PRIMARY HEALTH CARE SYSTEMS

(PRIMASYS)
Case study from Mexico

Abridged Version
WHO/HIS/HSR/17.3

© World Health Organization 2017

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike
3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes,
provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion
that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If
you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If
you create a translation of this work, you should add the following disclaimer along with the suggested citation:
“This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content
or accuracy of this translation. The original English edition shall be the binding and authentic edition”.

Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation
rules of the World Intellectual Property Organization.

Suggested citation. Primary health care systems (PRIMASYS): case study from Mexico, abridged version.
Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.

Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit
requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.

Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as
tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and
to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-
owned component in the work rests solely with the user.

General disclaimers. The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any
country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full
agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed
or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by WHO to verify the information contained in this publication.
However, the published material is being distributed without warranty of any kind, either expressed or implied.
The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be
liable for damages arising from its use.

The named authors alone are responsible for the views expressed in this publication.

Editing and design by Inís Communication – www.iniscommunication.com

 Primary Health Care Systems
(PRIMASYS)
Case study from Mexico

Overview of primary health care system

According to a 2015 survey (between two censuses), the
estimated population of Mexico was 119.5 million people
in that year, with a projected 137 million by 2030.1 In 2015,
the population aged under 15 years represented 27% of
the total population, people aged between 15 and 64
represented 65% and those above 65 were 7.2%. Mexico
has undergone an increasing urbanization process. In
1950 around 43% of the population lived in urban areas;
by 1990 this population represented 71%, attaining
79% in 2015.2 According to the National Council for the
Evaluation of Social Development Policy (CONEVAL, for its
Spanish initials),3 in 2014, 46% of the population lived in
poverty, of which 36.6% lived in moderate poverty and
9.6% in extreme poverty.4
As the 10th Revision of the International Classification of
Diseases and Related Health Problems (ICD10) states, the
main mortality causes were diabetes mellitus, ischaemic
heart diseases, cerebrovascular disease, cirrhosis and other
chronic liver diseases, and chronic obstructive pulmonary
disease. At the same time, there has been a significant
increase in risk factors, such as obesity and overweight,
physical inactivity, consumption of high caloric content
food, as well as use of tobacco, alcohol and illicit drugs.5
The Mexican economy has experienced a long-term
decrease of its growth rate during the last three decades.
In 2015, Mexico’s gross domestic product (GDP) was
US$  1143.79 billion, while the GDP value of Mexico
represented 1.84% of the world economy. According
to per capita GDP, Mexico is ranked 76th among 196
countries. The Gini coefficient, measuring inequality of
income, was 0.503, placing Mexico as a country with a
significant income inequality. Total health expenditure
as a proportion of GDP is 5.78%, below the percentage
of other Latin American countries such as Uruguay and
Brazil (both 8.9%). Public health expenditure is 53% of
total health expenditure, while out-of-pocket expenditure
accounts for 41%.
In 2015, the number of first-level health care units reached
28 366 – 98% in the public sector and only 2% (627) in
the private sector. In the same year 4456 hospitals were
counted, of which 69% (3070) were in the private sector.
The availability of human resources for health is 2.47
physicians (OECD 3.27) and 2.77 nurses (OECD 9.09) per
1000 inhabitants.
Table 1 summarizes demographic and health indicators
for Mexico, while Figure 1 provides a timeline of key
developments in the Mexican health system.

1 Proyecciones de la población 2010–2015. Consejo Nacional de Población (http://www.conapo.gob.mx/es/CONAPO/Proyecciones, accessed 25 May 2017)
2 World urbanization prospects: the 2014 revision. Population Division of the Department of Economic and Social Affairs, United Nations (https://esa.un.org/unpd/wup/,
accessed 20 June 2017).
3 To facilitate identification, all initials of Mexican institutions are provided as they are originally written in Spanish.
4 Medición de la pobreza en México: resultados de pobreza en México 2014 a nivel nacional y por entidades federativas. Consejo Nacional de Evaluación (http://www.coneval.
org.mx/Medicion/Paginas/PobrezaInicio.aspx, accessed 25 May 2017).
5 Boletín de información estadística 2014–2015. Secretaria de Salud (http://www.dgis.salud.gob.mx/descargas/pdf/Boletxn_InformacixnEstadxstica_14_15.pdf, accessed 25 May 2017).
 Case study from Mexico

