INTERNATIONALBANK FOR WORLD BANK R E T C N O E N STRUCTION PM AND DEVELO March 2003 No. 20 A regular series of notes highlighting recent lessons emerging from the operational and analytical program of the World Bank`s Latin America and Caribbean Region MEXICO: REACHING THE POOR WITH BASIC HEALTH SERVICES Patricio Marquez and Willy de Geyndt The Problem: Low Access to Basic Health The PAC's realistic and achievable objectives and three Care Among Poor Mexicans components were completely aligned with the Government's health strategy and with the World Bank's Country Assis- In the mid-1990s, many Mexicans lived in poverty without tance Strategy. The Project reflected Mexico's broad con- adequate access to health and social services. Of a total sensus on a three-pronged approach to: population of 84 million, 25 percent were considered poor and 16 percent, extremely poor. Urban areas had health (i) reduce inequities, increase access to basic health services indicators similar to OECD countries, with an increasing and improve quality and resource use, targeting the least- burden of non-communicable diseases developed states; (ii) decentralize services and injuries, while many people in rural and functions; and (iii) modernize the areas and the southern states still SSA. suffered from common infectious diseases and malnutrition. Life A health sector study initiated by the Gov- expectancy in rural areas was 55 versus ernment in 1994, with assistance from the 71 in urban areas and 53 among the World Bank, IDB, and PAHO/WHO, poor. helped outline priority policies and invest- ments, appropriate roles of the SSA, social The Mexican government realized that security, non-governmental organizations inequitable access to basic health care (NGOs) and private sector, and ways to for poor and indigenous people strengthen sector financing and efficient hampered economic development, resource use. jeopardized investments in basic education and deprived citizens of their The project benefited from lessons learned constitutional right to attain good health. while implementing the First Basic Health So it devised a strategy to reduce Care Project (Ln. 3272-ME, 1991-1996). inequities, improve health care, and This experience highlighted the modernize the Federal Health importance of: (a) improved targeting in Secretariat (SSA). A 1994 presidential delivering a cost-effective basic health care decree created a Health Cabinet package in the most disadvantaged (Gabinete de Salud) headed by the President with municipalities within poor states; (b) rehabilitating first level representatives from social security, finance and other social health centers and second level hospitals to improve access sector entities, to guide the SSA restructuring, promote to basic health care; (c) recruiting and training community coordination among sectors, and oversee the health care workers to staff health posts in communities decentralization of health services. without medical doctors; (d) building ownership in the states through institutional capacity development and decentralized The Second Basic Health Care Project (PAC/ project implementation; and (e) joint annual review meetings Programa de Ampliación de Cobertura; Ln. to evaluate the previous year's work plans and prepare next year's investment and implementation plans. 3943-ME) 1 PAC Components Health Agencies in improving financial management, training managers, building information systems, improving procurement and inventory systems and enhancing the Basic Health Care Services (US$335 million). This overall quality of the health care delivery system. component aimed to provide basic health services to targeted, uninsured, hard-to-reach groups. Initially, health The Modernization and Restructuring of the SSA component jurisdictions and municipalities in eleven states (Oaxaca, (US$47 million) helped redefine the mission, objectives and Chiapas, Guerrero, Hidalgo, Puebla, Veracruz, Zacatecas, functions of the SSA. It financed 60 person months of Michoacan, San Luis Potosi, Campeche and Yucatan) with technical assistance, numerous policy studies on optimizing health indicators below the national average were selected, the provision and utilization of health services, and develop- using a poverty targeting mechanism based on the CONAPO ment of a national health communication and information (Consejo Nacional de Poblacion-National Population system. Council) poverty index.1 As provided for in the project design, coverage was later extended to extremely poor, difficult to reach populations in 8 more states (Chihuahua, What were the Results? Durango, Guanajuato, Jalisco, Mexico, Nayarit, Queretaro, and Sinaloa). Improved access to basic health care. PAC successfully Following the guidelines of the 1993 World Development provided basic health services to about 9 million poor people Report "Investing in Health," expenditures were redirected (90 percent of the Health Sector Reform Program 1995-2000 to the 13 most cost effective health interventions. The target), mostly indigenous and often non-Spanish speaking, in 878 municipalities and "If they couldn't come to us it was clear we had to go to them" more than 46,000 isolated rural communities in 19 states, Two of the main obstacles to improving public health services for Mexico's poor have been the an unparalleled feat in Latin population dispersion in rural areas and difficult geographic conditions. There are more than America. Unprecedented 151,000 communities with fewer than 100 inhabitants with a combined population of 2.6 mil- collaboration between the lion. federal and local governments galvanized hundreds of mobile units to deliver the "Not many people would have believed it when we were experiencing our worst economic cri- basic health care package. sis," said a Director of Mexico's PAC in 2000. "But now we are only a step away from provid- ing universal basic services to every Mexican. If they couldn't come to us it was clear we had to go to them, because for many of these communities, the closest clinic was two days by mule," Decentralizing the he added. responsibility for service delivery to the state level triggered increases in "When you talk about mobile units, most people think of trailers or jeeps. But they come on