The political economy of medical underemployment in Mexico: Corporatism, economic crisis and reform

Health Policy, 15 (1990) 143-162 143

Elsevier

Chapter 6

The political economy of medical underemployment in Mexico: corporatism, economic crisis and reform Julio Frenk

Introduction There seem to be periods in human history when a worldwide phenomenon affects countries at the most varied levels of economic development. In recent decades one of these phenomena has been the appearance of fundamental manpower imbalances in the health field. Such imbalances have adopted many forms, from geographic maldistribution to functional disparities among various personnel categories [3]. Of all these forms, probably the most prevalent has been the increase in the supply of physicians beyond the needs of the population, the capacity of the health care system to absorb them, or both. It is indeed a challenge to social, political and economic theory to explain the processes through which widely differing national circumstances can lead to such a similar result. While the problem itself of increased physician supply is shared by many countries, the social response has varied substantially across them. Some societies have been able to cope with the excess of physicians by diverse mechanisms, such as the reduction of working hours, the displacement of nonmedical providers, the growing medicalization of life, the encouragement of medical out-migration, or even the deliberate and planned export of physicians. In other countries, however, it has been impossible to fully utilize the increased supply of doctors. Probably the worst outcome has been the coexistence of underemployed physicians with large groups of people who lack ready access to medical services. This is the most extreme contradiction facing today the health care systems of many Latin American countries, Mexico among them. A survey carried out in 1986 revealed that 23 500 of the 81000 active physicians living in the 16 major cities of Mexico were un- or underemployed [14]. At the same time, official statistics placed at 9.3 million (or 11% of the national population) the number of people without permanent health services (Ref. 7, p. 74). How did Mexico arrive to this state of affairs, which is obviously opposite 016%8510/9Ok$O3.50@ 1990 Blaevier Science F’ublishen B.V. (Biomedical Division) WI

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to the explicit goals of health policy? The present paper will attempt to answer this question by tracing the historical evolution of medical manpower policy in Mexico. Such policy has been shaped by the interaction of fundamental political and economic processes. Two of them are salient. The first one is the corporatist system of interest representation that has prevailed since the end of the Mexican Revolution of 1910 and that has given the State the central role in conducting national affairs, including health care. The second is the economic crisis that has intermittently affected the country since the mid 1970s. The interaction of these processes has largely determined the scope and nature of decisions regarding both the production of physicians by the medical education system and their employment by the medical care system. Hopefully, the case of Mexico will serve to identify new avenues for theoretical advancement that will have cross-national relevance.

The Mexican health care system The thirteenth largest economy in the world, Mexico is also a country of profound contrasts. The health arena reflects and magnifies such inequalities. As far as its health conditions are concerned, Mexico has benefited from half a century of continuous declines in mortality. Life expectancy at birth, which was only 37 years in 1930, approached 65 years by 1985. However, this improvement has not been uniform. Like many other middle-income countries, Mexico is currently undergoing a complex epidemiologic transition [18]. While common infections and malnutrition still take an unacceptable toll of life and vigor, new ailments are emerging prominently: cardiovascular diseases and accidents are today the first two causes of death, mental problems are on the rise, and the urban areas face the growing threat of AIDS. The problem is not the coexistence of various kind of pathology per se, but their very unequal distribution among social and regional groups. The result of this distribution is that there is an ‘epidemiologic polarization’ of the population [ 111. Despite its increasing complexity, the health care system has so far been unable to fully meet the needs of the population in an egalitarian way. Although, as we shall discuss later, a new paradigm of primary health care is slowly emerging, the dominant health care model is still based on the paradigm of ‘scientific medicine’, which became prominent during the 1950s. This paradigm privileges acute and episodic satisfaction of demand over comprehensive and continuing responsibility for the needs of defined populations; hospital-centered care over networks of community-based health centers with ready referral channels to hospitals; clinical specialists over a balanced mix of general practitioners, public health personnel and nonmedical workers; complex and expensive technology whose effectiveness is not always tested over a definition of high-quality care as the one that is best adapted to the specific epidemiologic reality and resource constraints of a country. In addition, the Mexican health care system has adopted a peculiar institutional contiguration, which reflects the corporatist tendencies of its political system, as will be analyzed later. The way in which different occupational groups have been [701