Table 1. Mexico: demographic and health indicators

Indicators Year Results Source of information

Total population of country 2015 119 938 473 National Statistics and Geography Institute
(INEGI)
Distribution of population (rural/urban) 2015 21% World Banka
Life expectancy at birth 2015 74.9 years General Directorate for Health Information
(DGIS)
Infant mortality rate 2015 12.51/1000 live births Millennium Development Goals Information
System (SIODM)b
Under-5 mortality rate 2015 15.06/1000 live births SIODM
Maternal mortality rate 2015 34.59/100 000 live births SIODM
Immunization coverage under 1 year 2013 BCG 94.9 % INEGI
(including pneumococcal and rotavirus) 2014 HB 84.7%
2015 Pentavalent 69.4%
2016 Pneumococcal 80.8%
2016 Rotavirus 63.5%
2016 Basic scheme 85.29%
Income or wealth inequality (Gini coefficient) 2014 0.503 CONEVAL
Total health expenditure as proportion of 2014 5.78% Ministry of Health, Statistical information
GDP bulletinc
Public expenditure as proportion of total 2014 52.62% Ministry of Health, Statistical information
expenditure on health bulletin
Private expenditure as proportion of total 2014 48.38% Ministry of Health, Statistical information
expenditure on health bulletin
Primary health care (PHC) expenditure as % 2014 24.90% Estimation from Mexico Health Accounts
of total health expenditure database
% total public sector expenditure on PHC 2014 55.00% Estimation from Mexico Health Accounts
database
Per capita public sector expenditure on PHC 2014 US$ 306 Estimation from Mexico Health Accounts
database
Out-of-pocket payment as proportion of 2013 40.80% Ministry of Health, Statistical information
total expenditure on health bulletin
Proportion of households experiencing 2012 2.08% Ministry of Health, Statistical information
catastrophic health expenditures bulletin

a. World urbanization prospects: the 2014 revision. Population Division of the Department of Economic and Social Affairs, United Nations (https://esa.un.org/unpd/wup/,
accessed 20 June 2017).
b. Sistema de información de los Objetivos de Desarrollo del Milenio (http://www.objetivosdedesarrollodelmilenio.org.mx/odmING.htm, accessed 25 May 2017).
c. Boletín de información estadística 2014–2015. Secretaria de Salud (http://www.dgis.salud.gob.mx/descargas/pdf/Boletxn_InformacixnEstadxstica_14_15.pdf, accessed
12 March 2017).

4
 Primary Health Care Systems (PRIMASYS)

Figure 1. Timeline of key developments in the Mexican health system

1976
Coverage Extension Programme
An effort of the Ministry of Health to
bring essential health care services to
rural communities
1985
Constitutional reform
Recognition of citizens’ right
to receive health protection
and replacement of the
old Sanitary Code by the
General Health Law
1997
PROGRESA Coverage
2003
Extension Programme
Social Protection for Health
Cash transfer programme geared
System
to schooling of children and
1. Financial protection offering
attendance to periodic health
voluntary public health insurance 2012
care visits
to the population without social PHC Services Observatory
security Report on PHC units quality
2. Health provision for health improvement opportunities
prevention and promotion

1996 2006
Health services decentralization Health Promotion
1. Decentralization of health services for Operational Model
1979 uninsured population This model defines 2015
IMSS-COPLAMAR 2. Creation of the states health services the basis for health Comprehensive
This programme 3. Extension of coverage promotion Health Care Model
emphasized preventive 4. Improvement of efficiency and quality The model placed PHC
health activities based through sector coordination as the most important
on community work to strategy for health care
promote development in Mexico

5
 Case study from Mexico

Governance
The Mexican health system (Figure 2) is a segmented and under the Institute for Social Security and Services for State
fragmented system with both public and private sector Workers (ISSSTE); as well as the employees of the national
participation. The public sector is responsible for the oil company (PEMEX), of the Ministry of Defence, through
health care of both the beneficiaries of the social security the Social Security Institute for the Mexican Armed Forces
institutions and the population without social security, (ISSFAM), and of the Marine Secretariat (SEMAR), including
which is covered by the System of Social Protection in their families. On the other hand, the private sector offers
Health.6 Health care in the latter case is the responsibility health care to very diverse populations – from people
of its executive arm, Popular Health Insurance, which lacking employment in the formal sector of the economy
is provided by the Ministry of Health, the State Health to the wealthiest populations. All of them buy a range
Services (SESA) and the Prospera Social Inclusion of health care services of varying cost and quality from
Programme. Besides health care, the social security private medical offices, clinics, hospitals and insurance
institutions also offer other social advantages, such as companies.7,8
retirement insurance. These institutions cover the formal
private sector employees and their families, under the In terms of organizational structure, the Ministry of Health
Mexican Social Security Institute (IMSS); the employees does not include any high-level office or department
of the federal and state governments and their families, specifically responsible for primary health care (PHC).

