Abstract
Abstract—This article uses political economy analysis to identify the factors that contributed to the adoption of policies to expand social protection in health (SPH) in Mexico in the early years of the 21st century. It focuses on the adoption stage of these policies to answer two questions: (1) Which contextual factors created the window of opportunity where SPH reforms could be adopted in Mexico? (2) What political strategies did the main actors driving the reform use to promote its adoption? Two types of analysis were developed: an analysis of the context and a stakeholder analysis. The analysis of the context was used to identify the “enabling factors” (epidemiological, political, and economic) that created the window of opportunity to place the problem of limited health care coverage in Mexico on the national policy agenda. The stakeholder analysis was used to (1) construct a map of actors, positions, and power during the deliberation of these policies in the Mexican Congress; (2) evaluate the behavior, intentions, interrelations, agendas, and interests of key actors; and (3) assess the influence and resources that actors brought to the debate and the strategies used by proponents to pursue and achieve adoption of the policies. This article shows that actors with high political power can take advantage of a propitious context (a window of opportunity for major change) through effective political strategies to design, promote, and successfully negotiate SPH policies, even in the absence of beneficiary mobilization. This was the case in the adoption of Mexico's health reform in 2003.
Many countries around the world have recently begun pursuing the goal of universal health coverage through national health reforms whose explicit aim is to extend access to comprehensive health services with financial protection to all citizens. This article uses political economy analysis to identify the factors that contributed to the adoption of policies to expand social protection in health (SPH) in Mexico in the early years of the 21st century. We focus on the adoption stage of these policies to answer two questions: (1) Which contextual factors created the window of opportunity where SPH reforms could be adopted in Mexico? (2) What political strategies did the main actors driving the reform use to promote its adoption? We do not examine the implementation of these policies or their impact on health conditions and financial protection of the Mexican population, because these questions have been addressed elsewhere.Citation1–3 Instead, we focus on the political economy of the reform adoption process, which has not been sufficiently analyzed previously.
The article is divided into four sections. In the first section we discuss the methods and materials used to develop the analysis. We then describe the content of the Mexican health reform and its expansion of SPH. In the third section we discuss three contextual factors that created a window of opportunity to adopt new policies to extend SPH in Mexico: the epidemiological transition, the democratic transition, and relatively high rates of economic growth. We consider these as enabling factors but not necessary conditions for the adoption of SPH policies, because similar policies have been approved in other countries in the absence of these factors and not all countries with these factors have enacted reforms. In the fourth section, we examine the driving factors behind the adoption of these policies in Mexico, with attention to proponents, opponents, and beneficiaries of those policies.
The central message of this article is that actors with high political power can take advantage of a propitious context (a window of opportunity for major change) through effective political strategies to design, promote, and successfully negotiate SPH policies, even in the absence of citizen or beneficiary mobilization. This was the case in the adoption of Mexico's major health reform in 2003.
MATERIALS AND METHODS
This article uses a political economy approach to analyze the policy design and adoption stages of the policy cycle. For the purpose of this article we define political economy as “a variety of approaches for studying economic and political behavior, and the understanding of how political institutions, social and political power relations, and the political and economic environment influence each other.”Citation4 We focus on the influence of the political and economic environment on the design of a policy to expand social protection in health in Mexico and on the behavior of the actors involved in its design and approval.
The concept of policy cycle refers to common patterns in the processes that lead to the design and implementation of a public policy.Citation5 This cycle describes how an issue moves from the recognition of a social problem to the adoption, implementation and evaluation of a public policy that seeks to solve it.Citation6,7 We focus on the initial stage of this cycle—adoption—which includes the identification and framing of the problem, its incorporation into the national policy agenda, the design of a possible solution, its debate in the legislature and other political circles, and its eventual approval. We do not assume that this is a linear process. On the contrary, we recognize the existence of important overlaps of these phases in ways that produce changes in how the problem is framed and the policy is formulated.