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able to negotiate with the State, as well as the ideological commitment of the latter to the welfare of the masses within a mixed-economy framework, have led to a segmentation of the health care system into three major components: private sector, social security, and public assistance. There are, in turn, many variations within each of these categories. The private sector comprises four segments. Indigenous practices outside the mainstream of Western medicine are still prevalent in some rural areas and urban slums, although their influence was largely reduced as a result of the cultural colonization that followed the military conquest of ancient Mexico by Spain in the 16th century. Philanthropy, mostly linked to religious concerns, was the dominant form of providing health care from the Colonial period until the last century; afterwards its importance has declined steadily. The preponderant form of private medicine is nowadays represented by networks of solo or group practices with admitting privileges to modem hospitals. This type of practice covers only an estimated 5 to 10% of the population but absorbs a disproportionate share of resources, which is the reason why it is generally perceived to provide the highest quality of care. Its benefits are distributed exclusively according to the purchasing power of clients, and most of the payments are made out-of-pocket, since Mexico has lacked a vigorous tradition of private health insurance and prepayment schemes. As a result of the oversupply of physicians, a new segment has begun to appear in the private sector. This is represented by recent graduates who establish independent practices with very low productivity, some of whom supplement their incomes with other jobs outside of the health sector [ 141. Social security has become the institutional segment that commands the greatest amount of resources and covers the largest number of people. In contrast with the common Western European model, social security in Mexico is not only a financial instrumentality, but it also operates its own health care facilities and hires its own medical and nursing staff. By far, the dominant institution within this subsystem is the Mexican Institute of Social Security, which covers all wage earners outside of government and their relatives, plus agricultural laborers during the work season. In 1973 this Institute adopted the concept of ‘social solidarity’, and in 1979 it launched a very large program to offer basic medical services to the rural uninsured population. Currently IMSS covers more than half of the population, 32 million through its insurance schemes and 11 million through the social solidarity program. In addition, federal civil servants have a separate social security institute. This is also the case for the armed forces. Finally, the third element of the Mexican health care system is public assistance. This anachronistic concept is being displaced as the Constitution has recognized, since 1983, a social right to health care. Nevertheless, the health system still has a set of distinct organizations that care for the rural and urban poor who do not participate in the formal sector of the economy, either because they devote their energies to subsistence agriculture, work in the underground economy, or are unemployed. Traditionally, the dominant institution within this subsystem has been the Ministry of Health. A fundamental part of the advanced research and training activities of the health sector are carried out, under the coordination of the [711

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Ministry, by ten semiautonomous National Institutes of Health, eight of which also provide tertiary medical care mostly for the noninsured population. In addition, this population benefits from the activities of a governmental organization called the National System for the Integral Development of the Family, which is in charge of social assistance for vulnerable groups. In summary, whereas there is a recent tendency towards higher degrees of integration, the Mexican health system is still segregated on the basis of occupation. Indeed, those people (comprising about 45% of the population) who do not belong to one of the specific clienteles of the social security agencies are not allowed to utilize their medical services (excluding emergencies and some preventive measures like vaccination and family planning). The paradox, then, is that the State owns all medical facilities belonging either to the social security or the public assistance subsystems, that the same State has recognized a universal right to health care, but that still it has proved politically unfeasible to integrate all those facilities into a unified system where access is rationed by need and not by occupational ascription. The poor are further segregated from the modem private sector by their inability to pay the costs of care. The system, then, resembles a sort of ‘medical apartheid’, except that segregation is not based on race but on occupation and income. The existence of different subsystems to care for different segments of the population would not in itself pose any problem if resources were distributed among the subsystems in proportion to the needs of their respective populations. In Mexico, as in many other countries [15], the opposite is true. To give one example, expenditures per capita are three times higher in the social security than in the public assistance institutions. As a result, there are large differences in the quality of the care provided by each subsystem [5]. A second paradox therefore emerges: a social instrumentality, like health care, whose ultimate objective is to increase equality of opportunity may end up reproducing original inequalities [27].

Medical manpower policy: actors and eras The policies that have guided the numbers of trained physicians, the kind of medicine that they know and prefer to practice, their professional orientation, the employment opportunities, and the type of work settings available must be analyzed through the complex interaction of two major social institutions: the medical education and medical care systems. Furthermore, such interaction must be placed in the specific social and political context in which it takes place, and it must refer to the concrete actors that make the most important policy decisions. Since the beginning of the 20th century, the central actor in the medical arena of Mexico has been the State*. Before that, its role had been limited mostly to * In this

paperwe

follow the usual practice of adoping the narrow definition of the State as the institutions

of government providing the administrative, legislative, and judicial vehicles for the actual exercise of public authority and power, rather than the broad definition of the State as the total political organization of a society, including its citizens.

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a ‘medical police’, through sanitary control and surveillance of epidemics. The promulgation of the 1917 Constitution, which emerged from the civil strife of the Mexican Revolution, marks the beginning of a process of progressive public involvement in all health matters, including the training and hiring of physicians. However, the State cannot be seen as a monolithic actor. As far as physician manpower policy in Mexico is concerned, it is possible to identify at least two major blocks within the governmental apparatus. The first one is the health technocracy, constituted by experts with decision-making authority who operate from the health sector institutions. The ostensible purpose of this group is to establish the mechanisms for the most efficient running of the health system. The second block, usually more powerful than the first, is represented by the system controllers, who operate from the organizations charged with political control and system maintenance. For this group, health care and medical education are subsidiary means, which can be manipulated to serve the ultimate end of political stability. Outside of the formal structures of the State, it is possible to identify two additional actors. First, there are the universities. Most Mexican universities are public and might therefore be considered as part of the State. Nevertheless, since 1929 most universities have been granted autonomy by the State. Beyond their financial dependence from the latter, the universities do exercise this autonomy in their internal governance and in the approval and certification of study programs. In fact, universities often harbor important opposition groups. For all these reasons, they must be considered as an actor in themselves. We must again realize, however, that they are not monolithic. For the purposes of this paper, three subgroups stand out: (a) central university authorities, who may sponsor projects and interests that include but are not restricted to the specific problems of the health field; (b) medical school authorities, whose narrower interests around physician manpower issues may coincide or conflict with the former group; and (c) students, among whom we include not only the students actually enrolled at a given time, but also the social groups that aspire to be admitted into the university, The last actor that needs to be considered is the medical profession. Needless to say, members of the profession are included in some of the aforementioned groups, especially the health technocracy and the medical school authorities. What we are interested in, however, is the social action of the profession qua profession, that is to say, its defence of the collective interests of the particular occupational group represented by physicians, vis-a-vis the interests of other groups, such as the labor movement, private industrialists, or nonmedical health occupations. Bearing in mind this broad classification of actors, we will next analyze the historical evolution of medical manpower policy in Mexico. We will attempt to relate the major groups of actors to the two institutional arenas that were identified at the beginning of this section: medical care and medical education. To this effect, we propose a division in four historical periods: 1. 1917-1958: Institution-building period 2. 1958-1967: Scientific medicine period 3. 1967-1979: Crisis period 4. 1979-1988: Reform period [731

