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La Semana: Sunday, Mar 6
The week in drug shortages and the approaching recall referendum
Welcome to the Sunday edition of The Mexpatriate.
In today’s newsletter, you will find the first in a two-part series on the public health fiasco known as the “desabasto”, as well as follow-up on the upcoming presidential recall referendum:
Deciphering Drug Shortages (“desabasto”) in Mexico: Part I
To vote or not to vote?
Please send me your comments, feedback and questions, and feel free to forward this to anyone who may be interested. You can always find all sources (with links) at the bottom of the email.
Deciphering Drug Shortages (“desabasto”) in Mexico: Part I
“There is no medicine more expensive than the one you can’t get.”
Irene Tello & Denise Tron (Operación Desabasto)
Timing is everything. When the López Obrador administration took office in 2018, one of the first initiatives on the agenda was a reform of legislation governing public procurement, which AMLO suspected was a potential magnet for corruption. As part of this reform, the massive government acquisition of drugs and medical supplies was to be completely overhauled and centralized in the Department of the Treasury and Public Credit (OMSHCP). As part of the anti-corruption crusade, three of the largest distributors of pharmaceuticals in Mexico were also vetoed from participating in government contracts. By the second half of 2019, reports of shortages—particularly of specialized oncology drugs—began to appear. And by early 2020, when ominous scenes from Wuhan foreshadowed a coming pandemic, thousands of complaints were being logged across Mexico at public pharmacies where patients were told they could not fill their prescriptions. A weakened system was about to confront the biggest supply chain catastrophe in modern memory.
“When a patient is going to receive a heart transplant, he or she is connected to a life support system while their heart is removed and the donor heart is put in. In the case of medical supplies, it is tantamount to the government removing a patient’s heart without even having a donor heart ready.”
This is analyst Xavier Tello’s striking image of the scope of Mexico’s drug and medical supply shortage problem in his book La Tragedia del Desabasto. The shortages have been a public relations headache for the AMLO administration and caused suffering and economic ruin for many Mexican families.
“We went from a situation where there were medicines and surely there was corruption, to a situation where there are no medicines and we don’t know if there is corruption.”
Octavio Gómez Dantés
As I have been researching for this article, the vastness of the topic has brought to mind the challenge faced by an astronomer who combs the heavens, searching for planets beyond the solar system. Too distant to be seen by any telescope, she can only infer a planet’s existence through indirect observations, recording its effect on the star it orbits. In the case of the “desabasto” of medical supplies, we can observe its impact on the country, even if concrete data on the problem are obscured.
According to a comprehensive report on healthcare from 2017-21 released by Colectivo Cero Desabasto on Mar. 2, there has been an average 40% increase in out-of-pocket medical expenses for Mexican families from 2018-21. Public healthcare spending in Mexico has long been lower than in other economies (5.5% of GDP) and as of 2018, Mexico was already leading OECD countries in out-of-pocket medical expenses at 41.4% of total healthcare spending, compared to 11.6% in the U.S. in 2020. The platform cerodesabasto.org has received 7,996 reports of medical supply shortages from patients and healthcare professionals between Feb. 2019-Dec. 2021 and complaints made to public health departments have jumped: in 2017, IMSS received 686 complaints, in 2021 they registered 11,367. These are just a few of the indirect statistics shining light on the scope of the crisis.
In order to understand the root causes of this problem, we have to start with an aerial view of the Mexican healthcare system. Mexico has a hybrid public and private healthcare system which purports to provide universal coverage. The majority of public healthcare is provided today by IMSS (Mexican Institute of Social Security) to employees in the private sector (51% of the population), and by INSABI (Institute for Health and Well-being) for the unemployed or informally employed, though six states opted out of INSABI when it replaced the Seguro Popular in 2020. Government workers are provided with healthcare by ISSSTE (Social Security Institute for Federal Employees), Pemex (Mexican Petroleum), SEDENA (Department of Defense) and SEMAR (Department of Marines). The dissolution of the Seguro Popular and transition to INSABI left many Mexicans behind: between 2018-2020, citizens without access to healthcare grew from 16% to 28% of the population.
In Mexico, the government directly purchases all drugs and supplies required to stock public hospitals and pharmacies. This makes the Mexican government’s procurement of pharmaceuticals and other medical supplies unique in volume and complexity. During the previous administration of Peña Nieto (2013-18), this was carried out in a “compra consolidada” (consolidated purchase) negotiated by IMSS, which gathered projections of required medical supplies from their facilities all over the country as well as those run by other state institutions. This catalogue of “claves” (everything from paracetamol to chemotherapy drugs to syringes) was opened to public bid and some contracts were also directly awarded. While shortages did occur, from 2013-18 the number of unfulfilled “claves” fell from 13% to 5% and prices on average came down 20%.
In the first government acquisition negotiated by AMLO’s administration for the second half of 2019, 62% of the required “claves” were left empty; in other words, no suppliers had made offers to fulfill them. In comparison, for 2017 and 2018, the percentage of unfulfilled “claves” was 9.6% and 4.9%, respectively.
What caused this disaster? The president blamed the pharmaceutical industry, which he had already targeted as “immoral” in a statement from March 2019, accusing them of “blackmailing” the administration. The focus of his ire was Mexican companies, particularly the ten primary national distributors of drugs, three of which handled the majority of the titanic logistical task of delivering drugs and supplies to thousands of government facilities across the country. But research conducted by the NGOs Impunidad Cero and Justicia Justa detailed how the call for bids had been delayed 60 days past deadline while the government did “market research” and by the time it was opened to bidders, they were given only 48 hours to present bids.
