Globalization and its impact in Public Health
Globalization significantly influences our daily lives, particularly in health, affecting both health determinants and outcomes The rise of urbanization, industrialization, and changes in diet and lifestyle have contributed to a surge in non-communicable diseases (NCDs), such as diabetes, cardiovascular diseases, chronic respiratory diseases, and cancers (Lee et al 2002; Parish 2006) Currently, NCDs represent the leading cause of death worldwide, accounting for approximately 35 million fatalities annually, which constitutes 60% of all global deaths (WHO Action Plan 2008).
Communicable diseases, like tuberculosis and malaria, transcend national borders and are influenced by various vectors (Parish 2006:1) In contrast, non-communicable diseases (NCDs) are increasingly similar across nations, largely due to a global "obesogenic" environment that promotes sedentary lifestyles and easy access to energy-dense foods (WHO 2004) This environment significantly heightens the risk of developing diabetes, a prominent NCD.
Diabetes is a chronic and currently incurable disease characterized by insufficient insulin production by the pancreas or ineffective use of insulin by the body There are two primary types of diabetes: type I and type II, with type II accounting for 90-95% of all cases Its development is associated with genetic factors, while obesity, physical inactivity, and an unhealthy diet are significant contributors to its onset.
Uncontrolled diabetes can result in severe complications such as amputations, blindness, and kidney and circulatory diseases, significantly affecting patients' quality of life and leading to premature deaths These complications also impose substantial financial burdens on healthcare systems, with direct costs of diabetes accounting for 2.5% to 15% of annual health care budgets, depending on local prevalence and treatment sophistication Additionally, the rising incidence of type 2 diabetes among working-age adults poses challenges for labor productivity and overall household income.
Managing diabetes is a lifelong commitment that involves daily treatment and lifestyle adjustments For individuals with type 1 diabetes, this includes a strict diet, regular physical activity, frequent home blood glucose monitoring, and daily insulin injections Similarly, type 2 diabetes management requires dietary control and exercise, and may involve oral hypoglycemic medications or insulin injections as needed Adhering to these treatment plans is essential for maintaining health and well-being in those living with diabetes.
Currently, approximately 171 million people globally are affected by diabetes, a number projected to double by 2030 Alarmingly, four out of five individuals with diabetes reside in developing nations, predominantly impacting working-age men and women By 2030, it is estimated that three-quarters of all diabetes patients will be from low-income countries, indicating that low and middle-income countries (LMIC) will face the most significant challenges related to the diabetes epidemic.
1 ‘Double Burden’ in Latin America
Problem Formulation
In light of the complex health challenges, it is crucial to examine how public health policies in Brazil and Mexico are responding to the increasing prevalence of diabetes.
This study investigates the public policy processes in Mexico and Brazil, focusing on diabetes, to evaluate the priority-setting process and readiness to address the evolving health landscape, as well as to analyze the implementation and effectiveness of diabetes-related policies By critically comparing the two countries, the research aims to provide a richer characterization of their policies and processes Additionally, this comparative analysis seeks to enhance dialogue and knowledge transfer among states, particularly in light of shared factors influencing diabetes Further details on the analysis structure will be discussed in the Methodology chapter.
This project is structured into four key sections: first, it outlines the methodological and theoretical approaches; second, it provides a detailed analysis of health policies in Brazil and Mexico individually; third, it offers a comparative analysis between the two countries; and finally, it concludes with insights and future perspectives.
Methodology
Use of Sources
The analysis relies primarily on secondary data from both countries, encompassing regulatory documents like congressional bills, constitutional amendments, and official licenses Key information is also drawn from governmental websites, communication materials, official statements, and media interviews However, it is important to note that a bias may arise, particularly concerning policy selection and its outcomes.
To enhance the credibility and validity of the results, this study will employ triangulation of sources, a method defined by O’Donoghue & Punch as "cross-checking data from multiple sources to search for regularities in the research data" (2003: 78) This approach aims to minimize potential biases and ensure a more robust analysis.
Scholarly essays will serve as a crucial source for analyzing the evaluation and outcomes of public policies, particularly in Brazil and Mexico While extensive academic work has been produced on public health policies in these regions, a significant drawback of using secondary data is that it may not directly address the specific research questions of this study, leading to potential gaps in information Nevertheless, the available data must be utilized, and many analyzed articles reveal trends and applications of policies in both countries, with some findings being extrapolated for broader insights.
In-depth interviews serve as a crucial source of qualitative data, providing personal perspectives on issues within each country As noted by Guion (2006), this open-ended, discovery-oriented method effectively captures the processes and outcomes from the viewpoints of key stakeholders or the target audience These interviews not only generate valuable insights but also help validate findings obtained from other sources, enriching the overall understanding of the topic.
In-depth qualitative research interviews utilize a semi-structured script that allows the conversation's flow to determine the sequence and selection of questions, as noted by Guion (2006: 1) Additionally, the script, which can be found in ANNEX 1, includes open-ended questions, enabling interviewees to discuss topics in a more unrestricted manner.
The interviews, recorded in audio format and accessible upon request, have been fully transcribed and summarized in ANNEX 2, which includes translations of key points The interviewees represent the public health care systems of their respective countries, and while their names have been omitted for confidentiality, their ranks and titles are provided in ANNEX 2.
While some scholarly essays are accessible in English, most governmental documents and interviews are in Portuguese and Spanish The author provides translations of relevant sections when needed.
Use of Theory
Understanding the public policy process requires recognizing its multidisciplinary nature, drawing insights from sociology, economics, and political science At its essence, public policy involves the exercise of power, highlighting the significance of power dynamics and the state's role in contemporary societies.
The public policy process model, which categorizes policy-making into distinct stages, will serve as the primary theoretical framework for this discussion The Theory chapter will examine various models and their respective limitations.
Social constructivism plays a crucial role in understanding the positions and perceptions of various actors in decision-making processes Constructivists argue that the human world is not merely a natural phenomenon but is actively constructed through the actions of individuals (Kratochwil, 2001) This perspective aligns with public policy studies, where policymakers must recognize that "facts" can be contentious and influenced by differing interests (Hill, 2005) By integrating social constructivism with institutionalist and functionalist approaches, we can better contextualize the political processes involved in formulating and implementing health policy, situating specific developments within a wider framework of social and institutional dynamics (Crinson, 2009).
The sociology of organizations plays a crucial role in understanding the policy-making process, as it helps interpret how policies are implemented within complex institutions This perspective is essential for examining the behavior of employees as policies transition from theory to practice The subsequent chapter will summarize the key tools offered by Institutionalism to enhance this understanding.
Functionalist explanations emphasize the economic factors influencing decision-making and policy implementation They are especially valuable for analyzing how governments assess and measure the effectiveness of their policies Given the rising costs of healthcare, these explanations provide insights into the motivations behind the choices made by various stakeholders.
Analysis Structure
Health policy can be understood through macro and micro social processes The macro level examines the functioning of social and institutional structures, including the State and formal social welfare institutions In contrast, the micro level focuses on the effects of policy on healthcare professionals' practices and the experiences of service users This study primarily emphasizes macro analysis while also considering the outcomes for patients, aligning with Crinson's definition of micro social processes.
This project operates on the premise that financing mechanisms and health system regulations create incentives that significantly affect care patterns, costs, and outcomes (OECD 2003: 97) The study aims to analyze these incentives within the health policy frameworks of various countries, focusing on how different stages of the public policy process can either hinder or enhance diabetes management By examining the policy content related to healthcare, particularly diabetes, we seek to identify factors that could improve health outcomes for affected populations (Hill 2005: 5).
Chapter IV outlines the context that informed the development of specific programs, actions, or policies, detailing the key stakeholders involved, the objectives set, the intended beneficiaries, and the policy's scope at the national, state, or municipal level, as well as its implementation and potential reforms.
In the public policy process, two key stages stand out for their critical role in addressing problem formulation: 'initiation' and 'policy implementation, monitoring, and control' (Jenkins in Hill 2005: 20).
The initiation phase, which includes the articulation and aggregation of interests within institutions, is crucial for understanding the recognition of diabetes on a national level As noted by Green Pedersen & Wilkerson, “A central insight of policy agenda-setting research is that political attention affects policy” (2008: 81) Additionally, this article will explore the role of structures and agencies in conducting Cost-Effectiveness Analysis (CEA) to evaluate priorities in diabetes management.
CEA was first applied to health care in the mid-1960s, and has become a common feature in medical literature (Effective Clinical Practice 2000) It can be defined as:
Cost-effectiveness analysis is a method used to prioritize competing needs when resources are scarce Typically, it involves comparing a new strategy to existing practices, referred to as the 'low-cost alternative,' to determine the cost-effectiveness ratio This ratio reflects the 'price' of additional benefits gained by adopting the new strategy, such as $10,000 per life year If this price is deemed sufficiently low, the new strategy is classified as cost-effective.
Health Technology Assessment (HTA) is a vital form of policy research that evaluates the social implications—such as societal, economic, ethical, and legal aspects—of technology use in healthcare (Goodman, 2004: 12) It focuses on the effectiveness, appropriateness, and cost of health technologies by comparing them with existing alternatives The integration of Cost-Effectiveness Analysis (CEA) in priority-setting can significantly influence policy-makers' decisions Relevant questions regarding CEA have been included in the interview script (ANNEX 1), and the structures for cost-effectiveness analysis will be thoroughly examined in chapter IV.
