Understanding the Unique Nature of IMSS-Bienestar
Health reforms often fail due to well-known reasons: incomplete diagnoses before implementation, lack of funding, conflicts between government levels, resistance from stakeholders, or excessive promises without operational backing. However, the IMSS-Bienestar case is different; it’s not a classic reform with systemic design, regulatory architecture, and gradual construction. Instead, it’s an accelerated administrative reorganization driven from the center of power, with little effective transition and scant technical deliberation.
The Decree and Its Political Implications
In August 2022, the Organismo Público Descentralizado (OPD) IMSS-Bienestar was formally created through a decree. On paper, this marked an inflection point: a new entity with legal personality, its own budget, and the mandate to operate health services for the population without social security. However, the decree primarily symbolized a political reaffirmation of an operational centralization model where the federal government absorbs what states previously managed, under the promise of gratuitousness, efficiency, and equity.
Institutional Shift and Its Consequences
The federal government decreed the integration of the historical IMSS-Bienestar program into the regular IMSS regime in 16 out of its 19 operating states by July 1, 2025. This move formally ends a decades-long strategy of bringing primary care to marginalized rural areas. Yet, this decision doesn’t alter the OPD IMSS-Bienestar’s functioning, which remains the operational hub for health services of the uninsured population in adhering states. The coexistence of overlapping models and superimposed legal frameworks further complicates the system’s architectural complexity.
The True Meaning of Consolidation
Consolidating a system means more than just expanding its operation or increasing coverage. It involves building robust, reliable, and sustainable institutions. This requires more than just will; it necessitates clear norms, stable structures, guaranteed funding, professionalized staff, integrated information systems, evaluation mechanisms, and most importantly, social legitimacy.
Partial Consolidation: An Intermediate Stage
Some might argue that consolidation has already begun, pointing to IMSS-Bienestar’s operation in 23 entities (with three more expected to join soon), its staff hiring, and the transfer of thousands of health centers. However, this represents only an initial phase, a partial and operational consolidation where control is centralized but quality and access aren’t necessarily improved.
Lack of Structural Clarity
To speak of structural consolidation, a more robust legal framework is needed—legislation that precisely defines rights, obligations, funding schemes, shared responsibility mechanisms, and participation forms. A single decree or fragmented state agreements aren’t enough. For instance, the fate of non-adhering state systems, harmonization of labor regimes, and implications of the recent amendment to the General Health Law that formalizes INSABI’s disappearance without explicit new guarantees remain undefined.
The Absence of Functional Efficiency
Beyond structure, functionality is missing. The system should operate efficiently, consistently, and with quality; people should receive timely and effective care; medications should be available; referrals should work, and health professionals should work in dignified, stable conditions. There’s no public evidence of this yet. No external evaluations have been published, health indicators’ impact isn’t known, and there’s unclear information on user satisfaction or equity in care.
The Role of Human Resources and Political Dimensions
Another critical aspect is the role of human resources for health. Thousands have been absorbed under precarious conditions, without labor security, permanent positions, or full social security. The promised “regularization” progresses slowly without clear criteria and amidst tensions between levels, institutions, and contracts. Without stability for those sustaining the system from the bottom, there’s no continuity of care or institutional legitimacy.
Lastly, the political and social dimension of consolidation is crucial. A health system needs not just infrastructure or personnel but also trust—from patients who should feel protected, from staff who must feel valued and secure, from local governments who should feel part of the project, and from citizens who must believe in a public system that’s more than empty promises.
The Path Forward: A Balancing Act
To envision a desirable consolidation by 2036, several conditions must be met: primary healthcare as the system’s organizing principle with stable, skilled teams embedded in communities; active state participation in model design, evaluation, and continuous improvement; a single interoperable information system supporting clinical and management decisions based on data rather than decrees; and a regulated private sector complementing, not replacing, the public system.
The clearest sign of this consolidation would be the most intangible: people visiting health centers not out of resignation but with trust. They’d know there’s care, continuity, and response because the system would be more than a structure—it would be a kept promise.
This horizon is possible only if institutions are consolidated, but more importantly, if a pact is forged between governments, health personnel, and citizens. In this pact, caring, listening, and accountability would be daily actions, not campaign promises.
*The author is a Tenured Professor in the Department of Public Health, Faculty of Medicine, UNAM and Emeritus Professor in the Department of Health Measurement Sciences, University of Washington.
The opinions expressed in this article do not represent the position of the institutions where the author works.
[email protected]; [email protected]; @DrRafaelLozano
