By Cynthia L. Michel, Guillermo M. Cejudo
and Adriana Oseguera Gamba
When we talk about the care crisis, some people think it's too abstract a problem, a niche agenda, or an issue that can wait. But every day that goes unaddressed is a day in which inequalities deepen, burdens are placed on women and families that, at best, complicate their lives, but in most cases, deny caregivers and those in need of care the possibility of a dignified life. People are left at the mercy of what their households can afford to pay for care, or the public services they, with luck and great effort, manage to access.
Therefore, it is good news that the issue is central to the public agenda and that all parties are making proposals to build a care system or, at least, to improve or expand the range of programs and services. This has helped pave the political path toward addressing the care crisis: it is reasonable to expect that, in the coming months, once the next president takes office and Congress begins sessions, the legislative process will resume to guarantee the right to care and to have a law that supports a national system. After that, however, the technical challenge remains. Many decisions must be made about the specific design, the populations to prioritize, the responsibilities between different sectors and levels of government, the governance mechanism to operate the system, and the sources of funding for it. None of these decisions will come from a manual or can be automatically derived from "best practices." Instead, these are decisions that must be aligned with the agreed-upon objectives regarding guaranteeing the right to provide and receive care, but also with existing capacities in terms of information systems, infrastructure, personnel, and services. It's not just a matter of adding what already exists, but it's also not a task that can be separated from the starting point. It's these institutions, organizations, and capacities that will shape the system.
And although in previous posts we have written about the complexity of many of these decisions, and the risks of poor design, in this last post in the series on building a care system, we focus on arguing that it is possible and necessary to establish the national care system now. The political opportunity that has been built with so much effort should not be wasted, but we cannot assume that political will is the only challenge: the system design must be done well, leveraging evidence, building serious diagnoses, and imagining a feasible but ambitious implementation path.
The conditions exist to build a care system
Today, Mexico has the opportunity to launch a national care system. Not only has the creation of such a system been proposed by the three candidates aspiring to govern our country, but proposals on the matter have also been made in virtually all the states that will renew their governorships in the upcoming elections. Furthermore, there are legislative initiatives in both Congress and the Senate, and several efforts have already been implemented in some municipalities. In October of this year, Mexico will have its first female president, a likely gender-equal Congress, and several new female governors and municipal presidents, who will be able to take advantage of the push that social organizations, feminist groups, government specialists, international organizations, and academia have given to the issue in recent years.
In addition to the visibility of the issue and the election of leaders promoting new agendas, there is an additional favorable condition: unlike other issues, caregiving easily generates political consensus, largely because all of us at some point have required or will require care. We have also seen how our mothers, grandmothers, and sisters prioritize the well-being of others within the home at the expense of their own self-care or professional development. With varying degrees of closeness, we have also seen how our grandmothers and grandfathers age, and in some cases, our parents. We know that their care needs are different, as are the possibilities each home has to provide them. And we understand that caregiving is a collective challenge: caring is not the responsibility of isolated individuals or families, but a common challenge, with the State as the guarantor of the quality of care and the rights of caregivers.
It is a complex task, but not impossible. Other countries in the region with similar characteristics to Mexico have achieved this or are already well advanced in the process. Chile has the Chile Crece Más child protection subsystem and is in the process of implementing its national system, Chile Cuida. In Uruguay, the National Integrated Care System has been in place for several years. Costa Rica also approved the National Care Policy a couple of years ago and is in the process of regulating its system. Brazil and Colombia have also been working on their national care policies for several months.
Mexico can no longer postpone the creation of its system. Today, several factors are converging that give us the momentum we need to boost the national care system. We must not waste the opportunity before us to get started. It's not necessary for everything to be resolved at once or for us to have the most ambitious system we can aspire to from the start. The creation of the system we need can be gradual, but it must begin now. There may be budgetary constraints and even political resistance, but that shouldn't be an absolute impediment. We can start with a few priority municipalities and populations (children ages zero to four), as in Chile, or focus first on older adults (as in Costa Rica) and gradually expand coverage. Another option is to start with the group of interventions with the greatest impact, but with the aim of gradually incorporating others. What's important is that the design isn't subject to current budgetary constraints or political resistance, but rather that it addresses them as they go along, with medium-term milestones established.
The care system is not a law, but a set of enforceable rights, with information, budgets and responsible parties.
Martha is a person with a disability. She is in charge of her daughter's care, who has autism, and is also the primary caregiver for her parents, who are deaf. Martha lives in Mexico City, which gives her the right to care and receive care, or at least that's what her city's constitution says. The truth is that she cannot exercise this right because the local Congress has not passed a Care Law (nor discussed any of the initiatives that have been presented) that would shape a care system in the city. The problem is that, without a care system, it is practically impossible for Martha to have access to a (quite diverse, but specific) set of services that would allow her to care for three people with disabilities without causing physical and emotional strain on herself. And, of course, it is also impossible for her to access the means to provide her own care, especially considering her specific needs.
Faced with the State's failure to act, Martha and two other women filed five injunctions seeking a judge to instruct Congress to legislate a City Care Law. The judge granted the injunctions and instructed Congress to study the proposed laws in committee and consult with people with disabilities, even though Congress argued that it was not obligated to legislate because a care system already exists in Mexico City.
