Health insurance coverage in Mexico: progress, inequalities and remaining challenges towards UHC2030 – Health Research Policy and Systems

Report on Mexico’s Trajectory Towards Universal Health Coverage and its Alignment with Sustainable Development Goals (2000-2023)

Executive Summary

This report documents Mexico’s progress and subsequent regression concerning Universal Health Coverage (UHC) between 2000 and 2023, analyzed through the lens of the Sustainable Development Goals (SDGs). The period from 2000 to 2015 saw significant advancements in health insurance coverage, aligning with SDG 3 (Good Health and Well-being) and SDG 10 (Reduced Inequalities), primarily through the Seguro Popular (SP) program. However, the dismantling of SP in 2019 led to a severe reversal, erasing over a decade of progress, exacerbating inequalities, and undermining Mexico’s commitment to the SDGs. This highlights the critical role of institutional stability, as outlined in SDG 16 (Peace, Justice and Strong Institutions), in sustaining development gains.

Progress and Setbacks in Achieving SDG 3 (Good Health and Well-being)

The Era of Seguro Popular (2000-2015): Advancing Universal Health Coverage (Target 3.8)

Between 2000 and 2015, Mexico made unprecedented strides toward achieving UHC, a key component of SDG Target 3.8. The implementation of Seguro Popular (SP) was a deliberate policy aimed at redressing historical exclusion and advancing health equity.

• Coverage Expansion: The uninsured population declined by nearly 90%, with 54 million vulnerable inhabitants gaining access to comprehensive health services.
• Financial Protection: The program reduced out-of-pocket expenditures and increased financial protection, particularly for the poorest groups, directly contributing to the financial protection aspect of SDG 3.8.
• Increased Service Utilization: SP not only expanded formal coverage but also led to higher utilization of health services among previously excluded populations.

Policy Reversal and Regression (2019-2023): A Detriment to SDG Commitments

The dismantling of SP in 2019 and its replacement by the Institute of Health for Well-being (INSABI) marked a significant setback for Mexico’s national health policy and its international commitments to the SDGs. The transition was poorly executed, lacking a clear legal mandate, operational framework, or transitional strategy, and was compounded by the COVID-19 pandemic.

• Loss of Coverage: By 2023, nearly one-third of the population reported being uninsured, effectively erasing the progress made over the previous 15 years and moving the country further from achieving SDG 3.8.
• Increased Financial Hardship: The loss of coverage was accompanied by a rise in catastrophic and impoverishing health expenditures, undermining financial protection and pushing households closer to poverty, in direct opposition to SDG 1 (No Poverty) and SDG 3.

The Intensification of Disparities: A Challenge to SDG 10 (Reduced Inequalities)

Disproportionate Impact on Vulnerable Populations

The policy reversal disproportionately affected marginalized groups, deepening existing social stratification and reversing progress made toward SDG 10, which calls for reducing inequalities within and among countries. The weakening of the equity focus that characterized SP undermined decades of progress in addressing structural exclusion.

• Indigenous Households: Experienced significant reversals in coverage gains.
• Households in Poverty: Were among the most affected by the loss of financial protection.
• Rural Communities: Saw a steep decline in access to health insurance.
• Women-Led Households: Were disproportionately impacted, highlighting a setback for SDG 5 (Gender Equality).
• Informal Sector Workers: Faced increased vulnerability due to the lack of a stable health safety net.

Subnational and Social Inequalities

The regression was not uniform across the country. States with historically high levels of social deprivation, such as Oaxaca, Chiapas, and Guerrero, which had benefited most from SP, experienced the steepest reversals. This dynamic reflects the dismantling of institutional mechanisms that had previously narrowed inter-state inequalities, a core objective of SDG 10.

Institutional Weakness and its Impact on Sustainable Development (SDG 16)

The Fragility of Health Reforms

The Mexican experience demonstrates that progress toward the SDGs is vulnerable if not anchored in stable and effective institutions, as emphasized by SDG 16. The transition from SP to INSABI was characterized by institutional disarray, which had disastrous consequences for health coverage and social justice.

• Lack of Legal and Operational Clarity: INSABI was introduced without a robust framework for affiliation, financing, or service delivery, leading to administrative fragmentation and disruption.
• Erosion of Public Trust: The generalized deterioration of the public health system, underfunding, and institutional instability led to a loss of trust in public provision, a critical challenge for effective governance and the pursuit of UHC.

Recommendations for Realigning with Sustainable Development Goals

A Five-Pillar Strategy for Rebuilding Momentum

To rebuild momentum toward UHC and realign with the SDGs, Mexico must adopt a strategy grounded in interdependent pillars that address the institutional, social, and political drivers of inequality.

1. Legal and Institutional Consolidation: Establish robust legal and institutional guarantees for health coverage to prevent future reversals, ensuring the stability required by SDG 16.
2. Territorially Differentiated Strategies: Empower subnational governments with resources and technical support to close coverage gaps, addressing the subnational disparities highlighted as a challenge to SDG 10.
3. Equity-Focused Governance: Ensure the needs of marginalized populations are explicitly addressed in policy design and implementation to advance SDG 10 and SDG 5.
4. Robust Citizen Participation: Promote accountability, social oversight, and the defense of health as a right, fostering the inclusive institutions envisioned in SDG 16.
5. Commitment to Dismantling Structural Inequalities: Address the underlying ethnic, class-based, and gendered inequalities that impede access to care and well-being.