The rise in healthcare expenditures and the availability of advanced technology significantly drive the adoption of cost-effectiveness analysis (CEA), yet its application remains inconsistent in middle-income countries Previous research highlights the critical role of expert consensus among public health stakeholders regarding the implementation of technologies and interventions to combat diseases A lack of agreement on the use of specific technologies poses a considerable obstacle to enhancing health access.
The 'policy implementation' stage will examine existing diabetes treatment policies, underlining the significant impact of government management on welfare and health care programs (Green Pedersen & Wilkerson 2008: 82) This analysis will specifically address the legislative and executive frameworks in Brazil and Mexico, emphasizing the interconnected nature of the public policy process, where each stage influences the others Additionally, the feedback effects of the CEA will be evaluated during the implementation phase.
The study of the public policy process often raises the question of whether it is feasible to differentiate between descriptive analysis of policy and normative analysis for policy In this context, policy analysts are viewed as engaging in normative analysis when tasked with proposing new policies or alternatives to existing ones Many scholars contend that separating these two forms of analysis is not possible.
This study, conducted in 2005, adopts a disinterested approach to critical analysis, focusing on the optimal use of resources and the best outcomes for patients However, it does not propose alternative policy suggestions.
Analyzing policy involves several noble goals, but it's crucial to recognize the complexity of the policy process, necessitating careful consideration of prescriptive approaches This study aims to take a foundational step toward a comprehensive understanding of the current situation.
Delimitations and Reservations
The subject of health policy is a universally relevant one But in order to narrow down the problem formulation into an achievable task, a selection of countries and issues was necessary
Brazil and Mexico, the largest countries in Latin America by population and economic size, wield significant influence over their neighboring nations, with their actions having far-reaching consequences Brazil, in particular, has established itself as a regional power in the Western Hemisphere, gaining increased stature and visibility Given their prominent roles, both countries have the potential to export successful health measures, acting as models for smaller nations in the region.
In May 2010, the "Brazil-Africa Dialogue on Food Security, Fight Against Hunger, and Rural Development" meeting in Brasilia showcased leadership in social technology, with participation from 36 African ministers and representatives from over 40 countries This event aimed to enhance South-South Cooperation to foster food security and development in Africa, highlighting Brazil's best practices for potential implementation in other developing contexts In contrast, Mexico has spearheaded the establishment of the Community of Latin American and Caribbean States (CELAC), a multilateral organization uniting all 32 nations in the region Salvador Beltrán del Río, Mexico's Foreign Relations Undersecretary, emphasized that CELAC fulfills the longstanding aspiration for a dedicated platform for dialogue and political resolutions among Latin American countries.
The two countries also have a number of characteristics that would make the comparison valid and feasible in terms of historical perspective, population size and health challenges
The focus on diabetes in Latin America is driven by its significant prevalence and impact on healthcare systems, highlighting the need for targeted health policies Addressing diabetes can also lead to broader health benefits, as effective diabetes management may reduce the risk of other non-communicable diseases, such as heart attacks and strokes Additionally, the complexity of public policy involving multiple stakeholders necessitates a concentrated analysis on diabetes rather than multiple health conditions.
The analysis of data focuses on decisions and actions taken from 2000 to 2010 in Mexico and Brazil, a period marked by a significant rise in diabetes-related mortality In Mexico, the mortality rate for type 2 diabetes surged from 43.3 to 53.2 deaths per 100,000 inhabitants between 1998 and 2002, accounting for 30% of adult mortality (Villalpando et al 2010) Similarly, Brazil experienced an increase in mortality from 16.3 to 24 deaths per 100,000 inhabitants from 1996 to 2006 (SBD 2009) This decade-long timeframe allows for the identification of trends in public policy processes related to diabetes management.
Since 2006, under the leadership of Felipe Calderón in Mexico and Luiz Inácio da Silva in Brazil, both countries have experienced stable political environments This stability has fostered the development of long-term and systematic health policies.
Comparative Analysis of Public Policies
Brazil and Mexico possess distinct healthcare systems, highlighting a significant area for comparative analysis According to Green-Pedersen and Wilkerson (2008), there is a lack of studies that effectively examine how healthcare issues influence political dynamics across different systems, particularly when comparing contexts like Denmark and the USA This gap underscores the need for more research to understand the political implications of healthcare in various countries.
The differing approaches of Brazil and Mexico to the same issue do not impede meaningful comparison; rather, they offer an intriguing methodological perspective that enhances the analysis.
International comparative studies are invaluable due to the significant differences in incentives and practices among nations These variations create a "natural experiment" that provides insights into the effects of various policies implemented across different countries.
This project aims to offer a fresh comparative policy perspective while identifying the most suitable policies for the Latin American context.
Terminology
This project attributes the actions and decisions of political leaders to states as entities, emphasizing the role of governments as primary actors rather than individual behaviors This approach is justified as it highlights policy actors—groups capable of influencing the policy-making process, both formally and informally (Lee et al 2002: 13).
When referencing agencies and governmental institutions, the full name will be presented in its original language, followed by an English translation upon first mention Subsequent references will use the original language acronyms.
In this article, program names will primarily be presented in their original language, with English translations used when suitable The National Diabetes Plans will be consistently referred to as NDP.
In Mexico, the primary federal health authority is the Secretaria de Salud, functioning similarly to a Ministry of Health This entity oversees health policies and initiatives, ensuring the well-being of the population.
Brazil and Secretaria de Salud in Mexico will be referred as Ministry of Health, MOH for short
In this study, the term 'Institution' has two distinct meanings: first, it denotes the organizational entities in the public sphere, such as congresses and parliaments; second, in the context of social sciences, it refers to the framework of rules, patterns, and actions that govern behavior within the policy-making domain.
The terms "health policy," "public health policy," and "public policy" are interchangeable, as are the phrases "public policy-making," "public policy process," and "policy process."
In the next chapter, many of these terms will be contextualized within their respective theoretical backgrounds.
The Public Policy Process: Theoretical Perspectives
Ideologies, Exercise of Power and State Organization
Ideology refers to a structured system of political ideas, such as communism, liberalism, and social democracy, incorporating moral and ethical values alongside pragmatic political issues These ideologies significantly influence public policy, functioning at both the conscious level and within established thought systems and discourses in society.
An ideal democratic state fosters conditions that uphold fundamental principles of equality and political freedom for both individuals and society (Bobbio in Andriguetti 2009) These principles are safeguarded through a comprehensive legal framework that ensures their enforcement (Ibid) In this context, the exercise of power is viewed as an intervention in societal decisions, guided by principles of equity and participation Therefore, for power to be exercised democratically, it is essential to have a foundational set of rules that delineate who is authorized to make decisions and the procedures they must follow.
In the 20th century, the concept of 'co-management' emerged, advocating for power sharing between the state and resource-using communities (Fleury et al 1997) Some authors argue that the goal of representative democracy should be to eliminate barriers between the state and citizens, fostering the creation of "new public spaces" to achieve tangible outcomes in a more streamlined, less bureaucratic way (Ibid).
Citizen empowerment is essential for holding governments accountable for service delivery This can be achieved through an institutional framework that guarantees justiceable rights to public services and redress Additionally, an effective accountability framework is necessary to address government failures.
In a democratic society, public benefits are contingent upon the authorization of funds by public authorities (Lipsky 2009: 138) This reflects the concept of a 'social compact,' where citizens have expectations of goods and services that should be provided by their political leaders Ultimately, citizens recognize their role as contributors to this social agreement, underscoring the mutual responsibilities between them and the government.
In democratic states, policy-making involves both action and inaction, a concept known as 'non-decision making' as highlighted by authors like Lukes and Dahl (in Crinson 2009) They assert that power is exercised even in the absence of observable conflict, as it lies in an individual's ability to influence others' behavior Lukes emphasizes that the most effective use of power often prevents conflicts from emerging, suggesting that non-decision making is a significant form of power that shapes the needs, values, and norms of actors Consequently, the policy-making process encompasses both visible conflicts among differing interests and the underlying tensions that could arise.
In order to reach such decisions – or rather to exercise the power of decision-making – actors function following a certain logic.
Functionalist Approaches: Rational decision-making
The functionalist approach suggests that actors behave rationally, pursuing their interests similarly to market participants (Hill 2005: 14) In the policy-making process, powerful economic forces often dictate decision-making, as illustrated by examples like budget constraints in healthcare systems This highlights the importance of examining the policy process through an economic lens, particularly in understanding how governments navigate limited resources and scarcity While public needs and desires may be infinite, governments must contend with finite resources, a reality that is especially pronounced in the health sector.
The rational decision-making model focuses on both the processes involved in making decisions and the subsequent actions taken, ultimately guiding individuals toward a state of preference equilibrium (Garson).
In 1986, it was argued that the rationality of institutions is fundamentally pragmatic, with decision-making involving the selection of options that best achieve organizational values through thorough analysis of alternatives and outcomes This rational decision-making model aligns with the economic principle of maximization, which may explain the increasing adoption of Cost-Effectiveness Analysis (CEA) in the public health sector.
Rational choice theory posits that decision-makers act as rational, self-interested optimizers, interpreting social phenomena through preference-maximizing strategies (Hall & Taylor, 1996) In the public sphere, these strategies involve a social bargain where compliance is exchanged for preferences; failure to uphold this bargain can disrupt established power structures (Levi, 1990) While rational choice theories aim to analyze institutional decision-making, they are frequently viewed in opposition to institutional theory.