Figure 2. Structure of the Mexican health system

SECTOR Public Private

Social security National Ministry of Health States Health Services (SHS)

Federal States
Government Employers’ Workers’ Govt Govt
Individuals Employers
contribution contribution contribution contribution contribution

Popular
FUNDS
health Private
insurance insurance
companies

ISSSTE National MoH PROSPERA

BUYERS IMSS PEMEX Social inclusion
Army / Navy SHS programme

Hospitals, clinics, doctors and nurses of Hospitals, clinics, Hospitals, clinics,

PROVIDERS
these institutions doctors and doctors and
nurses of these nurses of these
institutions institutions
Private providers

Workers Self-employed & informal

USERS in the Workers’ Population with paying
Retirees sector workers and
formal families capacity
unemployed
sector

Source: Adapted from Gomez-Dantés O et al. El sistema de salud de México.

6 Bonilla-Chacín ME, Aguilera N. The Mexican social protection system in health. Universal Health Coverage Studies Series (UNICO) No. 1. Washington (DC): World Bank; 2013.
7 Nava-Zarate N, Orellana-Centeno M, Orellana-Centeno JE, Onofre-Quilantan MG. Comparación de los sistemas de salud de México y de España. Salud en Tabasco 20131928-
36 (http://www.redalyc.org/articulo.oa?id=48727474007, accessed 25 May 2017).
8 Gómez-Dantés O, Sesma S, Becerril VM, Knaul FM, Arreola H, Frenk J. The health system of Mexico. Salud Pública de México. 2011;53(Suppl. 2):S220–32.

6
 Primary Health Care Systems (PRIMASYS)

Nevertheless, two general directorates (third hierarchical
level) are in charge of the organization of relevant aspects
of PHC and, most importantly, the implementation of
the Comprehensive Health Care Model (MAI). First, the
General Directorate for Health Promotion, under the
Undersecretary for Integration and Development of
the Health Sector, is responsible for a series of specific
action programmes directly linked with PHC, namely
health promotion, social determinants of health, healthy
communities and environments, food and physical activity.
Likewise, the General Directorate for Health Planning and
Development includes structures that are responsible
for outpatient health care, extending coverage, planning
health services networks, planning services exchange
and even traditional medicine.9 In 2012 the Primary
Health Care Services Observatory reported on the overall
conditions of PHC units, identifying opportunities and
strategies to improve the quality of PHC.10
As an expression of the federal character of the country,
the autonomy of each SESA creates a wide range of
modalities for PHC provision adapted to each state. As
in the Federal Ministry of Health, each SESA includes
several entities with PHC responsibilities. However,
except in the SESA in the states of Puebla and Michoacán,
they seldom include offices with explicit links to PHC. A
search for similar departments in the rest of the country
only identifies subdirectorates for health promotion and
disease prevention in Quintana Roo, prevention and
promotion departments in Hidalgo, and first-level services
and health promotion regulation departments in Morelos.
Concerning IMSS – the provider of health care for the formal
private sector workers and their families – the Directorate
for Health Care Services Provision includes a Primary
Health Care Unit. This directorate is divided into three
coordination offices: one responsible for comprehensive
health care at the primary care level; one responsible for
occupational health, which is focused on employment; and
one responsible for epidemiological surveillance, linked to
the diagnosis of public health from which the portfolio of
services is elaborated.11 ISSSTE also lacks an explicit PHC-
linked office. Nevertheless, the Subdirectorate for Health
Promotion and Disease Prevention, which is part of the
Medical Directorate, does have an Office of Family Medical
Care Services. This office is responsible for the first-level
services network, and well as for family medical care
services. In addition, another office is responsible for the
prevention of chronic degenerative diseases, and another
department is in charge of the regional and local health
systems.12 The organizational structure of PEMEX includes
the Administration for Preventive Medicine, in which are
located the Prevention Unit and the Subadministration
for Preventive Medicine. Within the latter, the Department
for Primary Prevention and Community Action and the
Department for Secondary Prevention and Assistance are
mandated to perform PHC-linked activities. In relation
to the public sector, consideration must also be given to
health services for the members of the armed forces and
marine services and their families. Even though each one
of these institutions includes particular organizations and
systems related to health care in general, the available
information regarding their organizational structure is not
sufficiently clear to distinguish any entities specifically
responsible for PHC.13
Finally, while there is no structured policy or complete
information on the role of the private sector in relation to
PHC, this sector certainly plays a relevant role in offering
first-contact health care to the population, even to those
who benefit from other forms of health coverage. As an
example, using outpatient care as a proxy for PHC, the
present study found that, in a context in which around
40% of the out-of-pocket spending of families is used to
pay for private medical consultations, between 2000 and
2012, the proportion of all kinds of health-related out-of-
pocket spending increased from 31% to 38.9%.

