An online search for medicine shortages in Mexico produces hundreds of thousands of news stories and articles documenting just how serious the problem has become in the country. Earlier this year, for example, relatives of children with cancer staged a protest outside Mexico’s health ministry, holding aloft banners that read “We want to live”, “There’s no chemo treatment” and “Our children’s health is not a game”. Behind the protest was a common plea for the government to open up and share details of procurement contracts with patients and their families.
Patients are uniquely placed to understand problems related to medicine shortages. They are the ones affected by disruptions and they often develop a deeper knowledge than the State’s own analysts of why medicines fail to reach them in time.
With the belief that medicine procurement can only be analyzed properly if patients themselves are involved, PODER México and the NGO Nosotrxs joined forces to develop the data report Salud, Dinero y Corrupción [Health, Money and Corruption]. The analysis involved journalists, health policy experts, and over 60 patient organizations, making up the Cero Desabasto [Zero Shortage] initiative to investigate medicine procurement by the Mexican Social Security Institute (IMSS), the largest public health organization in Latin America.
Months of downloading data and a detailed analysis of two million contracts between 2008 and 2018 revealed a figure that shocked the country: according to the investigation, the overspend on the IMSS’ medicine purchases was more than 18.4 billion Mexican pesos (around $925 million) during that period. For each of the medicines analyzed, the report stated how many drugs could have been bought if the processes had been efficient. The data was illustrated with patients’ own experiences.
When the findings were made public, the news spread like wildfire within government circles and in the space of 10 hours, the IMSS issued a press release announcing that it would conduct an investigation into the findings.
Data: the essential ingredient in all good research
When PODER México discovered the IMSS procurement platform, they knew this could provide a unique insight into how the government buys medicines. But, “we needed to do some data scraping, which was not tremendously difficult. We had done something like this before but, previously, we worked mostly with databases that could be downloaded,” says Eduard Martín-Borregón, Poder’s Head of Data, Journalism and Technology.
Ultimately, it took more than a year from the time PODER México to when they started downloading data. When the program for downloading the records was finally ready, the team began collecting thousands and thousands of records. They could see that each product purchased by the IMSS had a reference code, the name of the medicine, its unit price, the reference price and the price that the IMSS ended up paying, as well as other fields.
But little of the data, such as the “Product” and “Description” fields, were not standardized. VAT was added inconsistently to purchases, information was inaccurate, and documentation was missing. From the start, the team documented all the challenges they came across and explained how they solved those challenges. In doing so, the organizations auditing what was going on behind the data also started to explain their process to make it easier for citizens to reproduce their results.
Once in open format, the data had one big advantage. PODER México already had QuienEsQuienWiki, a platform that allowed the team to upload data in a clear and structured manner to facilitate the process of data analysis. The site also integrates with Kibana, a tool for cross-referencing large volumes of data both easily and quickly.
This meant existing open source software used in other projects became an essential tool for Salud, Dinero y Corrupción, opening up the project to a wide range of participants.
An initiative with patients at the center
Nosotrxs and PODER México knew that they shared common interests, such as working with public procurement data in the health sector, but did not actually know each other personally. In 2020, they happened to meet at an event and the initial contact was then followed by many more where they examined the figures emerging from the IMSS data, discussed the system for accessing medicines in the country, and listened to patients’ stories and experiences about trying to get their hands on the medicines they needed for their treatment.
“All the deliverables that we generate (reports, investigations, etc.) are shared with them [the patients] before being published so that we can get feedback from those most affected. Once we have that feedback, we arrange a discussion session to which patients are invited and we then publish the deliverables,” says Frida Romay, Head of Health and Wellbeing Causes at Nosotrxs.
Patient voices were not just expressed in the articles themselves. The investigation into overspending also contained information about shortages reported by health system users. The sheer number of reports about shortages became an important statistic in showing that there were other problems with procurement processes: medicines were not arriving when patients needed them.
Romay explains that the work alongside patients struggling to access medicines was possible because Nosotrxs has an internal group of 67 organizations called Cero Desabasto (Zero Shortage). This group, formed four years ago, aims to bring together “patients with different conditions who demand access to quality medicines, care and a guaranteed right to health”.
