ABSTRACT This article aims to analyze the reform of Mexican health system, from the implementation
of Popular Health Insurance, highlighting its operation, positive and negative aspects. An integrative
review of the literature was conducted using Lilacs and SciELO Regional databases from January 2011 to
December 2018. Publications included addressed three main themes: history of Mexican health system,
its functioning and positive and negative points of the Popular Health Insurance. The literature points
out that Popular Health Insurance emerged after a process of neoliberal reforms in the Mexican health
system, consonant with the Universal Health Coverage proposal, which aims to reduce impoverishment
by health spending in the population without social security. Popular Health Insurance offers a smaller
variety of diagnoses and treatments than social security, less number of consultations, urgent care and
medications. Its greatest impact was on indigenous and rural populations, but 20% of the general population
remains uncovered and care is unequal still. Popular Health Insurance analysis allows us to infer possible
impacts that the affordable health plans would have on the Brazilian scenario, resulting in access to a
smaller set of procedures for the population currently covered by the public health system in place (SUS).
KEYWORDS Health system. Health policy. Health services reform. Mexico.
RESUMO Esse artigo objetiva analisar a reforma do sistema de saúde mexicano, a partir da implantação
do Seguro Popular de Saúde, destacando seu funcionamento, aspectos positivos e negativos. Foi realizada
uma revisão integrativa da literatura nas bases Lilacs e SciELO Regional no período de janeiro de 2011 a
dezembro de 2018. Foram incluídas publicações que atendiam a três questionamentos: história do sistema de
saúde mexicano, seu funcionamento e pontos positivos e negativos do Seguro Popular de Saúde. A literatura
aponta que o Seguro Popular surgiu após um processo de reformas neoliberais no sistema de saúde mexicano,
consonante com a proposta de Cobertura Universal de Saúde, que visa reduzir o empobrecimento por gastos
em saúde na população sem seguridade social. O Seguro Popular oferece menor variedade de diagnósticos e
tratamentos do que a seguridade social, menor número de consultas, atendimentos de urgência e medicamen-
tos. Seu maior impacto foi nas populações indígena e rural, mas 20% da população continua descoberta e o
atendimento permanece desigual. A análise do Seguro Popular permite inferir possíveis impactos que teriam
os planos de saúde acessíveis no cenário brasileiro, acarretando acesso a um elenco menor de procedimentos
para a população atualmente coberta pelo Sistema Único de Saúde.
PALAVRAS-CHAVE Sistema de saúde. Política de saúde. Reforma dos serviços de saúde. México.
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273
Analysis of Mexican Popular Health
Insurance: an integrative review of literature
Análise do Seguro Popular de Saúde mexicano: uma revisão
integrativa da literatura
Laís Cristine Krasniak
1
, Soraia de Camargo Catapan
1
, Gabriella de Almeida Raschke Medeiros
2
,
Maria Cristina Marino Calvo
1
DOI: 10.1590/0103-11042019S522
1
Universidade Federal de
Santa Catarina (UFSC) –
Florianópolis (SC), Brasil.
2
Universidade do Vale do
Itajaí (Univali) – Itajaí (SC),
Brasil.
REVIEW | REVISÃO
This article is published in Open Access under the Creative Commons Attribution
license, which allows use, distribution, and reproduction in any medium, without
restrictions, as long as the original work is correctly cited.
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Krasniak LC, Catapan SC, Medeiros GAR, Calvo MCM274
Introduction
Mexico is an emerging country, with large
geographical dimensions and latent social in-
equalities. Regarding health, the country has
going through an epidemiological transition
characterized by the predominance of non-
communicable diseases, reduction in overall
mortality and increased life expectancy
1
.
Considering this scenario, the influence of
international entities such as the World Bank
(WB), the International Monetary Fund
(IMF) and the World Health Organization
(WHO) in the health policies adopted by
the last governments is emphasized. Most
recently, these entities have been advocating
the Universal Health Coverage (UHC) pro-
posal as a way to address the new Mexican
health conditions
2
.