9 Manual de organización específico de la Dirección General de Planeación y Desarrollo en Salud. Secretaría de Salud, México; 2012 (http://www.salud.gob.mx/unidades/
transparencia/UNIDAD_DE_ENLACE_POT/Politica_de_Transparencia/Temas_TransparenciaFocalizada/MOE/DGPLADES.pdf, accessed 29 May 2017).
10 Observatorio de los servicios de atención primaria 2012. Dirección General de Evaluación del Desempeño. Secretaría de Salud, México; 2013 (http://www.dged.salud.gob.
mx/contenidos/dess/descargas/upn/OSAP_2012.pdf, accessed 29 May 2017)
11 Instituto Mexicano del Seguro Social: estructura orgánica operativa. Instituto Nacional de Transparencia, Acceso a la Información y Protección de Datos Personales (http://
portaltransparencia.gob.mx/pot/estructura/showOrganigrama.do?method=showOrganigrama&_idDependencia=641, accessed 18 April 2017).
12 Manual de organización general del Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado. México: Instituto de Seguridad y Servicios Sociales de los
Trabajadores del Estado; 2010 (http://normateca.issste.gob.mx/webdocs/X8/201103312204482488.pdf?id=002708, accessed 21 April 2017).
13 Manual de organización de la Subdirección de Servicios de Salud y Unidades Operativas. Dirección Corporativa de Administración. México: Petróleos Mexicanos; 2007
(page 30) (http://www.pemex.com/servicios/salud/NormatecaServiciosdeSalud/Normateca/mo_sss_oct_07.pdf, accessed 15 April 2017).

7
 Case study from Mexico

Financing
In 2014, the total health expenditure in Mexico was a percentage of total health expenditure (PHCE%) is
US$ 124 410 million (purchasing power parity = 8.002),14 determined by the following formula:
equivalent to 5.78% of its GDP, while public spending
represented 52.62% of this amount (US$ 65 467 million). outpatient curative care expenditure
As stated, funding for this expenditure comes from both (HC.1.3)+preventive care expenditure (HC.6)

the public and private sectors. In this analysis we will only PHCE%= x 100
consider the public expenditure on PHC. total health expenditure (H)

Public financing of health care has two components:

financing for the population with social security, and
financing for the population without social security
(Figure 3). The first component, mainly in the cases of
IMSS, ISSSTE and PEMEX, is characterized by the inclusion
of mandatory contributions from workers and their
employers.15 On the other hand, the expenditure for the
population with no social security is dedicated to financing
government plans and programmes to improve access to
health care for the self-employed, unemployed and informal
workers. This expenditure includes the Ministry of Health (in
which the System of Social Protection in Health must be
mentioned), the Health Care Services Contributions Fund
(FASSA), Prospera and expenditure by states.
This analysis uses the Classification of Health Care
Functions developed by the Organisation for Economic
Co-operation and Development (OECD),16 which is the
basis for the expenditure accounts of Mexico through
the Federal and State Health Accounts Subsystem
(SICUENTAS).17 According to the OECD definition of
primary health care, this analysis only considers outpatient
curative care and preventive health services as indicators
of PHC expenditure, all of which are included in functions
HC.1, “curative care”; and HC.6, “preventive care”. Only
“outpatient curative care” (HC.1.3) was used as an indicator
of PHC expenditure (Figure 3). So PHC expenditure as
The public health expenditure allocated to PHC in Mexico
is US$ 36 465 million, or 29.4% of total health expenditure
and 55% of public health expenditure. Figure 3 shows that
5.7% of public health expenditure goes to preventive care,
while 49.3% goes to outpatient curative care. However,
those percentages vary by financial source: IMSS allocated
73.8% of its total health expenditure to PHC (70.1% to
outpatient care and 3.7% to preventive care), while the
Ministry of Health allocated 57.8% (50.7% to outpatient
care and 7.1% to preventive care).
Human resources
In 2015 there was a total of 745 040 health workers in
Mexico (including medical and nurse students in practice).
Of those, 57% were working in hospitals, 40% in primary
health facilities and 2% in other health facilities. Physicians
and nursing personnel represented the majority of human
resources working in primary health facilities, with little
change in the trend between 2013 and 2015 (Table 2).
The distribution of physicians and nursing personnel
in primary health facilities follows the same trend. The
Ministry of Health has the highest proportion of medical
and nursing staff, followed by IMSS and ISSSTE (Table 3).

