budget and health

The real priorities of governments are reflected more in the budget than in the speech. Considering that health is one of the issues that matters most to citizens and that it has been one of the issues identified as a priority by this government and in which important changes have been implemented, it is worth reflecting a little on how health is in the Expenditure Budget Project (PPEF) sent to the legislature.

We still face enormous health challenges. Some come from long ago, such as the fragmentation and inequity of the health system and incomplete coverage and low quality. However, there are others that have been recently created or have worsened as a result of changes in policies and bad decisions. What to say about the effect of the Covid pandemic and the poor response to it, whose impact is measured in hundreds of thousands of preventable deaths.

It would be desirable for the proposed budget to reflect not only attention to current issues, but also to help create the foundations for achieving better health outcomes for all, now and in the future. This is particularly relevant given the ambitious goal set by the government to guarantee universal coverage of health services and free medicines for all, which requires a much greater financial effort than the current one. Consider that the population that lacks access to health services has grown considerably: from 16.2% of the population in 2018 to 28.2% in 2020 according to CONEVAL. The PPEF does not reflect it, in fact, the project considers health spending only 4.2% higher than budgeted in 2022 -including what goes to the Ministry of Health, states and municipalities and social security institutions-. This represents 2.8% of GDP, far from the 6% recommended internationally. The IMSS Welfare, the body that will be responsible for increasing coverage to replace INSABI, will have a lower budget next year.

It matters not only the amount but in what and how it is used. México Evalúa has documented how the number of consultations offered by Insabi is considerably lower than those with Seguro Popular. In addition to the lack of coverage, this leads to higher future expenses for not being diagnosed and starting the treatment of conditions in a timely manner. It also forces families to significantly increase their out-of-pocket health spending. On the other hand, the PPEF maintains inequity in health services, manifested, among other things, in the great difference in spending per patient depending on the institution that offers the services. In addition, despite the widely documented shortage of medicines, the projected spending on medicines for 2023 is 15% lower than in 2022.

Particularly alarming is the scant importance given to prevention. The probability of death from preventable diseases such as cardiovascular diseases, diabetes or chronic respiratory diseases is increasing, as is the probability of death due to the high prevalence of overweight and obesity, a risk factor for multiple diseases, but what is destined for prevention as well as control of obesity and diabetes increases only marginally. Vaccination is one of the most efficient and cost-effective prevention measures. Coverage with a complete scheme has fallen drastically: from almost 80% in 2012 to only 35% today, and outbreaks of diseases that were already rare, such as measles and tuberculosis, are beginning to be seen. Despite this, the PPEF plans to reduce the vaccination budget to less than half, when it should be higher to address the backlog.

In order to achieve universal coverage with quality services, it is also necessary to consider two major transitions that Mexico is going through and that will have enormous implications for the health needs of the population and the expense to attend to them. I am referring to the demographic transition and the population aging that it entails, as well as the epidemiological transition, which implies changes in the patterns of disease and death: from transmittable infectious diseases to a higher prevalence of non-communicable diseases, such as cardiovascular, renal and cancers, which require more specialized and expensive care. The PPEF does not seem to recognize these irreversible changes. On the other hand, the Covid pandemic showed us that we have to be better prepared and increase our resilience to future pandemics that are sure to come. Again, the PPEF does not reflect this.

Mexican life expectancy fell four years between 2019 and 2021, a sad reflection of health outcomes and other factors. Neither the proposed budget nor many of the changes in health policy seem affected by it.

*The author is the leader of the Public Policies and Health Unit of the Institute for Obesity Research and of the Public Policies and Health Initiative of the Tecnológico de Monterrey..