Innovation in primary care: Community health services in Mexico and the United States

Sm. Sci. Med. Vol. 35, No. 12, pp. 1433-1443, 1992

Printed in Great Britain. All rightsreserved

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INNOVATION IN PRIMARY CARE: HEALTH SERVICES IN MEXICO UNITED STATES MARGARET SHERRARD SHERRADEN

Social Work Missouri-St

0277-9536/92 65.00 + 0.00 1992 PergamonPressLtd

COMMUNITY AND THE

and STEVENP. WALLACE

Department, Centers for International Studies and Metropolitan Studies, University of Louis, MO 6312i, U.S.A. and Department of Community Health Sciences, School of Public Health, University of California-Los Angeles, CA 90024, U.S.A.

Abstract-Providing adequate health care to a nation’s citizens is a challenge in every country. Despite large differences in wealth, health care organization, and health politics, both Mexico and the United States undertook similar efforts to expand primary care to previously underserved populations during the past 30 years. This study analyzes common antecedents, contexts of change, elements of the innovations, problems with entrenched interests, and resources that have allowed both programs to survive in difficult environments. We show that new forms of primary health care can face similar problems and prospects

in very different countries because of similar political, bureaucratic, and economic limitations. Key words-primary

care, Mexico, underserved, community heatlh centers, health policy, rural health

The growing crisis in health care financing and delivery in the United States has led to increased interest in the health care programs of other nations. Most comparisons are made with other technically advanced, industrialized nations such as Canada, England and Sweden [1, 21. By limiting comparisons to these wealthy nations, however, we fail to explore how health services might be provided with limited resources and under less optimal circumstances. Over the past two decades, less technically developed countries around the world have piloted health programs designed to reach impoverished and disenfranchised populations. Many of these programs have been part of an international effort spearheaded by the World Health Organization to provide “health for all by the year 2000” [3-51. This article compares the development of two programs that provide community health services for the undeserved poor in very different contexts, Mexico and the United States. We show the common challenges that are faced in developing innovative health care programs and identify strategies that have been successful. The Mexican program was established in 1979 when federal policy-makers in Mexico City designed a program to deliver health services to millions of the rural poor. The program, IMSS-COPLAMAR (now renamed IMSS-Solidaridad), was created by a rural development program called the Coordination of the Plan for Depressed Zones and Marginal Groups (COPLAMAR), and administered by Mexico’s large social security institution, the Mexican Social Security Institute (IMSS) [6-121. The U.S. program, Community Health Centers (CHCs), was founded in 1965 as a small part of the War on Poverty. Originally the program was called the Neighborhood Health Center program and was

under the Office of Economic Opportunity (OEO), the central War on Poverty agency. The program was later shifted to the Department of Health, Education, and Welfare (now Health and Human Services). Both nations’ programs were designed to bring health services to areas with limited or no existing health care. In Mexico, the focus was on rural areas, while in the United States the focus was more urban. Both were large programs. At its height in 1985, IMSS-Solidaridad officially covered over 13 million people in 31 states through a network of 3246 rural clinics and 65 hospitals [13]. Program staff estimated that 3040% of the users were from indigenous ethnic groups (many of whom, especially women and the elderly, spoke no Spanish), and l&50% of users lived in conditions that put them below basic subsistence levels [13, p. 58, 14, 151. In the United States, CHCs served 4.2 million persons through 872 centers at their peak in 1982. The users were mostly poor and from minority groups [16]. By 1990, the CHC program consisted of 535 centers serving over 5 million persons [17]. There is evidence that both programs were successful in improving health services. In Mexico, an unprecedented commitment of resources pen ritted IMSS-Solidaridad to develop a health service infrastructure in remote rural areas that previously lacked institutional services [18]. As a result, permanent prevention programs and medical services were introduced into thousands of rural comma nities. In the United States, evaluations have found that CHC services have improved access to primary care, reduced hospitalization, and improved the health status of users [19,20]. The following sections examine the history and functioning of these two programs and how each

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program might learn from the problems and innovations of the other. The analysis is noteworthy because of the common challenges of health care innovation faced by these two very different countries. STUDY DESIGN

Data on Mexico came from 18 months of field research in Mexico conducted between 1986 and 1988 and updated in 1990. Data are derived from interviews with federal program officials, health planners and researchers, staff in federal and state offices, and community clinic staff. In addition, indepth interviews have been conducted with 42 medical and community action promoters (PACs) in the states of Puebla and Oaxaca [21]. Informal interviews and observations have been undertaken at 31 village program sites. Information on the U.S. Community Health Center program is based on published and unpublished program data along with interviews conducted during 1991 with nine of the CHC directors or their designates in two U.S. cities (Los Angeles and St Louis), interviews with three community health activists in those cities, and two key Congressional staffpersons [22]. INNOVATION

AND ITS ANTECEDENTS

It is commonly accepted in public scholarship that most policy making is incremental. Established interests are often difficult to dislodge and rewards for bureaucrats and legislators for radical innovation are few. Both programs in this study diverged from this incrementalist tendency in that they represented significant departures from previously held health policies. In Mexico, prior to the creation of IMSS-Solidaridad, a few health resources went to the rural poor. Instead, extensive health and other benefits were used as rewards for key occupational groups in the rapidly expanding urban industrial and civil service sectors [23,24]. The Ministry of Health (SSA), the principal public health agency, concentrated most of its efforts in cities and larger towns. In 1978, it was estimated that out of a population of nearly 70 million, between 20 and 25 million had no access to permanent health services. Most of these were in rural areas [24]. However, earlier efforts to extend health services to rural areas had provided valuable experience and models of service delivery, and by the end of the 1970s rural areas were targeted by reformers in IMSS and COPLAMAR for development of a health services infrastructure [24-291. Likewise, in the United States, the Community Health Center (CHC) program departed significantly from the U.S. model of health care in the mid-1960s. The newly enacted Medicare and Medicaid programs reinforced the prevailing model of health care delivery by purchasing care on a fee-for-service basis

STEVEN P.