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The Appendix summarizes the principal historical events that have characterized each period, with respect to both the service and the education systems. We will next highlight the most important of those events. 1917-1958: Institution-building

period

This era contains the progressive efforts of the State to lay the institutional foundation for its dominance of health policy in Mexico. As part of the design of a new political structure for the country, the 1917 Constitution mandated the establishment of a General Health Council and of an executive Department of Public Sanitation. The process of building the institutions of modem medical care in Mexico had its high point in 1943, with the establishment of the Mexican Institute of Social Security (IMSS) and of the Ministry of Sanitation and Assistance (SSA)*. Although there had been some social insurance organizations in the past, the creation of IMSS was part of a broader effort by the State to control the labor movement, which had grown into a formidable political force with the advance. of industrialization. Indeed, social security emerged during a period of great activity by the labor movement. A few years before, President Lbaro Ckdenas had founded the Mexican Revolution Party - forerunner of the Institutional Revolutionary Party (PRI), which has been in power since then. The party had (and still maintains) a corporatist structure based on ‘sectors’, the most important of which was the ‘labor sector’. Together with this political arrangement and with changes in the leadership of the main unions, the promulgation of the Social Security Law constituted a control measure insofar as it offered a substitute to the demands for higher wages. In any event, social security became the cement that sealed the growing alliance between the State and the labor movement, an alliance that has been a major reason for the sixty years of social peace that Mexico has enjoyed. For its part, the creation of SSA and of its forerunners seems to have been based on a logic of legitimizing the postrevolutionary State, not only by providing sanitary control measures, but also by extending basic medical services to the peasants, who had borne most of the military burden of the Revolution. Such an extension was greatly facilitated in 1936, when President Ckdenas established a compulsory ‘social service’ whereby all medical students had to practice in rural areas after their formal studies. The foundation of the new State-owned institutions of medical care drastically altered the labor market for physicians. As Donnangelo (see Ref. 8, pp. 48-59) has pointed out, State intervention usually has a dual effect: on a quuntitutivefront, it expands the employment opportunities for physicians; perhaps more importantly, it introduces qualitative modifications in the prevailing paradigms about medical practice, which define the dominant sites for medical care (ambulatory vs. hospi* It was not until 1985 that the SSA changed its name to Ministry of Health, reflecting a conceptual shift from the old concept of assistance as the obligation of the State to help the needy, to a modem concept based on the recognition of the right of every citizen to health care. For simplicity, however, we will refer to the SSA as the Ministry of Health throughout the text.

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tals), types of activity (general vs. specialized practice), and institutional settings (private vs. public) [lo]. Thus, the growing participation of the State during this period began to shift the emphasis of medical care towards specialized practice in hospitals, as manifested by the creation of the first national institutes of health, As for the institutional settings, this period launched a process of growing dominance of the public over the private sector. The shifting nature of the dominant paradigm was also evident in the medical education system. For most of this period medical education was dominated by the French model, which emphasized the use of sensory, clinical skills in a rather unspecialized approach to the human body. Around the decade of the 1940s the French model began to give way to the Flexnerian model of medical education, which proposed a division of courses according to medical specialties, a use of the hospital as a major training setting, and a substitution of sensory skills in diagnosis and treatment for the hard data of laboratory results. The shortage of medical personnel produced by World War II in the United States opened opportunities for Mexican physicians to do internships and residencies at American hospitals (see Ref. 6, p. 36). Postgraduate internships were also opened at Mexican hospitals. The School of Medicine of the National Autonomous University of Mexico (UNAM), the leading school in the country, began an experimental program of ‘pilot courses’ that embodied the principles of the F’lexnerian model. 1956-l 967: Scientific medicine period

