La Paz, Baja California Sur Monterrey, Nuevo Leon Health Policy and Federalism Workshops in Mexico In Brief Workshops on Health Policy and Federalism were held in three cities in Mexico from November 4 to 8, 2002. The workshops were organized by the Forum of Federations in partnership with the National Institute for Federalism and Municipal Development (INAFED) and three participating Mexican states. The cities participating were La Paz, Baja California Sur; Puebla City, Puebla; and Monterrey, Nuevo Leon. The Forum of Federations recruited practitioners and experts from five countries: Brazil, Canada, Germany, Spain, and Colombia. As well, Carlos Gadsden, Director General of the National Institute for Federalism and Municipal Development, Antonio Heras, Director General of Policy and Evaluation in the Federal Health Department, and Tlatoani Real, Deputy Director, National Health Board also delivered presentations at the three workshops. In La Paz and Monterrey the State Secretaries of Health opened the workshops, while Melquiades Morales Flores, Governor of the State of Puebla, inaugurated the Puebla workshop. The presentations delivered by the international participants and Mexican federal representatives were nearly identical in all three workshops. Approximately 30 people attended the workshops in La Paz and Monterrey, while the Puebla one counted with around 40 participants. Most were representatives of the State health departments and were interested in the municipalization of the health sector. Different levels of economic development and decentralization distinguished the states; as well, different political parties also governed the three states. Goals The purpose of each workshop was to compare the experiences of different federal countries, evaluate policies and programs, and work towards a better implementation of the principles of good federal governance as they apply to health care. The topics were identified in consultation with the Mexican partners and included fiscal and financial decentralization and intergovernmental relations. Highlights and Focus of Discussions La Paz, Baja California Sur The workshop in La Paz was inaugurated by Raul Eduardo Rodríguez Pulido, Secretary of Health of the State of Baja California Sur; Ana Maria Guemez, INAFED; and Diana Chebenova of the Forum. Raul Carrillo delivered the first presentation, in representation of Raul Eduardo Rodriguez Pulido, State Secretary of Health. It was mentioned that state health services in Baja California Sur have been operating in a decentralized form since 1995. Even though Baja California Sur is a very young state, it distinguishes itself for its social and economic development, including a clear definition of strategy for managing health services, reflected in decentralization of public health services. During his presentation, Enrique Gomez Saguchi, Municipal Director of the Municipality of Los Cabos emphasized the need for a strategy on joint responsibility between the three orders of government to deal with health issues. He stressed the need to create a Municipal Health Council, whereby all popular representatives, directors of health institutions, and representatives of the three levels of government would be represented. Fernando Moreno Abarroa, Jurisdictional Head of La Paz stressed in his presentation on experiences and expectations of the municipalization of health services the slow progress in budgeting. The consolidation of the health sector in the state of Baja California Sur, according to Mr. Moreno, requires the transfer of operational resources, autonomy and financial resources to the state. Tlatoani Real Mata, Deputy Director at the National Health Board described the Board as an institution created by both federal and state governments. The Board favors federalism and works on the basis of consensual decision making on the issues suggested to it by both federal and state governments. This is the result of the process of decentralization that was initiated in the eighties. Antonio Heras Gomez of Federal Health Department spoke about cooperative federalism in health sector and the strategies of the National Health Program. He mentioned that as the process of decentralization in Mexico culminates, the current agenda focuses on how to build cooperative federalism in health sector, considering mainly the following aspects: i) clear distribution of competencies between the levels of government; ii) availability of instruments for evaluation of performance and accountability; and iii) revision of the way resources are distributed, as an incentive to improve health conditions. Following these guidelines, the National Health Program 2001-2006 has the following objectives: i) to finalize the decentralization; ii) to establish new institutional arrangements for coordination and joint responsibility in the National Health System; and iii) to gradually move forward with the process of municipalization of health services. Wayne Fritz, former Director of the Policy and Intergovernmental Liaison Unit, Department of Health, Saskatchewan, Canada spoke about the challenges and change in Canada’s Health System. His presentation made it clear that the Canadian health system differs from that of Mexico mainly in that it is not a unified national health system, but rather each province/territory has its own health system and is responsible for provision of health services. Municipalities do not play major role in the provision of health services. Klausdieter Tschope, former Ministerial Counsellor and Head of the Division for Project Planning and Structural Issues Concerning Medical Schools, Federal Ministry of Education and Research and Advisor of the Land Government of Mecklenburg-Western Pomerania spoke about the essential features of health care in Germany and the objectives of health care reform. The German health sector distinguishes itself from Mexico and Canada’s models by the fact that health services are provided by private sector in which both medical and hospital associations participate in an organized manner. Financial management and supervision are located in both local and federal levels. The users are free to choose the physician and hospital they want to attend. The federal government is responsible for promoting reforms in the health system and the lander governments supervise the obligatory health insurance. Guillem Lopez Casasnovas, Director of the Centre for Health and Economics, Professor in Applied Economics and Dean of the School of Economics and Business, Pompeu Fabra University in Barcelona spoke about territorial decentralization of public health spending and equalization mechanisms in Spain. He summarized the Spanish experience from 1981 – 2002. In Spain, the autonomous communities are responsible