WALLACE

from existing doctors and hospitals. The CHC program, in contrast, was founded by reformers in the federal government who wanted to develop a new model of primary health care. They hoped that the successful operation of a network of community based health centers in poverty areas would serve as the impetus for establishing comprehensive community health centers in nonpoverty areas as well, thereby significantly changing the structure of the U.S. medical care system [30]. THE CONTEXT

OF CHANGE

In some ways, both Mexico and the United States found themselves in similar circumstances during these periods of primary health care innovation. Both countries had faced social unrest and discontent during a period when resources were available to finance health services. In Mexico, the ruling Institutional Revolutionary Party (PRI) was concerned about loss of its base of rural political support. Years of promises of agrarian reform with only limited results, political repression, and growth of export-oriented agriculture had contributed to independent peasant organizing and discontent [31]. The PRI was searching for new strategies to shore up its alliance with the peasant sector. Falling agricultural productivity also prompted government reformers to shift resources to the peasant sector in an effort to bolster the rural economy. One of the most important initiatives was COPLAMAR [31,32]. By directing funds to impoverished rural areas, the goals of COPLAMAR were to increase productivity, employment, and public services coverage [33]. IMSS-Solidaridad, the rural health program, was a centerpiece of this large rural development program. Finally, the development of rural health services was aided by IMSS’s decision to use the COPLAMAR program as a method to approach its historical mandate of providing universal coverage. Unable to incorporate the rural poor under the traditional financing mechanisms of social security, IMSS officials viewed COPLAMAR as an opportunity to increase substantially its ‘solidarity’ with the rural population [l 11.In 1985, IMSS provided health coverage to 32 million of Mexico’s almost 80 million people. By including the 13 million people covered by IMSS-Solidaridad, IMSS’ coverage grew to more than half the Mexican population. Although IMSS provided extensive administrative and technical support, its direct financial contributions totaled less than 10% of rural health budget, with the remainder coming from general revenue. In the United States, the civil rights and black power movements and the urban riots of the 1960s provided a context in which poor and minority communities were demanding government attention to the problems of discrimination and poverty. While

Innovation in primary care

health care was not originally anticipated as a War on Poverty program, other community based initiatives highlighted the ill health of many of the poor, and the lack of accessible and affordable medical care [34-361. Social unrest often provides the impetus for policy innovation, but if resources are scarce policies may be only symbolic. On the other hand, if resources are abundant, the policy innovation may be substantial. An unusual feature of the United States during the 1960s and Mexico during the 1970s was that both nations were in economic boom periods. As the economy grew rapidly, government officials in the United States worried about the harmful effects of federal budget surpluses in the early 1960s. Scores of new programs were initiated with little initial concern about their costs [37]. In Mexico, revenues from recently exploited oil fields were flowing into the treasury, buoyed by OPEC price hikes. Western banks, in order to gain access to OPEC capital, were encouraging borrowing by countries like Mexico. Thus, between 1979 and 1982, Mexico had its own money to spend as well as easy access to credit. This allowed the government to expand services to the countryside while maintaining services to important constituencies in the cities. STRUCTURE,

GOALS AND PROGRAMS

Clinics of IMSS-Solidaridad and the initial CHCs were each designed to serve a catchment area, with services available to any family living in the area regardless of ability to pay. This community focus departed from the Mexican model of covering selected occupational groups, and also departed from U.S. model of solo practice and fee-for-service payments. In both Mexico and the United States, the primary targets of the new programs were areas that had previously received no permanent institutionalized health care or were designated as medically underserved [35,38,39]. The Mexican program provided clinic-based primary health services and rural hospital care in all thirty-one states, but with special emphasis on impoverished indigenous and peasant areas in south and central Mexico. Services were aimed at the prevention and treatment of respiratory, gastrointestinal, and parasitic infections endemic in rural areas. The small rural clinics provided family medicine, maternal and child care, detection and control of chronic and degenerative diseases, prevention and immunization against contagious diseases, and family planning. For example, according to official program statistics, 31.6 million vaccinations were administered between 1983 and 1986; over 13 million cases of chronic disease, including malnutrition, rheumatic fever, and hypertension, were detected between 1982 and 1986; and over 25 million office visits were made between 1982 and 1986 [15]. SW

35;12--B

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Major community health objectives in Mexico were to improve sanitation, nutrition, housing, and health education [40]. Although financial, material, and human resources for these community projects were more limited than medical care, many clinics successfully encouraged building of latrines, construction of floors in houses, improvement of community water supplies, boiling water, and eradication of pests. For example, in 1986, the program supported improvements in sewage treatment, garbage disposal, and water purification for over 300,000 families each. The program estimated that 25% of families in its catchment area were affected by these community health activities [14, 151. In the United States, the initial CHCs not only provided basic medical services such as physician care, X-rays, and pharmaceuticals, but also offered transportation, preventive care, health education, social services, and outreach [41]. With their broad community focus, some centers helped residents improve sanitation by building wells, repairing homes, and providing job training. One center even assisted in setting up a farm co-op to improve the availability of food. Centers were seen as taking part in the War on Poverty not only by improving the health of area residents, but also in meeting basic needs [16, 191. While the scope of CHC goals became more focused on direct health services over the years, they continued to reach significant numbers of persons. In Los Angeles alone in 1990, federally funded CHCs provided a variety of medical services to over 100,000 persons. Over one-third of the users were reproductive aged women and one-quarter were children [17]. The CHC system was designed to provide only primary care since acute care hospitals were generally available. In some areas, however, patients were forced to use distant public hospitals because some centers did not have viable relationships with nearby private hospitals [42]. In rural Mexico, where few hospitals existed, IMSS-Solidaridad constructed 65 hospitals to provide secondary care for patients referred from clinics, as well as primary and secondary care for patients from the surrounding area. Distance and lack of transportation have reduced rural hospital utilization rates by community clinic patients [18]. For tertiary care, patients must travel to large Ministry of Health (SSA) hospitals in the cities. Personnel

Staffing concepts are similar in both Mexican and U.S. clinics. However, the staffing model has not been as great a departure for Mexico as it has been for the United States. In Mexico, each clinic has a doctor, clinic assistants, and outreach workers. With few exceptions, each clinic is directed by a doctor [43]. Most doctors are recent medical school graduates, including a large number completing the mandatory one year of Social Service required of all medical students in Mexico [44]. The system helps slightly to

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redistribute medical resources away from urban centers and into rural areas. By providing field training in family, and rural practice and by encouraging doctors to commit more than the required one year of Social Service, the program has developed a corps of rural doctors [45]. Unfortunately, these efforts-particularly field specialization in family practice-have been constrained by financial pressures since the mid-1980s. In Mexico, the use of indigenous health workers at the community level has been introduced, but has not substantially altered, existing status relationships in the medical system. At each clinic, two village women, trained by IMSS, serve as assistants. They undertake essential medical tasks (such as administering injections and first aid), assist the doctor in the clinic and in the community, and keep the clinic clean. The assistants are also bilingual and act as interpreters and links to the community. Outreach workers also are recruited locally and work in surrounding communities to provide rudimentary health services, make referrals, and help organize health projects. Clinic staff are encouraged, with some success, to train and develop working relationships with traditional health practitioners, especially midwives. Despite these important efforts, training and support for indigenous health workers are still limited. In the United States, all forms of group practice have been vigorously opposed historically by the American Medical Association, as have arrangements that might reduce physician autonomy and control [46]. The establishment of CHCs contradicted those traditional arrangements by using salaried physicians in an interdisciplinary group practice that included other health professionals, including nutritionists, social workers, and health technicians. Like the Mexican system, the CHCs came to rely on recent medical graduates who were completing a service payback. The U.S. program, the National Health Service Corps (NHSC), began in 1970 and grew to become an important source of financial aid for medical school students by the early 1980s with as many as 8000 students on award or deferment status [47]. The program required a service playback which could be rendered as a solo practitioner in a medically underserved community or by practicing in a community health center. The Reagan administration greatly curtailed the NHSC. In the early 1990s there were fewer than 100 new service obligations coming due annually [39].