14 Paridades de poder de compra. Instituto Nacional de Geografía y Estadística (INEGI) (http://www3.inegi.org.mx/sistemas/paridades/estructura.aspx?idEstructura=1150058

00010&T=Paridades%20de%20poder%20de%20compra&ST=Paridades%20de%20poder%20de%20compra&tipoInfo=tipo%20de%20conversi%C3%B3n%20monetaria,
accessed 25 May 2017).
15 Social security schemes concerning ISSFAM and SEMAR only report their total expenditure but do not provide detailed information on the origin of their funds.
16 A System of Health Accounts 2011: revised edition. OECD, Eurostat and World Health Organization; 2017 (http://www.keepeek.com/Digital-Asset-Management/oecd/social-
issues-migration-health/a-system-of-health-accounts-2011_9789264270985-en#page3, accessed 25 May 2017)
17 Subsistema de Cuentas en Salud (SICUENTAS): Clasificador por Funciones de Atención. Secretaria de Salud, Dirección General de Información en Salud (http://www.dgis.
salud.gob.mx/contenidos/basesdedatos/da_sicuentas_gobmx.html, accessed 25 May 2017).

8
 Primary Health Care Systems (PRIMASYS)

Figure 3. Percentage of public expenditure destined to primary health care, by source of financing, Mexico, 2014

IMSS-PROSPERA 0.2% 23.3% 76.5%

States health services 7.5% 17.6% 74.9% Financing Agents of

Población without
Social Security
FASSA 11.9% 23.2% 64.9%

Ministry of Health 7.1% 50.7% 42.2%

National 5.7% 49.3% 45.0% National

PEMEX 0.6% 16.5% 82.9%

Social security 4.0% 21.2% 74.8%

in the States Financing Agents
of Población with
Social Security
ISSSTE 4.1% 35.6% 60.3%

IMSS 3.7% 70.1% 26.2%

Preventive care services Outpatient curative care Other functions

Source: Adapted with information from DGIS and SICUENTAS.

Table 2. Human resources in primary health facilities in Mexico, by category

2013 2014 2015

n = 249 247 n = 269 057 n = 291 047
Health personnel n % n % n %
Physicians 75 828 30 81 481 30 93 096 32
Nursing personnel 73 089 29 79 760 30 91 552 31
Other professional personnel 24 449 10 25 562 10 13 047 4
Technical personnel 22 110 9 23 994 9 31 251 12
Other personnel 53 771 22 58 260 21 62 101 21

Note: Does not include medical and nurse students in practice; includes personnel from IMSS, ISSSTE and Ministry of Health.
Source: Human resources information from DGIS, 2016.

Table 3. Distribution of physicians and nursing personnel in Mexico, by institution

Physicians Nurses
2013 2014 2015 2013 2014 2015
Institution n % N % n % n % n % n %
Ministry of Health 36 803 49 40 806 50 41 893 45 37 893 52 37 893 51 37 893 46
ISSSTE 10 171 13 11 354 14 11 193 12 10 090 14 10 330 14 10 532 13
IMSS 28 854 38 29 321 36 40 010 43 25 106 34 25 366 34 34 514 42

Note: Does not include medical and nurse students in practice.

Source: Human resources information from DGIS, 2016.

9
 Case study from Mexico

Accreditation of nursing and medical schools is guided Planning and implementation

