RESUMO
2023 marks the 20-year anniversary of the creation of Mexico's System of Social Protection for Health and the Seguro Popular, a model for the global quest to achieve universal health coverage through health system reform. We analyse the success and challenges after 2012, the consequences of reform ageing, and the unique coincidence of systemic reorganisation during the COVID-19 pandemic to identify strategies for health system disaster preparedness. We document that population health and financial protection improved as the Seguro Popular aged, despite erosion of the budget and absent needed reforms. The Seguro Popular closed in January, 2020, and Mexico embarked on a complex, extensive health system reorganisation. We posit that dismantling the Seguro Popular while trying to establish a new programme in 2020-21 made the Mexican health system more vulnerable in the worst pandemic period and shows the precariousness of evidence-based policy making to political polarisation and populism. Reforms should be designed to be flexible yet insulated from political volatility and constructed and managed to be structurally permeable and adaptable to new evidence to face changing health needs. Simultaneously, health systems should be grounded to withstand systemic shocks of politics and natural disasters.
Assuntos
COVID-19 , Cobertura Universal do Seguro de Saúde , Humanos , Idoso , México/epidemiologia , Pandemias/prevenção & controle , COVID-19/epidemiologia , COVID-19/prevenção & controle , Política , Política Pública , Reforma dos Serviços de Saúde , Política de SaúdeRESUMO
This paper discusses the origins and content of the framework that guided the creation of the Center for Public Health Research in 1984 and the modernization of the School of Public of Health of Mexico, established in 1922. These two institutions eventually merged with the Center for Research in Infectious Disease to create, in 1987, the National Institute of Public Health of Mexico, one of the leading institutions of higher education and research in public health in the developing world.
Assuntos
Saúde Pública , Mudança Social , Humanos , Saúde Pública/educação , México , Instituições AcadêmicasRESUMO
We present a new concept, Punt Politics, and apply it to the COVID-19 non-pharmaceutical interventions (NPI) in two epicenters of the pandemic: Mexico and Brazil. Punt Politics refers to national leaders in federal systems deferring or deflecting responsibility for health systems decision-making to sub-national entities without evidence or coordination. The fragmentation of authority and overlapping functions in federal, decentralized political systems make them more susceptible to coordination problems than centralized, unitary systems. We apply the concept to pandemics, which require national health system stewardship, using sub-national NPI data that we developed and curated through the Observatory for the Containment of COVID-19 in the Americas to illustrate Punt Politics in Mexico and Brazil. Both countries suffer from protracted, high levels of COVID-19 mortality and inadequate pandemic responses, including little testing and disregard for scientific evidence. We illustrate how populist leadership drove Punt Politics and how partisan politics contributed to disabling an evidence-based response in Mexico and Brazil. These cases illustrate the combination of decentralization and populist leadership that is most conducive to punting responsibility. We discuss how Punt Politics reduces health system functionality, providing lessons for other countries and future pandemic responses, including vaccine rollout.
RESUMO
Abstract The purpose of this paper is to discuss one of the most common ethical predicaments faced by public health practitioners: the distribution of limited resources for health. The question we address is the following: If there are limited resources to provide necessary health care, how can we reasonably establish priorities? We discuss this question using as reference a real-life situation, which was the establishment of priorities in the design of a package of high-cost interventions for Seguro Popular in Mexico, a public insurance scheme that extended social protection in health to over 50 million people between 2003 and 2018. The main conclusion of this paper is that the use of explicit ethical assumptions in the design of public policies contribute to their acceptability and eventual success.
Resumen El propósito de este artículo es discutir uno de los dilemas éticos que con mayor frecuencia enfrentan quienes se dedican a la salud pública: la distribución de recursos limitados para la salud. La pregunta a la que se pretende responder es la siguiente: si existen recursos limitados para prestar los servicios de salud necesarios, ¿cómo podemos fijar prioridades? Intentamos responder a esta pregunta haciendo referencia a una situación de la vida real que fue el establecimiento de prioridades en el diseño de un paquete de intervenciones de alto costo para el Seguro Popular de México, un seguro público que extendió la protección social en salud a más de 50 millones de personas entre 2003 y 2018. La principal conclusión de este artículo es que el uso de un marco ético explícito en el diseño de las políticas públicas incrementa su aceptabilidad y favorece su eventual éxito.