COMMUNITY

PARTICIPATION

One additional innovation is the commitment to community participation. In Mexico, community participation was perceived originally as a way to empower communities, but it has been utilized primarily as a mechanism to increase community

P. WALLACE

involvement in service provision and compliance with health objectives. In the United States, community participation was seen primarily in political and economic terms. The centerpiece of community participation in IMSS-Solidaridad is in-kind contributions by villagers in ‘payment’ for health services. A family’s in-kind contribution usually consists of family health activities such as constructing a latrine, attending a health education session, bringing a child in for a well-baby check-up, making home improvements, or planting a garden. Although families are required to make some form of contribution, health care is rarely denied those who do not participate. Beyond family-focused health activities, health infrastructure projects are also undertaken in some communities. In the absence of adequate funding for sanitation, water, and nutritional programs, families and communities make contributions of labor, land, and sometimes money, for clinic construction, sanitation and water projects, and nutrition programs. Sometimes the government or a non-profit group provides the raw materials for these projects. But communities have assumed major costs associated with community health projects. These efforts diminished somewhat during the economic crisis of the 1980s but have reportedly increased since 1990 with the initiation of the National Program of Solidarity, a development program created by President Carlos Salinas de Gortari [48]. To help in program operations, a structure of community participation has developed in each community. Villagers are involved in the community health program as volunteers and members of health committees. Volunteers monitor health needs, help in the clinic, and learn basic nursing skills. Locallyelected health committees oversee the community health program and provide supportive services. At the municipal level, health councils bring together village leaders, school directors, and public agency representatives to promote involvement in the health IMSS-Solidaridad employs speciallyprogram. trained community action promoters (PACS) who spend 1 or 2 weeks annually in each community helping staff with participation activities and searching for resources for health projects. Although community participation was originally conceived of as a way to strengthen the planning and negotiating capacities of poor communities in Mexico, participation focuses on service delivery [33]. It does not promote formal and direct involvement in policy decisions at the state and federal levels [49]. The highly centralized political and bureaucratic structures leave the important policy decisions in the hands of central authorities. In the United States, community participation in CHCs was viewed more as a part of broader social change. The key concept in the CHCs was that there should be “maximum feasible participation” of the community, a form of empowerment that would

Innovation in primary care improve health services as well as provide skills to help in the larger War on Poverty [50]. Participation was initially seen as assisting communities in enhancing control in all spheres of life [36]. The major innovation was the attempt to give local communities control over their own centers. This was accomplished by encouraging centers to have governing boards-and mandating them after 1975-where local residents would form a majority. According to national policy, those boards had authority to establish general policies, approve budgets, and approve the selection of the CHC director [41]. In the early 1990s about half of all board members nationally were clinic users, conforming to minimum requirements [35]. Respondents from St Louis and Los Angeles CHCs generally reported ‘active’ boards, but as in many organizations, the most significant policy and operational initiatives were likely to originate from executive directors. The U.S. model also encouraged community participation by hiring community residents to work in the clinics. In the early years, even board members received a small stipend for their participation [51]. While the centers increased local employment opportunities, most employees from the target neighborhoods were in lower paying positions with little or no career ladder [34]. By emphasizing employment, officials in the United States effectively encouraged a degree of local support. However, this model involved a smaller segment of the community in creating the clinics than the Mexican model. The small base of community participation in the United States created problems in mobilizing community support when funding was cut and clinics closed in the early 1980s. While most federal job training funds for CHCs were eliminated in the 1970s [19], many centers have continued to foster community involvement and training at some level. Two centers in the Los Angeles area, for example, provide job training programs using special grants. Most of the centers also report the use of community volunteers in their centers, building links to the community and perhaps providing volunteers with new skills. RESISTANCE OF ENTRENCHED INTERESTS

There have been three types of resistance to innovative health programs in both Mexico and the United States: local, professional, and bureaucratic. Although local officials in Mexico were generally eager to have clinics in their communities, many were less supportive of community participation efforts. Some local officials viewed community participation as an incursion into local affairs and a possible threat to their positions as mediators between villagers and the larger society [52,53]. In most cases, resistance was expressed through lack of support or withholding approval. In extreme cases, clinic staff were threatened and clinics sabotaged. Resistance by local officials has decreased over the years. Not only have

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IMSS-Solidaridad’s staff learned to work more closely with local officials, but community participation demands have changed. Instead of mobilizing villagers for community-wide development projects, the program began to emphasize family health issues and behavior changes. Activities such as constructing family latrines and immunizing children are less threatening to a local official than projects that may affect community power relations, such as water distribution or formation of committees. Also at the local level in Mexico, resistance by traditional health practitioners has challenged program staff. This resistance reflects a more generalized hesitancy on the part of the population towards aspects of institutional medicine. Among all traditional practioners, working with midwives is easiest because their support can be won by providing training and free birth supplies. Clinic doctors generally have not adopted a competitive stance with respect to midwives. However, practitioners such as curanderos, bonesetters, and herbalists, have presented a more complex dilemma. This dilemma arises in part because traditional medical roles often overlap with other roles, such as spiritual healers, mentors, or fellow villagers, and in part because many clinic doctors present their medicine as a preferred alternative to traditional medicine. Since the early 198Os, program planners have responded with a series of initiatives including studies and training that address the relationship between institutional and traditional medicine [54-561. Unlike the United States, there has been little organized resistance by medical practitioners in Mexico. A tradition of public service in medicine, shortages of physicians in rural areas, severe unemployment among physicians, and a less powerful physician lobby have facilitated IMSS-Solidaridad’s efforts to win support among medical practitioners [57-591. In addition, although many doctors are reluctant to leave their urban homes and work in rustic conditions in the countryside, some have been willing to do so because employment in the rural health program has been an avenue to stable employment with IMSS [60]. Resistance, however, did come from Mexico’s principal public health agency, the Ministry of Health (SSA). With its meager budget, SSA had provided most rural health services prior to 1979. When IMSS signed the agreement to provide rural health services, it was taking over part of SSA’s traditional constituency-the poor. In 1984, President de la Madrid, following plans initiated in the previous Presidential administration and under pressure from international lending agencies, ordered a ‘decentralization’ of rural health programs. Decentralization transfered responsibility for rural health from IMSS to state level health services funded by SSA. A total of 14 states were transfered by 1987. But the process was halted midstream in response to footdragging by IMSS and the nation’s economic crisis. Currently, the rural