On the basis of the institution-building activity of the previous decade, the period from 1958 to 1967 witnessed an accelerated expansion of the health sector. At the same time, the paradigm of ‘scientific medicine’ [4] became definitively established as the dominant form of structuring medical work and the State consolidated its position as the main source of medical care in Mexico. Within the public sector, social security became the predominant element. A major explanation for the growth and strengthening of social security seems to be the large number of labor conflicts that occurred in 1958, including 740 strikes (Ref. 17, p. 218). In the face of such a level of unrest, the new government that took office that year adopted the policy of extending benefits to workers. Not only did IMSS grow in a spectacular manner [13], but in addition the Institute of Social Security and Services for Federal Employees (ISSSTE) was created in 1960. As the medical care system was expanding mainly through hospital services, including the opening of large medical centers for tertiary care, medical schools were also responding to the paradigm of ‘scientific medicine’ by officially adopting the Flexnerian type of curriculum that had been tested a few years earlier. This curriculum exposed the student, during the first two years, to courses in the basic sciences, followed by two more years of clinical specialties in hospitals. The fifth year was occupied by an undergraduate internship, whereby the student had to devote full time to work in a hospital, prior to the year of ‘social service’. In the delicate balance between medical care and medical education, this period was characterized by qualitative harmony but quantitative imbalance. Indeed, as we [751

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have seen, both the health care institutions and the medical schools embraced the paradigm of ‘scientific medicine’. But while the former were expanding rapidly, the latter were not increasing their production of new doctors to fill the growing number of positions. Thus, enrollment at UNAM was kept practically constant between 1958 and 1967, and only two new medical schools were added during this whole period to the 21 that existed in 1957. Part of the ensuing shortage of medical manpower was compensated for by the undergraduate internship that the new curriculum had introduced and by the increasing number of residencies that specialization had brought about. Another form of imbalance had been created by the new paradigm about medical care. The large capital investments that it required were achieved at the expense of recurrent costs, including the salaries of physicians. In 1964 a group of interns and residents went on strike demanding higher pay and job security, thus starting what was known as the ‘medical movement’. This conflict began as the same Administration that had dealt with the 1958 strikes by expanding medical care was coming to an end. Staff physicians soon joined the movement and formed the Alliance of Mexican Physicians, an organization that grouped doctors from all the public sector. The new regime refused to negotiate and instead introduced a cleavage into the movement by raising the salaries of IMSS doctors above those of other institutions. The movement was dissolved as its leaders were repressed [20]. The ‘medical movement’ ended with a profound political disadvantage for doctors. In the context of a corporatist* system of interest representation, physicians were singled out as a group that would not be allowed to establish an occupational association to negotiate with the State (see Ref. 6, p. 76). Instead, the representation of their interests was diluted in the unions that were established separately by each health care institution and that included all employees together with physicians. Elsewhere [12] we have argued that a major predictor of the power of the medical profession in a given country is its mode of interest representation compared to that of potentially competing groups. The worst possible political outcome for the medical profession is to lack a corporatist mode of representation in the context of a system where other groups are allowed such a mode of representation. This is precisely the situation that prevailed in Mexico after the ‘medical movement’. As will become evident later on, the absence of a unified association capable of defending the interests of the profession vis-a-vis the State is one of the main explanatory factors for the outcomes of medical manpower policy in Mexico. On the medical education side, this period also ended with disruptions. In 1966 the rector of UNAM was forced to resign. The pressure that had been mounting for increased access to the university was set free, and an open admission policy * According to Schmitter’s (Ref. 22, p. 13) classical formulation, ‘Corporatism can be defined as a system of interest representation in which the constituent units are organized into a limited number of singular,

compulsory, nonccmpetitive,

hierarchically ordered and functionally differentiated categories. recognized or

licensed (if not created) by the state and granted a deliberate representational monopoly within their respective categories in exchange for observing certain controls in their selection of leaders and articulation and supports’.

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was adopted. UNAM implemented a planning system that was based on satisfying the social demand for higher education. This policy set the stage for the deep crisis that was to characterize the following decade. 1967-1979: Crisis period

The most salient feature of this period is that the quantitative imbalance between medical education and medical care became reversed with respect to the previous period: while most health care institutions substantially reduced their growth rate, medical schools experienced an explosive expansion [13]. Such an imbalance gave expression to the many contradictions that the paradigm of ‘scientific medicine’ had been accumulating during the era of health care growth. The sharp reduction in the growth of health care infrastructure seems to be closely related to the economic crisis that the country began experiencing in 1974 and that reached its worst point in 1976, when the currency suffered a 100% devaluation after 20 years of stability. Thus, federal investment per capita in hospitals and other medical care units grew steadily (at constant prices) until a peak in 1973; thereafter, it declined to the levels of the previous decade. The health care system was unable to keep pace with population growth. The National Health Plan, which was supposed to guide health policy from 1974 to 1983, officially estimated that 35% of Mexicans lacked access to health services (see Ref. 23, Vol. 1, pp. 47-52). It is ironic that, just when health planning became politically fashionable and technically feasible, economic conditions hampered the implementation of its ambitious goals. While the medical care system was undergoing its slump, medical education became the subject of pressures from all fronts to expand at unprecedented rates. Nineteen sixty-eight was a watershed in the political and educational history of the country. Like in other parts of the world, students in Mexico led a widespread movement which so threatened the status quo that the government had to resort to repression. One of the main consequences of this episode was the realization of the political might of student mobilization. Shortly after a new regime had taken office, vowing to heal the political wounds from the 1968 movement, new student protests in 1971 led the government to promote an open-door policy at universities. The model of the ‘university of the masses’, as opposed to the ‘elitist university’, became widely accepted, without regard for its potential deleterious effects on the quality of education. The School of Medicine was already suffering the effects of increasing admissions, and its dean proposed a tougher admissions policy. But all the other political actors were lined up against such a policy. After three decades of sustained demographic, economic, and urban growth, the middle classes had expanded substantially, and higher education had come to be seen as one of the most legitimate avenues of upward social mobility. The 1968 student movement had given expression to the claim for a more open society; the openness included, as one of its central elements, the university. The growing demand for higher education, itself the product of economic prosperity, was compounded, in the early 197Os, by a deteriorating economic environment. Indeed, the labor market was unable to absorb the large number of young people [771