In cases like Martha's, and those of millions of caregivers in this country, it is essential to distinguish what a care system is not and, on the contrary, what its components are. As we stated earlier in this series, a set of isolated interventions does not constitute a care system. And that is precisely the only thing Martha can access now.
Cases like Martha's, and those of millions of people who require care in this country, demand a careful design of our care system. Above all, because the easiest thing to do is to fail; the easiest thing to do is to continue, almost inertially, with what already exists—making changes in form, perhaps, but not in substance. The worst scenario we could face is one in which all political capital is invested in pushing through a law, and then the entire system is exhausted by "adding" to the existing offerings or labeling the same insufficient and poor-quality services that exist today as a "care system."
For the care system to function and guarantee rights, beyond the law, technical issues must be resolved to ensure the necessary conditions are created so that people can provide and receive care without compromising anyone's well-being. And this requires technical decisions and administrative processes.
In building a care system, it is not enough to simply define who the priority populations will be; it is also necessary to build an administrative pathway to identify, locate, and link them with the services they require. And, more importantly, to ensure that the entry mechanism into the system is sufficiently robust to gradually incorporate new populations. In other words, it is not enough to say that people with disabilities, young children, and the elderly will be the target populations of the care system. It is also necessary to create information systems to understand who these people with disabilities are, for example, what disability they live with, who cares for them, who they live with and under what conditions, but, above all, where they are located. Without this, it is impossible to create a service that is relevant and accessible to their needs.
This brings us to a second point: all the diagnoses generated so far indicate that the interventions we already have in place regarding care are not enough. And the reason is simple: the actions we have in place regarding care in the country are fragmented across various agencies and levels of government, making it impossible for someone who is not an expert in public administration to understand and enforce them. But even if this were possible, the numerous diagnoses we currently have also indicate that what exists has insufficient coverage and is of lower quality than desired to guarantee rights.
The insufficient supply, which is also fragmented, leaves no room for doubt: a care system needs to be built with a budget to coordinate the existing institutional offering and to expand it in the cases and for the populations where necessary. Of course, this will require a significant budgetary effort: expanding coverage, launching new services and programs, investing in new human resources, and creating an administrative structure for system coordination all require a budget. Although the exact amount will depend on the system model adopted, the experience of other countries in the region indicates that it is close to 1.5 % of the national GDP. In addition to estimating this cost, which is equivalent to what the Ministry of Finance itself has already contemplated, it will be necessary to define the most appropriate administrative framework to implement concrete actions that can be implemented by the country's various agencies.
Finally, one of the most complex decisions will be designing the governance mechanism. How will the care system operate and be coordinated? What relationships will be built between the actors—federal and local—responsible for influencing care? Will it operate from a Secretariat or will a specific institute be created? How will it coexist with the structure and logic of the DIF or SIPINA? Will there be a national coordination body that articulates other sectors? Will there be intergovernmental coordination or financing mechanisms? Who will be responsible for its evaluation and monitoring? What mechanisms for participation by civil society and target populations will be provided? Again, none of these questions have obvious answers.
Let's get started now
In the series of posts that conclude this text, we have discussed the multiple complexities of building a care system. We have explained why what exists today is not enough and why what we are promised during the campaign is not enough either. We have shown that design is not free from difficult decisions regarding priority setting and major technical requirements. We have discussed the intergovernmental challenge of a care system in a federal country and have rejected the facile ideas that suggest that simply passing a law, adding to existing offerings, or claiming that it doesn't require much money.
None of this should be read as an argument against the construction of a care system, but rather in favor of a well-designed system. As with any public policy, good design requires clearly defined objectives, a characterized and identified population, well-calibrated instruments, and a clear understanding of how they will change reality and an understanding of the necessary capabilities of the organizations and individuals in charge. Furthermore, a design that anticipates the challenges of implementation. Instead of assuming that there will be no obstacles or resistance, failures, and delays along the way, we must assume precisely the opposite: that, as with any public policy, these will exist. Therefore, the system's design must also consider monitoring, feedback, learning, and correction mechanisms to steer the operation toward the system's objectives.
For all these reasons, the system must have a medium-term perspective. Not all dimensions of the care crisis can be addressed immediately, nor can all populations be included, nor can all services be improved. But there must be a path that leads us there with a progressive logic. And this medium-term logic means that the coalition of organizations, institutions, and individuals who have championed the issue cannot let their guard down: the installation of a system will be a new starting point, which will require continuing the battle for good design and proper implementation.
Let us take advantage of the fact that all Mexicans share the need for a system that empowers childhood development, guarantees the rights of people with disabilities, and allows those who have cared for us our entire lives to age in dignified conditions. Let us also take advantage of the fact that Mexicans share the indignation of seeing, too frequently and closely, people who give up their own lives every day because they cannot share the responsibility of caring for others. Let us build, with equal doses of conviction and intelligence, a good national care system.
FountainArticle originally published in Nexos magazine (May 2025). Retrieved from https://redaccion.nexos.com.mx/ahora-o-nunca-el-sistema-de-cuidados-es-posible/
NOTECynthia L. Michel is a PhD candidate at the Hertie School. Guillermo M. Cejudo is a professor in the Public Administration Division at CIDE (Center for the Study of the State of Mexico); and Adriana Oseguera Gamba holds a Master's degree in Comparative Social Policy from the University of Oxford and a Master's degree in Social Policy Evaluation from Rice University.