The similarity between the terms
‘Universal Health Systems’ and ‘Universal
Health Coverage’ is undeniable and may
contribute to conceptual misconceptions.
For this reason, it is important to differen-
tiate them, by demarcating the underlying
understanding of society and State in each
of these proposals.
In the first case, health is conceived as a
right of citizenship through universal and
equitable access, and the State is respon-
sible for its provision and financing. The
‘Universal Health Systems’ have in Primary
Health Care their structural axis, consid-
ered as a care network advisor, offering a
comprehensive range of services, guided by
the formation of bond, longitudinality and
comprehensiveness. In the case of UHC, the
concept of health meets an economic logic,
in which the role of the State is restricted
to the regulation of the system, combining
public and private funding. Thus, access to
services is directly related to the purchasing
power of each individual or family. The ap-
proach is centered on individual care, where
a restricted basket of services is offered in a
fragmented manner, without care coordina-
tion or territorialization
3
.
In 2012, the Mexico Declaration was
signed, during the Forum on Universal
Health Coverage, which placed this theme
as a central element for global development
4
.
Mexico is an example of trying to adopt UHC
from Popular Health Insurance, a govern-
ment-subsidized health plan for the popula-
tion with no social security.
In order to glimpse possible developments
of affordable health plans in Brazil, it was
decided to review and analyze the literature
on the reform of the Mexican health system,
based on the implementation of Popular
Health Insurance, highlighting its function-
ing, positive and negative aspects.
Material and methods
For this integrative literature review study
5
,
a search for scientific publications in the
electronic databases Lilacs (Latin American
and Caribbean Health Sciences Literature)
and SciELO Regional (Scientific Electronic
Library Online) was carried out during
February 2019, both of which are open to
the full texts. The descriptors used were:
‘health insurance’, ‘health care reform’,
‘right to health’, ‘social inequity’, ‘health
policy’, ‘social security’, ‘social health pro-
tection system’, ‘health reform’, ‘health
system’, ‘social health protection’; associated
with the word ‘Mexico’ and its English and
Spanish equivalents.
To integrate this research, publications
in the full article format, free of charge, in
Portuguese, English and Spanish published
between January 2011 and December 2018
were included. This time frame was used by
the estimate that until 2010, UHC would be
implemented for all Mexicans by the Popular
Health Insurance
6
. Another reason for this
cut is that in 2012 the Encuesta Nacional de
Salud y Nutrición (Ensanut) was conducted,
a survey of data related to the health and
nutrition of Mexicans, enabling compari-
son with the survey conducted in 2006 and,
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Analysis of Mexican Popular Health Insurance: an integrative review of literature
275
consequently, the analysis of the implemen-
tation of the Popular Health Insurance.
The guiding questions of this review sought
to describe the Mexican health system and the
changes that have occurred since the imple-
mentation of Popular Insurance. The articles
identified were analyzed for contributions in
at least one of the following aspects: a) the
Mexican health system before and during
the implementation of the Popular Health
Insurance; b) operation of the Popular Health
Insurance, scope and coverage; c) positive
and negative points of the implementation
of the Popular Health Insurance in Mexico.
Duplicate articles and those that did not meet
the guiding questions of the research were
excluded from the analysis.
Initially, 2,214 articles were found, 2,110
in Lilacs and 104 in SciELO Regional. The
reading of the title was carried out, excluding
2,150 articles unrelated to the issues of interest,
resulting in 64 for reading the abstracts. Of this
total, 8 articles were duplicated, remaining 56.
After this step, 23 articles were excluded for
not being related to the issues of interest ac-
cording to the summary, resulting in 33 articles
for analysis, 23 in the Lilacs database and 10 in
the SciELO Regional, as illustrated in figure 1.
