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El subsistema privado de atención de la salud en México. Diagnóstico y retos

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Miguel Angel Gonzalez Block at Universidad Anáhuac
Miguel Angel Gonzalez Block
Ricardo Aldape Valdés
Ricardo Aldape Valdés
Ricardo Aldape Valdés
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Lucero Cahuana-Hurtado at Universidad Peruana Cayetano Heredia
Lucero Cahuana-Hurtado
Sandra P. Díaz-Portillo
Sandra P. Díaz-Portillo
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... The deficient supply of public services across all schemes, worse in the case of services for people without social insurance coverage, explains the large role of the private sector; the poor quality and limited access of public programmes implicitly incentivises or forces many people of all income levels to use private services, 2 but with a difference in the type of service. Low-income people could only access private primary care, while interventions that require hospitalisations are only affordable to high-income groups (González Block et al., 2018Block et al., , 2020. ...
... The growing trend was reversed in the second half of the decade; by 2019, the year before the pandemic, public spending represented 2.7% of GDP, 49.3% of total spending, and US$558 per capita (OECD, 2022). The reasons for these decreasing trends may be found in the fragmented healthcare architecture, which, after an initial boost to public spending due to the expansion of voluntary health insurance, obstructed the further aggregation of political preferences for a better supply of public services, along with the large role performed by the private sector, which reaches diverse population groups, including low-income families who can afford primary care in private doctors' offices, many times adjacent to pharmacies (Bernales-Baksai and Velázquez Leyer, 2021;González Block et al., 2018). ...
... The levels of human resources have improved during the present century. The number of doctors per 1,000 population passed from 1.6 in 2000 to 2.4 in 2019 (OECD, 2021), and from that total, the proportion of doctors employed in the public sector increased from 59% in 2000 to 71% in 2016 (González Block et al., 2018). During the same period, the number of nurses increased from 2.2 to 2.9 per 1,000 population (OECD, 2022), of which more than 90% are employed in the public sector (González Block et al., 2018). ...
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... In the case of the non-insured, up to 33% of total outpatient consultations and 14.8% of hospital care is supplied by private providers. Public health care services are preferred for the more costly care while the private sector is often the first choice of care for minor conditions as well as for continued care among the wealthy, particularly those covered by private health insurance (González Block et al., 2018b). ...
... The population represented in these strata also has geographically varying access to 2829 hospitals nationally, of which 2400 are up to 14 beds in size and the rest between 15 and 49 beds. Private providers supply between 18-33% of ambulatory care and 10-27% of hospital care across strata E to C, paying mostly out-of-pocket (González Block et al., 2018b). ...
... Private health insurance covers mostly private hospital care, although privately insured patients accessing highly specialized MoH institutes are also reimbursed. Private insurance is estimated to save IMSS and ISSSTE up to 7.6% of their total hospital costs by funding private care for those patients who are also privately insured (González Block et al., 2018b). ...
Mexico: Health System Review
Article
Full-text available
  • Apr 2020
This analysis of the Mexican health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Mexican health system consists of three main components operating in parallel: 1) employment-based social insurance schemes, 2) public assistance services for the uninsured supported by a financial protection scheme, and 3) a private sector composed of service providers, insurers, and pharmaceutical and medical device manufacturers and distributors. The social insurance schemes are managed by highly centralized national institutions while coverage for the uninsured is operated by both state and federal authorities and providers. The largest social insurance institution - the Mexican Social Insurance Institute (IMSS) - is governed by a corporatist arrangement, which reflects the political realities of the 1940s rather than the needs of the 21st century. National health spending has grown in recent years but is lower than the Latin America and Caribbean average and considerably lower than the OECD average in 2015. Public spending accounts for 58% of total financing, with private contributions being mostly comprised of out-of-pocket spending. The private sector, while regulated by the government, mostly operates independently. Mexico's health system delivers a wide range of health care services; however, nearly 14% of the population lacks financial protection, while the insured are mostly enrolled in diverse public schemes which provide varying benefits packages. Private sector services are in high demand given insufficient resources among most public institutions and the lack of voice by the insured to ensure the fulfilment of entitlements. Furthermore, the system faces challenges with obesity, diabetes, violence, as well as with health inequity. Recognizing the inequities in access created by its segmented structure, both civil society and government are calling for greater integration of service delivery across public institutions, although no consensus yet exists as to how to bring this about.