Resumo O propósito deste artigo é discutir um dos dilemas éticos que com maior frequência aqueles que se dedicam à saúde pública enfrentam: a distribuição de recursos limitados para a saúde. A pergunta que se pretende responder é a seguinte: se existem recursos limitados para prestar os serviços de saúde necessários, como podemos fixar prioridades? Tentamos responder a esta pregunta fazendo referência a uma situação de vida real que foi o estabelecimento de prioridades na concepção de um pacote de intervenções de alto custo para o Seguro Popular do México, um seguro público que estendeu a proteção social em saúde a mais de 50 milhões de pessoas entre 2003 e 2018. A principal conclusão deste artigo é que o uso de um enquadramento ético explícito na concepção das políticas públicas aumenta sua aceitação e favorece seu eventual sucesso.
Assuntos
Humanos , Política Pública , Saúde , Reforma dos Serviços de Saúde , Ética , MéxicoRESUMO
Resumen En este ensayo se discute la situación de la atención a la salud en Mesoamérica antes e inmediatamente después de 1519. En los primeros 50 años después de la Conquista, los españoles hicieron un uso muy extensivo de la medicina náhuatl. Sin embargo, con el tiempo, el ámbito de influencia de esta tradición se vio limitado debido a la rápida imposición de un sistema de atención muy diferente que poco aprovechó, entre otras cosas, la riqueza terapéutica de la medicina prehispánica.
Abstract This paper discusses the situation of healthcare in Mesoamerica before and immediately after 1519. In the first 50 years after the Conquest, the Spaniards made extensive use of Nahuatl medicine. However, the influence of this medical tradition was limited due to the rapid imposition of a very different medical system which took little advantage of, among other things, the therapeutic wealth of pre-Hispanic healing traditions.
Assuntos
História do Século XV , História do Século XVI , História do Século XVII , História do Século XVIII , Atenção à Saúde/história , Medicina Tradicional/história , Atenção à Saúde/etnologia , Atenção à Saúde/organização & administração , Epidemias/história , Hospitais/história , MéxicoRESUMO
This paper discusses the situation of healthcare in Mesoamerica before and immediately after 1519. In the first 50 years after the Conquest, the Spaniards made extensive use of Nahuatl medicine. However, the influence of this medical tradition was limited due to the rapid imposition of a very different medical system which took little advantage of, among other things, the therapeutic wealth of pre-Hispanic healing traditions.
En este ensayo se discute la situación de la atención a la salud en Mesoamérica antes e inmediatamente después de 1519. En los primeros 50 años después de la Conquista, los españoles hicieron un uso muy extensivo de la medicina náhuatl. Sin embargo, con el tiempo, el ámbito de influencia de esta tradición se vio limitado debido a la rápida imposición de un sistema de atención muy diferente que poco aprovechó, entre otras cosas, la riqueza terapéutica de la medicina prehispánica.
Assuntos
Atenção à Saúde/história , Medicina Tradicional/história , Atenção à Saúde/etnologia , Atenção à Saúde/organização & administração , Epidemias/história , História do Século XV , História do Século XVI , História do Século XVII , História do Século XVIII , Hospitais/história , MéxicoRESUMO
This paper describes the creation of the legal framework and the origin, growth and consolidation of the institutions and interventions (initiatives, programs and policies) that nourished public health in Mexico in the past century. It also discusses the recent efforts to guarantee universal social protection in health. This quest, which lasted a century, developed through three generations of reform that gave birth to a health system that offers protection against sanitary risks, protection of health care quality and financial protection to all the population in the country.
En este artículo se describen la creación de los marcos legales y el origen, crecimiento y consolidación de las instituciones e intervenciones (iniciativas, programas, políticas) que han conformado la salud pública moderna en México. También se discuten los esfuerzos recientes por hacer universal la protección social en salud. Esta gesta, que duró un siglo, se fue abriendo paso a través de tres generaciones de reformas que dieron lugar a un sistema de salud que hoy ofrece protección contra riesgos sanitarios, protección de la calidad de la atención y protección financiera a los habitantes de todo el país.