This project used two types of analysis: an analysis of the context and a stakeholder analysis. The analysis of the context was used to identify the enabling factors (epidemiological, political, and economic) that created the window of opportunity to place the problem of limited health care coverage in Mexico on the national policy agenda. We borrowed the idea of enabling factors from the behavioral sciences, referring to Andersen's behavioral model of families, which was widely used in the 1970s by health system and health management researchers. According to this model, enabling factors are forces that facilitate individual, collective, or environmental change based on their level of availability.Citation8–10 In this article, we looked for factors in Mexico that facilitated the identification of limited social protection in health as a major social problem and the design of a policy to solve it. However, these factors do not by themselves guarantee the incorporation of a policy into the government's agenda or its approval. Enabling factors are not sufficient conditions to create the adoption of a public policy. Adoption requires some driving factors, forces or agents that take advantage of enabling conditions to design, push, and negotiate a new public policy.
These driving factors are defined as the forces that trigger change in an organization or system; they are the forces that make change happen.Citation11,12 The driving factors of the SPH policies adopted by Mexico were identified through a stakeholder analysis of the negotiation process used by the Ministry of Health of Mexico (MoH) to promote the new national SPH policies adopted in the early 2000s. The stakeholder analysis was used to (1) construct a map of actors, positions, and power during the deliberation of these policies in the Mexican Congress;Citation13 (2) evaluate the “behavior, intentions, interrelations, agendas [and] interests” of key actors;Citation14,15 and (3) assess the influence and resources that actors brought to the debate and the strategies used by proponents to pursue and achieve adoption of the policies.
We gathered information for the two analyses of context and stakeholders through an academic literature review and direct interviews. We explored electronic databases using structured searches of Boolean combinations of the keywords “political,” “economy,” “universal,” “health,” “coverage,” “care,” “social,” and “protection.” JSTOR returned 1238 papers; PubMed, 203; BASE, 11; and Social Science Research Network, 4. We further refined our search by including the terms “Mexico,” “Mexican,” “reform,” and “Seguro Popular.” We identified 163 additional documents in Spanish (academic articles, institutional documents, technical reports) through personal contacts and a Google/Google Scholar search.
For the stakeholder analysis we compiled a list of the main actors involved in the discussion of SPH policies and collected information about them. We then developed a semistructured interview guide, which we used to interview a small set of key informants, including two researchers familiar with the Mexican reform and six actors directly involved in the discussion of SPH policies in the Congress or other political circles, including some former high officials of the MoH who participated directly in the negotiation process. The interviews were conducted by two authors (O.G.D. and F.G.L.). We asked each informant to validate our actor's inventory; identify the actors who supported or opposed the SPH policies; evaluate their level of power; assess their level of support or opposition to the policies; and discuss the reasons why different actors took particular stances. The input from these informants was used to adjust the stakeholder analysis as we conducted the interviews. With this information and the information gathered from academic and gray literature, we built a position map of major players using as reference the level of power of each actor and the level of support or opposition (or their indifference) to the proposed policies. Permission was requested to tape the interviews, which were transcribed. The map, the discussion, and the conclusions constitute a blend of the opinions of both the informants and the authors. We promised to share a draft of the article for comments with all informants and not to quote any of them by name without written permission. The institutional review board of the institution where the research project was based (National Institute of Public Health of Mexico) granted an exemption of review by the ethical committee on the basis that the interviews did not place the informants at any type of risk.
In sum, the study used a blend of perspectives: (1) inside information provided by one of the authors (O. G. D.) who was involved in the reform process and some key informants; (2) an external perspective provided by one of the authors (M. R. R.), who was not involved in the reform process; and (3) finally, information gathered from academic and gray literature.
CONTENT OF SPH POLICIES IN MEXICO
Until 2003, access to comprehensive health services in Mexico with financial protection was limited to the workers of the formal sector of the economy and their families, through social security. Health services for this salaried population were provided mostly by the Mexican Social Security Institute (IMSS; for private sector workers) and the Institute for Social Security and Services for Civil Servants (ISSSTE; for public sector workers). The rest of the population received health services either from the MoH under public assistance or by purchasing services in the private market. On February 3, 1983, an amendment to Article 4 of the Mexican constitution created a new right to the protection of health,Citation16 which established the constitutional platform for pursuing universal SPH policies. However, it was not until 2003 that the secondary laws and the financial mechanism to guarantee the universal and effective exercise of this right were approved by the Mexican Congress with the creation of the System of Social Protection in Health.Citation3 It is important to mention that the original vision of the reform was a unified system that would cut across all of the Mexican health sector, but that idea was abandoned due to resistance from the IMSS director general and the IMSS trade union, resulting in a reform of just the main institution providing services to the nonsalaried population, the MoH.