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... In the case of the non-insured, up to 33% of total outpatient consultations and 14.8% of hospital care is supplied by private providers. Public health care services are preferred for the more costly care while the private sector is often the first choice of care for minor conditions as well as for continued care among the wealthy, particularly those covered by private health insurance (González Block et al., 2018b). ...
... The population represented in these strata also has geographically varying access to 2829 hospitals nationally, of which 2400 are up to 14 beds in size and the rest between 15 and 49 beds. Private providers supply between 18-33% of ambulatory care and 10-27% of hospital care across strata E to C, paying mostly out-of-pocket (González Block et al., 2018b). ...
... Private health insurance covers mostly private hospital care, although privately insured patients accessing highly specialized MoH institutes are also reimbursed. Private insurance is estimated to save IMSS and ISSSTE up to 7.6% of their total hospital costs by funding private care for those patients who are also privately insured (González Block et al., 2018b). ...
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... *Sindicatos beneficiarios de segmentación y jerarquización del sistema de salud. Fuente: Elaboración propia con datos de González et al. (2018);y de ENIGH 2016(Inegi, 2017. ...
... Gutiérrez (2018), los indicadores de infraestructura varían según el tamaño de los hospitales. Con base en sus resultados vale pena cen-Fuente: Elaboración propia con datos de ENIGH 2014(Inegi, 2015), Boletín de información estadística 2014-2015 de la Secretaría de Salud, Informe de Resultados 2014 del Sistema de Protección Social en Salud y Dirección General de Información en Salud (Secretaría de Salud, 2014). ...
Claves universalistas de la reforma de salud en México
Chapter
Full-text available
  • Jun 2020
En el campo de las políticas sociales, la focalización y el univer- salismo suelen oponerse porque cada uno deriva de experiencias y momentos distintos en el desarrollo del capitalismo y de las instituciones de bienestar.2 La base teórica e ideológica del paradigma de la focaliza- ción es el liberalismo, y se remonta a los primeros días de las leyes de pobres inglesas, y parte de la premisa de que los canales fundamentales para satisfacer las necesidades de un individuo son el mercado privado y la familia. Por ello, este enfoque considera que sólo cuando estos pilares del bienestar fallan es legítimo que las instituciones estatales y de la política social (en adelante PS) entren en acción.3 La PS focalizada ofrece beneficios básicos y temporales a los pobres y vulnerables que logran demostrar que son incapaces de satisfacer sus necesi- dades de bienestar a través de su propia iniciativa. Este tipo de políticas selecciona rigurosamente a sus beneficiarios, utili- zando pruebas de medios y condicionalidades. Sin embargo, la provisión de servicios no es necesariamente pública, porque se considera legítimo hacerlo a través del mercado o de organiza- ciones de la sociedad civil4 (Mkandawire, 2005, pp. 2-3; Peyre, 2007, p. III; Barba, 2013, p. 528). En contrapartida, el paradigma universalista que surgió a fina- les de la Segunda Guerra Mundial, considera que todos los ciuda- danos –sin distinción de clase, posición en el mercado, trayectoria y desempeño laboral, prueba de medios o contribución financiera– tienen derecho a acceder a los servicios sociales. Esta perspectiva descansa en la solidaridad interclasista, en impuestos universales y en sistemas públicos unificados de protección social y enfatiza una amplia desmercantilización del bienestar social (Esping-Andersen, 1990, p. 47; Barba, 2013, p. 528). Las PS universalistas son concebidas como mecanismos para transformar la realidad social y construir una sociedad más equitativa (Titmuss, 1974, p. 145). Los servicios sociales universalistas erosionan las barreras formales que discriminan a los pobres porque reemplazan el doble estándar de los pro- gramas focalizados que ofrecen servicios de segunda clase para ciudadanos de segunda clase (Titmuss, 1965, p. 19). Por ello, promueven la igualdad de estatus y de derechos, garantizan los mismos beneficios sociales, con la misma calidad,5 a todos los ciudadanos, independientemente de su posición de clase o laboral y su situación en el mercado6 (Skocpol, 1995, p. 251; Esping-Andersen, 1990, pp. 47-65).
