Setbacks in the quest for universal health coverage in Mexico: polarised politics, policy upheaval, and pandemic disruption.

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.
Competing Interests: Declaration of interests FMK is President and Founder of Tómatelo a Pecho. FMK participated in the design, financial calculations, and implementation of the Seguro Popular, collaborating with Mexico's Ministry of Health. She is married to JF who was Minister of Health of Mexico from 2000 to 2006. FMK was employed by the Ministry of Education and the Ministry of Social Development of Mexico during the administration of President Vicente Fox. FMK received research grants from Merck and EMD Serono to the University of Miami outside the scope of the submitted work and from Merck Sharp & Dohme, Avon Cosmetics, and S de R L de C V to Tómatelo a Pecho, all outside the scope of the submitted work. FMK received research grants from the US Cancer Pain Relief Committee to the University of Miami and the Medical Research Council to the University of Miami and Funsalud (Mexican Health Foundation) for work related to palliative care. FMK has also received consulting fees from Merck and EMD Serono and Instituto Tecnológico y de Estudios Superiores de Monterrey, Mexico outside the scope of the submitted work. FMK is a member of the Board of Directors of the International Association for Hospice and Palliative Care. FMK collaborates as a Sistema Nacional de Investigadores researcher at the Mexican Health Foundation, where she has been affiliated since 2000. HA-O is a Research Professor of the Institute for Obesity Research of Tecnológico de Monterrey, is Executive Director of Tómatelo a Pecho, and participates as an Associate Researcher at Funsalud (Mexican Health Foundation). HA-O received consultancy fees from Merck through the University of Miami outside the scope of the submitted work and from Merck Sharp & Dohme, Avon Cosmetics, and S de R L de C V to Tómatelo a Pecho, AC outside the scope of the submitted work. HA-O received consultancy fees from the US Cancer Pain Relief Committee to the University of Miami and the Medical Research Council to the University of Miami and Funsalud (Mexican Health Foundation) for work related to palliative care. HA-O collaborates as a Sistema Nacional de Investigadores researcher at the Mexican Health Foundation, where he has been affiliated since 2003. TM receives consulting fees for research and writing from the University of Miami Institute for Advanced Studies of the Americas. OG-D and ES-M were partly funded by the National Institute for Health and Care Research (NIHR) Global Health Policy and Systems Research researcher-led grant (NIHR150067) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK Government. OG-D was Director General for Performance Evaluation at the Ministry of Health of Mexico during 2000–06, which was the initial period of implementation of the Seguro Popular. PK was Vice Minister of Health of Mexico from December, 2011, to December, 2018, under the administration of Enrique Peña Nieto. AM-V participated in the design and implementation of the Seguro Popular between 2001 and 2007. AM-V was also Director General of Planning and Evaluation at the National Coordination of the Oportunidades Program between 2009 and 2011. He also served as the Deputy Director General of the Economic Analysis Unit between 2013 and 2016, and Director General of Evaluation between 2013 and 2019, both at the Ministry of Health. JF was responsible for the design and implementation of the Seguro Popular. All other authors declare no competing interests.
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