Octavio Gómez Dantés: “The Universal Health Service is a reckless proposal”

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VOICES · HEALTH SYSTEM INTEGRATION · MEXICO

Octavio Gómez Dantés is a researcher in medical sciences at the Center for Health Systems Research of Mexico’s National Institute of Public Health (INSP) and a level III member of the National System of Researchers. From 2002 to 2006 he was director general for performance evaluation at the federal Ministry of Health. A physician trained at the Metropolitan Autonomous University in Xochimilco, he holds master’s degrees in public health and in health policy from the Harvard T.H. Chan School of Public Health and has published more than 150 articles in scientific and general-interest journals. The opinions he expresses in this interview are his sole responsibility.

He speaks as Mexico attempts to knit together a fragmented public health system. A presidential decree published on April 17th created the Universal Health Service (SUS), under which people will gradually be able to seek care at the Mexican Social Security Institute (IMSS), the Institute for Social Security and Services for State Workers (ISSSTE), IMSS-Bienestar (the federal health service for people without social security), the medical services of the state oil company, Pemex (which has up to three years to join), the federal referral hospitals and Mexico’s National Institutes of Health, regardless of affiliation. The institution a patient belongs to must compensate the one that provides the care. The first stage, starting on January 1st 2027, covers vaccination, primary and emergency care, heart attacks, strokes, high-risk pregnancies and continuity of treatment for conditions such as cancer, kidney failure and HIV (human immunodeficiency virus). Meanwhile the Chamber of Deputies must approve the 2027 budget by November 15th; the bill proposes a real increase in health spending.

In this written interview, he explains why he expects the SUS to strain the social-security institutions, where the supply of medicines breaks down and why Mexico must spend much more on health.

The interview

Since 2009 an agreement among the Ministry of Health, IMSS and ISSSTE has let obstetric emergencies be treated in their hospitals regardless of affiliation, with payment between institutions. From January 2027 the SUS will extend that exchange to emergencies, heart attacks, strokes, high-risk pregnancies and continuity of treatment. What would it take to extend it to the ongoing care of chronic diseases?

The SUS is, in my view, a reckless proposal. It promises to integrate the public health system and make access to health services universal before this administration ends. The SUS will begin operating in 2027 with seven interventions of very different complexity: vaccination, basic outpatient care, emergency care, heart attacks and strokes, high-risk pregnancies and continuity of certain outpatient treatments. These interventions will most likely be sought above all by people without social security, at IMSS and ISSSTE units. Yet the constant complaints of social-security members and the recent protests by IMSS workers are evidence that these institutions’ responsiveness has deteriorated. Under these conditions, it is quite possible that the SUS will generate additional demand that exceeds the operating capacity of IMSS and ISSSTE. Extending SUS coverage to all chronic diseases before the end of this six-year term, as the current administration intends, requires a substantial injection of resources to strengthen the supply of services at IMSS and ISSSTE, resources the federal government does not currently have.

On September 29th Eduardo Clark, the health ministry’s undersecretary for sectoral integration, said more than 7 million people had registered for the SUS, which emphasizes primary care. Beyond registration, which indicators of effective primary-care coverage should the system publish to show whether real access is improving?

The most reliable indicators of effective access to primary care come from independent surveys. One is particularly useful: the National Health and Nutrition Survey (ENSANUT), run by the National Institute of Public Health. Among many other things, it records the percentage of the population that, when facing a health need, receives care at a public or private facility. In 2023, 46% of the population facing a health need used a public outpatient facility. If the SUS works effectively, it should produce an increase in the share of people using public outpatient services.

“It is quite possible that the SUS will generate additional demand that exceeds the operating capacity of IMSS and ISSSTE.”

Under the decree, the institution a patient belongs to must pay the one that treats them, settling accounts at least monthly. Can that compensation work between IMSS, ISSSTE and IMSS-Bienestar, whose costs and finances differ so much?

As I noted earlier, the logical assumption is that with the SUS, IMSS-Bienestar users will seek care at IMSS and ISSSTE. There is a perception that social-security services are better. IMSS and ISSSTE may face no great obstacles in treating new users with inexpensive problems, such as common infections, minor injuries and even childbirth. But barriers (denial of service, long waiting times, rationing) will begin to appear with costly problems, such as heart attacks and strokes. Juan Manuel Lira [a medical specialist and health analyst, writing in El Financiero in January] explains this very well. The so-called “clearinghouse” under which the SUS will operate rests on two assumptions: that there is idle capacity to sell and that the buyer has the liquidity to pay. Today neither assumption holds in Mexico. The social-security institutions have little idle capacity to treat heart attacks or strokes, and the potential buyer, IMSS-Bienestar, lacks the means to pay the “real cost” invoices issued by the provider, IMSS’s regular [contributory] scheme, whose costs are higher. This will force that regular scheme “to absorb part of these costs, using worker and employer contributions to subsidize a fiscal obligation of the state.” And Lira concludes: “If patients are allowed to migrate freely, demand will concentrate in IMSS. Faced with saturated facilities and no real payment, IMSS will inevitably impose administrative barriers (‘disguised rejection’) to protect its capacity.”

