The anti-corruption president has set some stringent targets for the health system—critics worry that these are brash and could be damaging to the system. David Agren reports.
When he was asked to drastically cut his operating schedule in February, paediatric oncology surgeon Pablo Lezama knew something was amiss. It wasn’t long until nurses became suddenly unavailable for evening and night shifts, forcing a 30% cut in surgical procedures. In May, budget cuts and a lack of anaesthesiologists would reduce his schedule by another 50%—Lezama, head of oncological surgery at the Children’s Hospital of Mexico Federico Gómez, could no longer hold back.
His Facebook post, outlining his situation, went viral—it was shared 25000 times.
“Children with cancer is a very sensitive point for everyone”, Lezama said when asked to explain his viral post. “It was not attacking anybody. It was not against the new regime [in government] or in favour of the past one. It was just descriptive: we are having this trouble, we need things to be normalised.”
Bearded, soft-spoken, and no stranger to putting in unpaid extra hours in an underfunded public hospital—part of the country’s prestigious National Institutes of Health—Lezama’s post captured the angst of the moment in Mexico, where cuts to health care have prompted protests, speculation of scarcity, and at least one high-profile political resignation.
A steady stream of stories on cuts to health services has made the news in Mexico in recent weeks. These are part of austerity measures announced by Mexico’s President, Andrés Manuel López Obrador, who took office on Dec 1, 2018, on a platform of combatting corruption, slashing perks on privileges for public servants, and putting the poor the first.
López Obrador, commonly known as AMLO, practises personal austerity: he travels on commercial flights, abandoned the presidential palace for a modest dwelling, and is chauffeured around Mexico City in a Volkswagen Jetta. “You can’t have a poor people and a rich government”, he often says.
AMLO applied similar principles to the health system. But rather than substantially increasing spending, he has bet on tracking inefficiencies— mostly by trying to wring what he considers rampant corruption out of the health system through a series of measures that physicians and public health analysts interviewed by The Lancet consider poorly conceived and executed with haste.
“They never saw the possibility of creating a strategy for the cuts”, said health policy analyst Ricardo Baruch. “It was an immediate order: ‘You have to cut spending between 30% and 40%’. And that particularly affects human resources.”
Think tank México Evalúa said in a statement on June 3 that 10% less money—a reduction of 4 billion pesos (£160·1 million)—was spent on health in May, 2019, when compared with the same month of 2018. Those savings continue being absorbed by Pemex, the state oil company and a pillar for AMLO’s industrial and economic plans.
López Obrador denies cutting frivolously. In December, he boasted the health budget was bigger than the year before. He has outlined goals such as expanding access to health care and making the health system universal, with all Mexicans covered by a single institution rather than separate social security systems for private and public sector workers, along with federal and state health systems for those lacking coverage. AMLO has also promised to lower the cost of pharmaceuticals for public hospitals. Mostly, however, he has promised to curb corruption.
“Some medications may be lacking but the problem will be resolved and service will improve”, he said in a May 27 press conference. “This is a change of regime, not a change of government, and that means uprooting the corrupt regime. That causes some inconveniences, but it is necessary. We couldn’t continue with more of the same.”
Mexico’s Minister of Health Jorge Alcocer Varela was unavailable for comment on this article.
Several policy changes have already been undertaken by the López Obrador administration, including cutting all contracts with third parties, such as outsourcing agencies, who provided personnel to public hospitals. These personnel included nurses and anaesthesiologists, according to Lezama, who called outsourcing “suboptimal” but important in keeping things running. López Obrador has also cut all funding to non-governmental organisations (NGOs), including women’s shelters, daycares, and groups working on health issues such as HIV testing and prevention.
He lumped in those groups competing for government projects with other parts of “civil society” sponsored by business, calling them “conservative” and “fifí”—a slang word meaning posh. AMLO also has inferred NGOs have formed to pilfer public money and has a vision of providing stipends to social service recipients, avoiding intermediaries and bureaucrats.
Groups working on HIV issues across Mexico have had to cut staff and services such as testing due to the National Centre for the Prevention and Control of HIV no longer offering contracts for projects to NGOs. “The present results in HIV issues would not have been possible without us”, said Aarón Rojas Cortés, director of programmes and education at Inspira Cambio in Mexico City. “There are going to be setbacks in every way imaginable”, Rojas Cortés added, warning of setbacks in HIV prevention, linking infected individuals with medical care, and making sure people on antiretroviral drugs stick with their regimes.
Shortages of antiretroviral drugs were reported in some states earlier this year, although the federal government says the situation is under control. A new antiretroviral regime—which costs less than what was previously offered and has the support of HIV experts and activists— will be offered to patients, according to Alcocer Varela, the health minister. The López Obrador government has said it will centralise the purchasing of pharmaceuticals to curb corruption and get better prices. It has also vetoed several established distributors—a risky move, according to an industry consultant, as distribution in Mexico has been effective and no competitors or government entity could quickly take over. “At the core of this vision is a conviction on the part of the government that purchases over the years with Mexican laboratories— through distributors—have been about corruption”, said the consultant.
López Obrador has said he will buy medicines abroad to beat down prices in Mexico, sparking concerns those products might come from countries where quality control and regulatory processes are lax, the consultant said.
Research in Mexico has also faced cuts—to the point that researchers affiliated with the National Council of Science and Technology have to ask presidential permission to leave the country. The National Academia of Medicine of Mexico has also had funding cut for administrative costs, even though it plays an advisory role to the federal government.
“They are cutting, but with a machete, not a scalpel”, said a physician, who requested anonymity due to his senior position in a public institution. “The problem is the president wants to control everything.”
The impact on the health system has surfaced in a series of social media posts, small protests, and physicians speaking out.
None spoke as loudly as Germán Martínez, who resigned on May 21 as director of the Mexican Social Security Institute (IMSS), which provides health and pension benefits to nearly 70 million members employed in the private sector, with workers, employers and the government providing equal contributions.
In a blistering resignation letter, Martínez complained of “pernicious interference” in the IMSS from the Finance Ministry and said “Excessive saving and controlling of the health budget is inhumane. That control ends up skimping on the resources for the poorest Mexicans”.
López Obrador publicly backed the Finance Ministry in the squabble. He has long railed against shortcomings in the health system that have existed for decades, which he attributes to corruption. The complaints include shortages of staff and medicines in clinics and hospitals being half- built, with politicians cutting ribbons and the facilities never operating. López Obrador counts at least 80 such hospitals in Mexico.
He has also attacked Seguro Popular, a programme for providing coverage to the uninsured, calling it “not secure and not popular”.
“I believe in 3 years, medical attention and medicines will be free for all Mexicans and we are going to have a health service equal to that of the Nordic countries...equal to Canada”, he said on April 15. “That is my commitment.”
AMLO’s plan has left many in the medical profession still looking for details. Physicians say their profession is split over AMLO, with some expressing worry over cuts and many willing to give him time to fix what he often calls a country “in ruins” that he inherited.
“It is absurd to think 70 years of corruption could be eradicated in 5 months”, said Onix Garay, an IMSS oncologist.
“I agree with the president: we have to get rid of corruption and we see where the money goes. But that is not done by cutting medical attention— rather, organising and restructuring”, said Fernando González Ledon, a paediatric urologist, whose petition for restoring health funding on Change.org attracted 105000 signatures. “I think that is what happened: they wanted to do it in one fell swoop, but you can’t stop providing health care.”
Some of the physicians’ protests— such as Gónzalez’s—seem to have spurred responses. In late May, 800 million pesos (£32 million) was restored to the budget of the national health institutes and federal hospitals.