Federalist flirtations: The politics and execution of health services decentralization for the uninsured population in Mexico, 1985-1995

Around the world health services delivery systems are undergoing decentralization, responding to pressure to increase equity, efficiency, participation, intersectoral collaboration and accountability. This study examines the Mexican health decentralization efforts of the past decade to discern the motivations for the reform, the context for its implementation, the politics of its downfall, and the reform's impact at subnational levels of government. Sparked by economic crisis and pressure from international creditors for fiscal reform; demands for greater democracy, equity, and quality; and technocratic impulses to rationalize health services delivery, the decentralization reform could not overcome the authoritarian centralism of the federal government and its corporatist clients. In the end, even in the most technically capable states, the reform was unable to overcome political obstacles to decentralizing fiscal power, redistributing resources in an equitable fashion, and eliminating the inefficiencies of separate but unequal health systems for social security recipients and the uninsured population.