Figure 1. Flowchart of integrative literature review
Return from initial search in
data base
Lilacs (n = 2.110)
SciELO Regional (n = 104)
n = 2.214
Posts deleted
by title
n = 2.150
Publication excluded
by abstract
n = 23
Publications identified
for abstract reading
n = 64
Publications excluded
by duplication
n = 8
Publications selected
for review
Lilacs (n = 23)
SciELO Regional (n = 10)
n = 33
Publications selected
for abstract reading
n = 56
Source: Own elaboration.
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Krasniak LC, Catapan SC, Medeiros GAR, Calvo MCM276
Results
The analyzed studies were organized
according to year of publication, authorship
and title, as presented in chart 1.
Chart 1. Articles selected for literature review
Year Author Title
2011 Aracena-Genao B, González-Robledo MC, Gon-
zaléz-Robledo LM, et al.
El Fondo de Protección contra Gastos Catastróficos: ten-
dencia, evolución y operación
2011 Contreras-Landgrave G, Tetelbron-Henrion C. El seguro popular de salud y la reforma a las políticas de
salud en el estado de México
2011 Dantés OG, Sesma S, Becerril VM, et al. Sistema de salud de México
2011 Ortiz-Domínguez ME, Garrido-Latorr F, Orozco
R, et al.
Sistema de Protección Social en Salud y calidad de la aten-
ción de hipertensión arterial y diabetes mellitus en centros
de salud
2011 Laurell AC. Los seguros de salud mexicanos: cobertura universal inci-
erta
2011 Sosa-Rubí SG, Salinas-Rodríguez AS, Galárraga
O.
Impacto del Seguro Popular en el gasto catastrófico y de
bolsillo en el México rural y urbano, 2005-2008
2011 Sojo S. Condiciones para el acceso universal a la salud en América
Latina: derechos sociales, protección social y restricciones
financieras y políticas
2012 Hebrero-Martínez M, Lerma RV, Trollé CM, et al. Sociodemographic characteristics of SMNG aliates
2012 Muñoz-Hernández O, Chertorivski-Woldenberg
S, Cortés-Gallo G, et al.
The Medical Insurance for a New Generation: a viable
answer for the health needs of Mexican children
2012 Nigenda G, Ruiz-Larios JÁ, Aguillar-Martínez
ME, et al.
Regularización laboral de trabajadores de la salud pagados
con recursos del Seguro Popular en México
2012 Pérez-Cuevas R, Doubova SV, Flores-Hernándes
S, et al.
Utilization of healthcare services among children members
of Medical Insurance for a New Generation
2013 Gutiérrez JP, Hernández-Ávila M. Cobertura de protección en salud y perfil de la población
sin protección en México, 2000-2012
2013 Heredia-Pi I, Serván-Mori E, Reyes-Morales H,
et al.
Brechas en la cobertura de atención continua del embarazo
y el parto en México
2013 Hernández-Ibarra LE, Mercado-Martínez D. Estudio cualitativo sobre la atención médica a los enfermos
crónicos en el Seguro Popular
2013 Ávila-Burgos L, Serván-Mori E, Wirtz VJ, et al. Efectos del Seguro Popular sobre el gasto en salud en hog-
ares mexicanos a diez años de su implementación
2013 Leyva-Flores R, Infante-Xibille C, Gutiérrez JP,
et al.
Inequidad persistente en salud y acceso a los servicios para
los pueblos indígenas de México, 2006-2012
2013 Nigenda-López GH, Juaréz-Ramírez C, Ruiz-
Larios J, et al.
Participación social y calidad en los servicios de salud: la
experiencia del aval ciudadano en México
2014 Bautista-Arredondo S, Serván-Mori E, Colchero
MA, et al.
Análisis del uso de servicios ambulatorios curativos en
el contexto de la reforma para la protección universal en
salud en México
2014 Florez CEF, Reveiz L, Idrovo AJ, et al. Gasto en salud, la desigualdad en el ingreso y el índice de
marginación en el sistema de salud de México
2014 Gutiérrez JP, García-Saisó S, Dolci GF, et al. Eective access to health care in Mexico
2014 Leyva-Flores , Servan-Mori E, Infante-Xibille C,
et al.
