The problem is that the word “unification” names too many things at the same time: interoperability, exchange of services, single credential, digital file, single provider, network integration. When a concept carries so many meanings, it becomes complicated for debate and demanding for reality.
That is why it is worth saying it from the beginning: unifying is not a single movement, but a combination of planes that can advance out of phase. There is a political-institutional component (who coordinates, what is unified and with what rules, governance and legal framework), a cultural-professional component (what people understand by the right to health, affiliation and treatment; what clinical teams accept or resist), an economic one (from which fund the payments come, with what incentives, what costs are recognized and which are transferred), a philosophical one (what idea of justice does the promise hold: full equality, guaranteed minimums, priority for the worst, gradualness, free of charge) and a technical one (standards, information, logistics, installed capacity and operational capacity). If these planes are not distinguished, the debate becomes a discussion about words; and the operation, a permanent management of bottlenecks, where the acute covers the chronic.
In Mexico, the unification of the health system is partial in its scope and partial in its architecture. Partial in scope means that the promise to “unify” is drawn within a circle. That circle is, for now, the public sector. But outside the circle there is another actor that cares, diagnoses, operates and charges millions of Mexican families: the private sector. If the unification does not name it, it does not disappear: it simply remains as a second circuit that continues to order access by ability to pay.
And it is partial due to its architecture because the public sector is not a uniform block. Different arrangements coexist: entities that already operate under a more centralized scheme and others that maintain decentralized forms, with different capacities and coverage. This duality makes inevitable a question that is rarely formulated clearly: is unification intended for the entire population as a universal rule, or to operate fully only in the bloc already integrated into the new arrangement? A unification by blocs may be a reasonable transitional step, but if it is presented as universal without explaining its scope, the country ends up discussing an ideal while experiencing an unequal implementation.
With this framework, doubts cease to be suspicion and become proof of reality. Unifying is sustaining care trajectories, not just sharing patterns. If that is the criterion, the rest is ordered.
The first contradiction is financial: any compensation scheme between institutions only integrates networks if the payment is automatic and credible. If it is not, it does not integrate care; integrates frictions. The announced justice becomes an accounting dispute and cooperation, intermittent.
The second contradiction is conceptual: digitalization may be a necessary condition, but it is not a sufficient condition. Digitizing can modernize the record without modernizing care: if the data remains organized by episodes and acts, the fragmentation only becomes more legible. The underlying question is not “will there be a platform?”, but “will the information serve to support clinical trajectories and responsibilities, or only to recount episodes that receive attention?”
The third contradiction is logistical. The promise of “relieving” services through exchange sounds plausible in a country with unequal saturations, but requires the ability to govern clinical and operational flows. Without that capacity, relief becomes a redistribution of delays: demand moves, care does not necessarily move.
And the fourth contradiction—the decisive one—is the real scope. As long as the private sector continues to function as a parallel circuit that absorbs demand from those who can pay, any strictly public unification runs the risk of producing two experiences of care: one regulated by the State and the other mediated by the market. And as long as the country operates with two public arrangements (integrated bloc and non-integrated bloc), unification can become—unintentionally—a new source of territorial inequality: better trajectories where the circuit is armed, more fragile trajectories where it is not.
If it is accepted that unifying is sustaining trajectories of care, then public discussion needs something less spectacular and more useful: verifiable criteria. Staying in the instruments—platforms, catalogs, clearing houses—does not allow us to organize the scope.
From there, unification is played in four simple tests: scope (what it includes and what it leaves out, and how it relates to the private sector), architecture (if there will be two speeds between entities and what is the route to close them), financial credibility (if compensation is paid automatically and verifiable) and clinical sense of the digital (if the file maintains continuity with responsibility and does not only record episodes). If these conditions do not become explicit, as we said before, the conversation remains instruments and reality will continue to be expressed in bottlenecks.
An idea remains from all of the above. The word “unification” can spark hope, but it can also cover up asymmetries if its scope is not explained. To unify is not to pronounce a historical direction; It is to build a daily experience of continuity: that the patient does not jump from window to window, that the transfer is not paid with family time, that the supply is not a lottery, that the file is not a file without a person responsible. If unification does not clarify who it includes, how it behaves in a country with two state arrangements, and how it makes payment and continuity credible, it risks becoming superficial modernization: a prettier narrative of the same fragmentation. The problem is not promising; It is promising without conditions. Because when the promise is not fulfilled, not only does a reform stumble: the trust of the population and institutional credibility are eroded.
*The author is a Full Professor of the Department of Public Health, Faculty of Medicine, UNAM and Professor Emeritus of 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