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health program remains split between the two federal entities [61]. In the United States, local officials were upset by many of the War on Poverty programs in the 1960s because they bypassed state and local political bosses. Since the concept was to empower the poor, not to enhance the power of local politicians, most War on Poverty programs provided grants and programs directly from the federal government to nongovernmental organizations in communities. This created competing sources of power in communities, and local political officials fought to gain control of the new resources [62]. However, this opposition by local power elites did not focus on CHCs in large part because community activities involving CHCs did little to mobilize local communities to broader action or otherwise threaten the position of local political officials (see below) [36,41]. Instead, medical professionals provided the main source of resistance in the United States. The power of organized medicine is well documented [46]. The medical profession and hospitals were successful in safeguarding their interests in the new Medicare and Medicaid programs in the mid-1960s [63], making it clear that the CHC program needed to avoid antagonizing the medical profession. Simple economic competition also generated resistance by local doctors and pharmacists [41, 511. Resistance was reduced, first, by selecting only medically underserved areas so that CHCs would compete with very few private physicians. Second, the initial clinics were sponsored by university medical centers, providing them with academic legitimacy and institutional backing [36]. Competition continued to be an issue, however. In some neighborhoods, local drug stores opposed including pharmacies in the CHCs. Physicians were concerned that the use of geographic catchment areas rather than categorical economic need criteria would draw away paying patients. To address physician concerns, Congress instructed CHCs to target services to the poor starting in 1967. Potential competition was further limited in 1969 by restricting private pay patients to 20% of a clinic’s caseload. [36]. Fears of competition by private physicians were largely unfounded. Only about one-quarter of CHC patients had previously used a private doctor [20]. By the early 199Os, almost all CHC patients had incomes below two times the poverty level, 49% had no public or private insurance, and only 12% had any private insurance [35]. There was also a degree of mistrust between African-American communities and the white power structure [51]. While using academic medical centers helped to reduce fears of local doctors, it also placed effective control over the centers in the hands of white professionals and universities. Although later grants for CHCs were awarded to community groups rather than medical centers [41], the early thrust of the U.S. program created inevitable conflicts

P. WALLACE

between radicalized communities, conservative medical centers, and a federal government that wanted quick results [34]. At the national level, there was conflict between health reform advocates in the OEO, where the program was initially housed, and traditional health bureaucrats in the Department of Health, Education, and Welfare (HEW). The health centers were gradually transferred to HEW as the War on Poverty was dismantled during the 1970s. HEW was more concerned with traditional outcome measures and less concerned with community development. The OEO held on longest to some struggling centers to protect them from a perceived hostile environment at HEW 1361. CHALLENGES TO PRIMARY HEALTH: LOCAL CONTROL AND COMMUNITY HEALTH

Both IMSS-Solidaridad and CHCs have encountered difficulties in fully implementing the primary health model championed by the World Health Organization (WHO) [3]. Three key challenges to the WHO model have been (1) how to give communities control over policies that affect program implementation at the local level, (2) how to develop a corps of health practitioners that are trained and committed to work in community health, and (3) how to address health concerns whose solutions lie partially outside the realm of medical science. Regarding local control, mechanisms are needed to ensure that health activities are responsive to geographic, economic, social, and political variations. In Mexico, however, IMSS-Solidaridad is highly centralized. Service delivery, staffing, and facility design are fundamentally the same in every community. This may help facilitate service delivery, maintain accountability, and contribute to equity in service delivery [64,65]. However, it also discourages local innovation. For example, one supervisor described an active but fragmented community in the State of Oaxaca. Because of the level of conflict, leaders divided the populace into health zones. Each had a health committee and was active in promoting street cleaning, latrine construction, immunizations, and so forth. This worked reasonably well. However, to meet formal requirements, the supervisor reported only one health committee to program officials. The supervisor thought that the community should have been able to be candid about its innovative solution, which might encourage further experimentation. The CHC program in the United States initially eschewed a single model so that communities could experiment and adapt programs to suit their needs. By the 1970s however, financial constraints and a more conservative federal government led to an increasingly uniform model and stricter federal mandates [36]. This uniformity was relaxed somewhat in the late 1980s as CHCs individualized their services to pursue contracts and grants. Examples of center-

Innovation in primary care

specific programs in Los Angeles and St Louis include a school based satellite clinic, immigrant services under the amnesty impact grant program, homeless health care projects, WIC (Women, Infants and Children program) services, AIDS services, and drug abuse programs. Reliance on extra programs generated by state and local grants contradicts the original CHC mission of providing comprehensive services based on community need. For example, one CHC in this study was forced temporarily into bankruptcy in part because it continued programs where there was a perceived need even after grant funds ended. While grants from multiple sources have helped individualize the programs of CHCs, they leave ultimate control over the availability of services in the hands of noncommunity agencies and the ever changing funding priorities for specific health problems. Turning to personnel, another issue in primary care is the need to develop a corps of community health practioners [45]. This requires more training and residency programs in community health care and family practice. In both Mexico and the United States, community health efforts have been frustrated by physicians trained for highly specialized hospital procedures, but relatively untrained for work in impoverished communities where the major health problems may be nutritional deficiencies, common infectious diseases, infant mortality, diabetes, or drug abuse [49, 59,651. More training opportunities are also needed for allied community health professionals and indigenous caregivers. Perhaps of greater importance is the lack of incentives for physicians and allied health providers to choose community health careers. Currently, there are high costs associated with this choice, particularly for physicians. These include limited job options, comparatively low salaries, poor working conditions, little public recognition, few research resources, and restricted career ladder options. In order to build a corps of community health practioners, these costs will have to be addressed. A third challenge to primary care is how to address broader community health issues. In both the United States and Mexico, the delivery of traditional primary care has received greater attention than prevention of health problems associated with malnutrition, poor housing, environmental hazards, and alcoholism and drug abuse. Several factors contribute to IMSSSolidaridad’s difficulties in addressing these broad health and welfare issues. Historically, low expenditures for rural social welfare have limited the scope and duration of rural programs [57, 661. Financial constraints have not permitted IMSS-Solidaridad to fund large-scale community health projects. Community action promoters were added in 1983, but additional resources have not become available for health projects they might initiate, such as water purification, waste disposal, nutritional supplements, adult education, and so forth. At the same time, other

