Health Care and Social Security
In the early 1990s, Mexico showed clear signs of having entered a transitional stage in the health of its population. When compared with 1940 or even 1970, Mexico in the 1990s exhibited mortality patterns that more closely approximated those found in developed societies (see table 5, Appendix). Health officials have also reported substantial reductions in morbidity rates for several diseases typically prevalent in poorer countries.
At the same time, however, government officials recognize that this transition is, at best, incomplete. Diseases associated with unsanitary living conditions, minimal access to health care, or inadequate diet continue to affect those in the lowest economic strata. Reductions in government health care expenditures during the economic crisis of the 1980s slowed progress in several areas. In addition, persistent underreporting of diseases in rural areas masks the true dimension of the health care challenge.
Mexico's social security program provides health care to formal-sector workers and their families, some 50 percent of the national population in 1995. This figure represented a drop from the 56 percent coverage rate in 1992. The Mexican Institute of Social Security (Instituto Mexicano de Seguro Social--IMSS) covers approximately 80 percent of these beneficiaries (all employed in the private sector). The Institute of Security and Social Services for State Workers (Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado--ISSSTE) covers government workers and accounts for 17 percent of the beneficiaries. The Secretariat of National Defense (Secretaría de Defensa Nacional), the Secretariat of the Navy (Secretaría de Marina), and Mexican Petroleum (Petróleos Mexicanos--Pemex) have their own health programs, which cover military and naval personnel, and petroleum workers, respectively (see Personnel, ch. 5). A tripartite funding arrangement finances IMSS operations, with contributions from the employee, employer, and government. ISSSTE programs, as well as those offered by the military and Pemex, are financed through employee and government contributions.
Those outside the social security network--the so-called "open population"--receive health care from a wide array of government agencies. Approximately one-third of the population is served by IMSS-Solidarity (IMSS-Solidaridad), the successor of IMSS-Coplamar (see Structure of Society, this ch.) IMSS-Solidarity is funded by general government revenues, although IMSS provides administrative direction. As part of President de la Madrid's decentralization effort and corresponding federal budget reduction, the population served by IMSS-Coplamar in fourteen states was reassigned to state health agencies under the overall direction of the Secretariat of Health (Secretaría de Salud--SS). The SS also serves as coordinator of the National Health System, which includes the health programs offered by the social security agencies. In keeping with its commitment to a new federal partnership, the Zedillo administration announced that it would transfer facilities and operations of IMSS-Solidaridad and the SS to the states in 1996.
Social security beneficiaries had greater access to health care than did their counterparts among the open population. In 1995 the rates of doctors and hospital beds per 100,000 persons stood at 121 and ninety, respectively, for social security beneficiaries but only 105 and eighty, respectively, for the open population. Social security beneficiaries were also nearly twice as likely as the open population to have consulted a doctor during 1995 and twice as likely to have had surgery that year.
Notable regional disparities in health care are also evident. In 1983 the government surveyed health care access nationwide as measured by thirteen basic indicators, including medical facilities, prenatal consultation, medical attention to various illnesses, and vaccination programs. The Federal District and three northern and northwestern states--Coahuila, Colima, and Nuevo León--recorded levels exceeding eighty out of a possible 100 points. In contrast, Oaxaca, Chiapas, and Puebla in southern and central Mexico averaged between forty and fifty points. Guerrero in the southwest posted a score of only thirty-nine.
In 1940 infectious, parasitic, and respiratory illnesses accounted for nearly 70 percent of all deaths in Mexico. Three decades later, these illnesses still produced more than half of all deaths. By 1990, however, their share of the overall mortality level had dropped to around 20 percent. Cardiovascular illnesses, cancer, accidents, diabetes mellitus, and perinatal complications emerged as the top causes of death in 1990, a sharp change from the previous pattern. Yet despite the progress, health officials recognize the continuing serious threat posed by infectious, parasitic, and respiratory illnesses. Two such illnesses--pneumonia and influenza--and intestinal infections remained within the top ten causes of death in 1990. Among the twenty leading causes of death were such maladies as nutritional deficiencies, chronic bronchitis, measles, tuberculosis, anemia, and severe respiratory infections.
Government census data record a continuous and significant decline in infant mortality from 1930 to 1980 (see table 6, Appendix). The infant mortality rate stood at 145.6 deaths per 1,000 registered live births in 1930. It dropped to 96.2 by 1950, to 68.5 in 1970, and to 40.0 in 1990.
Wide regional variations in infant mortality levels persisted into the 1990s. The 1990 census indicated, for example, that infant mortality rates clustered around the mid-twenties in Baja California Norte, Baja California Sur, the Federal District, and Tamaulipas, and the mid-fifties in Oaxaca, Guerrero, Puebla, and Chiapas (see fig. 8). Even more dramatic variations could be found across municipalities. In general, the lowest levels appeared in highly urban municipalities, especially state capitals and metropolitan areas. In contrast, the highest rates typically were associated with remote, rural, and largely Indian communities.
Nationally, 52 percent of all recorded infant deaths in 1990 occurred during the postneonatal stage, when infants are most susceptible to infections and poor diet. Although perinatal complications accounted for 35 percent of all infant deaths in 1990, intestinal infections and influenza and pneumonia also remained important causes, representing 15 and 13 percent of infant deaths, respectively.
