Healthcare in Mexico

In Mexico, the sixteenth century Badianus Manuscript described medicinal plants available in Central America.[6] Dr. Erick Estrada Lugo, Researcher-Professor in Phytotechnics at the State of Mexico’s Chapingo Autonomous University, told the National Autonomous University of Mexico’s digital magazine that “at least 90% of the population uses medicinal plants,” citing figures from Mexico’s Secretariat of Health. These include plants like Aloe vera, Arnica, and Valeriana.[7]

Hospitals were established in Mexico in the early 16th century, including ones exclusively for Indians. Some were established by the crown, others by private endowment, but most by the Catholic Church. Bishop Vasco de Quiroga established hospital complexes in Michoacan in the sixteenth century. In Mexico City, conqueror Hernán Cortés established the Hospital de Jesús Nazareno for Indians, which still functions as a hospital.[8][9][10]

Hospital de Jesús Nazareno stairs and murals.

Museum of Mexican Medicine

The Hospicio Cabañas in Guadalajara, Jalisco, Mexico, was founded in 1791. It is still functioning and is now a World Heritage Site. It is one of the oldest and largest hospital complexes in Latin America. The complex was founded by the Bishop of Guadalajara to combine the functions of a workhouse, hospital, orphanage, and almshouse.

The Mexican healthcare program, as we know it today, has its base on the creation of several health codes that ran during the first part of the 20th century.[11] In 1943, the Mexican Secretariat of Health and Assistance was established to merge the Department of Public Sanitation and the Secretariat of Public Assistance. In that same year, the Mexican Social Security Institute and the Mexican Children's Hospital were founded, during the presidency of Manuel Avila Camacho.[12] After this, several and important changes came, aiming to provide better health for the population. In 1959, the Institute for Social Security and Services for State Workers (ISSSTE) was formed as a way of more effectively covering the health services of individuals employed in government institutions. Finally, the Seguro Popular, or Popular Health Insurance, was implemented countrywide in 2003 after the creation of the Social System for Health Protection (SPSS), during the presidency of Vicente Fox Quesada. This institution was charged with covering the country's most impoverished communities— those not covered under the IMSS or the ISSSTE.[13] The new health system reform also emphasized the creation of thorough analytic methodology— most prominently in the form of reports and surveys. Additionally, a system fostering accountability within the system was established, with a formal accreditation process being introduced, and quality checks being implemented across the public sector. [14] During the next few years, some other changes in health policies have been made as a way of reaching universal healthcare. [1][11]

Centro Médico Excel a multi specialty private hospital in Tijuana Mexico.

The private healthcare sector makes up a substantial portion of the Mexican healthcare system with respect to both spending and activity. Recently, higher activity within the private sector of the Mexican healthcare system has been observed in comparison to its public counterpart. Overall spending being attributed to the private institutions accounts for approximately 52% of total health spending in the country. Furthermore, this proportion appears to be subject to a sustained increase in recent years.[15] The services provided by private institutions and private physicians in their offices are afforded by a part of the population, either by contracting a private insurance or by paying directly for the services obtained. It is estimated that around 6.9% of the Mexican population has private insurance coverage, mainly paid as an out-of-pocket expenditure. Generally, utilization of this sector of the healthcare system is limited to Mexicans of higher socioeconomic status. [16]

To meet the needs of the population, relationships between the private and public healthcare sectors are beginning to form in various capacities.[17] Recently however, studies have shown little coordination between this system and the other public sector institutions. The high fragmentation of the system has been observed to affect spending trends as well as the services received from beneficiaries.[16]

Private healthcare delivery is a heterogenous institution, with varying levels of regulation, quality, and government association being observed within the institutions which compose it. [18] Mexico has around 28.6 private facilities per 1 million inhabitants, which account for two thirds of all hospitals in Mexico, with 2,988 institutions.[19]

The increased use of the private healthcare sector may be attributed to the association of public forms of healthcare with restriction in accessibility and quality. The belief that these services are superior in quality appears to widespread—many patients depend heavily upon these forms of healthcare, even though public services are at times provided at no cost.[20] Private services tend to be associated with shorter wait times, less crowding, a stronger and more satisfying patient-provider interaction, and higher quality equipment and medications. Additionally, the duration of a visits in a private hospitals tend to be more than double that of their public counterparts.[21] The quality of services performed in these institutions, however, is of debate.[22] Especially in the field of prenatal care, disparities in quality exist among private and public institutions.[23]