It is also quite possible that excess demand will hurt the quality of care for social-security members, which will inevitably prompt complaints that are more than justified. Excess demand will also cause enormous discontent among health workers, who are already protesting in the streets over, among other things, excessive workloads.

In the 2027–2028 consolidated purchase, 626 of 766 codes for generics, cancer drugs and anti-infectives were awarded, worth about 84 billion Mexican pesos (MXN); 139 were declared void and will be tendered again before year-end, and one was dropped. A study you co-authored found that greater use of private services, especially for medicines, contributed to out-of-pocket spending. Beyond awarding contracts, what would have to happen between purchase and filled prescription for out-of-pocket spending on medicines to fall?

Assuming the consolidated purchase makes it possible to acquire the medicines the system needs, two processes would have to improve to ensure that prescriptions are filled in full at public institutions: the distribution of medicines and inventory control. The great challenge is distribution. The public sector has neither the experience nor the infrastructure to distribute medicines in a timely and effective way. Here it is essential to turn to the private sector. Mexico has some 1,000 drug distributors, 100 of them with national reach, years of experience and cutting-edge technology, such as specialized vehicles for transporting these products and digital delivery platforms.

In a September article in Este País, you noted that 5.7 million households incurred excessive health spending in 2024. The 2027 budget bill proposes more than MXN 1.1 trillion for the health function, 10.9% more in real terms. Where would such an increase do most to protect households without social security?

The 11% increase in the public health budget is good news, but it is not enough. It will barely bring us close to 3% of gross domestic product (GDP). Public health spending is plainly meager, and its most dramatic effect is the lack of coverage. Today 44 million Mexicans have no access to health services. To bring down excessive health spending, coverage of services has to be expanded. But that will not be achieved with small budget increases, changes in how scarce resources are distributed or organizational adjustments. Better allocation can marginally improve financial protection, but it cannot indefinitely substitute for the resources that are missing. Increasing public investment is an indispensable, though not sufficient, condition for recovering lost capacity and expanding coverage, which will reduce the incidence of excessive health spending. The goal should be to reach spending equivalent to 3.5% of GDP in 2030 and to rise gradually to the 6% recommended by the World Health Organization over the next ten years.^*

“Better allocation can marginally improve financial protection, but it cannot indefinitely substitute for the resources that are missing.”

The SUS plans to have 12,750 primary-care consulting rooms operating in stages from January 2027 in the 24 states served by IMSS-Bienestar, in existing IMSS, ISSSTE and IMSS-Bienestar units and in newly adapted spaces. In March, at El Colegio Nacional, you noted that the budget of Mexico’s National Institutes of Health, the 13 federal institutes that combine specialty care, research and teaching (INSP among them), fell from MXN 21.5 billion to MXN 18.2 billion in constant pesos between 2023 and 2025. How can the system pay for both primary care and high-cost specialist care, such as cancer, without the two competing for the same money?

It is important to clarify that 12,750 consulting rooms will be refurbished in the 24 states where IMSS-Bienestar operates: these are not new units. This will undoubtedly strengthen the supply of services, but not to the degree that twelve thousand additional units would. The most serious problem of our public institutions is primary care, whose responsiveness and problem-solving capacity must be expanded. This, however, must not be done at the expense of secondary and tertiary care. To deal properly with health problems, basic services, general hospital care and specialized hospital care are all needed.

The main causes of death in Mexico are cardiovascular disease, diabetes and cancer. It is important to act on the risk factors associated with these conditions and to strengthen their early diagnosis and treatment, which are almost always outpatient. But it is also essential to care for the millions of patients who suffer from these diseases and already show damage that requires specialized care. There are no easy or cheap ways out. To confront chronic noncommunicable diseases, which today dominate our population’s health profile, it is essential to strengthen, through a comprehensive approach, the whole spectrum of health care, from health promotion and tackling risks to palliative care, including, of course, highly specialized curative care. This requires a very significant increase in public investment in health.

*The 6% of GDP benchmark was set out by the Pan American Health Organization (PAHO), WHO’s regional office for the Americas, in its 2014 Strategy for Universal Access to Health and Universal Health Coverage.

Sources: Este País (author profile); Decree creating the Universal Health Service (Diario Oficial de la Federación, April 17th 2026); Adhesion agreement to the 2009 general agreement on obstetric emergencies (2011); Excélsior (7 million registered); El Imparcial (decree, first stage); Expansión (consolidated purchase); Este País (September 2026); El Financiero (Juan Manuel Lira, January 13th 2026); El Economista (consolidated purchase 2027–2028); Expansión (2027 health budget); Expansión (budget deadline); Health Economics Review (Cerecero-García, Gómez-Dantés et al., January 2026); IMSS joint bulletin (12,750 consulting rooms); El Colegio Nacional (March 2026); PAHO (Strategy for Universal Health, 2014).