Critics argue that the model fails to account for the limited time actors have to make decisions, suggesting that it is unrealistic to expect them to systematically evaluate all available options before arriving at a choice (Crinson 2009).
Institutionalism
Institutional theories highlight the significance of institutions in shaping political life, emphasizing their role in governance through established rules, norms, values, and cultural meanings Ostrom defines institutions as the framework that determines decision-making eligibility, permissible actions, aggregation rules, procedural requirements, information disclosure, and the assignment of payoffs based on individual actions In the public sphere, institutions are essential for creating checks and balances, fostering political cooperation, and mitigating uncertainties in the political landscape Consequently, policy-making actors often find their decisions influenced and constrained by the institutional structures in place.
Post-WWII upheavals, including the collapse of Communism, have significantly heightened academic interest in institutionalism, as noted by Campbell & Pedersen (2001) This interest is further influenced by a reaction against the emergence of behavioralism in social science, as highlighted by Hall & Taylor (in Garson 2008).
This approach emphasizes the importance of reintegrating the state into the analysis of politics and society, challenging the behavior-oriented, agent-centered perspectives that downplay the state's role According to Crinson (2009), (neo-) institutionalism asserts that political decision-making processes are inherently tied to the institutions that shape them Additionally, this theory portrays governmental systems as competitive entities engaged in a struggle for resource allocation, characterized by unequal power dynamics (Flexor 2006).
Historical institutionalism examines the evolution of institutions and structures, emphasizing the significance of event timing and phases of political transformation Rooted in political theories and structural functionalism from sociology, it provides a framework for understanding how historical sequences shape political outcomes.
The article emphasizes the importance of examining the evolution of modern state institutions, rather than merely their functions It posits that the historically established institutional constraints and opportunities significantly shape the actions of politicians and interest groups engaged in the policy-making process.
Institutional theories suggest that decision-making institutions tend to be biased and often uphold the status quo, as noted by Garson (2008) Skocpol (in Crinson 2009) emphasizes that the structure of governments and political systems shapes the actions of participants in the public policy process, while also acknowledging the independence of these agents.
Path dependency is a key concept in historical institutionalism, highlighting how the evolution of state institutions over time significantly influences their characteristics Defined by three phases, path dependency begins with an event that impacts the policy process, followed by a more restrictive policy direction, and ultimately leads to a self-reinforcing policy pathway characterized by feedback mechanisms Mahoney (2000) argues that certain events trigger a series of institutional changes, emphasizing the importance of culture, values, and norms over economic determinism Pierson (2000) further explores this idea, illustrating how institutional inertia creates obstacles to change, echoing North's (1990) insights on the self-perpetuating nature of organizational norms Overall, historical institutionalism underscores the constraints that institutional factors impose on decision-making and individual agency.
Incrementalism, also known as "muddling through," is a concept developed by Baybrooke and Lindblom (1963), which posits that policy decisions are made gradually within a broader policy framework This model emphasizes the importance of bargaining and negotiation among various interest groups, highlighting that the policymaking process is often characterized by small, incremental changes rather than sweeping reforms Cochran & Malone further contextualize this approach, illustrating its relevance in understanding the complexities of policy development.
Incrementalism is based on the idea that individuals and groups act out of rational self-interest, leading to conflicts between their interests To address these conflicts, compromises are necessary, resulting in minor adjustments to existing policies This approach simplifies the budgetary process, operating under the assumption that current programs will maintain their funding levels, which are viewed as equitable In cases of budget growth, each program typically receives a proportional increase, with well-supported programs benefiting slightly more, while those losing support may see smaller increases.
Incrementalism is often employed to achieve optimal budgetary decisions that are broadly acceptable; however, its primary drawback lies in its diminished empirical strength, as it fails to account for significant policy shifts over time.
Social Constructivism
An essential element to consider in the public policy process is the application of insights from organizational sociology, which can effectively illuminate the political behaviors of institutions.
Social constructivism shares significant similarities with institutionalism, particularly in their underlying social mechanisms Both theories can be compared and utilized together, as they address similar dependent variables, including identity formation and role enactment (Trondal 1999).
The exploration of who benefits or loses from policy has long intrigued political scientists, particularly through the lens of social constructivism, which is essential for understanding agenda setting and legislative behavior (Schneider & Ingram, 1993) Their theory highlights that the social construction of 'target populations'—those who benefit from public policy—significantly influences the policy-making process Public officials face strong incentives to create favorable policies for positively constructed groups while imposing punitive measures on negatively constructed ones (1993: 334) This framework elucidates why certain groups enjoy advantages over others, independent of conventional political power dynamics, and illustrates how policy design can perpetuate these disparities.
Wendt (in Klotz 2007) drew from social constructivism based on the understanding that agents interact through overlapping social spheres – being them ethnic, ideological, cultural or other (Klotz 2007: 7)
Social constructivism, akin to the institutionalism perspective, asserts that 'structures' within political systems emerge from a cluster of rules and stable meanings derived from institutional practices Agents operate based on these established rules, which can either reinforce or undermine these structures Collectively, individuals contribute to creating, maintaining, and transforming their environments; without their reinforcement of dominant meanings—often framed as 'historical facts' or unavoidable 'realities'—these structures would cease to exist Consequently, 'truth' cannot be viewed as a mere reflection of the external world; instead, the concepts generated within the social realm actively shape that world This highlights the interactive relationship between individuals and the ongoing evolution of meaning, emphasizing the mutual constitution of social realities.
Box III.1 Jenkins Policy Process model
Initiation Estimation Selection Implementation Evaluation Termination
Adapted from Hill 2005: 20 structures – or institutions - and agents, which is key to understanding the ‘health realities’ in each political system
Understanding the concept of multiple realities reveals that agents are influenced by their unique perceptions and behaviors An actor's actions play a crucial role in defining their identity, effectively addressing the fundamental question of "who am I?" (Youde 2008).
By analyzing institutions and agents, it is also useful to look at norms and their legitimacy Legitimacy can help illuminate the constitutive processes of current structures (Klotz
2007), and therefore the legitimacy of a certain ‘reality’ will influence of the decision of an agent to deal with this reality.
Overall, these ‘high-range’ theories provide the basis for understanding the public policy process However, it is also important to analyze in detail how the process works in practice.
Public Policy Process as Stages
In the 1950s, Harold Lasswell introduced the original public policy process model to enhance the understanding of public administration, conceptualizing it as a series of functional stages in policy-making (de Leon, 1999) His aim was to operationalize and develop a normative understanding of public policy practices By the 1970s, Jenkins expanded on this framework by presenting a stages model for the policy process (Hill, 2005).
The stages model provides a framework for understanding public policy as both a concept and a practical process, leading many scholars to concentrate on individual stages since its introduction.
Each stage of the policy process involves specific actors and exhibits a fluid dynamic where policies evolve over time This interaction creates a feedback loop among the stages, highlighting the importance of a multidisciplinary approach in policy science As de Leon notes, the cumulative analysis of these stages underscores the interactive effects that influence policy development (de Leon 1999: 22).
Hogwood and Gunn (in Hill 2005: 20) later offered a more complex model, adding a few more details:
Box III.2 Hogwood & Gunn Policy Process model
Deciding to decide Deciding how to decide Issue definition
Forecasting Setting objectives and priorities Option analysis
Policy implementation, monitoring and control Evaluation and review
The initial advantage was that it was possible to break down the process into a more pragmatic framework of analysis, as de Leon contends:
Policy stages models break down the complex interactions in public policy, contrasting with the traditional views in political science They identify distinct actions and objectives at each stage of the policy process For example, policy analysis is typically conducted by agency staff analysts, while implementation involves different actors who engage with external clients This differentiation highlights the varied roles and responsibilities in public policy transactions.
The implementation of the framework has solidified a multidisciplinary approach, highlighting the interactive effects among various stages of the policy process This shift has steered research away from a narrow focus on public administration and institutions, which are increasingly emphasized in political science, and the quasi-markets favored by economics As a result, it has introduced a new problem-oriented perspective that rationalizes the process, distinguishing it from its disciplinary predecessors.
The 'stages' framework is essential for addressing the complexity of policy actions, as it organizes diagnostic and prescriptive inquiries into manageable segments, facilitating a clearer understanding and analysis of the issues at hand.
Some authors advocate for analyzing policy as a network of interconnected elements, suggesting that these components interact in a fluid manner rather than adhering to a strict sequence of actions.
Figure 1.3 (adapted from Cochran & Malone 2005: 45) presents the cloud proposed by the authors:
This model proposes a similar method of analysis by breaking the process down to its individual parts, but it does not place them as a serial, one-way road.
This model is less effective for analysis because it combines influencing factors with specific process elements, resulting in a non-linear approach Crucially, it may lead to the assumption that 'problem identification' is an inherent step in the process.
On top of the description of the policy stages model, Blank & Burau (2007) also propose a specific model for the health policy context, in which, similarly to the cloud proposed by
Figure III.3: The Elements of Policy Analysis: A cloud of Criteria, Objectives, and Consequences
Political, economic and social factors
Figure III.4: Health policy context in developed nations
(individual rights, communitarian, technological fix, life- prolongation)
(diversity, conflicting views of health, religious differences)
(hospitals, doctors, nurses, allied health)
Cochran & Malone (2005), they single out the determinant factors in the health policy-making context:
Blank & Burau outline key variables in the health policy-making process, focusing on influential factors rather than the stages of policy development Although their model is based on developed countries, it is reasonable to assume that these variables are also applicable to developing nations, albeit with varying significance This framework highlights essential elements that will be explored in this study, particularly the application of Cost Effectiveness Analysis in both contexts, which will facilitate an examination of social factors influencing technology perception.
