Equity, governance and financing after health care reform: lessons from Mexico.

To determine, from the perspective of providers, community leaders and users of health services, equity, governance and health financing outcomes of the Mexican health system reform.Cross-sectional study oriented towards the qualitative analysis of financing, governance and equity indicators for the uninsured population. Taking into account feasibility, as well as political and technical criteria, six Mexican states were selected as study populations and a qualitative research was conducted during 2004-2006. Two hundred and forty in-depth interviews were applied, in all selected states, to 60 decision-makers, including medical and administrative personnel; 60 service providers at health centres; 60 representatives of civil organizations, including municipal representatives and, finally, 60 members of health committees and users of services at second and first levels of care units. The analysis of interviews was performed using ATLAS-Ti software. An outcome mapping of health reform was developed. For political actors, Mexican health system reform has not modified dependence on the central level; ignorance about reform strategies and lack of participation in the search for financial resources to finance health systems were evidenced. Also, in all states under study, community leaders and users of services reported the need to improve an effective accountability system at both municipal and state levels. Health strategies for equity, governance and financing do not have adequate mechanisms to promote participation from all social actors. Improving this situation is a very important goal in the Mexican health democratization process, in the context of health care reform. There are relevant positive and negative effects of the reform on equity, governance and financing in health. Special emphasis is placed on the analysis of lessons learned in Mexico and the usefulness of the main strengths and weaknesses, as relevant evidences for other middle-income countries which are designing, implementing and evaluating reform strategies in order to achieve equity in resource allocation, good levels of governance and a greater financial protection in health.