Decentralization Shifts Highlight States’ Public Health Role

State governments remain pivotal to Mexico’s public health. These institutions coordinate with the Ministry of Health to operate, manage, and strengthen the National Health System. Yet, nearly three decades after decentralization empowered states, federal initiatives like IMSS-Bienestar are reshaping their authority.

Mexico’s health system has long relied on decentralized structures to bring services closer to local populations, aligning public health planning with the unique needs of each state. Globally, state health departments are often responsible for primary prevention, health care delivery, regulation of providers, environmental health, and technical training. These functions are designed to foster trust and responsiveness within communities.

In Mexico, the General Health Law mandates that state governments coordinate with the federal Ministry of Health to operate, manage, and strengthen the National Health System. States are tasked with planning and organizing local health systems while ensuring alignment with federal programs to maintain consistency and participatory governance.

In 1996, the National Agreement for the Decentralization of Health Services marked a significant transfer of responsibilities from the federal government to the states, reports México Evalúa. The initiative included the movement of financial resources, personnel, and infrastructure, aiming to allow local authorities to address community health needs more effectively. The Health Services Contributions Fund (FASSA), established in 1997, provided secure payroll funding for state health workers, while programs like Seguro Popular, later replaced by INSABI, covered other medical costs. Unlike INSABI and IMSS-Bienestar resources, FASSA funds remain legally protected. 

Recent shifts, however, have begun to reverse this decentralization, according to México Evalúa. Under the IMSS-Bienestar model, states are returning infrastructure, personnel, and the majority of FASSA resources to the federal government. Twenty-three states now participate in IMSS-Bienestar, reflecting a movement away from fiscal federalism and highlighting fragmentation in Mexico’s health system.  

Reports from doctors and health personnel, combined with insufficient budgets in hospitals and care centers, indicate that the program has not achieved its intended outcomes, reports México Evalúa. Funding for health services remains both inadequate and inefficient, impacting the lives of patients and placing additional financial strain on low-income households, argues the organization.

Several states have yet to commit to joining IMSS-Bienestar, with Nuevo Leon standing among those expressing reservations. The state has raised concerns about transferring hospitals and services to federal control, citing the experiences of other states and noting that federal resources and infrastructure are insufficient to meet local demand. Given its industrial profile and the fact that the majority of healthcare is provided through IMSS, officials emphasized extensive waiting lists for specialized care and stressed that good intentions alone are inadequate to ensure continuity and quality of services.