Understanding the dynamics of the Seguro Popular de Salud policy implementation in Mexico from a complex adaptive systems perspective.

Gustavo Nigenda,Luz María González-Robledo,Clara Juárez-Ramírez,Taghreed Adam

doi:10.1186/s13012-016-0439-x

Abstract

BackgroundIn 2003, Mexico’s Seguro Popular de Salud (SPS), was launched as an innovative financial mechanism implemented to channel new funds to provide health insurance to 50 million Mexicans and to reduce systemic financial inequities. The objective of this article is to understand the complexity and dynamics that contributed to the adaptation of the policy in the implementation stage, how these changes occurred, and why, from a complex and adaptive systems perspective.MethodsA complex adaptive systems (CAS) framework was used to carry out a secondary analysis of data obtained from four SPS’s implementation evaluations. We first identified key actors, their roles, incentives and power, and their responses to the policy and guidelines. We then developed a causal loop diagram to disentangle the feedback dynamics associated with the modifications of the policy implementation which we then analyzed using a CAS perspective.ResultsImplementation variations were identified in seven core design features during the first 10 years of implementation period, and in each case, the SPS’s central coordination introduced modifications in response to the reactions of the different actors. We identified several CAS phenomena associated with these changes including phase transitions, network emergence, resistance to change, history dependence, and feedback loops.ConclusionsOur findings generate valuable lessons to policy implementation processes, especially those involving a monetary component, where the emergence of coping mechanisms and other CAS phenomena inevitably lead to modifications of policies and their interpretation by those who implement them. These include the difficulty of implementing strategies that aim to pool funds through solidarity among beneficiaries where the rich support the poor when there are no incentives for the rich to do so. Also, how resistance to change and history dependence can pose significant challenges to implementing changes, where the local actors use their significant power to oppose or modify these changes.

Highlights

In 2003, Mexico’s Seguro Popular de Salud (SPS), was launched as an innovative financial mechanism implemented to channel new funds to provide health insurance to 50 million Mexicans and to reduce systemic financial inequities
We used a case study approach to analyze the implementation of a financing reform policy, the Seguro Popular de Salud in Mexico from a complex adaptive systems (CAS) perspective This approach was selected for the following reasons: (1) the case study permits to analyze in depth a contemporary phenomenon in its real context, especially when the limits between the phenomenon and its context are not evident; (2) it focuses on responding the “hows” and the “whys” of a scarcely studied phenomenon; (3) relevant lessons could be obtained from a complex situation, based on the overall understanding of such situation, and (4) the results of the study can contribute to yield proposals for the definition or redefinition of public policies and give way to new research proposals [39, 40]
Results we first describe the range of the main actors that were involved in the implementation of the policy, the characteristics of their interactions, and how they coped and adapted in reaction to the policy (Table 1)

Summary

Introduction

In 2003, Mexico’s Seguro Popular de Salud (SPS), was launched as an innovative financial mechanism implemented to channel new funds to provide health insurance to 50 million Mexicans and to reduce systemic financial inequities. This paper seeks to add to this body of knowledge and understanding by applying a complex adaptive systems (CAS) framework to the question of how do health systems actors respond to new policies, how do they react to, adapt or change the path of policy implementation with respect to the way it was conceived. After decades of chronic underfunding, the Health Social Protection System (HSPS), and its financial component Seguro Popular de Salud, was introduced to channel new funds to provide a broad package of health services to around 50 million Mexicans who were not affiliated to any of the traditional social security institution [13], founded to provide health and other social services to formal industrial workers. Literature shows that the effect of SPS has concentrated on the reduction of catastrophic expenditure [17, 18]

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