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... En las últimas décadas, se incrementó la oferta y demanda de servicios de salud privados en todo el país. De acuerdo con un estudio realizado por González Block et al. (7) , el sector privado ofrece el 44% del total de las consultas ambulatorias y el 22% de los egresos hospitalarios. No obstante, una de las características centrales del sector privado en México es su segmentación y heterogeneidad, lo cual se manifiesta en los recursos, infraestructura, costos de los servicios ofrecidos, y en la población a la cual van dirigidos. ...
“¿Qué opción les queda a las personas, más que nosotros?”: Las funciones de los consultorios adyacentes a farmacias en la pandemia de covid-19
Article
Full-text available
  • Mar 2023
Con la llegada del coronavirus a México, los consultorios adyacentes a farmacias desempeñaron un rol preponderante en el diagnóstico, atención y prevención del covid-19. De acuerdo a las encuestas nacionales, entre el 11,7% y el 23% de las personas con síntomas de covid-19 se atendieron en uno. Por ello, este artículo busca identificar el papel de los consultorios adyacentes a farmacias (CAF) como sistema de salud privado que atendió a personas con síntomas de covid-19 en la ciudad de Oaxaca y describir y analizar los factores que influyeron en su utilización. Desde una metodología cualitativa, entre septiembre de 2020 y agosto de 2022 se entrevistó a 12 médicos y médicas y se aplicó un cuestionario a 59 personas usuarias de los consultorios adyacentes a farmacias del municipio de Oaxaca de Juárez. Asimismo se hizo una recopilación y análisis de fuentes secundarias. Entre los hallazgos, se describen sus funciones como frente de atención al covid-19 y a otras necesidades de salud que emergieron con la crisis sanitaria y se analizan los factores determinantes en las trayectorias de atención de personas usuarias de estos consultorios, como son el incremento en la percepción del riesgo y la desconfianza hacia los servicios públicos o hacia las estrategias implementadas por el gobierno federal.
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Avoidable Hospitalization Trends From Ambulatory Care-Sensitive Conditions in the Public Health System in México
Article
Full-text available
  • Jan 2022
Objectives To estimate and identify the variations in rates of Avoidable Hospitalization for Ambulatory Care Sensitive Conditions (AH-ACSC) in public institutions of the Mexican health system during the period 2010–2017. Methods Secondary analysis of the hospital discharge database of the Ministry of Health (MoH) from 2010 to 2017. AH for ACSC was calculated by age group and sex per 100,000. Variations per year between institutions were calculated with the extreme quotient (EQ), coefficient of variation (CV) and systematic component of variance (SCV). Adjusted AH rates were calculated by group of causes (acute, chronic and preventable by vaccination). Adjusted AH trend rates were analyzed by Join Point Regression. Results For the period 2010–2017, the number of AH for ACSC decreased from 676,705 to 612,897, going from almost 13% to 10.7% of hospital discharges. There is consistency in terms of relative variance magnitude. But, with regards to SCV, the change remained constant, and in a second period of 2015–2017, high variation was observed by SCV ≥ 3. All-cause AH is diminishing in all institutions. AH rates for diabetes are the highest, but like other chronic diseases, there was a decline in the period from 2010 to 2017. The relative reduction varied from 15% for heart failure to 38% for complications from diabetes or hypertension, to 75% for angina. Conclusions AH for ACSC is an indirect indicator of quality and access to first-level care. Variations by institutions are observed. This variation in CV and SCV across subsystems and states may be due to inequities in the provision of services. The factors that contribute to the burden of AH for ACSC in the Mexican Health System require detailed analysis.