According to Blank & Burau, numerous authors argue that scientific knowledge often has minimal impact on public health policies due to various determinants in the health policy process (Fleury 1997, Sommer 1996) This raises the question of what factors and dynamics influence the initial stage of public health policy-making.
5.1 ‘Initiation’: Agenda-Setting in Health
Limitations of Stages Framework
The critics of this conceptual framework argue that its main flaw is its inability to predict future outcomes with the same precision as other science theories (Cochran & Malone 2005: 39).
Focusing on individual stages of a model may lead policy researchers to overlook the overall process, resulting in a fragmented understanding of the interconnected activities involved.
The policy stages model suggests a linear progression through initiation, estimation, and subsequent stages; however, critics like Sabatier argue that it lacks predictive capability and fails to illustrate causal relationships between stages (De Leon, 1999) Authors such as Hill (2005) emphasize that while the model may reflect the gradual development of policy, it was not designed to predict outcomes at each stage Additionally, the policy process framework represents a system where analyzing individual stages does not diminish the overall complexity, but rather facilitates a deeper understanding of the interconnected nature of the policy process.
This chapter's theories will be applied at various levels to enhance our understanding of the democratic state's organization and power dynamics The institutionalist and functionalist approaches elucidate the interactions among governmental institutions and agents, while offering analytical insights into the policy process, including concepts like incrementalism, path dependency, and windows of opportunity The outlined 'policy process stages' serve as a framework for addressing the specific issue of diabetes, enabling a clearer and more structured presentation of the policies implemented in both countries.
This framework allows for a thorough analysis of the specific challenges related to policy formulation and agenda-setting By emphasizing agenda-setting, it is crucial to understand how policy-makers view priorities, recognizing that these priorities are shaped by social constructs.
The following chapter will build upon these concepts to present the public policy process in Brazil and Mexico.
Analysis: Public Health Policies in Brazil & Mexico
Diabetes: Directives for Policy
The past decade has been referred to as the "golden window for global health," marked by significant advancements due to new disease-specific initiatives and funding programs Public health scholars and intergovernmental organizations have produced numerous reports and policy notes on non-communicable diseases (NCDs) and diabetes, primarily focusing on countries at both ends of the development spectrum—offering alternatives for developed nations and addressing challenges faced by low-income countries, particularly in Sub-Saharan Africa While these normative studies provide valuable recommendations related to diabetes, they are not intended as direct policies for Latin America but rather as potential alternatives informed by other contexts Additionally, many of these studies highlight specific interventions but ultimately acknowledge the challenges of translating these interventions into effective public policies.
A public health approach to diabetes, as defined by Glasgow and colleagues, emphasizes a multidisciplinary perspective aimed at improving outcomes for all individuals with diabetes while prioritizing equity and efficient resource use to enhance the quality of life for patients and communities Recent reviews highlight the urgent need to address the global epidemic of type 2 diabetes, advocating for its prevention to be a central focus in global efforts to reduce health inequities, in alignment with the Millennium Development Goals.
Additionally, when understanding the use of cost-effectiveness studies in this context, it is interesting to note the three relevant arenas of activity highlighted by Frost & Reich (2010:30):
Political commitment is crucial for successful access to health technology Additionally, national regulatory authorities often require technology registration, which can delay product introduction The regulatory approval process is influenced by a nation's policies, market incentives, and existing market imperfections Finally, the acceptance of technology by policymakers within health ministries is vital, particularly in countries with significant public healthcare sectors, regardless of whether the government is a major provider through ministries or social security.
Diabetes prevention policies represent a significant public health challenge, as highlighted by Assunção et al (2001) These policies must address two key aspects: first, the need for behavioral change through the establishment of "primary prevention routines" within the population, and second, the importance of self-management, where patients take on substantial responsibility for monitoring and controlling their blood glucose levels Implementing primary prevention routines is crucial not only for preventing the onset of diabetes but also for mitigating complications in individuals already diagnosed with the disease.
Effective diabetes care, especially in low-resource settings, necessitates strong political commitment and local advocates to ensure access to insulin and comprehensive treatment Key elements identified for fostering a positive diabetes environment include the organization of the health system, efficient data collection, prevention strategies, adequate diagnostic tools and infrastructure, reliable drug procurement and supply, and ensuring affordability of care.
Ensuring the accessibility of medicines and care, addressing adherence issues, and empowering patients through education are crucial for effective diabetes management The involvement of healthcare workers and community organizations, including diabetes associations, plays a vital role in supporting patients Additionally, the establishment of a positive policy environment is essential This report emphasizes the necessity of developing a national diabetes program or policy to provide continuity and establish guiding principles for comprehensive diabetes care.
Diabetes associations play a crucial role in shaping public policies and providing treatment for individuals in underserved communities, thereby enhancing the overall management of diabetes within the health system (Beran & Udkin, 2010).
Other reports point to the importance of a) Assessment and Monitoring of communities’ health and b) the development of a Chronic Care Model which would improve access (Albright
The aspects underlined by these reports will be addressed in the analysis of the two countries.
Brazil: Socio-economic Markers & Milestones
Brazil, the fifth largest country globally with a population of approximately 190 million, is a federal republic consisting of 26 states and a federal district Originally a Portuguese colony, Brazil's diverse culture and rich history contribute to its unique identity.
In 2008, Brazil registered a total Gross Domestic Product of R$ 2,9 trillion (around US$
2 trillion), which represented a growth of 5,1% from 2007 (IBGE 2010) Since 2000, Brazil has seen a steady pace of growth in its GDP, and has a leading role in the region
Brazil has made significant strides in addressing social and economic disparities, as evidenced by its ranking of 75th in the Human Development Index (HDI) among 177 countries, according to UNDP data from 2009 Health indicators have shown consistent improvement over recent decades, particularly in maternal and childhood health, as highlighted in the 2010 National Report on Millennium Development Goals (MDG) Additionally, the report reveals a notable reduction in extreme poverty, dropping from 12% of the population in 2003 to 4.8% in 2008.
Following the end of Brazil's bureaucratic-authoritarian regime from 1964 to 1984, the decentralization process became a critical aspect of the country's democratization agenda This process involved transferring authority and responsibility from the central government to local and intermediate levels, as well as the private sector It played a vital role in shaping the healthcare system by enhancing decision-making capabilities and fiscal responsibilities at subnational levels, delegating the implementation of federal policies to various government spheres, and reallocating certain national government functions to private or non-governmental entities.
In 2002, Lula Inácio da Silva of the Worker’s Party was elected president of Brazil, prioritizing social equality and support for the impoverished A key initiative of his administration was the “Bolsa-família” program, which provides direct financial assistance to families living in poverty, currently benefiting around 12 million families with monthly incomes below R$ 140 (approximately US$79) Despite this focus on social redistribution, healthcare funding remained relatively low, with only about 3.2% of Brazil's GDP allocated to health services, a figure that has seen little change since Lula's election In contrast, neighboring Argentina invests around 6% of its GDP in healthcare, highlighting Brazil's comparatively lower commitment to health expenditure.
Brazil: Healthcare Structure
Following the redemocratization process, Brazil adopted a new constitution in 1988 that laid the foundation for its contemporary healthcare system This constitution introduced a decentralized model emphasizing municipal governance in healthcare delivery (Fleury et al., 1997).
The guidelines for health care emphasize the creation of the Unified Health System (SUS), which promotes cooperation among various government levels Responsibilities for health care, basic education, and social welfare are increasingly being delegated to municipal governments, while the roles of state and federal governments are being redefined.
The Sistema Único de Saúde (SUS) provides universal healthcare access to the entire Brazilian population, functioning as a tax-supported government system Despite this, private health insurance remains significant in Brazil, with approximately 45 million Brazilians holding private coverage as of 2007.
The Unified Health System (SUS) encompasses healthcare centers, hospitals, sanitation facilities, epidemiology centers, and research institutes Traditionally, funding for SUS is split evenly, with 50% sourced from the federal government and the remaining 50% managed by state and municipal authorities (SUS 2007).
The decentralization of healthcare in Brazil has been uneven, with each municipality developing its own model for resource allocation, as noted by Ortiz (2002) and Nepp This variability significantly affects the management of chronic diseases like diabetes, as municipalities can assess local health burdens and devise tailored solutions However, many smaller municipalities lack essential infrastructure, necessitating reliance on larger cities for healthcare access Ortiz also highlights that Brazil's vast size, with over 5,000 municipalities, contributes to this heterogeneity, while the political landscape is influenced by a culture of political maneuvering that impacts health policy implementation (Gerschman in Ortiz 2002).
Despite constitutional guarantees for health provision, Brazil's healthcare services frequently fall short of meeting demand, leading to long wait times, especially for non-emergency treatments related to chronic diseases like diabetes The country's healthcare landscape features a significant private sector, which complements public services and enhances overall access However, lower-income populations often face barriers to healthcare due to a lack of insurance and inadequate services Current statistics indicate a disparity in hospital bed availability, with public facilities offering 1.81 beds per 1,000 inhabitants compared to 2.9 beds per 1,000 in the private sector.
The private healthcare sector in Brazil, while strong, often fails to acknowledge the true costs of its services, frequently relying on public health infrastructure for support (Nishijima et al 1998) It wasn't until 2000 that the Agencia Nacional de Saúde Suplementar was established to address these issues.