Primary Health Care Utilization by the Mexican Indigenous
Population: The Role of the Seguro Popular in Socially
Inequitable Contexts
2015 Laurell AC. Three Decades of Neoliberalism in Mexico: The Destruc-
tion of Society
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Analysis of Mexican Popular Health Insurance: an integrative review of literature
277
Chart 1. (cont.)
2015 Doubova SV, Pérez-Cuevas R, Canning D, et al. Access to healthcare and financial risk protection for older
adults in Mexico: secondary data analysis of a national
Survey
2015 Enciso GF, Navarro SM, Martínez MR. Evaluación de los programas de atención a la salud de las
mujeres en las principales instituciones del sistema de
salud de México
2015 Mercado-Martínez FJ, Correa-Mauricio ME. Viviendo con hemodiálises y sin seguridad social: las voces
de los enfermos renales y sus familias
2015 Servan-Mori E, Heredia-Pi I, Montañez-Hernan-
dez J, et al.
Access to Medicines by Seguro Popular Beneficiaries:
Pending Tasks towards Universal Health Coverage
2015 Servan-Mori E, Wirtz V, Avilla-Burgos L, et al. Antenatal Care Among Poor Women in Mexico in the
Context of Universal Health Coverage
2015 Urquieta-Salomon JE, Villarreal HJ. Evolution of health coverage in Mexico: evidence of prog-
ress and challenges in the Mexican health system
2015 Arredondo A, Ororzco E, Aviles R. Evidence on equity, governance and financing after health
care reform in Mexico: lessons for Latin American coun-
tries
2017 López-Arellano O, Jarillo-Soro E. La reforma neoliberal de un sistema de salud: evidencia del
caso mexicano
2018 Báscolo E, Houghton N, Riego AD. Lógicas de transformación de los sistemas de salud en
América Latina y resultados en acceso y cobertura de
salud
2018 Greene J, Guanais F. An examination of socioeconomic equity in health experi-
ences in six Latin American and Caribbean countries
2018 Machado CV. Políticas de Saúde na Argentina, Brasil e México: diferen-
tes caminhos, muitos desafios
The results of the review indicate that of the
33 articles selected, 20 were published in the
Spanish language, 15 in the magazine ‘Salud
Publica de México’. The largest number of
publications occurred in 2015, with emphasis
on the authors Nigenda, Laurell, Servan-Mori
and Gutiérrez with the largest number of pub-
lications related to the theme. It is noteworthy
that Nigenda worked with the World Bank
and the World Health Organization, entities
of great importance in the defense of UHC.
The articles were grouped into three cat-
egories of analysis to support the results
and discussion, namely: 1) implementation
of Popular Health Insurance; 2) function-
ing coverage and coverage of the Popular
Health Insurance and; 3) positives and
negatives of the implementation of the
Popular Health Insurance.
Implementation of Popular Health
Insurance
The Mexican health system is based on coex-
istence between public and private services,
and public services are divided between the
population with formal work and, therefore,
with social security, and the population
without social security, which has govern-
ment assistance programs
1
. Historically, it
can be said that there is low investment in
health services for the Mexican population
without social security coverage. In 2000,
this population represented 60% of Mexicans,
requiring payment at the time of care, indi-
cating inequity in access to public services.
Still, in 2002, the government spent two to
three times more on social security than on
the population without it
7
.
Source: Own elaboration.
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The health system has been consolidated,
therefore, in a highly fragmented manner,
with the participation of numerous public
institutions in the provision of health services
7
,
as observed in figure 2.
Figure 2. Mexican health system in its dierent institutions, forms of financing and users
Source: Adapted from Dantes, 2011
1
.