Assuntos
Reforma dos Serviços de Saúde/história , Saúde Pública/história , Política Pública/história , Reforma dos Serviços de Saúde/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde/história , Acessibilidade aos Serviços de Saúde/organização & administração , História do Século XX , História do Século XXI , Humanos , México , Assistência Individualizada de Saúde/história , Assistência Individualizada de Saúde/organização & administração , Saúde Pública/legislação & jurisprudência , Política Pública/legislação & jurisprudência , Direito à Saúde/históriaRESUMO
Resumen: En este artículo se describen la creación de los marcos legales y el origen, crecimiento y consolidación de las instituciones e intervenciones (iniciativas, programas, políticas) que han conformado la salud pública moderna en México. También se discuten los esfuerzos recientes por hacer universal la protección social en salud. Esta gesta, que duró un siglo, se fue abriendo paso a través de tres generaciones de reformas que dieron lugar a un sistema de salud que hoy ofrece protección contra riesgos sanitarios, protección de la calidad de la atención y protección financiera a los habitantes de todo el país.
Abstract: This paper describes the creation of the legal framework and the origin, growth and consolidation of the institutions and interventions (initiatives, programs and policies) that nourished public health in Mexico in the past century. It also discusses the recent efforts to guarantee universal social protection in health. This quest, which lasted a century, developed through three generations of reform that gave birth to a health system that offers protection against sanitary risks, protection of health care quality and financial protection to all the population in the country.
Assuntos
História do Século XX , História do Século XXI , Política Pública/história , Saúde Pública/história , Reforma dos Serviços de Saúde/história , Assistência Individualizada de Saúde/história , Assistência Individualizada de Saúde/organização & administração , Política Pública/legislação & jurisprudência , Saúde Pública/legislação & jurisprudência , Reforma dos Serviços de Saúde/legislação & jurisprudência , Direito à Saúde/história , Acessibilidade aos Serviços de Saúde/história , Acessibilidade aos Serviços de Saúde/organização & administração , MéxicoAssuntos
Programas Nacionais de Saúde/legislação & jurisprudência , Cobertura Universal do Seguro de Saúde/legislação & jurisprudência , Reforma dos Serviços de Saúde/economia , Reforma dos Serviços de Saúde/legislação & jurisprudência , Humanos , México , Programas Nacionais de Saúde/economia , Patient Protection and Affordable Care Act/legislação & jurisprudência , Estados Unidos , Cobertura Universal do Seguro de Saúde/economiaRESUMO
This paper discusses the health challenges faced by countries in Latin America. These challenges have two dimensions: those related to the health needs of populations and those related to the way in which health systems are responding to these needs. The main conclusion is that in order to improve health conditions and move towards universal health coverage, Latin American countries need to design a new generation of policy innovations based on the separation of the three main functions of health systems: financing, delivery and stewardship.
Assuntos
Atenção à Saúde/economia , Atenção à Saúde/métodos , Cobertura Universal do Seguro de Saúde , Humanos , América Latina , Desenvolvimento SustentávelRESUMO
Mental and substance use disorders account for 18.9% of years lived with disability worldwide. A rising prevalence of mental disorders was identified in the past decade and a call for global attention to this challenge was made. The purpose of this paper is to discuss new strategies to address mental health problems in developing nations aimed at dealing with them within the frame of the overall health system. Mainstreaming mental disorders implies five dimensions of integration: i) incorporating mental health interventions to the global strategy to address non-communicable diseases; ii)moving away both from the biological and sociological reductionisms around mental health prevalent in the past century; iii) addressing the whole range of conditions related to mental health; iv) migrating from the idea that mental disorders have to be treated in secluded clinical spaces, and v) the use of a comprehensive approach in the treatment of these disorders.
Assuntos
Transtornos Mentais , Países em Desenvolvimento , Humanos , Serviços de Saúde Mental , Estigma SocialRESUMO
Abstract: Mental and substance use disorders account for 18.9% of years lived with disability worldwide. A rising prevalence of mental disorders was identified in the past decade and a call for global attention to this challenge was made. The purpose of this paper is to discuss new strategies to address mental health problems in developing nations aimed at dealing with them within the frame of the overall health system. Mainstreaming mental disorders implies five dimensions of integration: i) incorporating mental health interventions to the global strategy to address non-communicable diseases; ii) moving away both from the biological and sociological reductionisms around mental health prevalent in the past century; iii) addressing the whole range of conditions related to mental health; iv) migrating from the idea that mental disorders have to be treated in secluded clinical spaces, and v) the use of a comprehensive approach in the treatment of these disorders.