(ANS) was created as the normatization, regulation, control and fiscalization agency for private care activities (ANS Online).
The Unified Health System (SUS) plays a crucial role in providing health services to a significant portion of the Brazilian population, although delivering these services is just one aspect of the system's overall function (Baeza & Packard 2006) While the Ministry of Health is responsible for formulating national health policies, the actual implementation relies on collaboration with various partners, including municipalities and states (SUS Online) Both state and municipal governments have the authority to create their own health policies, provided they align with federal regulations.
Another step further in decentralization of health was implemented in 2006 as the Pacto pela Saúde - Pact for Health (SUS 2007) For a period time, the discussion on how to update the
The implementation of the Unified Health System (SUS) faces significant challenges, particularly from state and municipal health secretariats represented by CONASSEM and CONASS These managers often struggle with outdated and contradictory regulatory demands, leading to bureaucratic complexities that hinder effective SUS implementation (Miranda 2007) In response, the Pact for Health aims to initiate institutional reforms across various government levels to enhance health delivery processes and instruments (SUS 2007) A key component of this Pact is the establishment of Attention Networks (Redes de Atenção) at the municipal level to improve service delivery.
The funding process for health care has been significantly streamlined, simplifying the transfer of funds from federal to municipal levels, which previously involved over 100 methods (SUS 2007) While municipalities retain responsibility for health provision, the majority of funding now originates from federal and state sources According to Constitutional Amendment number 29 from 2007, municipalities are mandated to allocate at least 15% of their revenues to health, while states must dedicate 12% of their total revenue Additionally, fund transfers are categorized into five key areas: 'basic assistance' (which includes diabetes care), 'medium and high complexity assistance', 'pharmaceutical assistance', 'health surveillance', and 'SUS management' (Ibid).
The Pact for Health represents a significant initiative aimed at defining the various dimensions within the Unified Health System (SUS), and it has positively influenced diabetes management through its specific regulations regarding financing and responsibilities.
Policy Initiation in Brazil
Understanding the development of public health policies involves recognizing three key actors in the decision-making process First, local health secretariats at the municipal and state levels are responsible for making decisions and requesting funding for implementation Second, nationwide health policies are deliberated in two main bodies: the Conselho Intergestores Tripartite (CIT).
The CIT, comprised of members from the Brazilian Ministry of Health and health secretariats at state and municipal levels, along with representatives from CONASSENS and CONASS, conducts monthly meetings where decisions are made by consensus rather than through voting.
Another actor participating in the first deliberations of priority-setting is the Conselho
Nacional de Saúde – CNS, National Council of Health, which acts in a supporting role (CNS
The National Diabetes Federation (FENAD) plays a vital role as a member of the National Health Council (CNS), which includes not only government representatives but also civil society members By participating in this body, FENAD can influence governmental agencies and actively engage in the implementation of health policies through support and recommendations.
All three spheres, along with civil society members, have the chance to prioritize their most pressing issues on the agenda The concerns raised and actions proposed often receive backing from various agencies and sub-agencies, particularly those focused on building scientific evidence, as discussed in the following sections.
Regulatory and surveillance agencies are crucial in guiding decision-making within the CIT, particularly for diabetes-related policies Key governmental bodies, including the national regulatory authority (ANVISA), the Drug Market Regulation Council (CMED), and the Secretariat for Science, Technology, and Strategic Inputs (SCTIE), focus on optimizing health resource utilization.
2010) Among them, the SCTIE in particular is very active in supporting both the formulation and implementation of health policies
Box IV.1: Translating scientific evidence into policy in Brazil
In a 2008 interview, Dr Guimaraes, the then-director of SCTIE, highlighted Brazil's significant advancements in health research and knowledge, while acknowledging persistent challenges He emphasized the need to effectively disseminate research findings throughout the health system, stating, “We must make this knowledge reach the tip of the health system… we have great difficulty in knowing how to do that.” Dr Guimaraes pointed out that the issue lies not in the lack of tools, but in the challenge of creating a common language that resonates with all stakeholders involved.
A representative from SVS noted that cost-effectiveness studies in Brazil are still developing, with federal efforts focused on providing tools and training for local program managers to optimize findings from SCTIE and SVS However, significant regional disparities exist in program implementation across the country, with effective management correlating to better outcomes From the National Diabetes Coordination's perspective, the CEA studies have empowered Brazil by formalizing the incorporation of technology, reducing dependency on pharmaceutical groups (Interview # 1, ANNEX 2).
CEA and research are increasingly vital during the formulation and implementation stages of public policies; however, their integration into these policies remains limited.
Established in 2003 by presidential decree, the agency restructured the Ministry of Health's regulatory and surveillance bodies (GECIS 2008) It comprises three key departments: the Department of Pharmaceutical Assistance, which serves as the Union's primary drug purchasing entity; the Department of Science and Technology, responsible for funding research initiatives like ELSA-Brasil; and the Department of Health Economics, renamed in 2007 to the Department of the Industrial Complex and Health Innovation (GECIS 2008) In 2005, SCTIE launched the Agenda Nacional de Prioridades, focusing on national health priorities.
Pesquisa em Saúde – National priority agenda for health research It contains a section fully dedicated to NCDs
An important initiative promoted by the SCTIE is a study called ELSA-Brasil - Estudo
The Longitudinal Study of Adult Health is a comprehensive research initiative in Brazil, currently involving 15,000 participants across six federal institutions This study is crucial for identifying non-communicable diseases (NCDs) as it conducts long-term assessments without a set end date Spearheaded by the Ministry of Health in collaboration with the Ministry of Science and Technology, this initiative aims to continuously investigate adult health trends and outcomes.
In 2003, the Ministry of Health (MOH) underwent structural reforms that led to the establishment of the Health Surveillance Secretariat (SVS), aimed at enhancing epidemiological surveillance efforts This strategic move replaced the National Center of Epidemiology (CENEPI) and expanded the responsibilities of health surveillance within the MOH.
“coordination of non-communicable factors and conditions”, which not only includes NCDs but also accidents, addictions and violence (Ibid)
The extinction of the center for epidemiology has led the ministry to emphasize the benefits of centralizing information within a single organization, promoting a more integrated and efficient approach (SVS Online) The SVS collaborates with state and municipal agencies and is tasked with implementing the National Policy of Health Promotion (as detailed in section IV.5).
Policy Implementation in Brazil
With the growing support from agencies such as the STCIE, it is up to the Coordenacao
The National Coordination for Hypertension and Diabetes Mellitus (CNHD Online) is responsible for formulating federal policies aimed at addressing diabetes, while also collaborating with the Intersectoral Technical Committee (CIT) to ensure a comprehensive approach to managing these health conditions.
The National Diabetes Plan - Plano de Reorganizaỗóo da Atenỗóo à Hipertensóo arterial e ao Diabetes mellitus was established in 2001 by the Ministry of Health (CNHD Online).
The plan, developed in collaboration with medical and patient societies like the Brazilian Society of Cardiology, as well as state and municipal health secretaries through CONASS and CONASSEMS, aims to reorganize diabetes care within the SUS framework Although the SUS constitutionally ensures open-ended access to treatment, diabetes previously lacked specific regulations, prompting the need for this comprehensive approach to enhance patient care.
The plan aims to unify existing initiatives by setting parameters for pharmaceutical treatments, defining specific responsibilities across various levels of government, and creating a national registry for diabetes patients.
The Hiperdia program, initiated by NDP Brazil in 2001, established various protocols, consensus, and manuals developed by the Ministry of Health and healthcare societies to enhance the management of hypertension and diabetes Its primary focus is on training basic care professionals and ensuring accurate diagnoses to integrate patients into the healthcare system The plan emphasizes the necessity of a collaborative effort among the Union, states, and municipalities, along with scientific societies, to achieve its objectives It comprises four key stages: professional training, public information campaigns to identify suspected cases, creating a treatment database for patients in basic health units, and confirming diagnoses to initiate treatment To support these stages, several decrees were enacted, including the establishment of the National Program for Pharmaceutical Assistance for Hypertension and Diabetes and the registration process for patients The federal government is responsible for coordinating the registry and developing technical routines for effective implementation Hiperdia was designed as a software tool for municipalities to collect and analyze data, officially launched in March 2002, while participation is voluntary for municipalities that already have their own information systems.
The National Diabetes Plan (NDP) aimed to tackle diabetes treatment issues in the country; however, subsequent decrees indicated a gradual approach to diabetes policy regulation, characterized by incremental decisions within a broader framework (Baybrooke & Lindblom 1963) Notably, federal decrees MS/GM 1105 and MS/GM 2084, issued in June and October 2005 respectively, introduced significant changes to pharmaceutical assistance for diabetes These decrees restructured medication groups aligned with national health programs, moving away from the previous "kits" system, and facilitated the decentralization of resources for acquiring diabetes and hypertension medications, which were previously under centralized control by the Ministry of Health (Ibid).
In September 2006, federal law number 11.347 was enacted, ensuring that all diabetes patients across the nation receive free access to essential diabetes care, including medications and supplies This law mandates an annual review and update of the list of drugs and supplies to ensure its relevance and adequacy Its significance lies in the fact that patients can access this care without the necessity of judicial intervention, marking a pivotal advancement in healthcare provision for diabetes management.