Conclusion: Lessons for Global Development

The case of Mexico offers a critical lesson for all nations pursuing the 2030 Agenda: progress toward the SDGs, particularly UHC, is not irreversible. Sustaining development gains requires a steadfast political commitment that transcends electoral cycles, an institutional architecture capable of enduring partisan shifts, and active civic engagement to defend health as a fundamental human right. Without addressing these foundational elements, the promise of universal health coverage and a more equitable society will remain unfulfilled.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 3: Good Health and Well-being: This is the central theme of the article. The entire text revolves around Mexico’s journey toward Universal Health Coverage (UHC), the successes and failures of its health insurance policies (Seguro Popular and INSABI), and the impact on the population’s access to health services and financial protection. The article explicitly states the policy reversal is “a setback not only for Mexico’s national health policy but also for its international commitments to the SDGs, particularly Goal 3.8, which calls for achieving UHC.”
• SDG 10: Reduced Inequalities: The article extensively discusses how changes in health policy have disproportionately affected vulnerable and marginalized groups, thereby exacerbating inequalities. It highlights that the initial gains from Seguro Popular (SP) were most significant for “historically excluded populations – those in poverty, Indigenous households, rural communities and states with the highest levels of social deprivation.” Conversely, the reversal of these gains led to an “intensification of subnational and social inequalities,” with these same groups being the most affected.
• SDG 1: No Poverty: The article connects health policy directly to poverty by discussing financial protection and impoverishing health expenditures. It notes that the loss of coverage has been “accompanied by a rise in catastrophic and impoverishing expenditures.” This shows how the lack of a robust public health system can push households into poverty due to high out-of-pocket medical costs.
• SDG 5: Gender Equality: The analysis of inequalities specifically mentions gender as a factor. The article states that “Households led by women… were disproportionately affected” by the dismantling of SP, indicating a setback for gender equality in terms of access to essential services and economic security.
• SDG 16: Peace, Justice and Strong Institutions: The article critiques the institutional fragility and lack of a stable policy framework in Mexico’s health system. It points to the dismantling of SP and the rollout of INSABI “without a clear legal mandate, operational clarity or a robust framework,” highlighting weak, non-transparent, and unaccountable institutional processes. The text calls for “legal and institutional consolidation,” “robust mechanisms for citizen participation,” and policies that “transcend partisan cycles,” all of which are core principles of SDG 16.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. This target is explicitly mentioned in the article. The entire discussion focuses on Mexico’s progress and subsequent regression in achieving UHC. The concepts of “insurance coverage,” “access to comprehensive health services,” “reduced out-of-pocket expenditures,” and “financial protection” are central to the analysis, directly aligning with this target.
2. Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status. The article’s focus on how health policy changes affected specific groups directly relates to this target. It details how SP initially promoted the inclusion of “Indigenous households, rural communities,” and those in poverty. The subsequent policy reversal undermined this progress, disproportionately excluding these same groups from health coverage, thus working against the goal of social inclusion.
3. Target 1.3: Implement nationally appropriate social protection systems and measures for all, including floors, and by 2030 achieve substantial coverage of the poor and the vulnerable. The health insurance programs discussed, particularly Seguro Popular, are a form of social protection. The article describes SP as a “deliberate policy decision to prioritize the enrolment of socially marginalized groups” and a mechanism to grant “access to comprehensive health services for 54 million inhabitants, representing the most vulnerable groups in the country.” The failure of its replacement system represents a failure in maintaining a social protection system for the vulnerable.
4. Target 16.6: Develop effective, accountable and transparent institutions at all levels. The article critiques the policy transition from SP to INSABI, which was “introduced without a clear legal mandate, operational clarity or a robust framework for affiliation and financing.” This points to a failure in creating effective and transparent institutions. The text also highlights the “erosion of trust” in public institutions and calls for “accountability mechanisms,” which are central to this target.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Indicator 3.8.1 (Coverage of essential health services): The article uses several metrics that align with this indicator.
   • Percentage of the population with health insurance: The text tracks the “uninsured population,” which “declined by nearly 90%” between 2000 and 2015, and then rose to “nearly one third of the population” by 2023.
   • Self-reported affiliation to health schemes: The study’s methodology is based on “self-reported affiliation to specific schemes as recorded in the ENIGH survey.”
   • Service utilization: The article mentions that SP “increased service utilization.”
2. Indicator 3.8.2 (Proportion of population with large household expenditures on health as a share of total household expenditure or income): This indicator is directly addressed. The article refers to the “rise in catastrophic and impoverishing expenditures” and the reduction of “out-of-pocket expenditures” during the SP era as a key measure of success. The increase in these expenditures after 2019 is a primary indicator of the system’s failure.
3. Disaggregated data on coverage for vulnerable groups (related to Target 10.2): The article provides a qualitative analysis based on disaggregated data. It measures the impact of policy changes on specific populations, such as “Indigenous households,” “rural communities,” “households led by women,” and people in states with “high social deprivation.” The widening gap in coverage for these groups is a key indicator of rising inequality.
4. Public trust in institutions (related to Target 16.6): While not a formal quantitative metric in the study, the article implies this as a crucial indicator. It notes that the “decline in mixed coverage is arguably an indicator of both systemic weakening and the loss of trust in public provision.” It further argues that “rebuilding confidence in public health services is essential” and that the lack of trust is a “critical challenge for the pursuit of UHC.”

4. Table of SDGs, Targets, and Indicators

Source: health-policy-systems.biomedcentral.com