Primary care is essential for sustainable health care.1 Mexico is undergoing socioeconomic and health care developments, but a barrier is policy makers’ poor understanding of the role and function of primary care. Consequently, the country struggles to meet the health needs of its population. The Mexican College of Family Medicine (MCFM) has the potential to lead health systems change with strong primary care, but lacks capacity. A pre-conference at the 2015 Cancun NAPCRG conference aimed to develop an action plan and build leadership capacity for MCFM (http://www.napcrg.org/Resources/CancunManifesto/SupportingHealthReforminMexico-FullPaper).
International Collaboration
There is substantial international experience in implementing primary care policy to reform health systems.2–7 This policy implementation requires translating general principles of primary care to local circumstances and priorities; articulating primary care’s contribution to population health (ie advocacy); and engaging with multiple stakeholders in a bottom-up process to address population needs.
Mexican Health (Care)
Mexico is experiencing a demographic transition, with an aging population and an increase in chronic diseases (notably diabetes mellitus).8
Since 1943 the Mexican Health System has covered various sectors of the population. Additional legislation was introduced in 20149,10 and upgraded in 2015, to ensure full health care coverage.
Despite a convergence of services,11 each health structure that passed legislation has a vertical financing system which increases administrative expenses. In 2011 these administrative costs represented an estimated 10.8% of total expenditure on health.9
Coherent primary care is absent. Primary care is provided, depending on the funder, by institution-certified family physicians, general practitioners, or non-certified family physicians or social service interns.12 Practice visits are short (12 minutes) and curative in focus, with less than 10% being preventive in nature.13 Accordingly, family medicine accounts for only 4% of over 26,000 training positions.14 This gives urgency to focus health reforms on primary care, including financing and training.
In summary, the most urgent issues are:
Lack of structure and coordination between primary care and hospitals
Insufficient coverage and access for the many poor
Insufficient understanding of the primary care role
Lack of teaching, training, or research of health problems in the community
Poor socioeconomic status of family physicians
Two International Examples of Success
Ontario, Canada provides a lesson on system transformation through physician payment and interprofessional teams.15–17 Capitation payment blended with fee-for-service and pay-for-performance incentives became the preferred reimbursement, and about one-quarter of physicians were supported with interprofessional teams.
The health transformation increased physician reimbursement and satisfaction. Students’ interest in family medicine almost doubled to 40% of graduates. Important lessons learned were to adjust capitation to populations’ health needs and to align primary care incentives with the needs of the rest of the health system.
The US experience, often copied in Central American countries, demonstrates that health investment does not lead to a return in health outcomes,18 without investment in the primary care function. Additionally, markets with fee-for-service payments create mal-distribution of workforce away from areas with high health needs.
As an alternative, decentralized, local “communities of solution” are powerful in achieving more with less resources, as exemplified in the Hombro a Hombro project in Honduras.19 Through an academic/community partnership, “committees” for health identified social determinants of health needing greatest attention and prioritized resources accordingly.
Learning points for Mexico were:
Blended capitation payment for primary care
Describing the main health problems in the population
Family practice specialty training in the community setting
Insight into numbers and geographic distribution of health care professionals
Working With Stakeholders
Engagement between care providers, patients and their caregivers, managers, and policy makers improves responses to complex needs.20–23 To secure patient-centered care, primary care providers and researchers need to engage with those who will ultimately benefit.24–26 Meaningful engagement results in more rapid uptake of evidence into practice, and more satisfaction with care provided.27–29
Problems of working with patients in the Mexican situation were:
Unavailability of consumer organizations
Patients passive toward health care professionals
Patients poorly understood the role of primary care
Conclusion
The meeting participants proposed the Cancun Manifesto, an action plan for MCFM to lead a long-term strategy for health reform in Mexico.30 To increase understanding among stakeholders of the values of primary care, and to advocate its development, short-term objectives were identified:
Describing the Mexican Ecology of Medical Care31
Collecting patients’ experiences with their family physician
Defining role and function of primary care32 in the Mexican context
International support to the MCFM will continue. This pre-conference process can be used with other countries facing health systems change.
Footnotes
References available in pre-conference report at http://www.napcrg.org/Resources/CancunManifesto/SupportingHealthReforminMexico-FullPaper.
- © 2016 Annals of Family Medicine, Inc.
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- Primary care financing: a systematic assessment of research priorities in low- and middle-income countries
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- Strategies for Increasing the Role of Family Medicine in Mexican Health Care Reform