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Mexican federal agencies have withdrawn funds for rural development, making collaborative projects increasingly less common. Broadly conceived health projects were part of the initial design of the CHCs in the United States, and several early centers developed programs for inadequate income, insufficient food, and other community-wide problems [16]. However, as the network of CHCs expanded, there was increasing pressure on centers to obtain funds from traditional sources, especially Medicaid and Medicare. Since both of those programs fund only a narrow range of curative medical procedures, much of the community oriented programing has been abandoned [36]. This is an unfortunate development because, in national surveys, CHCs identify teen pregnancy, drug abuse, and infant mortality as the three most urgent needs in their communities [35]. These health problems require community-wide solutions in addition to individual medical services paid for by Medicaid or Medicare. Funding is not the only issue. In IMSS-Solidaridad, most key decisions are made by physicians at both the central and local levels, despite the multidisciplinary staff. Similarly, in the United States the principal concerns of policy makers appear to be finding and installing doctors in underserved areas and keeping medical criteria at the center of decision making [39]. These facts have undoubtedly contributed to the emphasis that both programs place on medical services and their difficulty in addressing broader community health issues. care is Finally, community-based primary hampered by fragmentation. In Mexico, fragmentation of services offered by social security and public health bureaucracies contributes to ineffiencies [67,68]. In the United States, many county clinics and programs are not coordinated with federally funded clinics. Most St Louis and Los Angeles CHCs reported limited or no contact, much less coordination, with county health centers. A Los Angeles respondent noted that county clinics were a ‘closed system,’ while a St Louis respondent had to be reminded that county clinics even existed.

SURVIVAL

OF INNOVATION

The worldwide recession of the 1980s threatened the resources of both IMSS-Solidaridad and CHCs. In Mexico, falling oil prices, a huge international debt, and neoliberal government policies led to massive cuts in health and welfare expenditures [69]. In the United States, President Reagan turned the War on Poverty on its head by giving tax breaks for businesses and the rich while cutting government programs for the poor [70,71]. Somewhat remarkably, however, both the Mexican and U.S. programs have survived due, in large part, to their institutional bases of support.

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SHERRADEN and STEVEN P. WALLACE

IMSS-Solidaridad’s continued survival is attributable, in part, to the institutional position of IMSS. This position has little to do with IMSS’s experience in assisting the rural poor, but rather its strong base of support among blue collar workers, employers, and the government. This support has created secure funding and a political base. Therefore, affiliation with the resource-rich IMSS has provided IMSSSolidaridad political support, indirect subsidies, a well-developed administrative structure, and a generally favorable reputation in health care delivery. Further evidence of IMSS’s powerful base is the suspension of the decentralization process in the late 1980s and renewed growth of IMSS-Solidaridad. Although IMSS-Solidaridad has not resumed jurisdiction over the 14 already-transferred states, it received increasing federal funds and added 731 clinics and one hospital in the late 1980s. Funding has come from the newly-created National Solidarity Program, a national development program designed much like COPLAMAR in the 1970s [48]. Leadership at the federal level has also generated a sense of commitment to IMSS-Solidaridad among administrators and staff. Planners created extensive linkages between central offices and clinics to ensure successful implementation. Supervision, supplies, and training have reached most clinics no matter how remotely located. Supervisors know what is happening at their clinics, they visit regularly, and they attempt to ensure that services are free and available to the entire community [18]. In the United States, analyses of CHCs have found limited political power and mobilization among the users of the centers [34, 361. Therefore, other factors have been involved in the survival of some CHCs through the 1980s as the Reagan administration proposed their elimination and budget deficits squeezed the federal funds available to CHCs. Fiscal crisis and concern over medical costs meant that the justification for CHCs could no longer be on the basis of improved access or medical innovation, but had to rest on cost effectiveness [19]. In the face of substantial budget cuts, the federal CHC leadership decided to close financially inefficient and politically embarrassing centers rather than subject all centers to equal cuts. As a result, approx 25% of the centers were closed and another 25% faced significant cuts, but half were able to retain nearly constant funding [36]. This was a political strategy taken at a national level, without consultation with affected communities. In short, it was not community political mobilization that helped CHCs survive, but bureaucratic strategy at the federal level. Prospects for CHCs in the United States have improved in the late 1980s and early 1990s. The centers have been moderately successful in diversifying their sources of funding. By 1990, on a nationwide basis, centers obtained only 40% of total revenues from the core federal program [17]. About 43% of revenues came from payment of services (e.g.

Medicaid), and this percentage is likely to grow because federal legislation has mandated that Medicare and Medicaid reimburse federally qualified CHCs for the full costs of services in place of the current fee schedule. All CHC respondents in St Louis and Los Angeles felt that this new provision would increase revenues, allowing them to expand services. In addition, most states have expanded the eligibility of mothers and children for Medicaid as a result of changes in federal laws. The increased number of women and children who will be able to pay for their services with Medicaid will increase the revenues of CHCs. The Medicare and Medicaid changes are particularly important because they are entitlement programs that may have a more secure future than the discretionary CHC grant program. As with efforts made to protect the CHC program in the 1980s expansions in the 1990s are the result of legislative and bureaucratic initiatives rather than community mobilization. Thus, both the Mexican and U.S. health programs have overtly attempted to involve local communities in the operation of the programs, but they have been bureaucratic and larger political ‘investments’ in the programs have been most influential in protecting funding during lean years and increasing funding when resources have been more available. SUMMARY

AND CONCLUSION

IMSS-Solidaridad in Mexico and CHCs in the United States have made important advances in health care for the poor, but there is more to be done. First, neither program provides adequate health services for all of the poor. In Mexico, beneficiaries of IMSS-Solidaridad receive fewer and less specialized services than urban IMSS beneficiaries, and access to both primary and secondary care is lacking in many rural areas. Between 5 and 7 million Mexicans still lack access to any institutional health care, and in 30% of communities between 500 and 2500 people there are no health services whatsoever [67, 721. In the United States, over 35 million people still have no health insurance and often obtain insufficient medical care. The poor disproportionately continue to use hospital outpatient clinics and emergency rooms where they receive episodic care [73,74]. The number of community health centers would have more than double to reach all areas currently underserved in the United States [35]. Thus, while both the Mexican and U.S. programs serve as important models for service delivery in poor communities, both lack the resources for expansion to the entire population in need of health care. Second, both programs bring to light the inadequacy of health care staffing in community health. Added incentives are required for doctors to serve in poor communities. Training and genuine career opportunities in health care to the underserved are needed. Paraprofessionals and non-medical