Mexico's new system of social protection was able to expand access to comprehensive health care with financial protection by increasing funding for health by over one full percentage point of GDP over a period of eight years. The vehicle for achieving this goal is a public insurance scheme called Seguro Popular (SP), funded predominantly through federal and state subsidies. Funding for the 32 state ministries of health, which are the local providers of health services, is now determined by the number of individuals affiliated to SP and is thus driven by demand.Citation3 SP guarantees access to over 280 interventions (as of December 2014), including all interventions offered at the primary and secondary levels of care.Citation17 It also covers a package of 59 high-cost interventions, including treatment for all cancers in children, HIV/AIDS, cervical and breast cancer, and myocardial infarction in adults under 60, among others.Citation18 The law creating the system of social protection in health established that SP would gradually expand affiliation over seven years (adding around 1.7 million families a year).Citation19 The number of health interventions covered by SP also increased gradually to reach its present number. The program has expanded significantly, so that by June 2013, over 45 million people were enrolled in it.Citation20 When this figure is added to those enrolled in social security institutions (49.5 million) and those with private health insurance (4.0 million), it shows that Mexico has made great progress in pursuing universal SPH in the past decade (), leaving only around 16% of the population without health insurance.
Table 1. Estimates of Health Care Coverage in Mexico, 2013
Enabling Factors
Three contextual factors created a window of opportunity for the adoption of policies to pursue the expansion of SPH in Mexico: the epidemiological transition, the democratic transition, and relatively high rates of economic growth.
Globally, the proportion of total deaths and disability-adjusted life years attributed to noncommunicable diseases (NCDs) has been increasing in recent decades, and the proportion of total deaths and disability-adjusted life years attributed to communicable ailments has decreased.Citation21 In Mexico, in 1990, 55% of total deaths were due to NCDs. By 2000 this figure had reached 69%.Citation22,23 The pressure of this health transition was adversely affecting the performance of the Mexican health system and demanding additional financial resources, transformations in the prevailing models of care, and new organizational behaviors to address the social and behavioral risks associated with the rising NCD pathologies. Indeed, health policy analyses about Mexico in the 1990s typically began with an explanation of the epidemiological transition and the aging process and their impacts on health expenditures, reflecting the importance of this contextual factor in setting the stage for a transformation of the Mexican health system.
Mexico also witnessed a trend toward growing democratization in the late 20th century. After six political and electoral reforms (1977, 1986, 1989–90, 1993, 1994, and 1996), the authoritarian-minded Institutional Revolutionary Party (PRI), which ruled Mexico for most of the 20th century, was ousted from the presidency in the 2000 national elections by Vicente Fox, the candidate of the conservative National Action Party (PAN). This election helped establish an effective multiparty system, based on the design and implementation of reliable electoral mechanisms, and led to the beginning of political alternation at the national level.Citation24,25
Finally, positive economic growth rates in Mexico around the turn of the century helped mobilize additional public financial resources for social development, including health care, which contributed to a willingness by government leaders to consider greater efforts at expanding access to health care. The average economic growth rate in the period 1990–2002 was 3.4% for Mexico.Citation26 This relatively prosperous situation was reflected in rising health expenditure. Between 1995 and 2002, health expenditure per capita in Mexico (in PPP$) increased from 388 USD to 584 USD.Citation27
These contextual factors created a window of opportunity for placing the problems of limited health care coverage onto the national policy agenda and helped frame a policy proposal to expand social protection in health in Mexico. The increasing prevalence of NCDs was a major reference point in the design of SPH policies in Mexico. Advocates for reform consistently referred to the epidemiological transition as one of the main reasons for mobilizing additional resources for health. Mexico's changing epidemiological profile had been thoroughly documented since the mid-1990s using both traditional health indicators as well as newly developed burden of disease indicators.Citation28 The transition was also addressed in relation to a possible reform in policy briefs extensively discussed by the transition team of President Fox and in the National Health Program 2001–2006 launched in July of 2001.Citation29,30 In short, the transformations in national disease patterns were presented as requiring transformations in the national health system.
