This is the first in a series of interviews with global experts on approaches to specific health challenges.
Sebastian Garcia Saiso, the General Director of Quality and Education in Health at the Mexican Ministry of Health, discusses the role of accreditation in Mexico with CEO Maureen Lewis at the International Foundation for Integrated Care Conference.
The Ministry of Health has an active accreditation process for healthcare providers that complements other initiatives aimed at raising quality and ensuring basic standards of care. The accreditation body’s enforcement has led to the sanctioning of hospitals and hospital departments. These facilities or departments are ineligible to receive public funding until their deficiencies are resolved. Dr. Saiso gives a comprehensive background to the accreditation policy in Mexico, explains the government role in accrediting both public and private hospitals, discusses quality of health and integrated care, and gives his views on enforcement.
ML (Maureen Lewis): Can you discuss the accreditation process for hospitals in Mexico, how it works, how you see this connecting to quality of care, and its importance in terms of healthcare delivery in the country?
SG (Sebastian Garcia Saiso): I am going to go slightly before that, before accreditation, because it’s important to understand where policy comes from. The health system in Mexico was officially established in 1943 with the creation of the social security system, and it has had several milestones along the way from 1943 to the moment.
The provision of services before 1983 was done through social security as a mechanism directly linked to labor. And it was in 1983 that we in Mexico changed the constitution, which reflected the right of health protection as a constitutional right, which later became a human right as established by the constitution. This is also linked to the decentralization of services in the ‘80s and ‘90s – all those services provided outside social security, provided by a network of providers at the national context, were given autonomy to each of the 32 states of the Mexican republic and that created a system comprised by social security on one side and 32 autonomous providers on the other side for those not enrolled in social security.
By 2000, there was a very important milestone in which Mexico carried out a study and detected that 50% of the population did not have access to a formal form of financing for health needs – meaning 50 million people did not have access to social security because of their labor status. That created a gap and inequities in different kinds of population.
In 2003, there was a very important reform pushed forward to establish Seguro Popular – it’s a financing mechanism based on general taxation for all those not enrolled in social security. Parallel to that reform, the accreditation system was established to guarantee Seguro Popular enrollees the minimum standards in terms of quality and capacity at the local level. This was set up as a strategy acknowledging that there was a very important difference across the 32 different state providers and that the financing from the federation was going to be generally the same, meaning the federation was going to pay for services in all the states.
In 2004, we started the accreditation process. It was a very important challenge to start accrediting for a financing mechanism that was already in place. So there was a huge rush to accredit establishments so that we could have units providing services to match the financing that became available. What’s happened since then is that we have about 12,000 medical units accredited within the Seguro Popular financing mechanism. It becomes a need to evaluate what has happened with this accreditation mechanism and to set forward new regulatory mechanisms so we make sure that this surveillance mechanism, which will ensure the minimum standards of quality and safety are in place not just across Segura Popular but also across different services, including social security.
So this is one of our main concerns at the moment in which we have managed to balance or reduce the gaps in financing between different populations with a particular set of providers and those outside the public financing mechanism, which includes the private providers.
Thinking of this is a very comprehensive and ambitious reform that would set up a horizontal as much as a regulatory mechanism in which accreditation would be one mechanism to ensure minimum standards. This means making sure that through accreditation and surveillance mechanisms that standards are met, but then also measuring how performance changes with these mechanisms so that we make sure that those who are not performing as well can have incentives also to move into this direction. So, by accrediting, you make sure that no one below this standard exists in a market of provision, and then later, through incentives, you actually make innovation and promote change towards where the system should be.
In a context like Mexico in which the demographic and epidemiological transition is such an important role in what healthcare delivery will be in the next few years, you need to have very small mechanisms to steer the system in that direction. Accreditation is one of the tools you have in the regulatory framework, and then you have to create different incentives and different mechanisms to promote it.
ML: I am also wondering – are you responsible for accrediting all public and private across the board?
SG: We are responsible at the General Directorate to accredit establishments across all different providers, but only when they are linked to the financing mechanism provided by Seguro Popular. If we have interventions provided by social security, we would accredit them – such as maternal emergency care, where regardless of the insurer we provide services across the spectrum and that is accredited by us. We have accredited private providers that are part of a local network of services especially for those services under the fund for catastrophic expenditure protections which includes the most expensive and specialized interventions within Seguro Popular and, of course, those public providers owned by the state which are the main provisions under Seguro Popular financing.
ML: Because we have been talking about integrated care, how do you see the regulations and accreditation trying to play a role in promoting integrated care going forward?
SG: Quality of healthcare is a very important part of integrated care. You may have many of the other aspects defined as components of integrated care, but if you do not have a strong quality framework, its very hard to achieve this interaction between different areas of healthcare, and different mechanisms to achieve a patient centered health policy. So regulation is one of these areas that we can use to steer the system.
We are working with other governments – here I prefer the experience that France has developed on tracing patients to ensure that healthcare is provided in a continuous manner. That is something that we are incorporating in our accreditation system to make sure that we follow patients at different levels to make sure that care is provided when the patient requires it at the type of facility which is ideal for this and by a group of people that is required to treat this condition.
So this means, for example, in care for pediatrics of quality, the patient is diagnosed properly in primary care, but it refers also to units that have the resources to actually treat the condition so we have problems for example in rural communities in which patients may delay a very long time before they are diagnosed and referred to a higher level of care, and this creates an opportunity cost which is sometimes very important in trying to achieve better outcomes in healthcare.
ML: What about enforcement of accreditation and the accountability that comes within it - how does that work, and how do you manage that within the regulatory system?
SG: It is something vital to any system, and it has to be constant. You have to always work on accountability of any system and any tool that you have to actually reach results. This is the case of accreditation and regulation in general in which you can never lose sight of what you are trying to achieve, and you have to work towards that all the time. The case in Mexico is very important, with as you have seen a few minutes ago, we evaluated the number of units that provide pediatric care and we find a great range of performance results in these units. That creates concern whether accreditation is actually achieving its purpose, meaning greater homogeneity in the provision of services.
What we are trying to do now - and it’s a great step forward in our accreditation policy - is that we are trying to evaluate risk, by measuring performance in each of the units that are accredited, and then creating a mechanism to survey those that are actually show a greater risk of not showing results and help them. One would be if they have lost the accreditation standards to push them to achieve them again without actually creating a risk to the patient. The other one would be to incentivize that they not only maintain these standards but also improve them so that we can raise the standard across the entire system. This creates a moving forward policy in which you don’t only make sure they have the minimum at this moment but you also follow them and evaluate them periodically so that you move the standard slightly upwards every once in a while.
ML: Is there anything else you want to add?
SG: I want to make sure that the point gets across that regulation is only one of the things that the system has to contain. It’s only one thing; there are no silver bullets in any health system. It’s such a complex array of circumstances, actors, and mechanisms that have to interact and move in the same direction, that regulation is only one way to equalize to make sure that everyone knows their role, at their time, and towards a particular goal.