Why It Matters
With his history as part of the Mexican Ministry of Health, Dr. Enrique Ruelas has a unique perspective on how governments can play a part in improving health care and population health.
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Lessons Learned about the Role of Government in Improving Health Care and Population Health

By Kimberly Mitchell | Tuesday, November 17, 2015

One individual has been pioneering quality improvement in Mexico for more than 20 years. IHI board member Enrique Ruelas, the former Vice Minister of Innovation and Quality for the Mexican Ministry of Health, led the development of the country’s first quality strategy in 2000, which earned him the 2005 Transparency Award by the Mexican government and helped foster a movement for quality and safety in Latin America. He is now advising the Ministry on a new National Quality Strategy that builds on the country’s first. In this blog post, IHI Project Assistant Santiago Nariño details what Dr. Enrique Ruelas has learned about the role of government in improving health care and population health and his activities since IHI's first interview with him.


Dr. Enrique Ruelas discovered his passion for quality in Canada. He was studying abroad there in 1983, and he found himself wondering why a country like Canada, which seemed to have everything, was so concerned about quality. Health systems in Mexico, which had not accomplished anything close to what Canada’s health system had, were simply not worried about it. From that experience, Dr. Ruelas decided he would work on quality in his own country. Dr. Ruelas’ role has changed drastically since the first quality discussions in Mexico — he is now a consultant to the process, instead of the leader driving it. He says that national quality strategies are his passion within the field of quality. “What is better than helping governments take this as their role, and have safety be a priority?” he says. Dr. Ruelas shared the following reflections on his learning from that QI strategy and the work ahead:
  • In quality improvement, pragmatic results are key to overcoming resistance to change. This was true in Mexico, as well. When Mexican doctors and nurses witnessed impressive results achieved through QI methodologies, they tended to be more open to having conversations around quality. “Whenever nurses and doctors are first brought together to talk about these issues,” Ruelas says, “they realize that they haven’t dedicated much time to thinking about the ambitious yet achievable impact associated with quality improvement. They begin to understand the importance of quality, and tend to engage in a retrospective analysis of the common quality problems that everybody faces in a work place, especially in a hospital.”
  • Governments play key roles in implementation when it comes to health care and population health, especially in Latin America, but the reality is that national quality strategies have to be both top-down and bottom-up initiatives involving stakeholders across the system: communities, facilities, districts, regions and states, and the national government.
  • When looking at national quality strategies, aspects of care such as access, effectiveness, safety, equity, patient experience, and efficiency are good places to start. The new quality strategy will create a concerted plan of action designed to achieve the IHI Triple Aim — improved population health, improved experience of care, and decreased per capita cost of care.
  • In the creation of the new national quality strategy with the Mexican Ministry of Health, Dr. Ruelas is aiming to have a focused scope. The previous strategy, he says, “was too broad — almost 6,000 organizations and nearly 50 measuring indicators, so only about 17 of those were measured well.”
  • One of the key successes of the last strategy was the Citizen Endorsement Groups, which engaged communities in the plan by incorporating nearly 1,500 organizations that have started measuring health outcomes. Dr. Ruelas hopes to re-engage with the Citizen Endorsement Groups he established to further continue the deep community engagement in this new national quality strategy.

As the planning of the new national quality strategy continues to come together, Dr. Ruelas will build on previous lessons learned to create a more comprehensive strategy, working alongside innovative leaders within the country. As the roles and responsibilities of the involved stakeholders become clear throughout the development of the strategy, Dr. Ruelas believes the government, private and public institutions, professionals, payers, and consumers must all work together to achieve the large scale systematic change that Mexico hopes to see in the next 10 years.

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