The government reported significant reductions between 1980 and 1990 in early childhood mortality. Early childhood mortality declined from 3.4 per 1,000 preschoolers in 1980 to 2.4 in 1990. Intestinal infections headed the list of causes of death, followed by measles, pneumonia and influenza, and nutritional deficiencies. Preliminary figures for 1991 suggested a sharp decline in early childhood mortality to 1.6 per 1,000 preschoolers. The 1991 figures pointed to notable statewide variations, with rates below one in Coahuila, Durango, Sinaloa, Sonora, Tamaulipas, and the Federal District, and above three in Chiapas, Oaxaca, and Puebla.
Maternal mortality also declined over the same period, with rates falling from 9.4 deaths per 10,000 registered live births in 1980 to 5.4 in 1990, and to 5.1 in preliminary 1991 data. Baja California Sur reported no maternal deaths in 1991, with several, mostly northern states--Chihuahua, Coahuila, Durango, Jalisco, Nayarit, Nuevo León, Sinaloa, Tabasco, and Tamaulipas--indicating rates below three deaths per 10,000 registered live births. In sharp contrast stood Oaxaca, with a rate exceeding fourteen deaths per 10,000 registered live births.
Although infectious diarrhea and severe respiratory infections have declined significantly as causes of mortality, they remain major illnesses in the early 1990s. Reported cases of infectious diarrhea escalated dramatically from 1,661 per 100,000 residents in 1980 to 2,906 in 1990, and to 4,685 in 1991. During the same period, severe respiratory infections climbed from 3,334 cases per 100,000 residents in 1980 to 10,800 in 1990, and to 13,732 in 1991.
Mexican health officials reported substantial progress in relation to several illnesses controllable by vaccination. Pertussis declined from 122.6 cases per 100,000 residents in 1930 to 4.4 cases in 1980, to 1.3 cases in 1990, and to only 0.2 cases in 1991. Chiapas's rate in 1991 stood at ten times the national average, however. The total number of cases of poliomyelitis declined from 682 in 1980 to seven in 1990 and to zero in 1991. The government recorded only a single case of diphtheria in 1991. Measles epidemics continued to occur, with rates surging from 24.2 cases per 100,000 residents to 80.2 in 1990 before falling sharply to 5.9 in 1991. Even here, however, improvement over past decades could be noted because epidemics occurred only every four or five years as compared with the previous pattern of occurring every other year. Somewhat less progress was apparent in the campaign against tuberculosis, with rates declining from 16.1 cases per 100,000 residents in 1980 to 14.3 in 1990.
Vector-transmitted illnesses remain major public health challenges, especially in southern Mexico. Malaria increased dramatically from 36.9 cases per 100,000 residents in 1980 to 171.5 cases in 1985, before dropping to 31.1 in 1991. Chiapas, Oaxaca, Guerrero, Michoacán, and Sinaloa are priority areas for government antimalarial campaigns. After not a single case of onchocerciasis was reported in 1980 and 1985, the disease reemerged in the late 1980s. Health officials identified 2,905 cases in 1987 and 1,238 cases in 1991, most of them in Oaxaca and Chiapas. In contrast, significant progress occurred in the reduction of dengue, with cases per 100,000 residents declining from 73.8 in 1980 to 6.9 in 1991. The disease is found along the Gulf of Mexico and Pacific coastal regions, the mouth of the Río Balsas, and central Chiapas.
Although most sexually transmitted diseases declined throughout the 1980s, acquired immune deficiency syndrome (AIDS) proved a glaring and deadly exception. Mexico reported its first cases of AIDS in 1983. Both the total number of cases and the ratio increased annually through 1993. In 1993 the government reported 5,095 new cases, or 5.4 cases per 100,000 residents.
Mexico's social security agencies are financed through contributions from members, employers, and the government. In the mid-1990s, contributions averaged around 25 percent of members' salaries. Although informal-sector workers may subscribe to the IMSS, they are effectively prevented from doing so because they must pay not only their own share but that of their employers as well. Members are eligible for a wide array of benefits including pension, disability, and maternity coverage. A variety of other services are also available to all Mexicans, including theaters, vacation centers, funeral parlors, and day-care centers. Approximately 1.5 million Mexicans received monthly pensions in the mid-1990s, a higher figure than in previous decades, reflecting gains in average life expectancy.
An actuarial crisis is expected to threaten the fiscal solvency of the social security system by the early twenty-first century. Analyst Carmelo Mesa-Lago has noted numerous problems confronting the system, including rising administrative expenditures, redundant physical plants, the high costs of complex medical technology for IMSS's approximately 1,700 hospitals, and continual transfers of pension funds to cover deficits in disability and maternity programs. In early 1996, IMSS projected its first annual budget deficit. In December 1995, the legislature approved a plan to enhance the viability of social security by expanding its contributory base from the informal sector. In addition, Mexicans can establish privately operated individual retirement accounts. That element of the plan, to take effect in January 1997, was also designed to increase domestic savings to finance future economic growth.
Despite impressive gains in the health care system during the second half of the twentieth century, Mexico's health care and education systems and, indeed, its entire society remain in a profound state of transition. The population of states in northern Mexico and many urban areas exhibits social indicators on a par with those of developed countries, whereas statistics for southern Mexico and most rural areas are comparable to those of the developing world. One of the key challenges for Mexico in the twenty-first century, therefore, will be to meet the needs of a rapidly expanding and urbanizing population while continuing to improve living conditions for the many disadvantaged segments of its society.
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