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who sought jobs. In this context, a ready alternative to defuse potential social unrest was to open the university, as a means of both satisfying the demand for higher education and postponing the pressures on the labor market. This seems to have been the rationale, on the side of the State, of the ‘system controllers’ as they attempted to influence universities in general, and medical schools in particular, to open their doors. The other relevant actors within the State apparatus, the health technocrats, were occupied with extending the coverage of the medical care system. Far from being a threat, the increased supply of doctors that an expanded enrollment into medical schools would produce was perceived as a facilitator of their goals. Inside the university, the central authorities were in favor of a more liberal approach to admissions. The only actor that would have had a vested interest in containing physician supply, the medical profession, had been deprived in 1965 of an effective organizational means for voicing its concerns. Medical school authorities at UNAM - who were the ones facing the lack of sufficient classrooms, laboratories and professors to contend with a sudden swelling of the student population - were thus left alone in their opposition to an opendoor policy. They had no choice but to yield to the mutifarious pressures on them. In 1971 all applicants to the School of Medicine of UNAM were admitted, and the first-year enrollment almost doubled in that single year. For the whole of the country, the total medical student population jumped from 21 127 in 1967 to 41675 in 1971-1972 [21]. Such an increase was achieved mainly through expanded enrollment in the existing medical schools, rather than through the creation of new schools. In 1973 a prominent physician-researcher was appointed as the new rector of UNAM. In contrast to his predecessor, he decided to support the proposal of the dean of the Medical School to curb admissions by not receiving any applications from states that had their own medical school or from foreign countries. At the same time, the decision was taken to decentralize UNAM, as its campus had grown to unwieldy proportions. One part of this decentralization strategy was to stimulate the creation of medical schools in state universities. As a result of these measures, enrollment in UNAM went down, but a second phase in the expansion of medical education began, one that was fed by the creation of new schools. In 1974, when first-year enrolments at UNAM peaked, six new schools were opened, five of them outside of Mexico City; seven more were added to the list the following year and still five more in 1976. The initial decentralizing intent was overtaken by two processes that in many respects perverted some of the beneficial effects of decentralization: first, the pressures for increased enrollment were displaced to state universities that were much weaker than the National University to resist; second, given the high demand for medical education, some private schools were opened that were more oriented to profits than to academic excellence. When all was said and done, the number of medical schools had grown from 27 in 1970 to 56 in 1979 (Ref. 2, pp. 20-21 and 57-60). Again, one notices the absence of an organized medical profession that could have regulated the proliferation of new schools through accreditation bodies. By 1975, the first realization of an impending problem of medical underemploy1781

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ment began to surface in public debate. Indeed, while the population of medical students had increased enormously, residency positions for postgraduate specialized training had remained practically constant throughout this period, as a result of the very slow growth of medical care facilities. Thus, in 1975 some 6000 medical graduates had to compete for less than 2000 residency positions. In light of the orientation of the medical care system towards specialization, it was increasingly difficult to find a job without lirst having completed a residency program. What had happened in effect was that the selection point had been transferred from the point of entry into medical school, where most admission barriers had been removed, to the stage of postgraduate training. Those who failed this true selection process were forced to enter a private medical market that was rapidly becoming saturated in the large cities [9]. One bright point of this crisis period was that the creation of so many new medical schools made it possible for some of them to experiment with various innovations. The most meaningful of these were intended to reorient the medical curriculum away from its emphasis on hospital specialization and towards primary health care (PHC). Thus, in 1974, four years before the Alma Ata Declaration, the School of Medicine of UNAM started a pilot program that exposed students from the very first year to a community-oriented program of studies. Several other schools also introduced innovative approaches that stimulated a more integrative approach to medicine. In addition, there were new developments at the postgraduate level, the most important of which was the recognition of family medicine as a legitimate specialty and the implementation of the respective residency programs. As happens with many crises, this period ended with something new, in this case the promise of an alternative paradigm of medical care. 1979-1988: Reform period