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Condiciones de trabajo en consultorios adyacentes a farmacias privadas en Ciudad de México: perspectiva del personal médico
Article
Full-text available
  • May 2017
  • GAC SANIT
Objective: To analyse the working conditions of physicians in outpatient clinics adjacent to pharmacies (CAFs) and their organizational elements from their own perspective. Methods: We carried out an exploratory qualitative study. Semi-structured interviews were conducted with 32 CAF physicians in Mexico City. A directed content analysis technique was used based on previously built and emerging codes which were related to the experience of the subjects in their work. Results: Respondents perceive that work in CAFs does not meet professional expectations due to low pay, informality in the recruitment process and the absence of minimum labour guarantees. This prevents them from enjoying the benefits associated with formal employment, and sustains their desire to work in CAF only temporarily. They believe that economic incentives related to number of consultations, procedures and sales attained by the pharmacy allow them to increase their income without influencing their prescriptive behaviour. They express that the monitoring systems and pressure exerted on CAFs seek to affect their autonomy, pushing them to enhance the sales of medicines in the pharmacy. Conclusions: Physicians working in CAFs face a difficult employment situation. The managerial elements used to induce prescription and enhance pharmacy sales create a work environment that generates challenges for regulation and underlines the need to monitor the services provided at these clinics and the possible risk for users.
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¿Qué compra, cómo y de quién el Seguro Popular de México? Experiencia con la compra estratégica nacional y en una entidad pionera
Article
Full-text available
  • Jan 2017
  • SALUD PUBLICA MEXICO
Objetivo: Analizar el alcance de los subsidios a la demanda mediante la compra estratégica de servicios de salud. Material y métodos: Entrevistas y revisión documental a nivel federal y estudio de caso en el estado de Hidalgo. Resultados: El Sistema de Protección Social en Salud (SPSS) prioriza las intervenciones por financiar de manera explícita y norma tabuladores y topes de gasto. Se financia predominantemente a prestadores públicos mediante la compra de insumos y la contratación de recursos humanos, sin competencia y con bajo grado de autonomía de gestión. El Seguro Popular en Hidalgo ha diversificado prestadores de servicios y mecanismos de pago. Conclusiones: El SPSS tiene amplia oportunidad para ampliar y profundizar la compra estratégica. Se requiere mayor autonomía de prestadores y pagadores así como reglamentación para promover redes de servicios en entornos competitivos.
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Costo-efectividad de una alternativa para la prestación de servicios de atención primaria en salud para los beneficiarios del Seguro Popular de México
Article
Full-text available
  • Sep 2016
Objetivo: Calcular la razón costo-efectividad de servicios públicos y privados contratados por el Seguro Popular en primer nivel de atención. Material y métodos: Se evaluó una experiencia piloto de contratación de servicios de primer nivel de atención a la salud en el estado de Hidalgo, México, midiendo, con base en una encuesta poblacional, la calidad general y la detección de disminución de visión. Se analizó la sensibilidad mediante simulaciones de Monte Carlo. Resultados: El prestador privado es dominante en calidad y costo-efectivo para la detección de disminución de visión. Conclusiones: La compra estratégica de prestadores privados de atención primaria es promisoria para mejorar los servicios de salud y reducir los costos.