IMSS=Mexican Social Security Institute; ISSSTE=Institute of State Workers Social Security and Social Services; Sedena=Secretariat of
National Defense; Pemex=Mexican Oils; Semar=Secretariat of the Navy; IMSS-O=Mexican Institute of Social Security-Opportunities
Program; SSA=Secretariat of Health; Sesa=State Health Services.
Private Sector
IMSS
ISSSTE
SEDENA
PEMEX
MARINA
Federal
Employer
Worker
State
Individual
Employer
Private
Insurance
Users
Formal Sector
Workers
Relatives
Retirees
Freelance Professionals, Employees
in the Informal Sector and Unemployed
Inside Social Security
Outside Social Security
Public Sector
Institutions
Financing
Population with
Paymant Capacity
SSA
SESA
Popular
Insurance
IMSS-O
From figure 2 it can be seen that there are
several institutions that provide health care
to formal workers, such as the Mexican Social
Security Institute (IMSS) and the Institute
of State Workers Social Security and Social
Services (ISSSTE), while the population
without formal work has other institutions,
such as the Secretariat of Health, the State
Health Secretariat (Sesa) and the Popular
Insurance. This segmentation of the health
system presents itself as a limitation to
achieve equity
8
.
The major changes in the Mexican
health system began after the 1982 crisis,
when the government of the Institutional
Revolutionary Party (PRI) accepted an IMF
program, in which the first step involved
reducing inflation and stabilizing public
finances and the second, consisted of struc-
tural reforms
9
. Healthcare reform has fol-
lowed WB guidelines, stimulating market
competition, reducing state intervention
and offering a basic package of services
10
.
The Mexican Health Foundation (Funsalud)
and the National Institute of Public Health
(INSP) were created by financing national
and international entrepreneurs to guide
these changes
11
. It is noteworthy that this
process deepened the condition of poverty
and inequity in Mexico, so that more than
half of the population was in labor informality
and helpless by social security
12
.
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Analysis of Mexican Popular Health Insurance: an integrative review of literature
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In the early 2000s, the National Action
Party (PAN) took over, appointing Julio
Frenk – who served at Funsalud and INSP
– as health minister. It was in his govern-
ment that the Popular Health Insurance was
implemented, aiming at the financial pro-
tection in health of the population without
social security
11
. Popular Insurance is a
voluntary insurance that covers informal
sector workers without access to Social
Security and offers some health interven-
tions and specific medicines
13
. It was esti-
mated that in 2010 or 2011 UHC would be
achieved in Mexico
7
.
Functioning, scope and coverage of
Popular Health Insurance
The Popular Health Insurance went into
operation on January 1, 2004, with the
purpose of facilitating access and reducing
the chance of impoverishment caused by the
payment of health services
10
. Membership is
made upon request, in which the individual
pays a yearly renewed family allowance that
entitles the direct insured, spouse, children
up to 18 years and parents over 65, economi-
cally dependent
14
. The services are offered
by private institutions or private provid-
ers. Ten years after its implementation, the
Popular Health Insurance had 51.1 million
members, which corresponded to 40% of
the Mexican population
12
. Other forms
of admission are the Medical Insurance
for a New Generation, for children born
after December 2006
15
and the Healthy
Pregnancy Program for pregnant women
without social security
7
.
The service package provides vaccines,
generalist medical consultations, diagnosis
and treatment of certain diseases, dental
care, family planning methods, diagnosis
and treatment of fractures
14
. It also offers
285 interventions, 522 medicines listed
in the Universal Health Services Catalog
(Causes) and 59 interventions funded by the
Fund for Protection against Catastrophic
Health Expenditure (FPGC) for high-cost
diseases. Catastrophic expenditure is
considered to be expenditure over 30% of
family income to cover health expenses. All
other services are paid separately
12
.