counterpart project funding mules, in boats, and on foot in geographically difficult places such as Chiapas or Durango," said from the Federal Government a PAC `s Operations Director in 1999. "The continuity of the project's achievements is guaran- (an extra US$115.4 million) teed by the fact that it's not ours [the federal government] nor the World Bank's," he added. "Thanks to the unprecedented and successful decentralization process, now the states and the lo- and from participating states cal population as a whole have the health services in their hands." (US$80.1 million more), which allowed additional personnel to be hired beyond the original project plans With component focused on (i) strengthening public health inter- community contributions of about US$4-5 million (1996- ventions that benefit the whole population, including safe 2001), total project spending was about US$639 million, far water and basic sanitation, health and nutrition information in excess of US$443 million envisaged at appraisal. and education, and vaccinations; and (ii) delivery of essential clinical services: reproductive health, child health, preven- _________ tion and control of tuberculosis and cervical cancer, and 1 The CONAPO poverty index ranked states, jurisdictions and treating parasitic and infectious diseases (intestinal infec- municipalities based on results of "principal components analysis," tions, pneumonia) and chronic diseases (diabetes, asthma, using the 1990 INEGI census, using the following variables: population hypertension). density, adult illiteracy, population >15 years without primary schooling, availability of basic sanitation services and drinking water, Institutional Development and Decentralization. This % of households without electricity, % of overcrowded households, component (US$61 million) supported decentralization of % of households with dirt floor, % of population in localities of fewer health services management from the SSA to the 32 states than 5,000 inhabitants, per capita income of less than two minimum and their health jurisdiction levels. It supported the State salaries, and presence of indigenous population. 2 Project services were coordinated and integrated with other SSA modernization and restructuring. The SSA was the only national programs to expand social services, especially the federal secretariat decentralized during the Zedillo anti-poverty Education, Health and Nutrition Program Administration (1994-2000). The federal level divested (PROGRESA). PROGRESA offers itself of all operational responsibilities cash transfers to eligible families and redefined its mission and role as one Table 1. Outcome/Impact Indicators for Beneficiaries in provided they obtain preventive the Six Poorest Project States of policy making and stewardship. health care, participate in growth 1995 1999 %Change Management of human, physical and monitoring and nutrition Life Expectancy at Birth financial resources--and three fourths supplements programs, and attend Female 75.1 75.4 0.4%of SSA's budget--have been shifted to education programs about health and Male 68.4 70.6 3.2%the states. A pioneering and unique hygene National Female 76.2 77.3 1.4%communication system (REDSSA) National Male 69.8 72.8 4.3%transmits data and voice messages Together, the programs extended -13.2% Total Fertility Rate* 3.17 2.75 electronically among 2,600 connection basic health service coverage to all points in the 31 states, the federal district Maternal Mortality /100,000 -18% the targeted 10.9 million poor, most 72 59 registered live births and 231 health jurisdictions. Mexico is in communities with fewer than 500 now a leader in health communication inhabitants. About 1.5 million of * Consejo Nacional de Población estimates for 1996 & 2000 and information systems in the these beneficiaries live in small rural developing world. and mountainous hamlets that could only be reached by traveling health teams. Most of these people saw a Forty two studies to guide policy making and health sector professional health care worker and received care for the reform were financed. Operational studies supported service first time in their lives. The intensity of services provided delivery improvements (baseline and annual evaluations, increased dramatically, almost doubling the number of mapping service delivery routes, improving the distribution medical visits per 1,000 people. The number of Mexicans of pharmaceuticals and supplies). Policy studies included with no health coverage decreased from 10 million in 1995 analyses of policy changes, prepaid medicine, a national to 1.5 million in 1999, according to a Government of nutritional survey, a feasibility study for privatizing Mexico/PAHO/WHO assessment. Experts expect the Project production and distribution of vaccines, and studies of to have helped reduce this to 500,000 by the end of 2002. specific public health problems such as HIV/AIDS, intra- family violence, and use of insecticides and toxic substances. Outcome indicators in Table 1 suggest that PAC helped reduce maternal mortality, increase life expectancy and Lessons Learned decrease fertility, bringing the poorest states closer to the national averages. Other social programs and changes in general economic conditions also contributed to the im- Government ownership is key. Project objectives were set provements. by the country, and commitment was firmly entrenched in the Government's program. The Bank's role was mostly to provide flexible support to facilitate timely achievement of These outcomes are consistent with the PROGRESA impact the objectives. evaluation findings of more utilization of public health clinics for preventive care, lower inpatient hospitalizations Responsible risk-taking pays off. The project was a and visits to private providers, reflecting less incidence of traditional investment loan infused with an adaptable lending severe illnesses, and significantly improved child and adults spirit, in that the World Bank agreed on a financial package health.2 without a detailed five-year spending blueprint. The Bank appraised the first year's activities, and participated in Institutional development and decentralization. The annual planning, performance budgeting and evaluation. operational capacity of the