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Public health-care spending amounts to about $800 per person in Mexico. ((Dario Lopez-Mills/Associated Press))

The swine flu outbreak in Mexico is testing the country's complex health system as thousands of worried people pour into hospitals and clinics for diagnosis and care.

The health-care system in Mexico is a patchwork of evolving and sometimes confusing services for 105 million people in a country still suffering from diseases of the developing world, such as tuberculosis and malaria. Meanwhile, first world maladies have also been emerging — the World Health Organization lists diabetes as the leading cause of death in Mexico, followed by heart and liver disease.

As the influenza crisis caused by the H1N1 virus has unfolded, that health system has come under increasing pressure. The ill have been going to local hospitals or clinics, but the idiosyncrasies of the health system mean the facilities they visit can depend on where they live, who they work for and how much money they make.

Mexicans have everything from a small, private system to huge universal health insurance programs that mix private, public and employer funding. Despite the array of services, it's an unequal system, says the Pan American Health Organization, "since the various providers receive different levels of payment and provide different levels of care at various levels of quality."

Public health-care spending in Mexico is rising, but it still has one of the lowest per capita expenditures among OECD countries, with just 6.6 per cent of gross domestic product (GDP). That worked out to about $800 per person in 2006.  Canada, in comparison, spent close to $3,700 per person that year and now spends more than $5,000 per person.

Here's roughly how the Mexican private health system is structured:

  • About three million wealthy and middle class Mexicans (and foreigners working in Mexico) pay private insurers to gain access to high-quality, state of the art medical services. Many Mexicans who are insured through the public insurance system also pay out of pocket for private care to get better service.
  • Mexico's private sector is booming. New clinics and specialized hospitals are growing rapidly in Mexico City, Guadalajara and especially Monterrey. In fact, Monterrey is becoming a big centre for medical tourism, particularly for Americans trying to escape their own expensive health-care system. They're flocking to the city's growing number of gleaming new hospitals for everything from obesity surgery and angioplasty to hip replacements. A hip replacement in the U.S. can cost from $43,000 to $63,000 but in Mexico it's a bargain at around $12,000.

There is also a public system:

  • About 50 million salaried Mexicans pay into an insurance scheme, along with their employers and the government, through the Institute of Social Security. The employee pays a progressive amount, according to his or her wage. The institute runs its own primary care units and state hospitals for insured workers, although the quality varies considerably. Critics say some establishments are not properly managed and lack adequate equipment.
  • About 17 million state employees have a separate, parallel scheme that they pay into through the Institute of Security and Social Services for State Workers.  They also have their own clinics and hospitals.
  • The army and navy also have their own separate insurance programs, funded partly through social services, as do employees at Mexico's state-owned petroleum company, Pemex. 

Universal health care

Roughly 40 million uninsured Mexicans — the country's poorest — all began moving toward universal access to full health coverage in 2003 through a program called Seguro Popular (Popular Health Insurance). It's the most ambitious health insurance program in Mexico to be launched since the beginning of social security in the country in 1943, and it's meant to reduce the inequality of health services and stop poor families from being financially wiped out by an illness.  The federal government has set a target date of 2010 to provide the coverage to all uninsured Mexicans although it's uncertain whether they're on track.

Families pay a premium to join, based on their income, and have to make preventive health-care visits at clinics. About 20 per cent of the poorest families pay nothing.

A recent study published in the British medical journal The Lancet says the insurance program has helped fulfil some of its promise by lowering catastrophic health costs by as much as nine per cent among those who participated. Members also used more in-patient and outpatient services, including checkups for hypertension, a common problem.

The former minister of health, Julio Frenk, said that special programs had helped reduce malaria rates by 60 per cent, TB mortality had fallen by 30 per cent and that Mexico was on track to reduce child mortality by two thirds by 2015.

Mexican children receive the same childhood vaccinations as Canadian children. Dr. Antonio Avina, a Mexican doctor studying in Canada, says that since 2007 there has been an annual flu vaccine for the young and the old, although he adds that it's too soon to say whether it had any protective effect during the swine flu outbreak. 

Progress, but problems remain

Avina, who was in Mexico at the start of the outbreak, acknowledges that TB is still "endemic" in Mexico and that the problems of swine flu were not well known in rural areas where there are fewer services for sick people than in urban centres.

'You're working with a country with limited resources …When I saw the Cuernavaca hospital, it looked like 1965.' —Lois Howland, nursing teacher

Lois Howland echoes that sentiment. The nursing teacher from San Diego, who has volunteered at an orphanage near Cuernavaca, says the health system remains fractured and many issues like medical training or followup are not well monitored.

"You're working with a country with limited resources," she says. "When I saw the Cuernavaca hospital, it looked like 1965." 

The nurses at the orphanage where she volunteered in Miacatlan couldn't get tuberculin screening materials and they weren't properly trained in how to find TB, she says.

Howland also says there's a "huge disconnect, especially for indigenous people" to get access to decent medical care.

Howland, who once taught nursing at Memorial University in Newfoundland, says that as a result she has a new ambition during her stints at the orphanage. She'll spend less time on the orphans and more time training the nurses.