The financing of the Popular Health
Insurance is federal and state, with family
co-participation. Popular Insurance re-
ceives a 22.5% ‘federal solidarity quota’
transferred to the State Health Secretariats,
which must maintain a fixed and equal
quota for every affiliated family
7
. The
poorest families make up the majority of
affiliates and are exempt from payment
16
,
the rest should contribute 3 to 4% of their
income. In comparison, the worker covered
by the IMSS pays 0.4% of his/her salary
9,17
.
Popular Health Insurance uses these re-
sources to buy services in Sesa or, when
necessary, in the private sector
1
.
To ensure the strengthening of health
services to affiliates, the government has
invested in the infrastructure of units,
with equipment purchases, staff hiring
and greater availability of medicines
18
.
Although Popular Health Insurance mainly
covers activities at primary and secondary
levels, the largest federal investment was in
highly complex hospitals
7
. There was also a
process of accreditation of health facilities
to meet individuals covered by the Popular
Health Insurance, identified as Regional
Specialized Care Centers (Crae)
1
.
The adhesion of the states to the Popular
Insurance was significant, since in 2005 it
was already implemented in 31 states. The
Federal District, due to political divergence,
was the last to implement it
11
.
The revised articles dealt with the
changes in the way of hiring employees who
work for Popular Health Insurance. After
extensive negotiation with the unions, there
was an expansion of five and a half months
to 12 months of contract and guarantee
benefits such as Social Security, pension,
retirement and vacation
19
.
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Positives and negatives points of the
implementation of Popular Health
Insurance
Between 2003 and 2008, there was a 0.19%
fall in Gross Domestic Product (GDP) for
social security
7
. Even so, in 2011, spending
per person covered by social security was
3.3 times higher than that recorded by the
Popular Health Insurance
20
.
With regard to coverage, in 2012, Popular
Health Insurance covered 38% of the popula-
tion, 40.6% was covered by social security
and 21.4% remained uncovered by health
services
4,12
.
Another difference is observed when
placing diagnostic coverage side by side. While
social security covers 14,900 different diag-
noses, Popular Health Insurance covers only
1,556
12
. However, coverage of interventions by
the Fund for Protection against Catastrophic
Health Expenditure rose from 4 to 6 in 2004,
to 59 in 2013, and the range of interventions
offered by the Popular Health Insurance also
increased over the same period from 90 to
285
12
. At first, the Popular Health Insurance
had an impact on catastrophic spending only
in the rural area, and today this impact is more
significant in the urban area
21,22
.
Although families with Popular Health
Insurance still have more expenses when com-
pared to social security, they are smaller when
compared to families without coverage, with
a protective effect in relation to outpatient
care expenses
21,23
.
Women’s health care indices were con-
sidered intermediate by both social security
and Popular Health Insurance
24
. However,
social security guarantees continuous and
higher quality care during pregnancy
25
.
When compared to the group without cov-
erage, the Popular Health Insurance showed
a four times greater chance of prenatal care
in adequate time
15
.
Medical Insurance for a New Generation
has great potential to reduce inequities in
the coverage of health services offered to
children
26
. However, in practice, it is found
that about 25% of affiliated children did not
use available services due to lack of knowledge
or because their parents prefer to provide care
in other services
27
. The results indicate that
most children receive more outpatient care,
while about 75% of mothers report delayed
waiting to use available services
26
. In addi-
tion, vaccination coverage is lower than that
of children covered by social security
20
.
With the implementation of the Popular
Health Insurance, the indigenous population
presented an increase in coverage from 14%
to 36% between 2006 and 2012
8,28,29
, with an
increase in preventive measures such as influ-
enza vaccine and diagnosis of Type 2 Diabetes
Mellitus (T2DM), but there was no change
in colpocytology coverage (Papanicolaou)
29.
