In 2002, only half of the Mexican population benefited from health insurance, largely through their employers.  The self-employed, part-time workers and unemployed had access to the health services only through public providers or paid for private healthcare themselves.
There had been a similar initiative in Mexico, the IMSS, which began as a healthcare and basic social security system in 1943. But it was always oriented towards workers and employers.
Poor and uninsured families, who were vulnerable to the financial consequences of illness or accidents, financed their healthcare expenditure out of their own pockets, In 2000, 55 percent of health expenditure was paid by individuals in this way. The budgets for public healthcare were uncertain and there was no defined package of free health services.
The Seguro Popular de Salud (“Seguro Popular”) is a public health insurance programme that began as a pilot programme and passed into law in 2003, with the enactment of the System of Social Protection in Health (SPSS) legislation. It covers a wide range of services, and was established by the Mexican government in an effort to expand healthcare to those without health insurance and to reduce health inequalities.
Its stated aim was to provide affordable healthcare to the 50 million uninsured people in Mexico by 2010. For those not covered by social security (around 50 percent of the population), services were to be provided by health clinics and hospitals. At state level, its aim was to reduce inequalities in public per capita health spending. At the household level, the aim was to achieve full coverage of the uninsured, mitigating their exposure to unaffordable medical expenditure.
In 2002-2003, the SPSS was created. Its origins can be traced back to “a constitutional reform in 1983 that entitled all Mexicans to health coverage as a social right.”  In 2003, the minister of health, Dr Julio Frenk, started Seguro Popular within the financial structure of the SSPH, with the aim of providing health insurance cover to millions of Mexicans, including the poor, unemployed, self-employed, retired and elderly.
The SSPH supported the expansion of Seguro Popular in 2009. The insurance was paid for in innovative but controversial way: tobacco companies Philip Morris and British American Tobacco (BAT) agreed to donate US$ 400 million to health programmes in Mexico during the first couple of years.
The public impact
By the end of 2014, the number of individual beneficiaries of Seguro Popular “was 55.6m Mexicans, having expanded enormously from just 5.3m in 2004.”  The gap in insurance coverage between the indigenous and non-indigenous population was virtually eliminated, and significant advances were achieved towards making health outcomes more equal.
There was a new programme offering preventive screenings to new beneficiaries, for a variety of conditions including high blood pressure and diabetes. By 2013, 22.8 million people had been screened.
Public Confidence Fair
The public had some confidence in the government, as President Fox had become the first Mexican president to defeat a sitting political party since 1910. He saw it as his mandate to propose fundamental reforms. However, the people started to lose confidence in him since he was not able to deliver on the promise to create 1.4 million jobs.
Stakeholder Engagement Good
The stakeholders, the federal government, in particular the president, Vincente Fox, the state governments, the beneficiaries, and the Economic Analysis Unit created by Dr Frenk were the stakeholders of Seguro Popular. President Fox and Dr Frenk were the primary stakeholders.
The funds were initially arranged through the tobacco companies Philip Morris and BAT. The Mexican government, in exchange for this donation, agreed not to increase taxes on tobacco in Mexico over that same period.
Political Commitment Fair
Although the federal government was committed to the programme, some state governments were opposed.
Clear Objectives Good
The objectives of Seguro Popular were clear and the outcome did address the relevant issues of non-accessibility of health insurance to poor Mexican citizens. Moreover they were measurable. The objectives, however, were modified over time as it seemed impossible to achieve the objective of providing universal access to healthcare by 2010, the timeline being extended to December 2011.
Seguro Popular started a universal enrolment pilot in five states in 2002 and then it was gradually expanded, although there is no evidence that the results of the pilot were used to amend the programme.
The programme is administered by the Ministry of Health, and the funding is received from federal and state governments as well as small contributions from the beneficiaries. The Social Protection in Health Regime at the state level is responsible for forming and coordinating the network of health service providers at state level.
Seguro Popular has effective measurement functions incorporated in the service design, the main indicator being the extent health insurance coverage. Multiple surveys, such as the national health survey and the national income and expenditure survey, were used to collect the required data.
All the stakeholders are aligned with the end goal of providing health insurance to those who do not have it. The federal and state governments, with some contribution from the population, funds the insurance. Dr Frenk and his team at the Economic Analysis Unit were highly motivated actors engaged in the reform.
However, in 2011 “Mexico’s health minister, José Ángel Córdova, acknowledged the gaps, noting that 8 percent of the country’s municipalities still lacked any kind of health facility. ‘There is still first-, second- and third-class medicine,’ he said.”