Resumen: Los problemas de salud mental y el abuso de sustancias concentran 18.9% de los años vividos con discapacidad. En la década pasada se identificó una creciente prevalencia de padecimientos mentales que obligó a hacer un llamado global para atender este reto. El propósito de este artículo es discutir nuevas estrategias para enfrentar los problemas de salud mental en los paises en desarrollo, en el marco de los servicios de salud convencionales. La incorporación de la salud mental al sistema de salud comprende cinco niveles de integración: i) sumar la salud mental a las estrategias globales vinculadas con las enfermedades no transmisibles; ii) alejarse de los reduccionismos biológico y sociológico asociados a la salud mental prevalentes en el siglo pasado; iii) atender todo el rango de condiciones relacionadas con la salud mental; iv) alejarse de la idea de que los trastornos mentales deben tratarse en espacios clínicos aislados, y v) tratar de manera integral los padecimientos mentales.
Assuntos
Humanos , Transtornos Mentais , Países em Desenvolvimento , Estigma Social , Serviços de Saúde MentalRESUMO
In this essay we discuss the need to reestablish the balance between health enhancing activities and care for the sick in order to meet the challenges of the 21st century. We first briefly review the historical evolution of personal and public hygiene. We then discuss the increasing emphasis on curative care that has characterized the modern world. We conclude that, in order to meet the emerging challenges, contemporary health systems need to adopt a comprehensive scope which include upstream interventions to address the determinants of health; public health interventions to deal with major risk factors; personal health services to manage common infections, reproductive problems, non-communicable diseases, injuries, and mental health problems; and palliative care to deal with old age and the final phases of the human life cycle.
Assuntos
Atenção à Saúde , Higiene , Saúde Pública , HumanosRESUMO
In this essay we discuss the need to reestablish the balance between health enhancing activities and care for the sick in order to meet the challenges of the 21st century. We first briefly review the historical evolution of personal and public hygiene. We then discuss the increasing emphasis on curative care that has characterized the modern world. We conclude that, in order to meet the emerging challenges, contemporary health systems need to adopt a comprehensive scope which include upstream interventions to address the determinants of health; public health interventions to deal with major risk factors; personal health services to manage common infections, reproductive problems, non-communicable diseases, injuries, and mental health problems; and palliative care to deal with old age and the final phases of the human life cycle.
En este ensayo se discute la necesidad de restablecer el equilibrio entre la promoción de la salud y la atención de la enfermedad con el fin de enfrentar los retos del siglo XXI. En la primera parte se hace una breve reseña de la evolución histórica de la higiene personal y pública. En seguida se discute el creciente énfasis en la atención curativa que ha caracterizado al mundo moderno. El ensayo concluye señalando que, para poder enfrentar los desafíos emergentes, los sistemas de salud contemporáneos deben adoptar una visión integral que incluya intervenciones para lidiar con los determinantes de la salud; intervenciones de salud pública para enfrentar los principales factores de riesgo; servicios personales de salud para tratar las infecciones comunes, los problemas reproductivos, las enfermedades no transmisibles, las lesiones y los padecimientos mentales, y servicios paliativos para afrontar la vejez y las etapas finales del ciclo de vida.
Assuntos
Humanos , Higiene , Saúde Pública , Atenção à SaúdeRESUMO
Prompted by the 20th anniversary of the 1993 World Development Report, a Lancet Commission revisited the case for investment in health and developed a new investment framework to achieve dramatic health gains by 2035. The Commission's report has four key messages, each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community. First, there is an enormous economic payoff from investing in health. The impressive returns make a strong case for both increased domestic financing of health and for allocating a higher proportion of official development assistance to development of health. Second, modeling by the Commission found that a "grand convergence" in health is achievable by 2035-that is, a reduction in infectious, maternal, and child mortality down to universally low levels. Convergence would require aggressive scale up of existing and new health tools, and it could mostly be financed from the expected economic growth of low- and middle-income countries. The international community can best support convergence by funding the development and delivery of new health technologies and by curbing antibiotic resistance. Third, fiscal policies -such as taxation of tobacco and alcohol- are a powerful and underused lever that governments can use to curb non-communicable diseases and injuries while also raising revenue for health. International action on NCDs and injuries should focus on providing technical assistance on fiscal policies, regional cooperation on tobacco, and funding policy and implementation research on scaling-up of interventions to tackle these conditions. Fourth, progressive universalism, a pathway to universal health coverage (UHC) that includes the poor from the outset, is an efficient way to achieve health and financial risk protection. For national governments, progressive universalism would yield high health gains per dollar spent and poor people would gain the most in terms of health and financial protection. The international community can best support countries to implement progressive UHC by financing policy and implementation research, such as on the mechanics of designing and implementing evolution of the benefits package as the resource envelope for public finance grows.