When compared to social security, the
articles revealed that Popular Insurance
offers fewer consultations, urgent care and
hospitalizations
7
. It is noteworthy that
the main causes of hospitalization are not
covered, such as acute myocardial infarction
and chronic kidney disease
6,30
, and patients
requiring hemodialysis may spend up to
1,500 monthly pesos with sessions, which
corresponds to about 2.5% of the national
minimum wage
30
. Similarly, specialized ser-
vices such as incubators, blood banks, labo-
ratories, and mammography equipment had
a significant reduction in membership avail-
ability between 2008 and 2010
12
. Patients
covered by the Popular Health Insurance
receive only 65% of prescription medicines
31
.
One of the items not available, for example,
is the material for insulin therapy
32
.
The opinion of health professionals re-
garding Popular Insurance differs according
to the workplace, being more favorable in
hospitals than among professionals working
in health centers
33
. Affiliates, in turn, com-
plain of lower quality inputs and lack of
medicines
32
. In the urban area, there are
problems such as long waiting times, lack
of medicines and some services, such as
dental care. In rural areas there is a lack of
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281
trained professionals and laboratory tests,
situations that imply expenses not foreseen
by families
16
.
Although members of the Popular
Health Insurance are more likely to use the
Secretariat of Health services than the un-
insured population
18
, a study in partnership
with Harvard University found that there is
no difference in the use of services among
the uninsured population’s and the members
of the Popular Insurance, just as there is no
impact on their health
7
.
Discussion
Among the different conceptions of health,
permeated by a political-ideological dialogue,
there are two that are in dispute: one that
defends universal health systems and another
that defends UHC
33,34
.
Universal health systems are defended by
progressive governments and parties, based
on the defense of health as a right and free
public systems with universal and equitable
access to all, according to their needs. The
UHC is, in turn, a proposal of the WB, WHO
and Rockefeller Foundation, which advocate
subsidy policies so that the poorest people
have access to health plans with less variety
of services, through co-participation
34
.
This process is a result of the neoliberal
political advance in Latin American coun-
tries that, since the 1980s, have gone through
two processes: structured pluralism, based
on the separation of public functions, and
the process of implementation of the UHC.
In the case of Mexico, Popular Insurance
is defended as a model to be followed by
other countries
35
. In line with the proposed
changes, Colombia, Chile, Peru, and Uruguay
also carried out reforms through economic
incentives aimed at the financial protection
of their population
36
.
Historically, Mexico has a fragmented
health system in several public institutions
that favor the population with formal work,
which represents only half of the Mexican
population. In an attempt to increase health
service coverage, Popular Insurance was
created in 2004 to achieve UHC and reduce
health spending for the population not
covered by social security.
An important advance was observed re-
garding the population coverage not contem-
plated by social security institutions after the
creation of Popular Insurance. In 2000, the
population without coverage corresponded
to 57.6%, rising to 50% in 2006 and 21% in
2012
10
. The increased health coverage of the
country, however, is in contrast to barriers to
access to these services, which remain and,
in the case of Mexico, reach up to 20% of the
population, being more pronounced in the
poorest segment
35
.
Parallel to this process, population cover-
age by the Popular Insurance reached 38%
in 2012, while social security remained at
40.6%
4,12
. Despite the improvement in these
rates, after more than a decade of operation, a
significant portion of the population remains
without coverage. By prioritizing the most
vulnerable populations, such as rural and in-
digenous, it is noted that these were the most
benefited by the Popular Insurance
9,28,29
.
Approximately 70% of the population
covered by Popular Insurance uses services to
control T2DM and/or hypertension
37
. Users
report that consultations boil down to blood
pressure measurement, weight and blood
glucose testing without metabolic control
or eye monitoring. After these consultations,
users eventually need to pay for medications,
given their unavailability
38
. Those affiliated
to the Popular Insurance with SAH or T2DM
have less chance of having catastrophic ex-
penses when hospitalized, than those without
the Popular Insurance
39
.