Mexico's democratization process was also crucial in opening the opportunity for reform in the health sector. This is consistent with the experiences in other countries where democratization has created opportunities to expand social welfare policies, including health policies targeting a broader proportion of the population.Citation31–33 Mexico's democratization process opened political space for health reform, as has occurred in other countries such as Brazil, Ghana, South Africa, and South Korea. The elections in 2000 ended the single-party corporatist rule that had dominated Mexico for 71 years. The benefits (including comprehensive health care) that were traditionally reserved for certain interest groups (mostly the unions of salaried industrial workers and civil servants) associated with the old regime now could be extended to all citizens, including the nonsalaried population.
The promoters of the reform for Mexico's health system recognized the historical moment and adopted the “democratization of health” as a core purpose, thereby placing health reform within the broader political agenda of the Fox administration.Citation30 They defined the democratization of health as “the application of the norms and procedures of citizenship to those institutions that were governed using other principles such as coactive control, social tradition, judgment of specialists and managerial practices.”Citation34 They then translated this broader objective into a set of guiding ethical principles that were explicit in the National Health Program 2001–2006: citizenship, solidarity, and pluralism.
Finally, the high rates of economic growth in the two decades of the 1990s and 2000s also helped open political space for health reform, by generating additional resources that could be used to expand SPH. Economic growth is an element that has been identified by Savedoff and colleagues as a common feature of many successful universal health coverage efforts.Citation35 It should be noted, however, that circumstances of economic crisis can also sometimes provide an impetus for health reform, as was the case with the creation of the Unified Health System or SUS in Brazil.Citation36 Mexico's economic growth was not explicitly used to promote the health reforms, but it gave the advocates of reform political and economic space for negotiations with the Ministry of Finance (MoF), as did the extraordinary oil revenues that boosted the federal budget in the early years of the new century.a
DRIVING FACTORS
The Mexican health reform is a classic example of minister-driven reform. The Minister of Health (Dr. Julio Frenk), with a team of people working closely with him, designed, developed, and drove the reform process, from beginning to end. The minister had headed several academic efforts since the late 1980s to examine the challenges confronted by the Mexican health system, especially demands associated with the epidemiological transition, and to propose specific measures to reform the Mexican health system.Citation37,38 These previous efforts helped (1) identify and frame the problems faced by the Mexican health system; (2) place the health reform issue on the national political agenda; and (3) provide a platform for designing a reform proposal to present to the Fox administration and the Mexican Congress.
The minister's reform team included persons with both strong technical and political skills, features found in other successful “change teams.”Citation33 This team took charge of promoting the policy proposal among the main actors involved directly or indirectly in the approval process: the heads of the social security institutions, the leaders of the three main political parties (the centrist PRI, the PAN, and the left-of-center Party of the Democratic Revolution or PRD), the leaders of the health sector unions, and other ministries and government bodies, such as the MoF, state governors, and members of Congress.
In 2001–2002, soon after the start of the Fox administration, the minister of health initiated a pilot program for health reform in five states. This pilot program was both a substantive effort (to show that the proposed changes would work) and a political strategy (to generate political support for the reform). Positive results from the pilot were crucial in generating support from the president, who, in the second half of 2002, allowed the minister of health to discuss the possibility of moving forward with reform with the minister of finance.
Efforts to promote the reform started in early 2002, once results became available from the pilot program. These efforts focused initially on the president and next on two key groups: high officials of the MoF (who would need to approve the reform proposal, before it could go forward) and members of Congress (who would need to vote on and approve a draft law).
Negotiations with the minister of finance were aided by the fact that some members of the MoH negotiating team had strong technical training in economics (including one person whose PhD in economics came from the same university as the minister of finance) and could discuss the proposal with MoF officials in their own language, including epidemiological data as well as economic analysis. Two ideas that were well received by MoF officials became part of the reform proposal that was sent to Congress: the idea of a demand-subsidy orientation and gradual implementation over a period of 7 years.