The law does not specify the source of funding for treatment, allowing municipalities to potentially shift financial responsibility to others, such as neighboring municipalities or the state This legislation builds upon earlier policies, as the Unified Health System (SUS) offered treatment to patients, but the quality and availability of care varied significantly based on the health unit and the patient's location.
Two articles from the submitted project were vetoed by both the House of Representatives and the Senate, preventing patients with "out-of-pocket" costs from seeking reimbursement from the state, thereby protecting the state's interests Additionally, the veto eliminated penalties for public servants who fail to comply with the law, along with removing direct accountability for the ministry and secretaries involved.
The National Policy of Health Promotion, established in 2006, plays a crucial role in diabetes treatment by promoting physical activity and healthy eating While the SVS oversees its implementation, the initiative was developed in collaboration with CIT and related agencies, highlighting the importance of lifestyle changes in managing diabetes effectively.
The shift in health directives is moving towards health promotion and prevention after a strong focus on access and treatment A key initiative from the SVS is Vigitel, an annual monitoring system established in 2008 to track risk factors and protective measures for non-communicable diseases (NCDs) The findings from Vigitel contribute valuable data to the CNHD and other health organizations.
IV.5.1 Access to Treatment: Judicial Cases
Access to pharmaceuticals and their distribution has long been a challenge in treating chronic diseases in the country Even prior to the enactment of Law No 11.347, numerous patients resorted to judicial requests for treatments through the Unified Health System (SUS) when the system failed to supply necessary medications or medical supplies.
2007) In general, the federal government funds 80% of these medicines and these are given to the secretaries of health (SUS 2007)
The judicialization of diabetes in Brazil reflects a global trend driven by resource scarcity, as noted by Vieira & Zucchi (2007) This phenomenon results in an individualistic approach to healthcare demands, undermining effective health planning and management The push for universal and equitable health access, in the context of democratic governance, exacerbates these issues As highlighted by Vieira & Zucchi, the "exponential growth of judicial cases" disrupts the continuity of public policy implementation In Brazil, the most frequently requested medications through legal channels include various types of insulin and chemotherapy drugs for cancer, as reported by Chieffi & Barata (2010).
The rise in judicial cases related to diabetes treatment highlights a significant connection to Law 11.347, enacted in 2006 This law reflects the state's recognition of systemic disparities in healthcare access and aims to address these differences through comprehensive regulations that ensure equitable treatment access for individuals with diabetes.
Path dependency illustrates how judicial cases trigger significant changes in treatment access Essentially, the establishment of the law stemmed from the 'learning effects' observed in these cases Despite the law's comprehensive nature, it did not eliminate all civil actions against the system.
In July 2010, a significant civil public action in Santa Catarina resulted in the Union and the state agreeing to provide modern insulins for all Type 1 diabetes patients, highlighting the prevalence of diabetes-related judicial cases, which accounted for 20% of all appeals in the state The Secretary of Health indicated that existing clinical protocols under SUS, as per Law 11.347, negated the need for new protocols, illustrating a shift of responsibility from the state to the federal level This scenario underscores the uneven decentralization process in healthcare, particularly regarding diabetes treatment, where federal decisions supersede state policies.
Policy Evaluation & Outcomes in Brazil
Evaluations of publicly available diabetes programs are scarce, with limited academic research assessing public policies in this area Most existing evaluations concentrate on individual case studies, making it challenging to obtain a comprehensive national overview of outcomes.
Several academic studies have evaluated the implementation of programs, with a significant emphasis on assessing the quality of treatment provided to patients through the Unified Health System (SUS).
A study conducted in Rio de Janeiro highlighted significant challenges in the clinical treatment of diabetic foot, including limited access for patients with chronic ulcers to various health services, a lack of integration among these services, and insufficient training for staff Additionally, the study identified difficulties in performing essential diagnostic procedures like Doppler exams and angiography, along with delays in surgeries and prolonged hospitalizations, which hinder access to care for other patients Moreover, there was an inadequate supply of prosthetics Notably, these complications could be mitigated through preventive measures such as effective treatment, blood glucose management, and regular screenings for diabetic foot, indicating that the latter issues are interconnected with the initial access and integration challenges.
Pozzan (2009) highlights the ongoing challenges in organizing preventive actions within the complex network of SMSDC-RJ, emphasizing the need for prioritizing initiatives based on epidemiological data and establishing an integrated, hierarchical network Key difficulties include the overwhelming number of new curative technologies lacking thorough cost-effectiveness evaluations, the necessity for continuous training of healthcare professionals, and the involvement of regional and local managers Additionally, the author points out the struggle to obtain structured and objective information on newly launched technologies and notes a prevailing culture that equates modern technologies with health improvements.
A study titled “Self-reported diabetes in the elderly: prevalence, associated factors, and control practices” (Francisco 2010) revealed that 75% of the elderly diabetic population in a Brazilian municipality had access to medical treatment through public health systems The author emphasized the importance of educational interventions by public health services, which focus on weight loss and healthy lifestyle changes, to empower patients in managing their condition Additionally, another study, “Healthcare assessment for patients with diabetes and/or hypertension under the Family Health Program in Francisco Morato, São Paulo, Brazil,” found that 58% of patients did not receive all necessary medications from public services, with up to 84% often needing to pay out of pocket It was also noted that many patients sought treatment in different municipalities when their local services were inadequate, while others were waiting for medications to become available in their area (De Paiva et al 2006).
The author argues that treatment compliance is related to the availability (access) to treatment, and therefore the lower the availability, less chances of the patient being in compliance (Ibid)
Recent evaluations of Physical Activity programs under the National Policy for Health Promotion of SVS, primarily documented in the June 2010 supplement of the Journal of Physical Activity and Health (JPAH 2010), focus on the public's awareness of these health initiatives (Simões 2009, Ribeiro et al 2010) While the studies reveal a general understanding and acceptance of physical activity among various populations, they were conducted in different municipalities However, it remains unclear whether these initiatives effectively enhance physical activity levels or contribute to improved health outcomes within these communities.
The federal financial auditing body, TCU (Tribunal de Contas da Uniao), conducted an audit of all family health programs under the Ministry of Health, including the diabetes program The audit revealed significant challenges, such as inadequate organization and structuring of municipal systems, insufficient planning, poor infrastructure, and a lack of commitment to health promotion.
Many municipalities lack a municipal health plan or annual health programming, while others have plans riddled with errors TCU Minister José Jorge highlighted that, despite 20 years of SUS implementation, health planning remains neglected, particularly regarding essential operational criteria The TCU recommended that the Ministry of Health prioritize municipalities lacking healthcare access when establishing new health units and urged the implementation of mechanisms to ensure municipalities contribute financially to the execution of various health programs.
Despite enhanced management efforts, assessments reveal significant implementation issues within diabetes programs Furthermore, systemic factors like inadequate infrastructure and funding continue to hinder effective program execution.
Mexico: Socio-economic Markers & Milestones
Mexico, the 11th largest country in the world with a population of approximately 107 million, gained independence from Spanish colonial rule in the 19th century This transition was fraught with economic and social challenges, ultimately leading to the Mexican Revolution in 1910 Today, Mexico is a democratic republic consisting of thirty-one states and a Federal District, reflecting its evolution since independence.
The 2000 general elections in Mexico marked a significant political shift as Vicente Fox of the National Action Party (PAN) became the first opposition candidate to defeat the long-dominant Institutional Revolutionary Party (PRI), which had been in power since the Mexican Revolution Following Fox, Felipe Calderón, also from the PAN, took office in 2006, prioritizing economic policies focused on poverty reduction and job creation.
The 2008 financial crisis significantly impacted the Mexican economy, leading to a 6.5% contraction in GDP in 2009, with the current GDP estimated at US$ 1.482 trillion However, Mexico began its recovery in 2010 and is now recognized as an upper middle-income and newly industrialized nation It ranks as the 13th largest economy by nominal GDP and the 11th largest when measured by purchasing power parity, according to OECD data.
Since the implementation of the North American Free Trade Agreement (NAFTA) in 1994, trade relations between Mexico, the US, and Canada have nearly tripled (CIA Online) In the same year, Mexico became the first Latin American country to join the Organization for Economic Co-operation and Development (OECD) (OECD Mexico 2005) Although Mexico is the second poorest member of the OECD, following Turkey, it remains one of the wealthier nations in comparison to its Latin American peers.
The Mexican government faces significant challenges, including low real wages, widespread underemployment, and stark income inequality, particularly between the wealthier northern states and the poorer southern regions For instance, GDP per capita in affluent areas like Mexico City, Estado de México, and Nuevo León can be up to six times greater than in less prosperous states such as Chiapas and Oaxaca This economic disparity also impacts access to public services, which tends to be more readily available in the central and southern parts of the country.
Mexico faces significant socio-economic inequalities, with the poorest families contributing only 1.3% to the GDP, while the wealthiest account for 39.7% (Secretaría de Hacienda y Crédito Público 2004) However, there has been a gradual improvement in the situation, as evidenced by the Human Development Index (HDI), which increased by 0.45% annually from 1980 to 2007 Currently, Mexico's HDI stands at 0.854, ranking the country 53rd out of 182 nations (UNDP Mexico Online).
Over the past decade, Mexico has implemented various social welfare programs, notably the Oportunidades initiative, which has been providing financial allowances to families since 2002 This program is designed to support families based on specific criteria, including education, nutrition, and healthcare needs.
With the rise of purchasing power and economic development, the burden of diseases has changes accordingly:
In many Mexican states, the patterns of mortality and morbidity have shifted from being primarily influenced by communicable diseases to a rise in chronic and lifestyle-related illnesses However, significant disparities persist, particularly in rural areas and states with lower socio-economic development.