states was strengthened, Design flexibility allowed PAC to adapt to the needs of additional staff were hired, and personnel were trained in participating states, especially when highly-dispersed groups general management functions and in specific functional needed to be reached. The Bank's flexibility and limited areas such as inventory control, management information control enabled the Government to take risks and learn while systems, epidemiological surveillance, and quality control. doing. Annual monitoring and evaluation of the project by States assumed responsibility for service delivery, increased an external firm was an important mechanism for providing their share in financing operating expenses, and put newly- _________ hired health workers on their regular payroll. Some of the goods financed by PAC were procured online using the 2This was a controlled randomized study design with household panel federal electronic COMPRANET system, which increased data. "An Experiment in Incentive-Based Welfare: The Impact of efficiency and lowered procurement costs, and became a PROGESA on Health in Mexico", Paul J. Gertler, UC-Berkeley and pilot intervention for procurement in other World Bank- NBER and Simone Boyce, UC-Berkeley, April, 2002. http:// financed operations. www.worldbank.org/research/projectProjects/service_delivery/ paper_gertler1.pdf). 3 input for planning the following year's program, coverage decrease the financial burden of catastrophic illnesses, that and activities. exacerbates poverty. The project's major components: (a) improving health services quality and equity for population Political commitment contributed to a highly successful groups in poor rural and marginal urban areas, including outcome. The country was politically committed to raising HIV/AIDS prevention and control, organizing health care the health status of the poorest groups, decentralizing health service delivery and modernizing its arrangements for serving Table 2. Output Indicators: uninsured people. Project performance was a) Coverage 1996-2001 1996 2001 % Change prominently mentioned in the President's Population served annual State of the Union addresses. Progress Total six poorest states 3,252,500 6,724,100 107% Total PAC beneficiaries 3,878,100 8,976,500 131% was reviewed and discussed weekly with the Number of Health Jurisdictions 31 100 222% Undersecretary of Health and monthly with the Number of Municipalities 380 878 131% Federal Health Secretary. It was recognized Number of Communities 10,764 46,493 332% Number of Itinerant Health Teams that reaching the poor in highly dispersed Mobile Units 613 geographical locations requires substantial Foot Brigades 181 resources. The Government (federal and state) Mixed 595 decided to finance a basic package of health Number of Health Centers 505 2404 376% care services for hard-to-reach rural groups, and added US$200 million more to the project than b) Health Services 1998 2001 % Change Medical Visits/1,000 people 605 1174 94% originally agreed. Nutritional control visits/1,000 1081 2263 109% children under 5 years Visits for Diarrheal Diseases/1,000 Consistent strategic approaches to reach the 531 724 36% children under 5 poor. The "symbiotic relationship" with Visits for Acute Respiratory 378 508 34% Infections/1,000 children under 5 PROGRESA proved highly effective in achieving Government's health priorities, using c) Human Resources Added 2001 Physicians 1552 the comparative advantage of each program. Nurses 1538 While PAC strengthened basic health service Other Health Staff 1604 delivery, PROGRESA used cash transfers as Non-Health Support Staff 434 incentives for families to invest in their Sources: children's health and education. SSA. Anuarios Estadísticos de la SSA 1995-2000. Managed Decentralization. Decentralizing SSA. Sistema de Información en Salud para Población Abierta (SISPA) 1998 - 2001. management of human, physical and financial SSA. Programas de Equidad y Desarrollo en Salud. principales Resultados resources to the 32 state and federal entities and 1996 - 2001. SSA. Catálogo de unidades médicas de primer nivel de atención 1998 - having states compete for resources may hurt 2001. weaker states; central level technical assistance CONAPO. Proyecciones de población 1995-2020 INEGI. XII Censo de Población y Vivienda 2000. Tabuladores básicos. and support is needed. Equity requires walking a fine line between letting go and being directive. networks, social communication, and state level investments (half of the US$581 million total project cost); (b) increasing Project components were mutually supportive. It is unlikely efficiency, institutional development and decentralization, that the basic health care component would have been as including restructuring health service delivery system successful without progress in decentralizing responsibility incentives, and more autonomy and financial responsibility for health services, and modernizing and restructuring the for local organizations and networks (12 percent); and (c) SSA. The Government's full commitment to these two innovation, pilots (e.g., the Seguro Popular health insurance components was fundamental to being able to provide basic scheme), policy studies and impact evaluation (13 percent). health care services successfully in dispersed rural areas. About the Authors Moving Forward Patricio is s a Lead Health Specialist in the World Bank's Latin America Caribbean Region and is the Team Leader for the The Mexico Third Basic Health Project (PROCEDES/ Project. Willy de Geyndt, a former Principal Health Specialist at Programa de Calidad, Equidad y Desarrollo en Salud, the World Bank in the Asia Region, was the lead author of the approved June 2001) builds on PAC's success and supports recently-prepared the Implementation Completion Report for the Government's Sector Strategy for 2001-2006. This aims the Project. to: (i) decrease social and regional inequities by reducing differences in health status among the Mexican population About "en breve" (e.g. life expectancy of poor groups is 17 years lower than non-poor); (ii) provide better quality health care services to To subscribe to "en breve" send and email to poor, disenfranchised and indigenous groups; and (iii) "en_breve@worldbank.org" 4