In 1979 the country began to experience an important economic recovery mostly due to the increased export of oil. The financial difficulties of the past five years had given way, in the words of President Jose Ldpez Portillo (1976-1982) to the problem of ‘administering abundance’. Perhaps the most interesting element of health care policy was that, at a time when the newly found oil wealth could have again sustained the growth of hightechnology, hospital-based medical care, the government shifted towards large programs to expand coverage on the basis of a PHC strategy. The notion of ‘social solidarity’, which had mostly lain dormant since its inclusion in the 1973 reforms to the Social Security Law, found a concrete expression in what came to be known as the ‘IMSS-Coplamar Program’. Launched in 1979, this program was soon to become one of the most intense health care efforts, as it built, in just four years, 3000 rural medical units and 1600 beds in rural general hospitals, with an estimated coverage of 11 million people (see Ref. 19, p. 25). In 1981 the Ministry of Health began its own large PHC program, this time directed to the slum dwellers in large cities. Using innovative planning methodologies for regionalization, 255 health centers were built covering some 4 million people. [791

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Like the hospital expansion of the 196Os, this new increase in governmental activity introduced important modifications into the medical labor market. On the quantitative front, new jobs were created, although the momentum in the growth of graduates made it impossible to absorb the surplus of physicians, and thousands of them remained un- or underemployed. Furthermore, the rural programs faced the paradox of being unable to fill all their vacancies, given the reluctance of the majority of doctors, even the unemployed ones, to work in the countryside. Such an imbalance reflected the fact that, despite the curricular innovations of the 197Os, most medical schools had still not shifted away from a Flexnerian model to one based on PHC. The extension of coverage was not the only impetus given to health care by oil abundance. In addition, the overall structure of the health system began to be revised. In order to fulfill a campaign promise, President L6pez Portillo formed in 1981 the Health Services Coordination, which was to report to him on the viable options for integrating the various health care institutions into a National Health System. For the first time, a special task force was formed by the highest political figure in the country to make recommendations on a highly sensitive issue within the Mexican corporatist system: the potential unification of all public agencies providing health services. Just as social security had been born during a labor crisis as a special subsystem reserved for industrial workers, so it seemed that the new prosperity might make the labor movement more agreeable to sharing with the rest of the population what was then the best medical care network in the country. The maturation of Mexican society - more prosperous, more educated, more demanding of democracy and justice - rendered the old corporatist and authoritarian political model obsolete [l]. In the health field, times seemed ripe for an effort to end the profound inequities produced by that model. However, the last year of the Lopez Portillo administration saw a collapse of world oil prices and, with it, the vanishing of many of its reform dreams. Not only that: oil wealth had also provided the ostensible guarantee for a very large increase in the foreign debt of the country. The simultaneous drop in oil prices and rise in interest rates combined to produce the worst economic crisis in the recent history of Mexico. An illustrative figure is that the Mexican peso suffered a 600% devaluation during 1982. It was in this adverse economic context that the administration of President Miguel de la Madrid (1982-1988) took office. On the basis of previous policy responses to economic crises, it could be anticipated that spending for social programs, including health care, would be severely cut. However, a new policy prescription was in the making. Indeed, the political campaign had made it clear that, together with the economic crisis, the regime was also suffering a legitimacy crisis. The risk of a substantial drop in living standards loomed high. As a consequence, the decision was made by the new administration to protect social spending, giving the highest priority to health care, education and housing programs. The rationale, although simple in appearance, actually reversed the logic of the previous policy conception, which saw social development as something that should come as a result of economic growth. The new conception reversed the direction of WI

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this relationship, so it saw social wellbeing as a condition for economic recovery and indeed as the ultimate sense of development. Furthermore, the new approach proposed that it was precisely in times of economic stress that the State should do an extraordinary effort to contain the deterioration of health conditions that the crisis would produce by itself. Based on these notions, the new administration launched the most ambitious health care reform since the era of intense institution-building. The work of the Health Services Coordination had culminated in a comprehensive report which, together with a ‘popular consultation’ carried out during the 1982 election campaign, provided the blueprint for the reform [26]. The appointment of the Health Services Coordinator as Minister of Health favored the implementation of this project. The reform laid its political and ideological foundation through a Constitutional amendment establishing a social right to the protection of health. It is indicative of the new policy conception about social development that, precisely during the worst economic crisis in decades, the Mexican State recognized the right of all citizens to receive health care - and hence its own active obligation to assure universal access. The major elements of the reform have been described in detail elsewhere [25] and are summarized in the Appendix. Suffice it to mention here that it included an intense legislative activity aimed at conforming a National Health System, based on five strategies that were delineated in the National Health Program 1984-1988: decentralization, sectorization, administrative modernization, intersectorial coordination, and community participation (see Ref. 19, pp. 51-58). The health care reform had profound implications for medical manpower policy. Among other changes, it introduced a new structural reality that was more amenable to joint decision making. Thus, the President of the Republic established in 1983 the Interinstitutional Commission for Health Manpower Development (ICHMD). This Commission is co-chaired by the Ministers of Health and of Education, and its members include representatives from all the health care institutions and from the universities. The ICHMD has proved to be a highly effective means to supersede the ‘era of mutual reproach (see Ref. 24, p. 17), characteristic of the 197Os, when health care institutions accused universities of not producing the number or type of required doctors, while the universities answered that the health care institutions had not defined their own requirements. The existence of a joint forum for the medical care and the medical education systems has produced a shift in the relative power of the actors that participate in health manpower policy. The net result of the style of political confrontation that characterized the crisis period had been that the actual definition of policies was left to the pressures of system controllers or students. In contrast, the new style of negotiation has actually strengthened both the health technocracy and the medical school authorities as they make joint decisions that carry great weight. The participatory process has made it possible to contain the medical education explosion of the previous decade. The population of medical students has steadily declined since 1980, when it peaked at 93 365; by 1983 there had been a 15% reduction. That same year, the number of graduates peaked at 14099 [16]. The

