many of the technocrats in those institutions have gone on to occupy key policymaking positions.
Third, we need to marry social science research with research on the science of health care. To this end, when governments initiate dramatic, broad-based reforms, they should also develop rigorous research efforts to track the effectiveness of such large-scale interventions. Doing so will not only provide feedback to policymakers to make necessary course corrections but will also inform science in terms of disease and health.
Finally, the Mexican reform shows that globalization can turn knowledge into a public good that serves as a leverage point for advocacy that concerned organizations and the government itself can use in the domestic debate to address local problems. When governments adopt reforms, their monitoring and evaluation feeds back into the global pool of experience, thus generating a process of shared learning among countries.