The negotiations with the MoF also included discussion of the need to expand public expenditure on health by one percentage point of GDP in order to reach universal coverage of social protection in health in Mexico. This figure made the Mexican financial authorities extremely nervous. In the initial negotiation phases, the MoF wanted to make the implementation of health reform conditional on the approval of fiscal reform. Given the fact that a previous fiscal reform attempt had failed, this would have been, in the words of Jason Lakin, “the kiss of death” for the reform.Citation39 This condition was rejected by the minister of health, but he was forced to include it in the draft law sent to the Mexican Congress for debate. Eventually, its exclusion was demanded by a group of senators from the PRI in the negotiation process, arguing that they could not pass a law that lacked the financial resources for implementation.Citation40
In parallel, the reform team started lobbying members of Congress. Conversations and negotiations with them started when the reform was still in the design phase and included over 100 meetings by the minister of health and his team with the leaders in Congress of the main political parties, the most prominent members of the senate and the chamber of deputies, and members of the Health and Finance Commissions of the Congress. The strategy used to negotiate with legislators supporting and opposing the reform proposal was straightforward: to (1) explain that the nature of the reform was consistent with the political platforms of all of the Mexican parties represented in Congress; (2) explain in detail the content and potential impacts of the reform; and (3) inform legislators that changes and additions to the reform proposal were welcome.
Opponents of the reform, in turn, voiced their opposition in various locations: the national and local press, debates in Congress, academic conferences and informal fora, and private meetings. They sought to convince members of Congress and public opinion to oppose the reform initiative. The opponents knew that reform supporters had enough votes, between the PAN and the PRI, to pass the reform proposal. Once the opponents realized that seeking to convince PRD legislators alone was a lost cause, they redirected their efforts at trying to change the votes of reform supporters. Reform promoters, on the other hand, did not seek to counteract the efforts of opponents, other than securing the votes of supporters in Congress, by stressing the potential benefits of the reform among those directly involved in its negotiation.
The position map in shows that the main driver of SPH policies in Mexico was the minister of health, who counted on strong support from the president and the great majority of PAN legislators, as members of the political party in power. The reform initiative received medium support from most state governors, who were expecting additional financial resources for health, and a large group of PRI members of Congress, who could not easily dismiss a reform proposal designed and promoted by a group of technocrats who had been high officials in three previous PRI administrations and with whom many of them had strong, long-standing personal and professional relationships. Various prominent members of the PRI were part of the Health Commission of the Senate and key supporters of the reform, including two former directors of IMSS and the leader of the MoH trade union and national leader of the Civil Servants Unions Federation (Federación de Sindicatos de Trabajadores al Servicio del Estado or FSTSE). The MoH union offered modest support to the reform proposal on the assumption that additional financial resources associated with the new insurance scheme would eventually improve the working conditions of the employees of the federal and state ministries of health. Finally, based on the negotiations discussed above, the powerful MoF showed guarded support for proposed reform.
Table 2. Position Map for Players in the Mexican Health Reform (First Trimester of 2003). Based on Ref. 56
Four important actors staunchly opposed the reform: a large fraction of the leftist PRD headed by the mayor and the minister of health of Mexico City, the leaders of the IMSS trade union, the director general of IMSS, and two prominent figures of the National Autonomous University (Universidad Nacional Autónoma de México or UNAM), the rector (and former minister of health) and the dean of the School of Medicine (and former vice minister of health).
Within the PRD, the minister of health of Mexico City, a long-standing personal rival of the federal minister of health, was the most active opponent of the reform. She argued that a personal financial contribution to SP (as an annual premium) was incompatible with the idea of health care as a social right.Citation41 The draft law included a premium scaled according to income class, with the lowest two deciles exempt from paying. She also stated that the proposed insurance scheme was designed according to a managed competition model, would increase the segmentation of the Mexican health system, and would grow at the expense of social security institutions.Citation42,43 She was also concerned that SP would undermine a free health care program that she had started in Mexico City (Programa de Servicios Médicos y Medicamentos Gratuitos, Free Health Care and Drugs Program). Her position was supported by Mexico City's mayor (Andrés Manuel López Obrador), a powerful political figure (who ran for president in 2006 and 2012), and a large number of PRD members in Congress (including the head of the Health Commission in the Senate), but not all. She was also unable to persuade any of the governors or ministers of health of the four other states governed by the PRD (Baja California Sur, Michoacán, Tlaxcala, and Zacatecas) to join her in opposition to the proposal.