Mexico's rapid and often unregulated urbanization has led to three-quarters of its population residing in urban areas as of 2001 Meanwhile, approximately 11 million indigenous individuals continue to inhabit rural regions, facing limited access to essential public goods and services.
Recent enhancements in access to public services and goods are linked to various factors, particularly notable fiscal and pension reforms implemented by the last two administrations Among these reforms are significant changes to the healthcare system, which will be detailed in the subsequent section.
Mexico: Healthcare Structure
The healthcare system in Mexico is characterized by low levels of public spending in health, and most spending in health is done through out-of-pocket payments (OECD Mexico
Before 2003, Mexico's healthcare system was often viewed as a Free Market model with minimal public involvement (Blank & Burau 2007) However, these theoretical frameworks should only be considered as initial points of reference, as they do not fully capture the complexities of the system.
Mexico actually encompasses several different models, or it is a ‘hybrid’ model, and has gone through significant changes in last years
Mexico's healthcare system faces significant challenges, particularly in terms of equity, financial protection against health shocks, and the quality of services provided Epidemiological changes necessitate a focus on preventing income loss due to illness Historically, insufficient funding has contributed to chronic setbacks in healthcare, highlighting the need for improved financial investment and resource allocation to address these pressing issues.
As of 2008, Mexico allocated 5.9% of its GDP to healthcare, which is below the Latin American average of 6.1% and less than countries with lower GDPs, such as Bolivia This underinvestment is linked to Mexico's fragmented healthcare system, characterized by multiple providers that create inefficiencies in care delivery Additionally, the funding landscape is complicated by various insurance schemes and a substantial role of the private sector in both healthcare provision and financing.
Since the 1940s, Mexico has operated under a social insurance model known as the IMSS (Instituto Mexicano del Seguro Social), which provides health coverage for salaried workers in the formal sector Despite the prevalence of out-of-pocket payments, approximately 40% of Mexico's population is served by the IMSS, highlighting its significant role in the country's healthcare system.
2000 (OECD 2005) A similar institute to cover workers in the public sector is entitled ISSSTE –
The Instituto de Seguridad y Servicios Sociales de los Trabajadores (Institute for Welfare and Social Services for Workers) offers free prescribed medicines at the point of care without any co-payment (Wirtz et al 2010) However, it's important to clarify that these institutions are often mischaracterized as social insurance; they actually function more like small health services Affiliates are required to utilize clinics operated by their insurance fund, resulting in a lack of competition among providers and no guaranteed package of services (Lakin 2010: 317).
The healthcare system in Mexico experiences significant fragmentation, with various entities like IMSS and ISSSTE, along with the Ministry of Health, providing coverage for workers in the informal sector and the unemployed Outpatient medications are subsidized for uninsured individuals, and the fees charged are inversely proportional to patients' income, ensuring accessibility for lower-income populations (Wirtz et al 2010).
In 2000, the total annual cost of managing diabetes and its complications in the country was estimated to exceed $15 billion, with direct medication costs accounting for around $765 million (Sosa-Rubi et al 2009) Additionally, approximately 44% of diagnosed adults lacked health insurance, which negatively impacted their adherence to medical care (Ibid).
Mexico remains one of the few OECD countries lacking universal or near-universal health insurance coverage, highlighting significant disparities in public health expenditure and health status between its northern and southern states.
In 1943, a significant reform in the healthcare system was initiated with the establishment of the Secretary for Health and Assistance and the creation of the IMSS, as mandated by constitutional article 123 (Soberan 2001) This marked the beginning of an "institutionalisation" process for medical attention and healthcare (Ibid).
The second large reform of the system was called “structural change of health” between
1983 and 1988, and comprised of a legislative renovation and structural reform and administrative reform that aimed at the previously uncovered population by the IMSS (Soberan
In 2001, legislative reforms began with the constitutional recognition of the right to health protection, leading to the introduction of six new regulations that replaced and simplified previous laws These changes fostered greater decentralization and enhanced collaboration among the three levels of government in developing and executing public health policies, exemplified by the establishment of the Consejo in 1986.
Nacional de Salud (CNS) - National Health Council (OECD Mexico 2005)
In 2003, Mexico introduced Seguro Popular, or Popular Health Insurance, aimed at transforming the existing healthcare system into a voluntary health insurance model for the uninsured This initiative sought to enhance government funding for healthcare and eliminate the segmentation of services based on population groups, thereby creating a more equitable health coverage system.
The Popular Insurance program was initiated in 2001 with a pilot project across five states and an investment of $25 million By 2003, the program expanded to 24 states, and on January 1, 2004, it was officially integrated into Mexico's System of Social Protection in Health (SPSS) The Ministry of Health (MOH) designed the insurance program to foster a "culture of prepayment" in Mexico, aiming to minimize out-of-pocket expenses and prevent medical impoverishment.
The program's expansion was designed to achieve full coverage for the population by 2010, reflecting a pragmatic government decision This gradual approach aimed to enhance service quality while allowing for necessary adjustments to the program over time.
Nevertheless, the goal of reaching the entirety of the population has not been achieved in
2010, so the plan has been extended to 2012: with a loan of US$ 1.25 billion from the World Bank, the Mexican government is committed to giving continuity to their goals (Financial 2010).
In March 2010, Salomón Chertorivski, Director of the National Commission for the Protection of Social Health, expressed his belief that Seguro Popular would establish new benchmarks for social health protection, potentially influencing other countries as noted by the World Bank The World Bank loan was partially a result of the Seguro Popular initiative, although Lakin criticized its implementation in 2008, highlighting its shortcomings on multiple levels.
The effort to implement a culture of prepayment in healthcare has not succeeded, and the promised basic health package remains inadequately provided Despite an increase in health spending, the anticipated financial contributions from both states and families have not been realized, jeopardizing the program's long-term viability Consequently, while there have been enhancements to the National Health Service, the shift towards an insurance-based system has not occurred since at least 2008.
While the reform was only partially successful, it had an impact in how diabetes was addressed in the country.
Policy Initiation in Mexico
In Mexico, the initiation of health policies is managed by the National Health Council (CNS), with a specific focus on diabetes addressed through collaboration with the Council for Non-Communicable Diseases (NCDs).
Consejo Nacional para la Prevención y Control de las Enfermedades Crónicas No Transmisibles
Established by presidential decree in February 2010, the Council for NCDs serves as the permanent coordination body for the prevention and control of non-communicable diseases (NCDs) Its key functions include formulating actionable proposals for federal programs, developing educational and healthcare training initiatives, and promoting preventive programs informed by national and international experiences The Council aims to include essential medications for chronic diseases in the national ‘Medicine Catalogue’ and to establish a national program addressing diet-related conditions like obesity in relation to NCD treatment Additionally, it seeks to create a National Registry for NCDs to evaluate treatment outcomes and quality, while fostering collaboration among federal entities Led by the Health Secretary as president and the sub-secretary of the Secretariat for Prevention and Health Promotion as vice-president, the Council was formed to tackle implementation challenges faced by diabetes programs in Mexico, addressing the lack of systematic coordination among various entities prior to its establishment.
The official decree emphasizes the council's responsibility to promote the inclusion of specific medicines in the government's basic list, highlighting its dual role as both an implementation body and an advocate for non-communicable diseases (NCDs).
The CNS serves as the primary decision-making body for health policies in Mexico, meeting at least every four months to discuss and propose new initiatives It includes a diverse range of representatives, such as the Health Secretary, National Defense Secretary, and directors from various social security and national organizations However, municipalities, which represent a significant portion of the population and face unique health challenges, are not fully integrated into this decision-making process As urbanization continues, many cities now exceed one million inhabitants, highlighting the asymmetrical power dynamics in health policy decisions that often overlook local issues.
The IMSS and ISSSTE social security institutions participate in Council meetings with a greater degree of autonomy compared to municipal and state levels, allowing them to create and implement national programs Some scholars, such as González-Rosetti and Mogollon (2000), suggest that the IMSS's involvement in policy formulation is influenced by a strong union that often favors maintaining the status quo.
The Council for NCDs regularly holds meetings to consult with experts and gather insights for policy development, with the most recent meeting taking place in September.
In 2009, the World Health Organization (WHO) emphasized the importance of utilizing technology to enhance treatment and proposed a system for monitoring patient care in Mexico (Cisneros-Gonzalez & Ceballos 2009) The primary goals of this tracking system include improving quality of life and reducing healthcare costs for institutions (Ibid) This meeting highlighted the increasing focus on Cost-Effectiveness Analysis (CEA) studies and registries, suggesting that an intergovernmental organization like WHO can significantly impact national policy formulation.
All of these actors, either within or outside of the CNS, receive assistance from other agencies for the initiation of policies, among them, the CEA agencies
Cost-Effectiveness studies in Mexico are still at a very early development stage. Specifically for the evaluation of health technology, the main actor involved is the CENETEC –
Centro Nacional de Excelencia Tecnologica en Salud, National center for Technological
Excellence in Health, established in 2004, is an independent organization that collaborates with the Ministry of Health (MOH) to enhance healthcare standards The organization concentrates on three key areas: medical equipment and devices, health technology assessment, and e-health services through CENETEC Online.
Additionally, there is a department of Health Economics within the MOH, with a specific focus on CEA studies, and the body for epidemiological surveillance, Centro Nacional de
Vigilancia Epidemiologica y Control de Enfermedades – CENAVE (CENAVE Online).