by the Mexican Council for Medical Education and the
Mexican Council for the Accreditation and Certification
of Nursing, which are both recognized by the Council
for the Accreditation of Higher Education. Despite the
existence of these organizations, full accreditation of all
the programmes in the country has not been achieved. In
fact, only 44 of 80 medical schools and only a few of the
600 nursing training programmes have been accredited.
Awarding degrees and certification is the responsibility
of universities and other higher education institutions,
together with the Ministry of Education’s General
Directorate for Professions, which is in charge of awarding
physicians’ licences.
Concerning PHC education, Mexico has an academic
structure for postgraduate studies. In 1994 the Mexican
College of Family Medicine was founded, gathering
around 36 state-level primary care associations and
medical colleges. Some universities have family
medicine departments, and the Mexican Council for the
Certification of Family Medicine can certify specialists in
family medicine.18 Regarding undergraduate education in
medicine, there is no information on the inclusion of PHC
in the curricula of any of the universities. Similarly, there
is a great variety of schools training nurses at technical
and Bachelor of Arts level, but there is no information on
the curricula for PHC nurses. Unfortunately nurses are still
being trained only to become the aids of physicians, while
their potential for strengthening PHC is neglected.19
Every five years, each health institution elaborates its
own programmes following the health sector’s goals and
including different strategies and activities related to PHC
units. All of these programmes are explicitly devoted to
prevention, health promotion and health recovery. The
Ministry of Health counts 18 such programmes, while
IMSS also encompasses 18 different programmes in its
large initiative called PREVENIMSS. Similarly, the Preventive
Medicine area of ISSSTE includes 15 programmes. In all
cases, programmes simultaneously target the individual,
families and communities. And even though each
institution is responsible for the implementation of its own
programmes, the Ministry of Health does play a certain
coordination role. At the same time, every institution
carries out performance evaluations of the health units in
which PHC is provided using a set of indicators that have
been called “walking towards excellence”.20 Besides, the
National Council for Evaluation of Development Policy is
in charge of monitoring and evaluating all programmes of
this kind and observes several efficiency indicators.21
As a steering entity, in 2015 the Ministry of Health launched
the MAI in order to standardize health care services,
optimize health resources and infrastructure, and promote
citizens’ participation. As one of the four strategies of MAI
was the renewal of PHC, the implementation of MAI
followed a series of guidelines:
• focus on the person, the family and the community,
considering the needs of the first two and the health
risks of the latter;
• prioritize health promotion and disease prevention
according to the epidemiological, demographic,
social and economic conditions of each region
through promoting capacity-building, intersectoral
participation and inclusion of different stakeholders,
while seeking to influence the social determinants of
health;

18 Prestación de servicios de salud: definición de un paquete de beneficios equitativo y fortalecimiento de la atención primaria. In: Estudios de la OCDE sobre los Sistemas de
Salud: México 2016. Paris: OECD Publishing (http://dx.doi.org/10.1787/9789264265523-7-es, accessed 25 May 2017).
19 Plan Nacional de Desarrollo 2013–2018. México, Gobierno de la República; 2013 (http://www.cmic.org.mx/comisiones/sectoriales/infraestructurahidraulica/PND_PLAN_
NAL_DESARR/PND-introduccion.pdf, accessed 25 May 2017).
20 Consejo Nacional de Evaluación de la Política de Desarrollo. Informe de la Evaluación Específica de Desempeño 2014–2015. México: Secretaría de Desarrollo Social; 2015
(http://www.coneval.org.mx/Evaluacion/Documents/EVALUACIONES/EED_2014_2015/SEDESOL/S072_PROSPERA/S072_PROSPERA_IE.pdf, accessed 7 June 2017)
21 Consejo Nacional de Evaluación de la Política de Desarrollo. Programa IMSS-Oportunidades. México: Secretaría de Desarrollo Social – Instituto Mexicano del Seguro Social;
2015 (http://www.coneval.org.mx/Informes/Evaluacion/Ficha_Monitoreo_Evaluacion_2013/IMSS-OPORTUNIDADES/19_S038.pdf, accessed 7 June 2017)