Innovation

professionals should be incorporated into the core of community health care. In order to serve poor communities, it is crucial to incorporate people into the health delivery system who speak the local language and understand local health issues. Third, community health programs should foster local decision-making. One of the recurring issues in development programs is how to give without taking away. Attempting to provide services without undermining effective and time-honored care arrangements is sometimes very difficult and requires tremendous flexibility in implementation. However, it is worth the effort because the program is better accepted and communities have much to offer in innovative ideas, labor, and financial assistance [75]. The accompanying risk is that increased local autonomy may become an excuse for reducing or eliminating the federal role in providing resources to needy areas [71]. The parallels in the histories of the two programs are noteworthy. Despite substantial differences in the power of the medical professions, the geographic locations targeted, and the political and economic contexts, both programs were established and developed in similar forms. Possibly this occurred because the programs were designed, implemented, and funded by policy elites, albeit reformist ones. Even though they tried to move away from traditional models of primary health care delivery, the ultimate institutionalization of the programs required that they operate without disrupting state bureaucracies and established political relationships. In the end, it was bureaucratic and political support that protected the programs in hard economic times. Other cases of primary care innovation should be examined in order to ascertain whether this pattern of innovation occurs in other settings. To determine how innovation in primary care can best be nurtured, we should examine grass-roots innovation (such as the U.S. free clinic movement), government-sponsored innovation in other nations, and innovation initiated within individual organizations. Acknowledgements-This research was supported by fellowships from the Inter-American Foundation, Fulbright, and Washington University Graduate School to Professor Sherraden, and research funds from the University of California-Los Angeles School of Public Health, and its Health Careers Opportunity Program to Professor Wallace. We would like to thank Louie Martirez for his help with the U.S. CHC interviews, anonymous reviewers for their helpful comments on an earlier draft, and the many people interviewed in Mexico and the United States for their assistance.

REFERENCES

For example, see Marmor T. American medical policy and the ‘crisis’ of the welfare state: A comparative perspective. In Health Policy in Transition (Edited by Brown L. D.), pp. 49-63. Duke University Press, Durham, NC, 1987. Hollingsworth J. R., Hage J. and Hanneman R. A. State Intervenrion in Medical Care. Cornell University Press, Ithaca, NY, 1990.

in primary care

1441

3. World Health Organization, Declaration of Alma Am, Report on the International Conference on Primary Health Cure (ICPHC/ALA/78.10). World Health Organization, Alma Ata, Russia. 1978. Mburu F. M. and Boerma J. T. Introduction: Community-based health care 10 years post Alma Ata. Sot. Sci. Med. 28, 1005-1006, 1989. Koch-Weser D. and Yankauer A. What makes infant mortality rates fall in developing countries? Am. J. Publ. Hlth 81, 12-13, 1991. The creation of IMSS-Solidaridad is discussed by Spalding R. State power and its limits: Coruoratism in Mexico.- Comp. Political Stud. 14, 139-161: 1981. For an in-depth study of an IMSS-COPLAMAR clinic in the highlands of Oaxaca, see Stebbins K. R. Curative medicine, preventive medicine and health status: The influence of politics on health status in a rural Mexican village. Sot. Sci. Med. 23, 1399148, 1986. 8. Stebbins K. R. Politics, economics, and health services in rural Oaxaca, Mexico. Hum. Organ. 45, 112-119, 1986. 9. For a discussion of various aspects of IMSS-Solidaridad, see Moreno Salazar P. H. and Redorta Zufiiga G. E. Notas Para el Analisis a’e la Politica del Sector Salud: El Caso del ZMSS-COPLAMAR. CIDE, Departamento

de Administracien

Wblica, Mexico. 1984.

10 Mesa-Lag0 C. El desarrollo de la seguridad social en America Latina. CEPAL, Naciones Unidas, Santiago de Chile, 1985. 11 International Labour Office (ILO) Primary Health Cure and Health Strategies in Latin American Social Security. ILO, Mexico, D.F., 1986. 12. Ward P. Welfare Politics in Mexico: Papering over the Cracks. Allen Unwin, London, 1986. 13. IMSS-COPLAMAR. Sistema unico de information. IMSS-COPLAMAR, Mexico, D.F., Xerox, 1986. 14. Six rural states in central and south Mexico had only one doctor for every 4000-5000 inhabitants in 1970, while in Mexico City the ratio was one doctor for every 474 inhabitants. Lopez Acufia [24]. A survey conducted by IMSS-Solidaridad in over 2700 rural communities in 1981 found that 67% of the households lacked water, 90% lacked sewage disposal of any kind, and 50% lacked electricty. IMSS Diugndstico de Salud en las Zonas Marginadas Rurales de Mexico, p. 55. Instituto Mexican0 de Seguro Social. IMSS-COPLAMAR. Mexico, D.F., 1983.15. IMSS Diagnostic0 de Salud en las Zonas Marginadas Rurales de Mexico. Instituto Mexican0 de Seauro Social, IMSS-COPLAMAR, Mexico, D.F., 1988. * 16. Geiger H. J. Community Health centers: Health care as an instrument of social change. In Reforming Medicine (Edited by Side1 V. and Side1 R.), pp 11-32. Pantheon, New York, 1984. 17. U.S. DHHS (Department of Health and Human Services). Unpublished data from the Bureau Common Reporting Requirements, Division of Primary Care Services, Bureau of Health Care Delivery and Assistance, Health Resources Services Administration, Washington, D.C., 1991. 18. Sherraden M. S. Social Policy reform in Mexico: Rural primary health services. Unpublished doctoral dissertation, Washington University, St Louis, 1989. Institutional health services refer to some form of western health care, such as government health services or private medical doctors. This type of health service is contrasted with traditional and domestic health care, which is pervasive in rural Mexico. 19. Davis K. and Schoen S. Health and the War on Poverty. Brookings Institute, Washington, D.C., 1978. 20. Freeman H. E., Kiecolt K. J. and Allen H. M. II. Community health centers: An initiative of enduring utility. Milbank Memorial Fund Q. 60, 245-267, 1982.

1442 21

22.