In addition to members of the Mexican populace, some individuals with connections to Mexico—including citizens, undocumented immigrants residing in the U.S., and even permanent U.S. residents with Mexican ties—associate private Mexican institutions with convenience, affordability, and efficacy, even rating them above their American public counterparts. This, in turn, has created a phenomenon, known as medical returns, in which select populations, such as migrants, preferentially return to Mexico in order to receive medical treatment. [24]

Additionally, Mexican providers, especially in the private sector, but also in its public counterpart, appear to be less restricted by the possibility of lawsuit in their practice, especially when compared to their equivalent American counterparts, which may contribute to a higher perceived standard of care. [24]

Central Offices of IMSS in Mexico city.

Public healthcare has an elaborate provisioning and delivery system instituted by the Mexican government. It is provided to all Mexican citizens, as guaranteed by Article 4 of the Constitution. [1]

Public care is fully or partially subsidized by the federal government, depending upon the person's employment status. All Mexican citizens are eligible for subsidized healthcare regardless of their work status via a system of health care facilities operating under the federal Secretariat of Health (formerly the Secretaría de Salubridad y Asistencia, or SSA) agency through the program called Seguro Popular, which offers coverage to Mexicans who do not have formal employment.[1] The program currently protects over 57 million inhabitants and covers around 260 common diseases and 18 high-cost interventions. [25] [26] This public insurance scheme, coupled with Social Security, represents 95% of the insured population in Mexico. [27] Funding for Seguro Popular is derived from the federal government, the Secretariat of Health, and the individuals who form a part of this system. However, approximately 20% of individuals in this system, representing the poorest covered sector, are exempt from this.[13]

Central offices of ISSSTE in Mexico City.

Employed citizens and their dependents, however, can use the program administered and operated by the Instituto Mexicano del Seguro Social (IMSS) (English: Mexican Social Security Institute). The IMSS program is a tripartite system funded equally by the employee, the private employer, and the federal government. There are more than 65 million people covered through IMSS and its programs.[26]Further, within IMSS there exists the IMSS-Oportunidades, a program established out of the Program to Combat Poverty, which is specifically targeted towards aiding the poorest individuals in the country in both the health and educational fields. This program is completely funded by the government.[13]

The IMSS does not provide service to public employees, who instead are serviced by the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) (English: Institute for Social Security and Services for State Workers), which attends to the health and social care needs of government employees at the local, state, and federal levels. Nearly 9 million people are covered by the ISSSTE.[26]

Secretary of Health of Mexico Julio Frenk with former President Vicente Fox and Reyes Tamez, Secretary of Education, in Los Pinos during the initialing ceremony of the National Institute of Genomic Medicine.

The state governments of Mexico also provide health services independently of those that are provided by the federal government programs. In most states, the state government has established free or subsidized healthcare to all of its citizens.[28]

The Secretariat of Health is the largest public healthcare institution, operating 809 hospitals throughout the country. The IMSS grants hospital care and services to employed citizens and their dependents and had 279 hospitals affiliated to it. The ISSSTE grants hospital care and services to government employees and has 115 affiliated hospitals. The other 279 hospitals are affiliated with 9 government dependencies, including State Facilities, Secretariat of National Defense (Secretaria de Defensa Nacional), Mexican Navy (Secretaria de Marina), Petroleos Mexicanos (PEMEX), and the Red Cross (Cruz Roja).[29] The health systems associated with SEDENA, SEMAR, and PEMEX cover over one million individuals combined.[13]

In 2007, there were a total of 23,858 health units within the Mexican state. Approximately 27% of these were contained in the public sector.[13]

General Hospital of Mexico in Mexico City.

Fray Bernardino Alvarez Psychiatric Hospital located in the Tlalpan Borough, in Mexico City

Mexico has seen an overall improvement in almost every aspect of health trend.[4] However, Mexico lags well behind other Organisation for Economic Co-operation and Development countries in health status and availability.[30]

The Instituto Nacional de Cancerología (The National Oncology Institute) located in Mexico City.