10
 Primary Health Care Systems (PRIMASYS)

• strengthen the sanitary jurisdictions as technical and services, to manage intersectoral participation in order to
management units for the coordination of the territorial address social determinants of health in each region, and
systems in order to survey the quality of PHC and thus to articulate outpatient medical care.24
guarantee access to health benefits;
• strengthen networks of facilities to ensure the provision The General Health Council is a collegiate organization
of standardized services for health promotion, disease with sanitary authority responsibilities. Several articles
prevention, health care, disease management, of the Mexican Constitution and the General Health
rehabilitation and palliative care, taking into account Law support the council as the main coordination and
cultural and social dimensions and emphasizing regulation entity of the National Health System. It is
outpatient care, with particular emphasis on PHC; integrated with the Secretary of Health; the directors
• develop the competences and capacities of human of the National System for the Integral Development of
resources and ensure their even distribution throughout Families and of the National Science and Technology
the country while adjusting them to local community Council; the medical directors of IMSS and ISSSTE; and
and geographical circumstances, with special attention representatives from the academic institutions related
to the professionalization of multidisciplinary groups in to the health sector.25 The functions of the council in the
charge of outpatient care; domain of PHC include (a) elaboration, dissemination and
• define the population and geographical realms of update of the basic catalogue of inputs for the primary
responsibility in such a way that each person or family health facilities, in coordination with the Ministry of
will be assigned to a services network cognizant of and Health and the other public institutions; (b) elaboration,
able to cater for their health needs. publication and update of the generic drugs catalogue;
and (c)  establishing actions for quality assessment and
certification of medical care facilities by defining standards
Regulatory process for the PHC certification of clinics.26,27
Health system stewardship depends on the federal The National Health Council, which includes the directors
government through the Ministry of Health, which is the of all the SESAs, was created in 1986 to coordinate
main organization responsible for strategic planning, programming, budgeting and evaluation of public
intersectoral coordination, sanitary regulation and health. Following its reorganization in January 1995,
evaluation of institutions, programmes, policies and services the National Health Council became the permanent
in the health sector. Regulation of provision is simultaneously coordination mechanism between the federal and
a responsibility of the federal government and of each state governments to support the health services
state’s ministry of health. Civil society organizations and decentralization process. Among its main functions are
professionals collaboratively conduct regulation of health the establishment of recommendations to unify criteria
care.22,23 At the state level, sanitary jurisdictions are the to attain the goals of public health programmes; the
technical and management units responsible for the promotion of priority health programmes in the states;
coordination of territorial systems based on PHC. Their and proposing complementary financing strategies for
objective is to guarantee quality of care and access to health public health.28,29,30,31
22 Nava-Zarate N, Orellana-Centeno M, Orellana-Centeno JE, Onofre-Quilantan MG. Comparación de los sistemas de salud de México y de España. Salud en Tabasco 20131928-
36 (http://www.redalyc.org/articulo.oa?id=48727474007, accessed 25 May 2017).
23 Gómez-Dantés O, Sesma S, Becerril VM, Knaul FM, Arreola H, Frenk J. The health system of Mexico. Salud Pública de México. 2011;53(Suppl. 2):S220–32.
24 Modelo de Atención Integral de Salud (MAI). Secretaria de Salud, Dirección General de Planeación y Desarrollo en Salud. México; 2015 (http://www.gob.mx/cms/uploads/
attachment/file/83268/ModeloAtencionIntegral.pdf, accessed 25 May 2017).
25 Soberón Acevedo G. El cambio estructural en la salud. Estructura y funciones de la Secretaria de Salud: del sector salud y del sistema nacional de salud. Salud Pública de
México. 1987;127–40.
26 Diario Oficial de la Federación, 11 diciembre de 2009. México: Reglamento Interior del Consejo de Salubridad General; 2009.
27 Sistema Nacional de Certificación de Establecimientos de Atención Médica: estándares para la certificación de clínicas de atención primaria y consulta de especialidades.
Consejo de Salubridad General; 2015.
28 Consejo Nacional de Salud. Secretaria de Salud; 2017 (http://www.cns.salud.gob.mx/contenidos/1_informaciongeneral.html, accessed 25 May 2017).
29 Soberón Acevedo G. El cambio estructural en la salud. Estructura y funciones de la SecretarIa de Salud: del sector salud y del sistema nacional de salud. Salud Pública de
México. 1987;127–40.
30 Consejo Nacional de Salud: información general. Secretaria de Salud (http://www.gob.mx/salud/acciones-y-programas/consejo-nacional-de-salud, accessed 25 May 2017).
31 Acuerdo por el que se establece la integración y objetivos del Consejo Nacional de Salud.DOF 27/01/2009. México; 2009.

