Last year Lancet published a series of articles on Mexico's 2004 health system reform. This article reviews the reform and its presentation in the Lancet series. The author sees the 2004 reform as a continuation of those initiated in 1995 at the largest public social security institute and in 1996 at the Ministry of Health, following the same conceptual design: "managed competition". The cornerstone of the 2004 reform-the voluntary Popular Health Insurance (PHI)--will not resolve the problems of the public health care system. The author assesses the robustness and validity of the evidence on which the 2004 reform is based, noting some inconsistencies and methodological errors in the data analysis and in the construction of the "effective coverage" index. Finally, some predictions about the future of PHI are outlined, given its intrinsic weaknesses. The next two or three years are critical for the viability of PHI: both families and states will face increasing difficulties in paying the insurance premium; health infrastructure and staff are insufficient to guarantee the health package services; and the private service contracting will further strain state health ministries' ability to strengthen service supply. Moreover, redistribution of federal health expenditure favoring PHI at the cost of the Social Security Institute will further endanger public health care delivery.

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Investing in Health is the World Bank's blueprint for a new health policy within the context of structural adjustment. While this document includes a broad range of arguments, its implicit premises are neoliberal as can be deduced from its "agenda for action." Health is defined as a private responsibility and health care as a private good. This leads to a health policy based on two complementary principles: the reduction of state intervention and public responsibility, and the promotion of diversity and competition (i.e., privatization). Thus, public institutions should provide only a limited number of public goods and narrowly defined, cost-efficient forms of relief for the poor. All other health-related activities are considered private duties, to be resolved by the market, NGOs, or families. The World Bank policy provides a pragmatic contribution to efforts to achieve fiscal balance. However, it also pushes to recommodify health care and to turn health into a terrain for capital accumulation through the selective privatization of health-related financial and "discretionary" services. The proposal implies large-scale experimentation and dismantling of public institutions which are the only alternative now accessible to the majority. It rejects health as a human need and a social right, and violates basic values by claiming that life and death decisions can be justly made by the market or through a cost-effectiveness formula.

The Mexican health reform can be understood only in the context of neoliberal structural adjustment, and it reveals some of the basic characteristics of similar reforms in the Latin American region. The strategy to transform the predominantly public health care system into a market-driven system has been a complex process with a hidden agenda to avoid political resistance. The compulsory social security system is the key sector in opening health care to private insurance companies, health maintenance organizations, and hospital enterprises mainly from abroad. Despite the government's commitment to universal coverage, equity, efficiency, and quality, the empirical data analyzed in this article do not confirm compliance with these objectives. Although an alternative health policy that gradually grants the constitutional right to health would be feasible, the new democratically elected government will continue the previous regressive health reform.

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Neoliberalism has been implemented in Latin America for about three decades. This article reviews Mexico's neoliberal trajectory to illustrate the political, economic, and social alterations that have resulted from this process. It finds that representative democracy has been perverted through fear, putting central political decisions in the hands of power groups with special interests. The border between the state of law and the state of exception is blurred. Economic structural adjustment with liberalization and privatization has provoked recurrent crisis, but has been maintained, leading to the destruction of the national productive structure in favor of supranational corporations, particularly financial capital. The association between criminal economy and economic criminality is also discussed. The privatization of social benefits and services requires state subsidies and allows the privatization of profits and the socialization of losses. The social impact of this process has been devastating, with a polarized income distribution, falling wages, increased precarious jobs, rising inequality, and extreme violence. Health conditions have also deteriorated and disorders associated with violence, chronic stress, and a changing nutritional culture have become dominating. However, in Latin America, massive, organized political and social mobilization has broken the vicious neoliberal circle and elected progressive governments that are struggling to reverse social and economic devastation.

The outstanding feature of economic globalization in Latin America is the application of neoliberal structural adjustment programs under the guidance of international financial agencies. These programs include state reform that redefines social policy and the role of state, markets and families in the satisfaction of social needs. This dual social policy aims at commodifying profitable social services and benefits and reducing public social services to a minimum for the very poor. These characteristics are analyzed specifically in the health services and social insurance reforms and poverty programs. Given the sustained increase in poverty and unemployment and falling family incomes, this policy aggravates the social crisis through simultaneous market and state `failure'.

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