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Consultorios adyacentes a farmacias privadas en México: Infraestructura y características del personal médico y su remuneración
Article
Full-text available
  • Jul 2015
  • SALUD PUBLICA MEXICO
Objective. To analyze and compare the physicians' characteristics, their remuneration, the compliance with regulation and the services offered between clinics adjacent to pharmacies (CAF) and independent medical clinics (CMI). Materials and methods. Questionnaire applied to 239 physicians in 18 states including the Federal District, in Mexico in 2012. Results. Physicians in CAF had less professional experience (5 versus 12 years), less postgraduate studies (61.2 versus 81.8%) and lower average monthly salaries (USD 418 versus USD 672) than their peers in CMI. In CAF there was less compliance in relation to medical record keeping and prescribing. Conclusions. The employment situation of physicians in CAF is more precarious than in CMI. It is necessary to strengthen the enforcement of existing regulations and develop policies according to the monitoring of its performance, particularly, but not exclusively, in CAF.
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Effects of the expansion of doctors' offices adjacent to private pharmacies in Mexico: Secondary data analysis of a national survey
Article
Full-text available
  • May 2014
Objectives To compare the sociodemographic characteristics, reasons for attending, perception of quality and associated out-of-pocket (OOP) expenditures of doctors’ offices adjacent to private pharmacies (DAPPs) users with users of Social Security (SS), Ministry of Health (MoH), private doctor's offices independent from pharmacies and non-users. Setting Secondary data analysis of the 2012 National Survey of Health and Nutrition of Mexico. Participants The study population comprised 25 852 individuals identified as having had a health problem 15 days before the survey, and a random sample of 12 799 ambulatory health service users. Outcome measures Sociodemographic characteristics, reasons for attending healthcare services, perception of quality and associated OOP expenditures. Results The distribution of users was as follows: DAPPs (9.2%), SS (16.1%), MoH (20.9%), private providers (15.4%) and non-users (38.5%); 65% of DAPP users were affiliated with a public institution (MoH 35%, SS 30%) and 35% reported not having health coverage. DAPP users considered the services inexpensive, convenient and with a short waiting time, yet they received ≥3 medications more often (67.2%, 95% CI 64.2% to 70.1%) than users of private doctors (55.7%, 95% CI 52.5% to 58.6%) and public institutions (SS 53.8%, 95% CI 51.6% to 55.9%; MoH 44.7%, 95% CI 42.5% to 47.0%). The probability of spending on consultations (88%, 95% CI 86% to 89%) and on medicines (97%, 95% CI 96% to 98%) was much higher for DAPP users when compared with SS (2%, 95% CI 2% to 3% and 12%, 95% CI 11% to 14%, respectively) and MoH users (11%, 95% CI 9% to 12% and 32%, 95% CI 30% to 34%, respectively). Conclusions DAPPs counteract current financial protection policies since a significant percentage of their users were affiliated with a public institution, reported higher OOP spending and higher number of medicines prescribed than users of other providers. The overprescription should prompt studies to learn about DAPPs’ quality of care, which may arise from the conflict of interest implicit in the linkage of prescribing and dispensing processes.
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Evaluación de la estrategia de portabilidad y convergencia. Cuernavaca, Instituto Nacional de Salud Pública, 2012. SSa. Evaluación y Estrategias de Portabilidad y Convergencia hacia la integración del Sistema Nacional de Salud
  • Jan 2011
  • González Block
  • Ma Y C López Santibáñez
González Block MA y C López Santibáñez. Evaluación de la estrategia de portabilidad y convergencia. Cuernavaca, Instituto Nacional de Salud Pública, 2012. SSa. Evaluación y Estrategias de Portabilidad y Convergencia hacia la integración del Sistema Nacional de Salud. 5 de Agosto de 2011.
Estudio sobre la práctica de la atención médica en consultorios adyacentes a farmacias privadas
  • Jan 2014
  • Funsalud
Funsalud. Estudio sobre la práctica de la atención médica en consultorios adyacentes a farmacias privadas, 2014.
Estrategias para la colaboración público-privada en la atención primaria de salud en México
  • Jan 2017
  • González Block
  • E Moreno Zegbe Y O Artaza
González Block MA, E Moreno Zegbe y O Artaza, "Estrategias para la colaboración público-privada en la atención primaria de salud en México", Congreso de Investigación en Salud Pública, Instituto Nacional de Salud Pública, Cuernavaca, 2017.