11
 Case study from Mexico
According to the Strategic Project for Sanitary Jurisdictions,
1989, the sanitary jurisdictions are responsible for the
coordination of the local health systems at the state
level. This project’s main objectives were (a) to promote
expansion of health services coverage, with emphasis on
PHC; (b) to contribute to the quality and productivity of
health services; and (c) to promote the decentralization
of resources and decision-making at the local level.32
The sanitary jurisdictions are responsible for planning and
assessing health services based on uniform, systematic
operations in order to guarantee quality of care in the
first-level units, according to the guidelines of national
and state health programmes.33 Their functions are (a) to
organize the medical care and public health actions
according to the norms (Law on Social Protection in
Health, last reform, 2011, provision of health care services,
last reform, 2016, and other guidelines and norms issued
by the Ministry of Health); (b) to review quality standards in
the primary health facilities; (c) to support the elaboration
of the health situation analysis and programmes; (d)  to
coordinate social participation in the local health system;
and (e) to support surveillance of the sanitary operation
and functioning of health care facilities.24 Nevertheless,
sanitary jurisdictions only encompass health services
provided by the Ministry of Health and SESA, while
health care provision at IMSS, ISSSTE and the other public
institutions responds to the criteria and guidelines put in
place by other organizations.
Monitoring and information system
The National System of Health Information (SINAIS)
makes available data from different units for provision
of health care services, including outpatient services.
Databases include information on health care coverage,
infrastructure, human and financial resources, services
utilization and performance indicators. However, SINAIS
does not integrate information from all health providers.
Despite some progress, most of the data come from
the Ministry of Health. There is as yet no free access to
information for other health institutions in the public
sector for consultation and analysis. Concerning
information on quality of care, even if the states collect
information on productivity indicators in hospitals and
32 Fortalecimiento de los sistemas locales de salud: Proyecto de Desarrollo de Jurisdicciones Sanitarias. Dirección de Desarrollo de Sistemas Locales de Salud. Salud Pública de
México. 1994;36(6):673–93.
33 Manual de funcionamiento de las jurisdicciones sanitarias del ISEM. Gobierno del Estado de México, Secretaria de Salud; 2015.).
34 Manual de indicadores de servicios de salud. Secretaría de Salud (http://www.dged.salud.gob.mx/contenidos/dess/descargas/ind_hosp/Manual-ih.pdf, accessed 25 May 2017
12
satisfaction surveys among patients of public facilities,
there is no autonomous agency capable of collating state-
level data. To estimate several indicators of outpatient
care in Mexico it is necessary to gather data from different
sources, including:
• demographic events registration
• population and housing census
• ordinary registries of health services
• epidemiological surveillance data
• sample-based surveys (population surveys)
• disease registration
• other data sources from different sectors (economic,
political, social welfare).
Since 2000, Mexico has developed initiatives to assess
health system performance, with the help of the World
Health Organization. Multiple indicators have been used
to assess the performance of health systems. In this
process, Mexico has developed a monitoring system for
external consultation units and outpatient services using
a number of indicators, including: 34
• average consultation per medical office
• percentage of pregnant women enrolled in the first
trimester
• average of prenatal consultations
• percentage of consultations for acute respiratory
infection
• percentage of controlled hypertensive patients.
Ways forward and policy
considerations
According to the National Health Plan 2013–2018, the
basis of MAI is the regeneration and strengthening of
PHC. It is therefore first necessary to review the ensemble
of health services to assess how they can coherently
respond to the health needs of the population. In that
regard, priority should be given to the implementation,
monitoring and evaluation of actions that support health
promotion and disease prevention, without disregarding
actions that support healing and rehabilitation.
The implementation of a PHC-oriented health care model
entails strengthening the training of human resources for
 Primary Health Care Systems (PRIMASYS)

health so that they acquire the necessary competences to

assure delivery of quality health care. It is also important to
bring up to date the skills profiles of health professionals,
including professional midwives, health promoters and
physical trainers, so that they can respond to the health
needs of the population.
The implementation of a health care model based on
PHC is essential to strengthen the primary care units. This
entails training professionals on management capacities
related to the provision of quality care. At the same time,
the capacity of health units must be improved so that
they can provide greater quality and quantity of human
resources, teams, drugs, appropriate technology and
other inputs.
At the community level, it is vital to engage citizens in
formulation of the diverse interventions related to their
health demands through the participation of diverse
stakeholders and actors from civil society. Disease
prevention and health promotion strategies need increased
financing, given their potential to influence lifestyles and
combat the risk factors behind the increasing prevalence
of chronic degenerative diseases in Mexico. Finally, it is
necessary to review how PHC is being financed: What are
the resource allocation mechanisms? How are resources
distributed among prevention, promotion, healing and
rehabilitation actions? and, What budget mechanisms are
in place?

13
 Case study from Mexico

Authors
National Institute of Public Health,
Centre for Health Systems Research:
Jacqueline Alcalde-Rabanal
Victor Becerril Montekio
Julio Montañez-Hernandez
Olga Espinosa-Henao
Rafael Lozano
Luis García-Bello
Elliot Lagunas-Alarcon
Alejandro Torres-Grimaldo

14
This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the
World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda
Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support
efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care
interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development
and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage
of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and
abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system,
tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points
to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an
audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health
care systems in selected low- and middle-income countries.

World Health Organization

Avenue Appia 20
CH-1211 Genève 27
Switzerland
alliancehpsr@who.int
http://www.who.int/alliance-hpsr