From an organizational chart, there are things that don’t make sense. The IMSS, ISSSTE, and other public providers aren’t just institutions; they are experiences. The crowding that turns the waiting room into a space with sparse air, the clock that becomes an adversary, the saturation that transforms a procedure into a marathon, the repetition of clinical history as if it’s being told for the first time, and the casual “come back tomorrow” spoken with the familiarity of having said it a hundred times. One can understand the legal architecture of the right to health, yet still not grasp what “access” means if it doesn’t pass through that scene. Because, in Mexico, access isn’t just about availability; it’s time, wear and tear, indirect costs, uncertainty. It’s daily life.
The Unification Discussion: Capacity vs. Shortage
In recent days, “unification” has been discussed as if Mexico were about to resolve fragmentation with a neat institutional move: a single credential, service exchange, a compensation chamber, and digitalization. It sounds modern. However, the crucial question remains more concrete: what exactly is being unified, capacity or shortage?
Distinguishing Between Coyuntura, Amenaza, and Megatendencia
To organize the debate, it’s essential to differentiate between coyuntura (episode), amenaza (threat requiring reaction), and megatendencia (the underlying current reordering what’s possible, fundable, and sustainable). Coyuntura is the episode; amenaza requires reaction; megatendency shapes what’s possible.
Advocating for a single system or effective unification of the existing system has clear characteristics of a megatendency. It’s not a new idea, and it doesn’t depend on a single government. This aspiration recurs because it addresses a real problem: fragmentation breeds inequality, absurd routes, and disjointed care experiences. Unification is attractive because it promises justice. However, being legitimate doesn’t mean it’s viable in any form. The crucial concept here is the “fine bet” for 2026.
The Fine Bet: From Theory to Operation
The “fine bet” is where a megatendency transitions from narrative to operation: budgets, payment rules, logistics, staffing, supplies, clinical times, and information systems that function. One can promise a unified system, but there’s doubt about sustaining the promise without turning it into deficit management.
The compensation chamber, as it has been presented, is an attractive idea in its logic. It allows people to seek care where capacity is available and then financially compensate the institution that provided the service. The implied image is money flowing naturally between institutions, as if the system were a well-pressurized hydraulic circuit. However, it’s crucial to introduce a metaphor that captures the problem: a compensation chamber is like a bank clearinghouse where payments between accounts are liquidated. It works when there are funds and when the payment is credible. If guaranteed liquidity isn’t assured, the chamber doesn’t create money; it merely makes the bounced check moment more efficient.
Given that Mexico’s system lacks symmetrical “pockets,” there’s a structural difference between social security and those without it. Simplified, social security has a distinct contributory base and institutional foundation; the other side relies more on annual budgetary transfers, changing priorities. This translates to a known asymmetry for anyone comparing actual response capacity: not just infrastructure, but also personal availability, supply continuity, and diagnostic opportunities. In this context, “compensating” can mean “promising future payments” in a country where the future competes with too many urgencies.
Lessons from the COVID-19 Pandemic
During the COVID-19 pandemic, the public sector turned to agreements with private providers to expand capacity: using installed capacity outside to support demand. The lesson is simple: announcing agreements is easier than timely payments. This experience highlighted the critical point of the mechanism: when the payer is a financially fragile entity or an unstable executor, agreements can get stuck in payment, time, and traceability. In contrast, when the payer has more stable flows—as is often the case in social security—settlement tends to be more predictable. If unification relies on compensations, the inevitable question arises: what guarantees payment?
Digitalization: Ordering vs. Reflecting Reality
In a country loaded with promises and good intentions, it’s tempting to believe that digitalization compensates. Digitalization can order and make visible, but this visibility is ambiguous. It can aid better governance, yes, but it can also become a high-definition mirror reflecting saturation without altering it. The episodic recording of deprivation is modernized, not the deprivation itself.
Unification of Care vs. Administrative Unification
When discussing a unified system, it’s essential to ask what type of unification is being pursued. There’s administrative unification—credentials, platforms, rules—which can help but doesn’t necessarily address the core issue. Then there’s unification of care: continuity, referral, and return with a plan, supplies, basic diagnosis, reasonable clinical times, and complete teams at the first level, along with a patient experience that doesn’t start from scratch every time. This is the unification felt in the body.
Territorial Medicine: Sustaining Continuity Where People Live
Here enters territorial medicine, the capacity to sustain continuity where people live, without romanticism. Mexico arrives at 2026 with repeated attempts to “reach the people.” The problem isn’t intuition but form: when the territory is treated as a showcase—visits, figures, episodic presence—visibility is achieved; when it’s treated as a system—living registry, follow-up, stable teams, logistics—continuity is achieved. What’s useful must be sustained without depending on circumstance or the snapshot.
Information System Orientation: From Episode-Focused to Care-Focused
Another often overlooked component when discussing reform is the information system’s orientation. Mexico can unify registries and still maintain a disease-focused model. This model organizes episodes—consultation, diagnosis, prescription, referral, discharge—and counts acts. It’s necessary but has a blind spot: it doesn’t organize trajectories. Today, much healthcare suffering occurs in trajectories: chronicity, multimorbidity, and home-based care. Thus, a care-focused system requires a different grammar: continuity, follow-up, team coordination, and clinical responsibility for trajectories. If data continues to be organized by episodes, unification will only strengthen fragmented clinical practice.
Back to the Initial Question: Capacity or Shortage Unification?
Returning to the initial question, if unification aims to unify without guaranteeing capacity, it risks becoming an experiment in deprivation management. A compensation chamber without earmarked funds and automatic payment rules might end up unifying what’s already unified: the wait.
The Fine Bet for 2026: Conditions for Successful Unification
The fine bet for 2026 isn’t “creating a unified system,” but making unification credible in a country with unequal capacities and an unresolved payment question. It requires, at minimum, three conditions: earmarked funding (so it doesn’t depend on “if there’s enough”), sustained operation (complete staffing, supplies, diagnosis, and logistics), and care-oriented information because if data continues to be organized by episodes, unification will only reinforce fragmented clinical practice.
The Unignorable Fourth Condition: Professional Culture
A care system isn’t sustained by rules alone; it requires professionals capable of inhabiting continuity. If medical training continues to focus on episodes and hospitals as horizons, the first level will remain a transit point, and the territory will remain execution. If it’s reoriented towards follow-up, teamwork, and clinical judgment in imperfect contexts, unification will have substance, not just narrative.
Sobriety in a Promise-Saturated Nation
In a nation saturated with promises, a rule of sobriety is advisable: unification shouldn’t be measured by design elegance but by changes in daily experience. Less pilgrimage, more trust in the first level, predictable supplies, referrals that respond, and files that serve to live a life, not just record an episode.
A Fragmented System Doesn’t Unify by Decree
A system born fragmented doesn’t become whole by decree. A tree that grew crooked can appear straight if its trunk is painted and its branches are tied, but it will continue to grow as it was born. In that case, the only thing truly unified is what was already unified: the wait.
2026: A Turning Point
2026 can be a turning point: unification either becomes capacity for care or remains sophisticated accounting of deprivation. In healthcare, fine bets cost money, organization, and credibility.
Suggested References:
- Agreement with Private Hospitals (April 13, 2020) – Mexican Government / Presidency:
- OCDE – Panorama de la Salud 2025: México (Spanish Version):
*The author is a Tenured Professor in the Department of Public Health, Faculty of Medicine, UNAM, and an Emeritus Professor in the Department of Health Measurement, University of Washington.
Author’s Contacts:
[email protected] ; [email protected]; @DrRafaelLozano