“The current drug shortages in the country result from a failed anti-corruption strategy and an attempt to cut costs in the acquisition of medical supplies by this administration. Not a single official [from previous administrations] has yet been charged for complicity in corruption related to drug purchasing,” notes the report Operación Desabasto. “We went from a situation where there were medicines and surely there was corruption, to a situation where there are no medicines and we don't know if there is corruption”, said Octavio Gómez Dantés, a researcher in health systems at the National Institute of Public Health.
Following the abysmal procurement attempt for 2019, the government changed gears and shifted responsibility to INSABI in 2020 and then finally, to the United Nations Office for Project Services (UNOPS) in 2021. According to the U.N. agency’s website: “To help maximize the efficiency, transparency and effectiveness of the procurement of medicines in Mexico, UNOPS partnered with the government in a landmark $6 billion USD agreement in 2020 to purchase medicines and medical supplies on behalf of Mexican health institutions.”
The non-profit, which manages an annual budget of $2 billion USD around the globe, will charge an as-yet undisclosed percentage on the $6 billion USD acquisition of medical supplies and as of January 2022, announced that they had obtained bids for 94% of the supplies for July-December 2022. But the UNOPS is not responsible for distribution, which has been placed in the hands of BIRMEX, a state-owned company that has up until now been in charge of development, production, importation and distribution of vaccines in Mexico. Public health experts have expressed doubts that BIRMEX has the capacity for the scale of distribution required.
While the “desabasto” has been consistently making headlines as patients protest and take legal action, clear and accurate data on its true scope have been difficult to obtain. Government records on the healthcare system vary across institutions and often do not differentiate within broad categories of data. For example, most government records do not distinguish between “issued” and “presented” prescriptions, so it is difficult to untangle the prescriptions written by a doctor and those presented to a pharmacy. INSABI does not currently maintain any records on numbers of prescriptions issued and filled. Some physicians may have stopped prescribing drugs they knew were not available, reducing the number of unfilled prescriptions on paper.
On the one hand, this allows AMLO and his government to minimize the problem—if you don’t measure it, then it must be imaginary, or the invention of a “right-wing campaign”—and has left public health experts, activists and journalists piecing together a picture of the crisis from fragmented sources.
In Part II of this series, I will examine the official and unofficial data collected on medical supply shortages, the population most affected, and also how Mexican civil society has stepped up to both document this issue and address the needs of patients left without adequate medical care.
To vote or not to vote?
In the past three weeks, a number of government officials have been chastised by the National Electoral Institute (INE) for promotion of the Apr. 10 recall referendum vote (“revocación de mandato”), including the mayor of Mexico City, Claudia Sheinbaum, who is also AMLO’s protegée. According to the constitutional amendment governing the referendum: “all broadcasting of any form of government promotion in media outlets must be suspended” during the “veda electoral” that started Feb. 4 and remains in effect until the date of the vote. In Mexico, campaigning prior to any election has a time limit and the period of “campaign silence” usually goes into effect within days of an election.
Sheinbaum was undeterred and in a press conference stated: “we will continue to talk about what they won’t let us talk about.” According to Sheinbaum and other Morenistas (members of the MORENA party), the promotion of the referendum by the INE has been lackluster and this is why they are committed to spreading the word about this act of “participatory democracy.”
While government officials and the INE engage in a fencing match, citizen spectators seem to fall into two teams: the pro-AMLO group actively promoting the referendum and the dismayed opposition squirming in indecisive angst. In a Mar. 1 opinion column by journalist Pamela Cerdeira, she talks through the arguments for and against participating in the recall. Her points against voting include the error of setting a precedent for de facto three-year presidential terms (a six-year term marked by a popular referendum at the half-way point), participating in an act that speaks to “the President’s obsession with his place in history”, and the potential instability that could arise if AMLO’s mandate were recalled and an interim executive had to be put in place. And yet, “voting in the referendum is a way to express discontent with this administration,” which leads her to conclude: “there are no simplistic answers to this question, and like all civic acts, it is a personal decision.”
As a backdrop to this debate, Mexico has gotten bad democracy grades from two sources in recent weeks: the Democracy Index 2021 (by the Economist Intelligence Unit) and the national Democratic Development Index (IDD). The report from the former downgraded Mexico from a “flawed democracy” to a “hybrid regime”, pointing to the increased centralization of power in the executive, attacks on the press, violence during recent elections and other markers of civil liberties to give a score of just 5.57 out of 10. The Latin American average score is 5.83. On Mar. 3, the IDD report showed a 24% drop on national measures of democratic development between 2020-21 and focused on trends of democratic decline, including polarization.
“Social justice remains the great unfulfilled promise for more than a century, since the Revolution, and the path of weakened institutions and challenges to the rule of law is very worrying,” noted Lorenzo Córdova, director of the INE, at the presentation of the report. “The politics of ‘us versus them’ is fertile ground for authoritarianism,” he warned.
To read more background on the “revocación de mandato”, refer to my Jan 23 newsletter.
Operación Desabasto (El Universal)
La Tragedia del Desabasto by Xavier Tello (Editorial Planeta Mexicana)
Radiografía del Desabasto (Cero Desabasto/Nosotrxs)
Lack of Medicines in Mexico (The Lancet)
Comisión de Abasto 2019-20 (CANIFARMA)
INE ordena a Sheinbaum borrar mensaje por violar veda (Animal Político)
Democracy Index 2021 (Economist Intelligence Unit)