for health services, even though the national government retains some health functions. The financing strategy of health is based on contributions from fiscal revenues at the national level, such as income tax and valued added tax that are used to finance different areas of social development (such as education, health, etc.). Marta Arretche, Professor of Political Science, State University of Sao Paulo presented the Brazilian model. The decentralization in Brazil has reached the municipalities, which are nowadays responsible for providing basic health services. They operate under a unified health system. The decentralization involved an important fiscal reform, in which 45% of taxes were transferred in direct form to the states and municipalities. In addition, both state and municipal governments are allowed to create instruments to raise revenues for financing of health services. Ivan Jaramillo Perez, former Secretary General of the National Hospital Fund and former coordinator of the Program for Consolidation of the National Health System summarized 10 years of fiscal and administrative decentralization of health services in Colombia. The decentralization of health sector in Colombia was an integral part of a broader process of decentralization of public services. The departments (state level) are responsible for the provision of the 2nd and 3rd level of health services, while the municipalities are responsible for the 1st level. Eighty per cent of health spending takes place at the municipal level. In the discussion, the representative of the State Health Department said that they agree with the federal principles of democratic decision making, but they do not agree when the decisions are made at the center and imposed on the state government and the state government is forced to accept them in order to receive financial resources. Baja California Sur has acceptable financial recourses in health, even though not sufficient ones. Each community has at least one physician for 1000 inhabitants. Puebla City, Puebla The workshop was inaugurated by Melquiades Morales Flores, State Governor; Jesus Lorenzo Aarun Rame, Secretary of Health of Puebla; Carlos Gadsden Carrasco, Director General of INAFED; and Diana Chebenova of the Forum. Carlos Gadsden Carrasco emphasized in his presentation the need to promote authentic federalism and build a modern architecture that would respond to the demands and expectations of the people. He explained the main features of the program “From the Local” (Desde lo local) promoted by INAFED that aims at assuring the inhabitants of each municipality the provision of all basic public services. The municipalities will determine the necessary actions to achieve this objective by an auto examination. This way, each municipality will determine what and when to decentralize, in accordance with its organizational, economic, and structural abilities. Jesus Lorenzo Aarun Rame presented Puebla’s proposal to municipalize health services. This process is based on the principles of equity, efficiency and efficacy. In accordance with the reality of the state of Puebla, it is considered viable to administratively decentralize the basic health units (“casas de salud”) to the municipalities. However, this process will require the support of the federal government. The state government will continue to be responsible for the hospitals and for development of the health programs. Eduardo Gonzalez Pier, General Coordinator of Strategic Planning, Federal Health Department spoke about federalism in health sector and fiscal reform. The objectives of fiscal reform are eliminate imbalances of diverse origin, establish joint responsibilities, and make sure that social rights are fully exercised. This will be achieved in three phases: i) update of jurisdictional frame, ii) reform of the Constitution (2003), and iii) preparation of the Law on Universal Social Protection (2004-2006). Maria Fernanda Merino Juarez, Director of Evaluation of Health Systems at the Federal Health Department spoke about national and state health accounts. She started her presentation by saying that the municipalization of health services is in accordance with the strategy of cooperative federalism in heath care. It is based on the principles of solidarity, subsidiarity, joint responsibility and asymmetry, and it respects the pace of each federating unit. The national health account is information available to the public about the health spending at the national level. It contributes to the process of transparency and accountability. Correspondingly, state health accounts are public information about health spending in the federating units that contribute to the same process of transparency and accountability, to the efficient and equitable distribution of resources, to the process of funds negotiation and evaluation of performance. A representative of the Department of Immigration delivered the last presentation. He mentioned that presently Mexicans who immigrated to and live in the United States send approximately 10 billion US dollars a year to Mexico in remittances. Many of these immigrants do not receive any health services in the United States. There is a program in place whereby Mexicans living in the United States are attended by a physician in Nuevo Leon via telemedicine. In order to develop and be able to operate similar programs, the decentralization of health services to municipalities is crucial. The presentations were delivered also by Tlatoani Real Mata, Antonio Heras Gomez, and the international experts. Monterrey, Nuevo Leon The workshop was opened by Jesus Zacarias Villarreal, State Health Secretary; Carlos Gadsden Carrasco, Director General of INAFED; and Diana Chebenova of the Forum. Jesus Zacarias Villareal presented the state vision of the decentralization of health services in Mexico, considering the way in which the health sector has developed since 1940. The decentralization has been conditioned by the transformations that Mexico has undergone in the second half of the 20th century. The country is now being adapted to the new reality so as to be able to respond to the new challenges, such as higher level of education, new epidemiological challenges, and the compromises resulting from the consultations with the population, which demands equity, efficiency and quality together with an adequate financial protection. In order to achieve this, new schemes of participation of the municipalities in the health sector are being contemplated. In the state of Neuvo Leon, first steps have been taken to deconcentrate the responsibilities of health services to the municipalities. The presentations were also delivered by Carlos Gadsden Carrasco, Tlatoani Real Mata, Antonio Heras Gomez, and the international experts.