YAUTEPEC, Mexico - When Azucena Mora Diaz’s twins were born prematurely, they were treated at the Women’s Hospital here at no cost to their parents, thanks to a government insurance plan. “We owe everything to this,” Ms. Mora said of her nowhealthy girls.

A decade ago, half of all Mexicans had no health insurance. Then the country’s Congress passed a bill to ensure health care for every Mexican without access to it. The goal was explicit: universal coverage.

By September, the government expects to have enrolled about 51 million people in the insurance plan it created six years ago - effectively reaching the target, at least on paper. The big question, critics say, is whether all those people actually get the health care the government has promised.

Many people are treated at no cost, and even critics acknowledge that the program saves lives and protects families from falling into poverty.

With a budget of about $12 billion this year, the task is enormous.

Still, Salomon Chertorivski, who is in charge of the government’s system of social protection for health, believes it is possible.

“Easy it isn’t,” he said. “And it shouldn’t just be sufficient, but it should also have the quality that you would expect.” He argues that because only 9 percent of Mexicans are over age 60, health costs for the country’s relatively youthful population are low.

In Mexico’s poorer states and among its most destitute, that quality is still lacking. A study by Mexico’s National Institute for Public Health questioned how well the plan was being carried out at the state and local levels, saying their contributions and lack of transparency “leave much to be desired.”

Mexico’s health minister, Jose Angel Cordova, acknowledges that 8 percent of the country’s municipalities still lacked any kind of health facility. The Health Ministry’s own statistics show that it is behind its targets in reducing infant mortality (it ranks 106th in the world) and maternal mortality - key health indicators - in the poorest states.

In Mexico, a small sliver at the top have private insurance, and most salaried workers are treated in a giant, but fraying, public health system known as the Mexican Social Security Institute.

Because the system links coverage to employment, it leaves out millions .

Before the federal government’s program was implemented, a health safety net for those people did exist often for a fee, with clinics and hospitals run by state governments. Once patients were discharged from the hospital, they had to buy their own medication. Many were unable to afford it.

This rickety infrastructure served as the base of the new Seguro Popular, or popular insurance, which was begun in 2004. Any
Mexican can sign up. A broad package of basic medical services is guaranteed, along with medicine and coverage for some catastrophic illnesses. The program was designed to charge a yearly fee based on income, but in practice hardly anybody pays because, the government argues, most of the participants are too poor.

Dr. Julio Frenk, the former health minister who designed the effort, says it ties government spending directly to how many people enroll. “We changed the budgeting logic,” said Dr. Frenk, now dean of the faculty at the Harvard School of Public Health.

The program has increased public health spending - by an additional 1.5 percent of gross domestic product .

But that still leaves it below developed nations and other Latin American countries, like Chile and Costa Rica, according to the Organization for Economic Cooperation and Development and the Pan American Health Organization.

Some analysts argue that a budget of about $200 per patient is too low.

The money goes from the federal government to state governments, depending on how many people each state enrolls.

It is up to the state governments to spend the money properly so that patients get the promised care.

That, critics say, is the plan’s biggest weakness. States have every incentive to register large numbers, but face no accountability for how they spend the money.

“You have people signed up on paper, but there are no doctors, no medicine, no hospital beds,” said Miguel Pulido, the executive director of Fundar, a Mexican watchdog group.

Mr. Chertorivski acknowledges that getting some states to do their work properly is a problem, but says, “You can’t do a hostile takeover.”

The result is that how Mexicans are treated is a function of where they live.

In Morelos State, officials point to the women’s hospital as one of their successes. Opened three years ago, it handles high-risk pregnancies, treats breast cancer and offers birthing classes and neonatal intensive care . But the standards seem to fall at local clinics.

“There is hardly any medicine there,” said Ms. Mora, the mother of the twins. “It’s just good for vaccinations.”

Mobile centers are at the center of Mr. Chertorivski’s plans for 2011, to focus on prevention and patients’ rights. But he acknowledged that ambitions and reality sometimes diverged. “Well,” he said, “I’m telling the story of what should be.”



ADRIANA ZEHBRAUSKAS FOR THE NEW YORK TIMES
Mobile clinics are at the center of Mexico’s effort to provide health care to all who cannot afford it.




By ELISABETH MALKIN