Popular insurance covers 30.9% of the
elderly population
20
. It is emphasized,
however, the lack of coverage for more ex-
pensive diseases, which mainly affect this
population. It is known that the older the
age, the greater the chance of an episode of
SAÚDE DEBATE | RIO DE JANEIRO, V. 43, N. ESPECIAL 5, P. 273-285, DEZ 2019
Krasniak LC, Catapan SC, Medeiros GAR, Calvo MCM282
acute myocardial infarction, cerebral hem-
orrhage or evolution to a chronic kidney
disease, morbidities not included in the
Popular Insurance, making the coverage of
this population fragile and increasing their
individual expenses.
In general, even with an increase in pop-
ulation coverage, members of the Popular
Insurance have fewer consultations and
urgent care per capita
7
. A lower hospitaliza-
tion rate is observed, but it does not neces-
sarily result from better health conditions
in the population, but from the fact that
the main causes of hospitalization are not
covered by the Popular Insurance
6,30
.
Another point of weakness is in relation
to prescription and availability of medicines,
one of the main complaints of members of
the Popular Insurance. Despite having more
prescription medicines in the consulta-
tions than the population without cover-
age, access to these medicines is restricted,
being available on average 65% of what has
been prescribed
12,31
.
In general, the implementation of Popular
Insurance has been criticized, including
the fact that millions of Mexicans remain
uninsured, direct disbursement spending
remains high, in addition to limited access
to health services and increasing inequality
in access to health
11
. Nevertheless, in a study
comparing six countries in Latin America
and the Caribbean, Mexicans were the most
optimistic about their health care system.
Approximately 75% said they believed that,
if they were sick, they would receive ap-
propriate treatment
40
.
Final considerations
This study was prepared to analyze the
process of implementation and operation
of the Popular Health Insurance in Mexico,
highlighting its positive and negative points.
Its implementation is a milestone in the
numerous changes in this health system,
consisting of social security institutions for
formally working Mexicans and others for
the uninsured population, for which Popular
Insurance has emerged as an alternative to
reducing health spending.
In fact, Popular Insurance reduces the
health expenses of the affiliated popu-
lation when compared to the uncovered
population, but with higher expenses than
social security users. Popular Insurance
offers a lower variety of diagnoses and
medical treatments than those provided by
social security, as well as fewer appoint-
ments and emergency care. Regarding
medicines, both the quantity and variety
available are smaller.
Vulnerable populations, such as indig-
enous people and rural areas, were the
ones who benefited most from Popular
Insurance, mainly through the implemen-
tation of preventive measures. However,
in addition to not achieving universal
coverage in more than a decade of opera-
tion, Popular Insurance has created a new
form of fragmentation, strengthening the
unequal character of health care. Its cover-
age is controversial, as their affiliates must
bear the costs of services and medicines not
included in their list.
For a more in-depth analysis of changes in
the Mexican health system and its possible
advances in recent years, up-to-date data
on its operation are needed, as those avail-
able in this review refer to Ensanut 2012.
Another gap found is the absence of vital
statistics that make it possible to compare
the different types of coverage.
The analysis of the Popular Health
Insurance provides good evidence of the pos-
sible impacts that health plans would have on
the Brazilian health scenario, as well as from
other countries with similar proposals. The
principles of universality, comprehensive-
ness and equity are strongly contradicted
when proposing the distinction of the popu-
lation and its fragmentation into different
services, offered in a restricted manner and
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Analysis of Mexican Popular Health Insurance: an integrative review of literature
283
with co-participation in payment. Popular or
accessible plans go against the foundations
and strengthening of the single health system,
and its main care and surveillance strate-
gies such as the adoption of Primary Health
Care as the entrance door of the system and
coordinator of care.
Collaborators
Krasniak LC (0000-0002-8203-8840)*,
Catapan SC (0000-0001-6223-1697)* and
Medeiros GAR (0000-0002-7406-3210)* con-
tributed to the conception and design of the
study, analysis and interpretation of results.
Calvo MCM (0000-0001-8661-7228)* critically
reviewed the manuscript. s
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Received on 04/29/2019
Approved on 10/23/2019
Conflict of interests: non-existent
Financial support: non-existent