23.

24. 25.

26.

21. 28.

29.

30.

31.

MARGARET SHERRARD SHERRADEN and STEVENP. WALLACE

Supervisors and PACs were chosen because they are particularly well-placed in the organization to shed light on policy implementation. In interviews, the most successful and least successful community programs in each supervisor’s zone were examined. One community in each supervisor’s jurisdiction was selected for indepth examination. The 1-2 hr interview consisted of both closed-ended and open-ended questions. Geographic, economic, political, and social characteristics of each village were discussed along with aspects of program implementation, including community participation, community acceptance, principal health problems, changes in health status, and staff performance. Extreme cases were chosen for discussion in an attempt to sort out the reasons for successes and deficiencies among community programs. Out of the 31 program sites visited, ten were communities examined in supervisor interviews. Observations and informal interviews in these communities offered a chance to corroborate data from interviews and to make independent observations [18]. These communities represent very different social, political, and economic contexts and will, therefore, show how centers respond similarly under different local conditions. Mesa-Lag0 C. Social Security in Latin America: Pressure Groups, Stratification and Inequality. University of Pittsburgh Press, Pittsburgh, 1978. Lopez Acuiia D. La Salud Desigual en MPxico. Siglo Veintiuno Editores, Mexico, D.F., 1984, 5th edition. It is important to note that Mexico had made efforts since the 1920s to provide rural health services. Mobile brigades in the 1920s provided rudimentary health care to some rural areas. Later, during President CHrdenas’s term and again in the 1950s and 196Os, health services were extended to some rural areas. Social Service by graduating medical students was also begun in the 1930s that provided doctor care in some rural areas. Although these programs were important antecedents, the efforts were fragmented, coverage was small, and their share of the budget meager. See HernLndez Llamas H. La atenci6n medica en el medio rural mexicano. In La atencidn MPdica Ruralen Mexico: 1930_1980(Edited by Hernandez Llamas), pp. 21-32. IMSS, Mexico, D.F., 1984. Alar&n Navarro F., Bravo Barrientos H. and Puriel Martinez A. El medio rural mexicano y 10s servicios de salud. In PlanSficacion Familiar, Poblacion y Salud en el Mexico Rural (Edited by Martinez Manatou .I.), pp. 13-50. IMSS, Mexico. IMSS. Extensidn de la Seguridad Social en el Medio Rural, IMSS, Mexico, 1976. In 1973, IMSS created a program called Social Solidarity that served as a prototype for IMSSSolidaridad. Social Solidarity provided limited medical services to agricultural workers in north and north central states of Mexico, but not the indigenous ethnic and poorer areas later emphasized by IMSSSolidaridad. CBrdenas de la Peila E. et al. Nuevos Rumbos: Seguridad Social en Mexico. IMSS, Mexico, D.F., 1975. IMSS. Servicios Medicos de Campo y Solidaridad Social. IMSS, Mexico, 1976; Sherraden [18]. In three years, Social Solidarity had only covered 1.9 million people with 310 clinics and 30 rural hospitals. The Ministry of Health (SSAI also oDerated rural clinics. but most were located ‘in large ruial towns relatively ‘inaccessible to remote rural villages. Schorr L. B. and English J. T. Background, context and significant issues in neighborhood health center programs. Milbank Memorial Fund Q. 46T, 1968. Fox J. The political dynamics of reform: The case of the Mexican Food System 1980-1982. Unpublished

32.

33 34. 35.

36.

37. 38.

39.

40.

41.

42.

43.

44.

45.

46. 41.

48.

49.

50.

doctoral dissertation, Massachusetts Institute of Technology, 1986. These efforts also included the creation of IMSSCONASUPO, a program designed to bring subsidized food to rural &mr&nities, and the Mexican Food System (SAM) which sought to rebuild Deasant amicult&e ani mo;e Mexico Toward food self sufficiency. Spalding R. The Mexican Food Crisis: An Analysis of the SAM. Center for U.S.-Mexican Studies, University of California, San Diego, La Jolla, CA, 1984. COPLAMAR. Memoria de Actividades 1976-1982. Presidencia de la Republica, Mexico, D.F., 1982. Marcus I. Dollars for Reform. Lexington Books, Lexington, MA, 1981. National Association of Community Health Centers. Access to Community Health Care: A Data Book 1991. NACHC, Washington, D.C., n.d. Sardell A. The U.S. Experiment in Social Medicine, the Community Health Center Program 1965-1986. University of Pittsburgh Press, Pittsburgh, 1988. Fuchs V. R. The Health Economy. Harvard University Press, Cambridge, MA, 1986. IMSS. Memoria: Primera Reunidn Anual de Ancilisis de1 Desarrollo de1 Programa ZMSS-COPLAMAR. IMSS, Mexico, 1981. In 1990 there were still 1930 primary care health manpower shortage areas in the United States. Those areas are defined as locations with physician-to-population ratios of approx l-3500 or greater (U.S. Senate, Committee on Appropriations. Community Health Center/National Health Service Corps. Hearings, U.S. Government Printing Office, Washington, D.C. 1990). IMSS El Modelo de Atencidn Zntepral al la Salud de1 Programa de Solidaridad Social por Cooperacidn Comunitaria ZMSS-COPLAMAR. Instituto Mexican0 de Seguro Social, Oaxtepec, Mexico, 1984. Anderson E. J., Judd L. R., May J. T. and New P. K. The Neighborhood Health Center Program. National Association of Neighborhood Health Centers, Washington, DC., 1976. Standard S. Comment on the neighborhood health center and the general hospital. Med. Care 8, 252-253, 1970. Rural health technicians replace doctors in a small number (139 in 1986) of the most geographically remote clinics. They have diverse backgrounds, ranging from former clinic assistant to vocationally-trained health technicians. Sherraden M. S. and Sherraden M. Mexico: Social service by university students. Children/Youth Services Rev. 13, 145-170, 1991. Ugalde A. and Homedes N. Toward a rural health corps concept: Lessons from the Dominican Republic. J. rural Hlch 4, 41-58, 1988. Starr P. The Social Transformation of American Medicine. Basic Books, New York, 1982. Mullan F. The National Health Service Corps and health personnel innovations: Beyond poorhouse medicine. In Reforming Medicine (Edited by Side1 V. and Side1 R.), pp. 176-200. Pantheon, New York, 1984. Consejo Consultivo de1 Programa National de Solidaridad. El Combate a la Pobreza: Lineamientos Programciticos. El National, Mexico D.F., 1990, Rojas Gutierrez C. Avarices de1 Programa National de Solidaridad. Comercio Exterior 41, 443-446, 1991. Sherraden M. S. Policy impacts of community participation: Health services in rural Mexico. Hum. Organ. 50, 256-263, 1991. Sparer G., Dines G. B. and Smith D. Consumer participation in OEO-assisted neighborhood health centers. Am. J. Publ. Hlth 60, 1091-1102, 1970.

