Decentralizing Health Services in Mexico: A Case Study in State Reform (review)

Núria Homedes and Antonio Ugalde have assembled a compelling new collection of studies confirming that health sector reform in Mexico not only has failed to achieve the democratization and empowered local level decision-making its proponents promised but also that the process has placed considerable resource strains on health systems at the state level. Over the course of ten articles, which scrutinize the origins, development and impact of World Bank-inspired decentralization schemes in diverse states, the collection sheds light on the significant challenges and, in a few cases, opportunities presented by decentralization. Homenedes and Ugalde conclude that health sector decentralization may work in countries where it is promoted for nationalistic or even religious ends. However, the editors and authors, who include social scientists, public health specialists, and physicians, show that in Mexico, where decentralization was introduced during the mid-1980s economic crisis, the federal government secured funds for international debt service but shifted the financial burden of health care to states ill-prepared to carry out the program monitoring and evaluation, not to mention the commodity procurement and distribution, necessary to provide citizens with access to quality health care services. Policymakers and those interested in the history of social-sector reform efforts in Mexico will find this collection useful and thought provoking.

In the late twentieth century health sector reform took place in two stages in Mexico, first in 1985 and more recently in 1996. To help readers understand the context in which reform was implemented, Homedes and Ugalde first establish the structure of the Mexican health system through an analysis of the history of health services in Mexico following the country's independence in 1821. They describe the variety of institutions that populate the Mexican health sector, including the Secretaría de Salud y Asistencia, which was the only federal health agency to be formally decentralized, as well as the Mexican social security institute, the IMSS, and the federal workers' social security program, the ISSSTE. And they specify the levels at which decentralization took place, including in organization, physical infrastructure, financially, in human resources, and at the program level.

Several case studies examine how the various states that signed agreements with the federal government in the 1980s experienced decentralization. Historian Anne-Emmanuelle Birn notes in her study of the experiences of Jalisco, Morelos, and Hidalgo that "benefits, services, spending, and quality of attention vary widely by health delivery sector due to historical factors and the differing political power of corporatist and union forces" (p. 129). Two subsequent chapters rely on interviews with officials familiar with the decentralization processes to demonstrate the disconnect between stated policy goals and the ways in which they were carried out at the state level with respect to governance, service delivery, labor, and funding; in her analysis of the failure of decentralization in Baja California Sur, physician Lucila Olvera Santana quotes one official as having observed that "although they send the funds to us, we have to use them in accordance with what the federal level dictates" (p. 165). And in her examination of the two-part process in Sonora, policy analyst Raquel Abrantes Pêgo notes, "Despite official discourse that portrays decentralization as a means to democratize decision making, the reform has been designed and imposed from above and its implementation has been complicated by a lack of details about how it should be carried out" (p. 206). By the time the reader reaches chapters on Guanajuato and Tamulipas, the fact that decentralization "accomplished very little" comes as no surprise. Interestingly, in Nuevo León, one of the more prosperous states in the country, officials were able to take "advantage of the small opening that decentralization allowed by, for example, signing contracts with municipalities and social security institutes and transferring power to the health districts and regional hospitals" (p...