This Friday, April 1, the new scheme that the federal government will use, through the IMSS Bienestar, to bring health services to the population without social security officially starts in the state of Nayarit. It is the beginning of the end of the Health Institute for Welfare (Insabi), which more than two years after starting operations, could not fulfill this which was its main task.
When it was announced that the Popular Insurance would be eliminated and replaced by the Insabi, the federal government assured that through this Institute free health services and medicines would be brought to the entire population that did not have social security, including the third level of care, which covers the high specialty.
The Insabi took office on January 1, 2020, after a reform to the General Health Law. According to the decree with which it was created, on November 29, 2019, the Institute and the federal entities would conclude coordination agreements so that they could execute the free provision of services and medicines to people without health coverage.
But “Insabi did not achieve the size of operation of the Popular Insurance, because it did not manage to grant medical consultations, nor the number of hospital discharges and neither the emergencies, and this was not only due to the closure of services of the pandemic and the focus on COVID, since 2019 the number of attentions began to fall because the Popular Insurance no longer existed and the Insabi was being conceptualized”, says Mariana Campos, coordinator of the Public Expenditure and Accountability Program of Mexico Evalua.
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The numbers of January 2022 already marked the death of the Insabi, according to an analysis carried out precisely by Mexico Evalua, in which it is pointed out that the situation observed in this month may well look like the prelude to the closure of the program: the total expenditure of the Insabi was only 34 million pesos (mdp), a fall of 94% (544 million pesos) compared to January 2021 or 99% (3,486 million pesos) compared to January 2019, when Seguro Popular still existed.
Although at the beginning of 2022, the analysis says, 6.6 billion pesos (mmdp) had been budgeted for Insabi, the sub-exercise of resources was almost total. This may be due to an early transfer of resources from Insabi to imss-bienestar. If this assumption were correct, resources would have been transferred to the IMSS before it took over the obligations of Insabi.
Along with the lower expenditure, says Mexico Evalua, the medical consultations of Insabi – which serves the most vulnerable people in the country – suffered another setback in January. Total attention was 996 thousand consultations, a drop of 30% (431 thousand consultations) less than in January 2021 or 83% (4.7 million consultations) less than in January 2019.
In January 2022, consultations to attend chronic-degenerative diseases – such as cancer, diabetes and HIV/AIDS – were only 229 thousand, a drop of 41% (159 thousand consultations) compared to January 2021 or 78% (828 thousand consultations) compared to January 2019.
Judith Senyasen Méndez, coordinator of Health and Finance of the Center for Economic and Budgetary Research (Ciep), points out that in reality the falls in consultations came already since 2015, but in 2020 the decrease was almost 50%, when in previous years they were 7 or 8%, this only in what refers to people without social security.
An analysis by year of the Ciep reports that the budget for the population without social security went from 31.8% of total health spending in 2017 to 28.6% in 2021 with the Insabi, the lowest proportion since 2016. In addition, in 2021, the Institute’s budget was 5.6% lower than that exercised by Seguro Popular in 2017, when it covered only 53.5 million Mexicans. Meanwhile, the target population of Insabi is 68.1 million people.
The budget of the Insabi, says Méndez, was not congruent with the objective of covering the entire population without social security, even the per capita expenditure for this population went from 3 thousand 656 pesos in 2019 to 2 thousand 911 pesos in 2021, a contraction of 20.3%.
Janet Oropeza, of Fundar’s Accountability program, points out that another cause for concern is that the limited coverage that the Catastrophic Expenses Fund of the Popular Insurance had (for diseases that involve a high cost in their care) to 66 ailments was not actually expanded with the change to the Health Fund for the Welfare of the Insabi.
“According to the rules of operation of this fund between 2 and 3% of the expenditure would be for other diseases, in addition to the 66 that were already covered, but there are still many ailments that are not covered and the expenditure of this fund was capped at no more than 32 billion pesos, which considering the 66 million people that are intended to be covered and the ailments they may have will be insufficient, “says Oropeza.
Start the new model
In Nayarit, the IMSS-Bienestar, which enters to relieve Insabi, will operate the 16 hospitals in the state, plus the Women’s Hospital that is about to be completed, and 261 first-level health centers, where 4,627 workers will be registered. The initial investment for this program in the state will be one thousand 438 million pesos for payroll of personnel, equipment and infrastructure.
The federal government has not presented a document to know what is the general plan so that now the IMSS-Bienestar is responsible for serving the population without social security in all entities, what has been announced is that collaboration agreements will be signed with the states that wish to do so so that they cede their physical and human infrastructure to the Mexican Social Security Institute.
These agreements, clarifies Janet Oropeza, of Fundar’s Accountability Program, are different from those signed with Insabi, because those were only made for the transfer of resources to the entities.
In the case of Nayarit, on March 17, the federal Secretary of Health, Jorge Alcocer, the general director of the IMSS, Zoé Robledo, and the governor of the state, Miguel Ángel Navarro Quintero, signed the act of integration of the transition table to specify the transfer of state health services as of April 1, through the IMSS-Wellness program.
In fact, since December 30, 2021, the decree authorizing the governor to disincorporate from the state’s assets various real estate located in the entity in favor of the Mexican Social Security Institute was published in the official newspaper of the government of Nayarit, through the Secretariat of Administration and Finance, IMSS-Wellness.
This, says the decree, to avoid the fragmentation of health services in Nayarit and that, through the IMSS-BIENESTAR Program, services are expanded and provided, through federalization, to people without social security.
In total, 135 assets are disincorporated, among these five dedicated to providing second-level services, such as the Las Varas Basic Community Hospital, the Santiago Ixcuintla General Hospital, the Rosa Morada General Hospital and the Jesús María Mixed Hospital.
The State Executive Branch, the decree says, will sign with the Mexican Social Security Institute the necessary agreements to guarantee the provision of health services to the population resident in the State of Nayarit that does not have social security.
The other two states that have already signed a framework agreement to federalize their health sector and offer services to this population through the IMSS Bienestar are Tlaxcala and Colima. But no date has been given for the official start in those entities.
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Currently, the IMSS Bienestar program operates in 19 states of the Republic and provides 11.6 million people living in marginalized rural or urban areas with first and second level health services that include specialties of general surgery, gyneco-obstetrics, internal medicine, pediatrics, anesthesiology, family medicine and epidemiology.
This through 3,622 rural medical units, 184 health brigades, 140 mobile medical units, 45 rural obstetric care centers and 80 rural hospitals.
On how the IMSS-Bienestar will do to serve the population that does not have social security, there are more doubts than answers, since there is no plan where the transition strategy has been stipulated, nor a regulatory framework or clarity in the budget.
“A lot of information is needed on how this transition is going to be made so that now IMSS Bienestar takes care of the population without social security and how the states are going to be integrated. This lack of information is worrying, because this cannot be another occurrence,” says Mariana Campos, from Mexico Evalua.
In the same sense, Judith Senyasen Méndez, of Ciep, points out that a plan should already be designed and presented, a strategy on how the IMSS-Bienestar will serve a much larger population than it is serving, since the objective of Insabi was to give attention to 60 or 65 million people.
“With Insabi we were two years without knowing how it was going to operate, hopefully in this case with IMSS Bienestar the clearest scheme is, but there is no official document, with the strategy, that we can review, everything is announcement and announcement,” says Méndez.
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