As Gustavo Leal Fernández points out in today’s interview, health policy discussions are all about money, not health. Who gets to profit from “care?” Who pays? Instead, he asks, let’s talk about how we can make a profound shift away from capitalist healthcare models that feature expensive western medical treatments and are often culturally inappropriate.

Gustavo Leal Fernández is Professor-Investigador at the Universidad Autonoma Metropolitana-Xochilmilco. He has been studying health care, pensions, housing, and social security in Mexico and globally since 1978. Most recently, he has analyzed living conditions and health policy under President Lopez Obrador’s 4th Transformation. Carole Browner, Research Professor at UCLA, joined our interview. Her interests include gender, inequality, and health.

Everyone wants to be healthy! What does “being healthy” mean to the average Mexican citizen?

This is the right question to start with! Because we have to build the healthcare system from the bottom up, beginning with the beliefs, desires, and needs of the people.

Before the early 20th century, people received many kinds of treatments and care. For example, women had their babies at home, aided by midwives. But then, in both Mexico and the US, western biomedicine became a monopoly. Medical cartels, for example, the American Medical Association, lobbied to exclude other practitioners. Midwives were even put in jail!

A better word than “health” is “well-being” or “living well,” meaning to live under conditions that promote as much as possible the absence of illness. That means a health system should start with a primary health care model based on prevention and promotion of public health, community health, and population health. Instead, the Mexican healthcare system has only attended to individuals who are already sick and needing drugs, surgery, and so on.

A better word than “health” is “well-being” or “living well,” meaning to live under conditions that promote as much as possible the absence of illness.

Yes, but if you need it, getting medical care, including hospitalization, is important. Before AMLO was elected in 2018, what kind of access was there?

Most Mexicans get state-funded healthcare, although a significant number still don’t have access. Under neo-liberal PRI governments, the healthcare sector was privatized in hopes that Mexico would be more attractive to private investment. Privatized medical care resulted in several bad trends: only those with money could afford care, private hospitals were located only in big cities, and the gulfs between rich and poor and urban and rural grew even wider.

During the PRI governments, private companies sold complex new medical technologies to the government at inflated prices. The Mexican government wanted to be seen as “modern,” but the technologies were hugely expensive, and often the intended users didn’t know how or were unable to use them! For example, what good are technical devices in rural areas that don’t even have electricity?

The World Bank, the International Monetary Fund, and the International Bank for Development facilitated these policies. Neoliberal PRI presidents supported them domestically in their health and budget departments.

One of AMLO’s campaign promises before his election was that he would improve access to care. Did he succeed?

He promised a public system of free care for all. But an important lesson in developing policy is that you need clear plans that are developed together with the people. AMLO’s first healthcare team was better at criticizing the existing system than developing a new explicit agenda. They were an interdisciplinary academic team, very theoretical, with almost no experience in operating a healthcare system or even understanding the actual state of the existing one. How many new clinics were needed? How many doctors? Where? They were experts in words but not prepared to move quickly.

And after 36 years of neoliberal governments prioritizing the needs of capital rather than the people, it was extraordinarily difficult to quickly get on track. Every public medical institution had been destroyed. The new hospitals, built as a boon for contractors, often remained empty.

Moreover, the initial team had unanticipated conflicts among themselves. They lacked consensus about the program’s direction, which was supposed to be developed in the context of the Fourth Transformation, that is, to prioritize Mexico’s poorest and guarantee their access to health care. On top of this — the COVID pandemic. It created an unprecedented emergency, which even further interrupted health sector reform.

What has happened since COVID? Can Mexico afford a universal system?

What can we afford? In Mexico and the US, we commonly debate how a national healthcare system should be financed and not so much about the mechanisms for delivering services! AMLO has always said that the money is there; that is not the problem.

Under past governments, health funds were channeled to the states. The system was riddled with corruption and also had profound design problems. One terrible example was the Seguro Popular, ostensibly a universal public health care program, which emerged from the desktop computer of Julio Frenk (today chancellor of the Universidad de Miami). The program had no operational knowledge about the great diversity of Mexico’s regions and ethnic groups. It might have been designed from the air by drones! Little of the money got to the people.

AMLO believes a strong central government manages the money and financing of health services better than the states, but health planning and programming must be local because conditions and populations vary in different parts of the country. In other words, the legal framework and funding stream must be centralized, but the operational side must be localized. Still, we need much more discussion on the ground as to what this should look like.

The domestic production of essential medicines and medical devices must also increase. Mexico’s health economy needs to be more self-sufficient to avoid the extortionist prices charged by foreign companies. Recently, AMLO announced a national mega-pharmacy that can supply the drugs that people need.

Most importantly, the healthcare focus will shift to primary healthcare and community action, as was proposed in the 1978 Alma Ata Declaration of the World Health Organization. That is, it will prioritize prevention. Public health initiatives will address infectious diseases, diabetes, heart disease, TB, and respiratory problems.

So, is health care a human right or a privilege? Do you have hope that AMLO’s promises can be fulfilled under a new president?

The market system operates to make health care a privilege granted to those who can pay. The Morena government believes that it is their duty to create the conditions for the well-being of the entire population.

Morena’s candidate, Claudia Sheinbaum, may well become president in 2024. The opposition, which wants to copy the US system, has been discredited and is not taken seriously. With her scientific background, Claudia will get the research done and collect the data to ensure that the people’s voices drive all plans to improve the population’s health and to provide free and accessible care.

However, the Business Coordinating Council (CCR) has already proposed a different model, “A Better Mexico for All,” that would continue promoting private health insurance, as in the US. And so, until the election, the matter is still up in the air.