SINAIS (Sistema Nacional de Información en Salud) is a comprehensive program implemented to enhance evidence-based decision-making in the health sector Established in 2004 and operating under the Ministry of Health, SINAIS is responsible for collecting, integrating, and analyzing health information related to population access to healthcare, available resources, and disease burden By tracking key health indicators, including demographic, economic, social, and environmental factors, SINAIS provides valuable insights for the formulation of health policies, such as those addressing diabetes This initiative aims to optimize public resource utilization within the health system while promoting transparency, as mandated by federal law, ensuring that individuals have access to information held by various federal entities.
Box IV.3: Segmentation of health in Mexico
The segmentation of Mexico's healthcare system has significantly affected the management of diabetes, with various autonomous care providers leading to inconsistencies in treatment approaches Despite government efforts to unify the system, such as the introduction of Seguro Popular, disparities remain among different entities An interview with the IMSS NCDs coordinator highlighted that while all levels of government are expected to adhere to the National Diabetes Plan, the financial resources and capabilities of institutions vary, resulting in a "modular" approach to care Conversely, a representative from the Ministry of Health acknowledged that social security institutions follow MOH guidelines but maintain their own programs He emphasized the growing awareness among political leaders about the importance of addressing diabetes, predicting that it will gain significant priority on Mexico's agenda in the next 5 to 10 years.
Policy Implementation in Mexico
Between 2000 and 2010, Mexico made significant strides in addressing diabetes through the development and execution of two National Diabetes Plans: the first from 2001 to 2006 and the second from 2007 to 2012.
The first Diabetes Plan, initiated in 2001 as part of Mexico's National Health program, focused on enhancing health promotion and early diabetes detection It comprised three strategic components: integrated detection, disease control, and complication prevention, each with specific actions and measurable goals evaluated by CENAVE By 2006, the plan aimed for 23 million annual detections, metabolic control in 40% of treated patients, and an increase in the average age of death for diabetic patients from 66.7 to 69.5 years Although the plan included additional councils for evaluation and program maintenance, a dedicated council for non-communicable diseases (NCDs) was only recently established.
In 2007, following Felipe Calderon's election, a new National Health Program (NHP) for 2007-2012 was introduced, which included specific action points addressing diabetes This program served as the strategic framework for combating diabetes during Calderon's administration, continuing the efforts of the 2001 Diabetes Plan while highlighting its disappointing outcomes.
Effective management of this condition relies on key strategies such as case detection, promoting physical activity, weight management, and treatment quality monitoring Unfortunately, treatment effectiveness remains low, with less than 40% of patients receiving adequate care across most federal entities Moreover, mortality rates have risen from 53 to 63 per 100,000 inhabitants over the past four years, indicating a troubling trend in disease outcomes (NHP Mexico 2007: 69).
CENAVE reports that hypertension treatment coverage has increased to 23.2% of the national territory, a notable improvement from 2000, when only 16% of the population had access to effective treatment for high blood pressure.
In response to these findings, the NHP aims to enhance its strategies by incorporating 'literacy in diabetes' (NHP Mexico 2007), emphasizing physical activity, proper nutrition, and self-care Recognizing that poor adherence is a significant contributor to diabetes complications, the initiative focuses on empowering patients through education and training to improve their management of the condition.
The 2001 Diabetes Plan has successfully implemented a key action aligned with the new literacy strategy: the establishment of self-help groups for individuals with hypertension and diabetes Launched in 2005, this initiative saw over 300,000 participants engaging in various activities aimed at promoting health and wellness (NHP Mexico 2007).
The National Health Program (NHP) outlines specific diabetes-related goals for the 2007-2012 period, building on the 2001 Diabetes Plan The primary objective is to reduce the growth rate of diabetes mortality by 20%, based on trends from 1995 to 2006 Key action steps include establishing an inter-institutional program focused on health promotion and obesity prevention, ensuring that 45% of diabetic and hypertensive patients are under control, and forming at least one self-help group per health unit Additionally, the NHP aims to enhance inter-institutional coordination for the prevention and control of cardiovascular risks and diabetes, with a target of increasing risk detection by 15% for individuals over 20 years old.
While the 2001 plan outlines specific goals, it lacks concrete suggestions for enhancing treatment quality, particularly in areas such as funding, organization, and treatment provision systems This absence of detailed proposals is a notable characteristic of both the current and previous plans.
The new National Development Plan (NDP) for 2007-2012 outlines specific programmatic actions and evaluates the achievements of the previous plan Unlike the 2001 NDP, this version is managed by the Secretariat of Prevention and Health Promotion While the 2007-2012 program shares similarities with its predecessor, it offers a more detailed framework for distributing responsibilities among various stakeholders, as illustrated in Figure IV.1.
The authors express concern over the segmentation of the health system, which may have hindered the successful implementation of the 2001 plan and its goals Additionally, the image underscores the numerous stakeholders involved in healthcare delivery in Mexico.
The Mexican Ministry of Health's strategy for diabetes, outlined in the 2007-2012 Program, emphasizes prevention initiatives aimed at addressing the rising rates of overweight and obesity Additionally, the program reiterates the need for a national diabetes registry, detailing the criteria and indicators for this system, which will be informed by international best practices.
The implementation of specialized medical units, known as UNEMES, has been a significant achievement of the Program, focusing on the care of non-communicable diseases (NCDs) such as obesity, cardiovascular risk, and diabetes These units are staffed by trained, multi-disciplinary teams that aim to enhance patient education and treatment adherence through standardized protocols Established by the Ministry of Health (MOH), UNEMES represent a key initiative in improving healthcare outcomes for patients with NCDs.
Since 2001, Family Medicine Units have established standardized protocols and educational tools for diabetes treatment, likely linked to the launch of the first Diabetes Program.
Mexican policies on diabetes and non-communicable diseases (NCDs) are characterized by a variety of active prevention programs Among these, several notable and recent initiatives are highlighted below.
One of the very popular prevention programs has been the 5 Pasos por tu Salud, para
Policy Evaluation & Outcomes in Mexico
The proposed diabetes policies cover various aspects, primarily focusing on detailed follow-up and evaluation strategies; however, official reports remain scarce In contrast, there exists a substantial amount of academic research assessing the healthcare system's overall response to diabetes management.
In a comprehensive analysis of diabetes outcomes for patients enrolled in Seguro
A study by Sosa-Rubí et al (2009), published in the Bulletin of the WHO, investigates the impact of Seguro Popular enrollment on healthcare access, focusing on medical visits, laboratory tests, medication use—including insulin injections—and blood glucose control, measured by the HbA1c standard The findings establish a clear link between program enrollment and improved treatment outcomes.
Patients enrolled in Seguro Popular demonstrated better glucose control, with a higher percentage achieving appropriate HbA1c levels compared to uninsured individuals (8.9% vs 7.4%) In contrast, uninsured patients exhibited significantly poorer glucose control, with a greater proportion falling into the poorly controlled category compared to those enrolled in Seguro Popular (46.2% vs 36.7%).
The study indicates that Seguro Popular has enhanced access to healthcare and improved biological health outcomes for adults with diabetes in Mexico, showcasing the effectiveness of this insurance program for the impoverished However, a significant number of both insured and uninsured individuals still exhibit poor glucose control, leading researchers to caution that it is premature to conclude that Seguro Popular will effectively reduce premature deaths from diabetes-related complications While these results highlight the positive impact of recent health reforms in Mexico, they also emphasize the necessity for ongoing commitment to ensure sustained biological improvements.
The study "Satisfaction of patients suffering from type 2 diabetes and/or hypertension with care offered in family medicine clinics in Mexico" (Doubova et al 2009) provides valuable insights into patient perspectives on healthcare services in Mexico, particularly within the IMSS and ISSSTE systems The findings suggest that patient satisfaction is closely linked to improved treatment compliance, a crucial factor for successful management and prevention of complications in chronic illnesses Furthermore, the authors highlight a gap in the existing literature, noting that research on patient satisfaction specifically for chronically ill patients remains limited on an international scale.
A recent study revealed that just over half of patients with type 2 diabetes and hypertension receiving care from IMSS and ISSSTE expressed satisfaction with their treatment, aligning with previous research indicating higher dissatisfaction rates among chronic condition patients The average satisfaction score for the family doctor-patient relationship was 3.84 out of 5, while the organizational arrangements index scored slightly higher at 3.89 The authors highlight that both health institutions have rigid structures that compel patients and family doctors to adapt to imposed conditions, which ultimately hinders effective healthcare delivery They emphasize the need for a deeper examination of the organizational barriers that contribute to user dissatisfaction, particularly for those with chronic illnesses.
In the following chapter, some of these outcomes are analyzed comparatively with theBrazilian outcomes.
Box IV.4: International Dialogue in Health
Brazil and Mexico have made strides in establishing international dialogues to exchange best practices in health, despite limited explicit partnerships with other countries For instance, Mexico actively engages in multilateral and bilateral forums, exemplified by a recent meeting between the Health Secretary and the US Minister of Health to address obesity among border residents Similarly, Brazil maintains open dialogues with Latin American and Portuguese-speaking countries, notably through the CPLP and initiatives like the CEDEBA research center The recent Latin American Diabetes Summit underscored the importance of mutual support among nations, with Cuba seeking assistance for upcoming discussions, highlighting the collaborative efforts in addressing health challenges in the region.