Health demographics

According to recent international statistics, Mexico has an estimated population of 130 millions of inhabitants, with a reported annual population growth rate of 1.2%. Since 1990 there was an increment of about 45 million people.[4]

Demographic transition have been notorious in the last 7 decades in Mexico. Life expectancy at birth (general) changed from being 45 years in 1950 to 71.5 years in 1990, and to actually reach 77.5 years, close to some high-income countries in America and the World. [31] [33] Child mortality rate, as one the major health trends, have improved most notoriously after 1950, when an average of 252 children under-five years were dead per 1000 live births, decreasing to 44.5 in 1990 and reaching 14.6, in 2018. [31] [33] Finally, after 1970, at least 20 years after the major changes in life expectancy and child mortality rate, there was a decrease in fertility rate. In 1950 it was estimated that for every woman, around 6.67 babies were born; in 1970, it increased to 6.8 and then, steadily decreased to 3.4 in 1990 to finally end in 2.1, which is below the world average.[31][33]

The IMSS La Raza Medical Center, a well known public hospital in Mexico City

Besides this demographic transition, there have been major changes in the principal causes of death and morbidities among Mexicans. Epidemiological transition has been notorious in the history of Mexico when it comes to Disability-adjusted life year (DALY) but not when comparing causes of death, with most data coming since 1990.[34][35] According to the Institute for Health Metrics and Evaluation, in 1990 the leading causes of death in the country were also cardiovascular diseases, neoplasms and diabetes, which remain the same until recent data. Some infectious diseases (respiratory infections, tuberculosis and enteric infections) were also among the most common causes in the 90's, which were displaced for other non-communicable diseases in 2017. Taking into consideration the burden of disease according to the years lost due to disability (DALY), in 1990, the three most common causes of disability were communicable and maternal diseases (maternal and neonatal disorders, respiratory infections, tuberculosis and enteric infections). In 2017, these 3 diseases were replaced by diabetes and kidney diseases, cardiovascular diseases and self-injuries, displacing most of the communicable diseases out of the top ten. [32] [34]

Vaccination of pediatric patients in San Miguel Topilejo, Mexico.

The Mexican healthcare system remains a continually expanding and progressive structure. Mexico first began enacting initiatives to extend health coverage, particularly in rural communities in 1979. Data from a national survey in 2012 demonstrated that a majority of Mexicans maintain a positive perception on the quality of their primary care. [37] In 2013, a report by the Ministry of Health projected that over 90% of the population was covered.[38] There are some areas, though, were inequities in accessibility can be seen. Results from a national survey conducted by Arredondo and Najera (2008) revealed stark disparities in accessibility despite expansion of services and coverage association, demonstrating that despite enhancements to the national health systems, inequities in accessibility of institutions, care, diagnostic services, medication, and travel were pronounced, especially as it related to rural and impoverished communities. These include insurance coverage, cost reduction, primary care association, and specialized services accessibility. [5][37][39][40]

Other factors

Health outpost operations in Izlapalapa, Mexico City

Factors that have demonstrated influence on the magnitude of accessibility available to healthcare include sparse distribution of institutional resources, and lack of specialized care services in isolated populations.[40][44]

Furthermore, preventative care remains to an under-focused area across the country. A 2015 projection model found that almost a quarter of the Mexican population did not have a regular primary care provider or institution that year. [37]

Accessibility as it relates to rural communities has been an especially studied topic and work here has revealed the existence of great disparities in breadth and effectiveness of service offered. Case studies involving clinical management of diarrheic disease in rural communities have emphasized concerns relating to the quality and range of services available to more isolated populations. [44] Additionally, in 2003, it was projected that up to a quarter of the population was afflicted with some form of mental illness. Rural populations made up especially large proportions of this demographic. Issues related to accessibility of specialized services, especially institutions offering forms of care related to mental health, are especially prevalent in these communities. Factors such as location, transportation, and the economic cost of implementation are the main factors associated with this. [40]

Urban populations are also subject to unique issues and conflicts, mostly related to delivery and the ability of the institutions to service the large populations they are associated with. [18]

• Mexico
• Social determinants of health in Mexico
• Poverty in Mexico