Serious opposition also arose from the leaders of the IMSS trade union, through newspaper declarations and through their representatives in Congress. They opposed the proposal by arguing that the reform would generate a redistribution of public resources for health that would negatively affect social security institutions.Citation44 They also felt threatened by a new form of social insurance that separated financing of health care from the direct provision of services, which disrupted the union's traditional model in IMSS, where a single organization provided both financing and services for its members.
The IMSS director general opposed the reform by claiming that SP would grow at the expense of IMSS and stimulate informality in the labor force.Citation45 On the latter point he argued that providing nonsalaried workers with better health services through a new insurance scheme would create a disincentive to joining the formal workforce and would thereby slow down economic growth in Mexico. He was also concerned that the new insurance scheme would threaten the existence of IMSS-Oportunidades (IMSS-O), a federal program for the rural poor managed by IMSS. This fear was shared by IMSS union leaders, who were negotiating the incorporation of IMSS-O workers into their membership.
Finally, the rector of UNAM and the dean of its School of Medicine opposed the creation of SP arguing that a better alternative was the gradual incorporation of the nonsalaried population into IMSS, using the optional Health Insurance for the Family (Seguro de Salud para la Familia) offered by IMSS to people ineligible for conventional social security. This option, however, was discussed at the beginning of the Fox administration and was rejected by both the IMSS trade union and the IMSS director general. The dean, a prominent member of the PRI, occasionally used his weekly column to oppose the reform, which he characterized as privatizing and demagogic, but his articles, published in a low-circulation national newspaper, had little influence on Mexican legislators or on public opinion.Citation46,47 A few months after the reform was approved, he anticipated its failure using dramatic language: “[The promoters of SP] … will be responsible before history for the weakening of public policies, the lack of health care coverage, and the fatal parenthesis they have opened which is causing disease, pain and death in spite of what was previously accomplished.” Citation48
Mexico's private sector (insurance, providers, and pharmaceutical industry), health-related nongovernmental organizations, and the beneficiaries themselves showed no clear preference or strong position on the reform proposal. The lack of mobilization of the last two actors illustrates the limited public debate around health issues in Mexico, the organizational weakness of Mexican physicians as an autonomous interest group, and the scarcity of civil society organizations in health, reflecting the low political power of Mexican citizens in the health arena.
The reform bill was sent to Congress by the minister of health on November 12, 2002. During the negotiation process, 100 amendments were made and 21 transitory articles were introduced before the bill reached its final form. The reform, with all of the amendments and transitory articles, was approved about five months later, on April 30, 2003, with 92% of the votes of the Senate (83 votes out of a total of 90) and 72% of the votes of the Chamber of Deputies (305 votes out of a total of 425).Citation49–51 Several PRD senators and all of the PAN, PRI, and Mexico's Green Ecological Party senators voted in favor of the law. Voting in the Chamber of Deputies was more complex. All of the PAN representatives present in the voting session (187), with the exception of one, voted in favor of the bill; 102 of the 160 PRI representatives present in the voting session also voted in favor; and the 45 PRD representatives present in the voting session voted against it.Citation52 Finally, 16 of the 25 remaining representatives of the other political parties present in that session voted in favor of the creation of Seguro Popular and nine voted against it.
CONCLUSIONS
Several conclusions may be drawn from the negotiation of SPH policies in Mexico and the legislative approval process that took place in 2002 and 2003.
First is the importance of contextual factors. Changes in the epidemiological profile of the Mexican population, a major step forward in the process of democratization, and the relatively high rates of economic growth all contributed to create a window of opportunity to introduce policies that would expand SPH. These enabling factors may not all be necessary to create opportunities for major reform (in Mexico or elsewhere), but they certainly are not sufficient. They create the context and open political space, which political actors can then exploit to move a reform proposal forward and create the circumstances for adoption. This process is inevitably political for a major reform because the proposal promises to change who gets what in society, an intentional redistribution of resources.