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creation of new medical schools has been halted, as only three additional schools appeared from 1979 to 1987 and none since then. At some places, like the School of Medicine of UNAM, the figures have been even more dramatic: first year enrollment in 1983 was nearly one third of what it had been in 1974. Apart from the quantitative aspects, the health care reform has sought greater qualitative harmony in the types of doctors being trained and hired. The reform explicitly adopted PHC as the central strategy to expand coverage. The growing awareness about the complexity of this strategy and the urgency to have personnel specifically trained in its implementation prompted the Ministry of Health to start an experimental three-year residency in PHC. It is still too early to know whether in fact we are witnessing the emergence of a new paradigm about health care. Until now, progress has been hampered by a vicious circle between the lack of PHC practice because it is not taught and the scarcity of teaching PHC because it is not practised. In order to break away from this situation, Mexico will have to further develop innovative models that bring both the educational and the health care models closer to the needs of the population. The rationalizing vein of the health care reform rectified another persistent imbalance in medical manpower: in 1986 the salaries of all physicians in the public sector were unified. As we saw earlier, from the time of the 1964-1965 medical movement, important pay differentials in favor of IMSS doctors had been a major factor for the fragmentation of the medical profession. The salary unification program could help to overcome one of the major hurdles to an effective integration of health care institutions. Medical manpower policy may thus be the cutting edge for the next stages of the health care reform.

Acknowledgements Several former leaders of the Mexican health care system, all of whom had previously occupied important positions in the higher education system, provided ‘me with valuable insights into the evolution of medical manpower policy in Mexico. I am specially indebted to Drs. Guillermo Sober&r, Jaime Martuscelli, Jose Laguna, and Jose Manuel Alvarez-Manilla. At the National Institute of Public Health, a competent team of researchers, formed by Cecilia Robledo, Catalina Ramfrez-Cuadra, Oscar Galvan, Laura Montoya, Gustav0 Nigenda, and Alonso Vilsquez, carefully collected the quantitative and historic data for this paper. Such information was complemented by a series of interviews, which were structured and conducted with the assistance of Dr. Lilia DtU&l. None of the aforementioned persons shares any responsibility for the views expressed in this paper or for its deficiencies.

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Appendix Major hislorlcsl

events of medical manpower

policy in Mexico

Historical period

Events Medical care system

Medical education system

1917-1958

1917: Constitutional mandate to create the General Health Council and the Federal Department of Public Sanitation.

1917-1950: Dominance of French model in medical education.

1924: First specialized wards at the General Hospital of Mexico.

1929: University reform granting autonomy to the National University of Mexico (UNAM).

1937: Establishment Assistance.

1936: Establishment of the ‘social service’ (compulsory one-year rural practice after medical school).

Institution-

building period

of the Ministry of Social

1943: Merger of the Department of Public Sanitation and the Ministry of Social Assistance into the Ministry of Sanitation and Assistance (later Ministry of Health, SSA). Creation of the Mexican Institute of Social Security (IMSS). Founding of the Childrens Hospital of Mexico (first semiautonomous tertiary hospital).

1942: First postgraduate internship. at the General Hospital of Mexico.

1944: Creation of the National Institute of Cardiology. Beginning of IMSS medical service.

943: Expansion in the number of Mexican physicians doing internships and residencies at U.S. hospitals.

1946: Founding of the Hospital for Nutrition Diseases (later National Institute of Nutrition).

954: Beginning of the postgraduate internship IMSS.

at

1946-1952: Slow growth of IMSS coverage.

1955: Beginning of the ‘pilot groups’ at the Medical School of UNAM, which represent a transition from the French to the Flexnerian model of medical education.

1954: First affiliation of agricultural workers to IMSS.

1956: Opening of University City, largest campus of UNAM, concentrating all schools and research institutes.

1831

158 1958-1967 Scientific medicine period

1958: Beginning of a rapid expansion of IMSS. Organization of regional&d system of health care units at SSA

1958-1966: Very slow growth of enrollment and number of medical schools.

1959: Reform to the Social Security Law to allow coverage of new occupational groups. Accelerated construction of new medical care units.

1959: Approval by the Medical School of UNAM of a new Flexnerian curriculum derived from the experience of the ‘pilot groups’ and based on ;$alization and hospital

1960: Transformation of the Office of Civil Pensions into the Institute of Social Security and Services for Federal Employees (ISSSTE).

1960: Academic reform at UNAM involving the establishment of new preparatory schools, the enforcement of strict admission requirements, full-time faculty positions obtained through open competition, and other measures to improve the quality of education.

1961: Opening of the National Medical Center, largest concentration of tertiary hospitals in the country, and transfer of its control from SSA to IMSS.

1962: Beginning of the undergraduate internship as full-time hospital experience for one year prior to the ‘social service’ year.

1963: Opening of four new hospitals at the National Medical Center. Affiliation of sugar cane workers to IMSS.

