We present a new concept, Punt Politics, and apply it to the COVID-19 non-pharmaceutical interventions (NPI) in two epicenters of the pandemic: Mexico and Brazil. Punt Politics refers to national leaders in federal systems deferring or deflecting responsibility for health systems decision-making to sub-national entities without evidence or coordination. The fragmentation of authority and overlapping functions in federal, decentralized political systems make them more susceptible to coordination problems than centralized, unitary systems. We apply the concept to pandemics, which require national health system stewardship, using sub-national NPI data that we developed and curated through the Observatory for the Containment of COVID-19 in the Americas to illustrate Punt Politics in Mexico and Brazil. Both countries suffer from protracted, high levels of COVID-19 mortality and inadequate pandemic responses, including little testing and disregard for scientific evidence. We illustrate how populist leadership drove Punt Politics and how partisan politics contributed to disabling an evidence-based response in Mexico and Brazil. These cases illustrate the combination of decentralization and populist leadership that is most conducive to punting responsibility. We discuss how Punt Politics reduces health system functionality, providing lessons for other countries and future pandemic responses, including vaccine rollout.

—Despite important progress in financial protection with the last health reform implemented since 2003 with Seguro Popular, effective access to health care in Mexico has not yet been fully achieved. The vision of the present Mexican health administration, 2012–2018, is to transform the Mexican health care system so that it ensures equitable and effective access to quality health care, regardless of the labor or socioeconomic status of the person who seeks care. This article is an overview of how we at the Ministry of Health plan to fulfill this vision. It analyzes three challenges that the Mexican health system currently faces to achieve effective access to quality health care and proposes specific strategies to address them. The first step to fulfill that vision is to strengthen the stewardship role of the Ministry of Health, through instruments such as new legal frameworks and better information for more effective regulation and permanent monitoring and evaluation of the health care system's performance, with a focus on quality of health care. In the short term, better coordination between institutions should be achieved by ensuring that resources follow the patient where she receives care through the instruments suggested above and by guaranteeing that resources are used efficiently and in a transparent manner. In the long term, Mexico's health care system should adapt its infrastructure and human resources to deliver primary care services to effectively meet the increasing demands for chronic disease prevention and management.

Although evaluation is now an integral part of the design and implementation of public programs in many countries, there is growing recognition that the utilization of evaluation results for improving implementation and decision making, particularly in developing countries, is limited. The objective of this paper is to describe the process by which the external impact evaluation has been used to increase the potential of Oportunidades to improve nutritional outcomes of the beneficiary population through modifications to its design and operation. We will summarize a series of studies that have guided this process and focus on key aspects that have facilitated the utilization of evaluation results for decision making in the program. Implementation of research to document the impact of programs and the publication of such findings in peer reviewed journals, although vital for improving our evidence base and for the advancement of researchers within the current academic system, is not enough to ensure that the program itself will benefit from the evaluation. The use of evaluation results as a basis for modifications to the design and implementation of the nutrition component of Oportunidades was favored by open dialogue among all sectors involved in the program and the evaluation team and a long-term commitment on the part of all those involved. We think that the lessons learnt from this process are relevant for other programs, even where resources may be limited.

The Mexican health system segments access and right to healthcare according to worker position in the labour market. In this contribution we analyse how access and continuity of healthcare gets interrupted by employment turnover in the labour market, including its formal and informal sectors, as experienced by affiliates to the Mexican Institute of Social Security (IMSS) at national level, and of workers with type 2 diabetes (T2DM) in Mexico City. Using data from the National Employment and Occupation Survey, 2014, and from IMSS electronic medical records for workers in Mexico City, we estimated annual employment turnover rates to measure the loss of healthcare access due to labour market dynamics. We fitted a binary logistic regression model to analyse the association between sociodemographic variables and employment turnover. Lastly we analysed job-related access to health care in relation to employment turnover events. At national level, 38.3% of IMSS affiliates experienced employment turnover at least once, thus losing the right to access to healthcare. The turnover rate for T2DM patients was 22.5%. Employment turnover was more frequent at ages 20–39 (38.6% national level; 28% T2DM) and among the elderly (62.4% national level; 26% T2DM). At the national level, higher educational levels (upper-middle, OR = 0.761; upper, OR = 0.835) and income (5 minimum wages or more, OR = 0.726) were associated with lower turnover. Being single and younger were associated with higher turnover (OR = 1.413). T2DM patients aged 40–59 (OR = 0.655) and with 5 minimum wages or more (OR = 0.401) experienced less turnover. Being a T2DM male patient increased the risk of experiencing turnover (OR = 1.166). Up to 89% of workers losing IMSS affiliation and moving on to other jobs failed to gain job-related access to health services. Only 9% gained access to the federal workers social security institute (ISSSTE). Turnover across labour market sectors is frequently experienced by the workforce in Mexico, worsening among the elderly and the young, and affecting patients with chronic diseases. This situation needs to be prospectively addressed by health system policies that aim to expand the financial health protection during an employment turnover event.

Monitoring and evaluation (M&E) have gradually become important and regular components of the policy-making process in Mexico since, and even before, the World Health Organization (WHO) Commission on Social Determinants of Health (CSDH) called for interventions and policies aimed at tackling the social determinants of health (SDH). This paper presents two case studies to show how public policies addressing the SDH have been monitored and evaluated in Mexico using reliable, valid, and complete information, which is not regularly available. Prospera, for example, evaluated programs seeking to improve the living conditions of families in extreme poverty in terms of direct effects on health, nutrition, education and income. Monitoring of Prospera's implementation has also helped policy-makers identify windows of opportunity to improve the design and operation of the program. Seguro Popular has monitored the reduction of health inequalities and inequities evaluated the positive effects of providing financial p...