Second, the Mexican experience shows that the problem needs to be framed in ways that will attract the attention and support of the main political actors so that the proposal can be incorporated into the national policy agenda. The Mexican reform proposal had to be designed to fit with the ongoing epidemiological, political, and economic transitions, so that key political actors would view the proposed changes in the health system as desirable, feasible, and necessary. Opposition to the reform was addressed by consistent arguments and analysis about the reform's anticipated benefits and by securing the firm commitment of legislative supporters in the Mexican Congress.
Third, the Mexican experience demonstrates that policies to expand health care coverage may be successfully promoted even by conservative governments because they can be persuaded to recognize the social, political, and economic importance of investments in health. The Mexican health reform was driven by the minister of health with strong support from the president and his center-right political party (PAN), medium support from the centrist PRI, and guarded conditional support from the MoF. Putting together this alliance of supporters required intense lobbying and persuasion by the minister of health and his change team. Without their efforts to bring together these diverse groups, the reform proposal would not have moved forward and would not have been adopted.
The Mexican reform process also suggests that a supportive relationship with the MoF is a necessary condition for approval of a reform proposal. The failure of the fiscal reform proposal in the initial years of the Fox administration encouraged the financial authorities to resist efforts to expand health care coverage. Three elements of the reform proposal aided negotiations with the MoF: the gradual expansion of population coverage, the gradual expansion of the covered benefits, and the demand-oriented nature of the proposal. The anticipated growth of the federal budget due to the expansion of oil revenues was also very helpful. Negotiators used all of these factors, explained in high-quality analysis prepared by the MoH through its Economic Analysis Unit, to argue that the proposed new system would not break the bank. But it was the sturdy support of President Fox that ultimately disabled the continuing resistance of the MoF. In this case, the decisiveness of the political leader trumped the cautiousness of the economic bureaucracy.
A fifth conclusion is that a pilot project phase can serve both substantive and political motives. The overall positive results of this experiment in Mexico were extremely useful in subsequent discussions with most political actors, to provide substantive arguments and evidence about how the reform would work. The pilot projects also showed the governors that the reform, if adopted, could provide significant new financial resources for them to use and allocate (with some flexibility) in their states. This experience suggests that evidence of practical feasibility and impacts, along with promises of new resources, can improve the chances of legislative approval for controversial policy reforms.
The SP experience also suggests that evidence alone is not sufficient to push a major reform forward to adoption. No matter how wide the window of opportunity is, how well placed the problem is in the national agenda, and how well framed the policy under negotiation is, legislative approval requires effective political strategies. Three factors of the Mexican experience should be highlighted: first, the existence of a team of negotiators with both technical and political skills; second, the early contacts with all stakeholders; and third, the repeated personal meetings with all relevant actors by the change team and the minister of health. In addition, requests from some stakeholders were taken seriously and incorporated into the proposal, as reflected in the 100 amendments that were included in the final bill. None of these were considered to be deal-breakers, according to most individuals interviewed for this article. But the compromises helped persuade reluctant legislators to support the bill.
Finally, the SP process shows that actors who usually support certain public policies may sometimes follow their political interests rather than their social values. The IMSS trade union and a large portion of the left-wing party (PRD), seeking to protect their organizational interests and existing benefits, opposed the reform even though it was intended to benefit mostly poor people. For example, John Scott has written that SP is one of Mexico's two most fiscally progressive public initiatives of the past two decades.Citation53 Nonetheless, the PRD, in this case, acted more as an opposition party might be expected to behave, driven in part by Mexico City's minister of health. This example suggests that, in certain circumstances, the defense of immediate labor, organizational, and even personal interests may be more relevant for political organizations (unions, political parties, and political actors) than the defense of a social goal (the expansion of social protection in health) that is strongly associated with working-class and left-wing traditions.
This analysis of the negotiation process of adopting Mexico's health reform underlines the importance of political factors in the approval of public policies that seek to expand social protection in health. Given the redistribution of resources and power implied in these reform processes, it is necessary to study, when evaluating them, the institutional, political, and economic contexts in which these policies are promoted and explore the interests, intentions, and power of the main stakeholders.
DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
No potential conflicts of interest were disclosed.
NOTE
[a] The price of the barrel of crude oil increased from less than 25 USD in early 2003 to over 40 USD in 2004, 75 USD in 2006, 99 USD by the end of 2007, and 141 USD in August of 2008, the highest levels in history.57
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