1966: Violent ousting of UNAM rector. Adoption of an open admission policy including the elimination of admission exams to graduates of UNAM’s preparatory schools. Implementation of an educational planning system based on satisfying social demand.

1964: Opening of ‘La Raza’ Medical Center of IMSS, another concentration of tertiary hospitals in Mexico City. Berrinnine of the ‘medical movement’ thr&gh &es of interns and residents in demand of higher pay and job SeClUity.

1965: Growth of the medical movement as staff physicians of all public institutions join it. Dissolution of the medical movement as IMSS doctors receive pay increases and leaders are repressed.

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Reform of the Social Security Law to include agricultural self-employed workers. 1967-1979 Crlsls period

1967: Beginning of a marked slowdown growth rate of IMSS and SSA.

1968: Creation of the Mexican Institution Assistance to Children.

in the 1968: Student movement involving large mobilization of university students and professors and ending with repression. Further opening of admissions policy to university. for

1970-1971: ISSSTE covers Federal employees working outside of Mexico City.

1971: New student movement. The government calls on universities to adopt an ‘open-door’ policy with respect to social demand for higher education. Directpressures on School of Medicine of UNAM to expand enrollment, resulting in a doubling of first year students to 4434. 1973: Strike by administrative workers leading to resignation of UNAM rector. Policies by new UNAM rector to curb admissions to saturated careers, redirect demand to other careers, and decentralize UNAM. Decision by School of Medicine of UNAM not to accept applicants from states with a medical school and from foreign countries. Beginning of a policy to stimulate the creation of medical schools in the States.

1970-1976: Large growth of the Federal bureaucracy, which increases the number of affiliates to ISSSTE.

1974: Opening of six new medical schools, the largest yearly increase ever. Beginning by UNAM of an experimental curriculum oriented towards primary health care.

1973: First National Health Convention, which defines goals and strategies for the National Health Plan.

1975: Opening of seven new medical schools, five of them in states.

P351

160 Reform to the Social Security Law introducing ‘social solidarity’ services. Approval of a new Health Law. 1974-1976: Sharp drop in federal public investmeni for hospital and other medical care units.

Beginning of a residency in family medicine. 1976: Opening of five new medicaischools; several of the new schools continue to innovate their curricula with orientation toward primary health care.

1976: Strike of interns and residents leading to 1978: Peak year for first-year enrollment in medical the establishment of the National schools, which reaches Association of Medical Residents. 20463, up from 8283 in 1970. 1977: Creation of the National System for the 1979: Number of medical schools reaches 56, up Integral Development of the Family from 27 in 1970. (DIF) through the merger of the National Institute for the Protection of Infants and the Mexican Institution for Assistance to Children. Reform to the Federal Labor Law giving residents partial recognition as workers. Beginning of two programs at SSA to expand rural coverage through simplifted care. 1977-1978: Further reduction in public expenditure for health care as a reHult of economic crisis. 1979-1988 Reform period

1979: Launching of the IMSS-Coplamar program &thin the social solidarity concent of IMSS. soon to become the large; effort at extending primary health and basic hospital care to the rural areas.

1980: Peak year for total enrollment in medical schools, which reaches 93 365, up from 28 731 in 1970.

1981: Launching of a large primary health care program for slum dwellers of large cities. Establishment of the Health Services Coordination headed by the immediate past rector of UNAM and charged with reporting to the President of the Republic about the feasibility of an integrated National Health System.

1983: Peak year for number of graduates from medical schools, which reaches 14 099, up from 2 493 in 1970. Establishment of the Interinstitutional Commission for Health Manpower Development, with representation of educational and health care institutions, charged with coordinating manpower policy.

1982: Health Services Coordinator appointed Minister of Health of the incoming Administration. Legal reform giving SSA the role of conducting national health policy and

1985: Standardization of a unified exam to enter medical residencies for postgraduate training.

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coordinating the health sector, to which DIF is incorporated together with the health program of IMSS and ISSSTE. 1983: Integration of the Health Cabinet, highest coordinating body for health policy, chaired by the President of the Republic. Constitutional amendment recognizing the social right to the protection of health. Creation of the Commission for Decentralization of Health Services.

1986: National survey of physicians in urban areas revealing 23 500 un- or underemployed doctors in the 16 major cities. Establishment of state Health Manpower Programming Committees. Beginning of a pilot three-year residency program in primary health care.

1984: Passing of a new General Health Law. Presidential decrease mandating the decentralization of health services for the noninsured population to state governments. Approval of the National Health Program. Administrative modernization of SSA.

1987: Number of medical schools stabilizes at 59.

1985: Change of SSA from Ministry of Sanitation and Assistance to Ministry of Health. Great loss of medical care infrastructure in Mexico City as a result of earthquakes; reconstruction program is based on further decentralization. 1986: Complete decentralization in 12 states, with integration of State Health Services encompassing all programs for the noninsured population. Establishment of the National Health Council, formed by the Federal and state ministers of health. Establishment of program to unify salaries among health care institutions. 1987: Complete decentralization in two more states; programmatic coordination in the rest. Accumulated extension of coverage through primary health care since 1983 reaches approximately 10 million people.

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