Innovation in primary care 51. Davis M. S. and Tranquada

52.

53. 54.

55.

R. E. A sociological evaluation of the Watts neighborhood health center. Med. Cure 7, 105-117, 1969. Par& L. Caciquismo y estructura de poder en la Sierra Norte de Puebla. In Caciquismo y Poder Politico en el Mexico Rural (Edited by Bartra R., Boege E., Calvo P., GutiCrrez J., Martinez VBzquez V. R. and Par&. L.), pp. 31-61, 7th edn. Siglo Veintiuno, Mexico, D.F., 1985. Hewitt de Aldntara C. Anthropological Perspectives on Rural Mexico. Routledge and Kegan Paul, London, 1984. Lozoya Legorreta X. and Zolla C. Programa de interrelaci6n de la medicina traditional con las actividades de1 IMSS-COPLAMAR. IMSS, Jefatura de Ensefianza e Investigacibn, Unidad de Investigacicin Biomtdica en Medicina Traditional y Herbolaria, Mexico, D.F. 1983. Lozoya Legorreta X. La medicina traditional en Mexico: Balance de una dCcada y perspectivas. In El Futuro de la Medicina Traditional en la Atenci6n a la Salud de 10s Paises Lutinoamericanos (Edited by Centro

Interamericano de Estudios de Seguridad Social), pp. 135-150. IMSS, Mexico, D.F., 1987. 56. Moreno Santos R. Experiencias de la interrelacibn de la medicina traditional y el Programa IMSS-COPLAMAR. In El Future de la Medicina Traditional en la Atencibn a la Salud de 10s Paises Latinoamericanos

(Edited by Centro Interamericano de Estudios de Seguridad Social), pp. 173-181. IMSS, Mexico, D.F., 1987. 57. Ramirez Almanza M. A. La formacibn de 10s mbdicos y su utilizacibn en el area rural. Salud Publica de Mbxico 25, 533-539,

1983.

58. Cleaves P. S. Las Profesiones y el Esrado: El Caso de Mkxico. El Colegio de Mbxico, Mexico, D.F., 1985. 59. Frenk J. Medical modernization in Mexico: Paradigms, Labor markets and the State. In Modern and Traditional

64. Leonard D. K. Analyzing the organizational requirements for serving the rural poor. In Decenrralizurion and Organizarional Linkages (Edited by Leonard

D. K. and Marshall D. R.), pp. l-39. Institute of International Studies, University of California, Berkeley, CA, 1982. Bozzini L. Local Community Services Centers (CLSCs) in Quebec Description, Evaluation, Perspectives. J. Publ. Hlth Policy 9, 346-375,

1988.

65. Collado Ardbn R. MPdicos y Estructura Social. Fondo de Cultura Econbmica, Mexico, 1976. 66. Hewitt de Alcantara C. Mexico: A commentary on the satisfaction of basic needs. In Another Development: Approaches and Strategies (Edited by Nerfm M.), pp. 153-163. Dag Hammarskjold Foundation, Uppsala, Sweden, 1977. 67. According to data reported in Cruz River0 et al. 1990, in 1988 only 13% of the federal health budget was spent on health care for “the open population,” who comprised 33% of the population. The “open population” is defined as those who are not covered by the better funded social security programs or by private care (Cruz River0 C., Lozano Ascencio R. and Querol Vinagre J. Consecuencias de la crisis econimica y las politicas de ajuste sobre la salud de la poblacion y la organization de 10s servicios de salud en Mexico. Mexico, October 1990, Xerox.) 68. For a discussion of fragmentation, coordination of services, and restructuringthe health system in Mexico, see Soberon G.. Kumate J. and Lamma J. (Eds) La Salud en Mexico: Testimonios 1988,~Fundam&zroi del Cambio Estructural. Secretaria de Salud, Fondo de

Cultural Econbmica. Mexico. D.F.. 1988. 69. Cordera Campos R: and Gonzalez Tiburcio E. Crisis and transition in the Mexican economy. In Social Responses to Mexico’s

Health Care in Developing Societies: Conflict and Cooperation (Edited by Zeichner C. I.), pp. 195-207.

University Press of America, New York, 1988. 60 The economic crisis of the 1980s has made the possibilities for permanent employment in IMSS’s regular social security programs less likely. Furthermore, employment at IMSS does not provide the benefits that it did in the past, when the Institute’s resources were more plentiful. Also see Ref. [44]. 61 This transfer was stopped in 1987 and additional resources were provided to IMSS-Solidaridad projects in the remaining 17 states in the early 1991; Gonzalez Block M.A. Economic crisis and the decentralization of health services in Mexico. In Social Responses to Mexico’s Economic Crisis of the 1980~ (Edited by Gonzhlez de la Rocha M. and Escobar Latapi A.), pp. 67-88. Also Ref. [48]. 62 Castells M. The Cify and rhe Grassroots. University of California Press, Berkeley, CA, 1983. 63. Marmor T. The Polirics of Medicare. Aldine, Chicago, 1973.

1443

70. 71.

72.

73.

74. 75.

Economic

Crisis of the 1980s

(Edited by Gonzilez de la Rocha M. and Escobar Latapi A.), pp. 19-56. U.S.-Mexico Studies Center, University of California San Diego, CA. Piven F. F. and Cloward R. The New Class War. Pantheon, New York, 1982. Palmer J. L. and Sawhill I. V. Perspectives on the Reagan experiment. In The Reagan Experiment (Edited by Palmer J. L. and Sawhill I. V.), pp. l-28. Urban Institute, Washington, DC, 1982. Vald6s Olmedo C. Bonanza, crisis, . . . Recuperacibn? Financiamiento de la salhd: 1970-1990 Una prospectiva hacia el afio 2000. Fundacibn Mexicana para la Salud, Presidencia Ejecutiva de Planeaci6n y Desarrollo, Mexico, D.F., February 4, Xerox, 1991. United States DHHS (Department of Health and Human Services). Health Status of Minorities and Lowincome Groups, 3rd edn. U.S. Government Printing Office, Washington, DC, 1991. Brown E. R. Access to health insurance in the United States. Med. Care Rev. 46, 349-385, 1989. Needing a local doctor, they increased taxes. New York Times. December 19, 12A, 1987.