Cero Desabasto played a key role in understanding how the system works in practice and impacted not only the work of the organizations but the organizations themselves: “We learn from them [the patients]. They are so well-informed and know so much about their condition, their medicines and the procurement system. They are the ones who gave us information and explained things about their conditions (…). Patients know all the vital information about their medicines, what they are called, the commercial name and the market costs”. Working with patients gave the data a face.
Making the complex simple: the calculation that shed light on what was going on in the system
With the data now downloaded and organized in QuienEsQuienWiki and with a strong partnership in place, it was time to analyze over two million pieces of data. The key lay in two data points: the reference price and the unit price reported by the IMSS. To obtain the reference price, the team calculated the “weighted average of all prices of the same IMSS code [same product] in the same year”. The advantage of this calculation is that it considers annual price variations and adapts to shortages. The downside is that if all purchases are overpriced, the reference price increases and the premium paid remains hidden. To overcome this blind spot in the methodology, the team used the reference prices of the Pan-American Health Organization (PAHO): “If the whole system is inflated and buys at a premium, we can only detect those who charge more. We compared our reference price with the PAHO reference prices and found that our reference prices are indeed much more expensive and that the system is inflated”. This calculation (see PODER’s full methodology) produced an overall figure that summarized what was happening in the IMSS procurement system: 18.4 billion Mexican pesos ($925 million) in price premiums for medicines over the period 2008 to 2018.
The investigation also showed that 278 suppliers or 1% received almost 80% of the total amount of IMSS contracts for medicines and medical supplies.
To support these figures, the Salud, Dinero y Corrupción website has a search function where users could consult all procurement procedures by year, subject matter, identification and other parameters. The figures are accompanied by statistics for each Mexican state, showing what was happening locally in each case. So, whereas the numbers gave an insight into the system, citizens themselves were able to find out detailed information about each of the procedures.
But the reports and analysis of what was happening at a national level were not the sole focus. The ability to investigate local procurement practices became a central pillar in the project. Here, QuienEsQuienWiki played a key role in providing detailed information about what was happening inside Mexico. The investigation revealed, for example, that second only to the IMSS central offices, the Nuevo León state government overpaid on its medicine purchases by almost one billion Mexican pesos. The independent news outlet ZonaDocs also analyzed the IMSS’s purchases in Jalisco and identified problems with shortages, reporting bluntly how people with illnesses such as hemophilia were turning to the black market as a result of the shortages. This situation showed how price premiums had real-life consequences.
The impact of the project
When Salud, Dinero y Corrupción was published, the reaction was swift. Within four hours of its publication, the IMSS issued a press release announcing the opening of an investigation amid numerous journalistic reports appearing in the media.
Nosotrxs coordinator Andrés Castañeda adds that Salud, Dinero y Corrupción “analyzed a model that didn’t exist yet” but needed to be looked at. According to PODER México, “we provided the necessary evidence for the discussion that was taking place (…) there was an idea that if the government were to change, the shortage problems would change but this was not the case. There was no solution.”
In fact, this problem prompted the Mexican government to sign an agreement in 2020 with the United Nations Office for Project Services (UNOPS) with the aim of setting up a transparent medicine procurement mechanism to ensure that supplies reach people in an efficient manner. However, a report by Mexico’s public policy research center (IMCO) published in May this year suggests that there are delays in procurement through UNOPS and that data about processes is not open, making it difficult to verify the figures reported by the government about savings made. While the data has improved since, it still lacks key information to properly analyze government spend on medicines.
Moreover, the initiative extended its reach beyond the organizations that were driving it. PODER México trained a network of journalists to use data search and analysis tools so they could work on their own stories. The integration between QuienEsQuienWiki and Kibana helped the media to cross-reference data enabling them to detect patterns and produce local articles of national importance about IMSS procurement. BI Noticias (Aguascalientes), Lado B and Serendipia (Puebla) were just some of the media outlets that published articles about IMSS procurement after receiving training.
The analysis to produce evidence about IMSS data between 2008 and 2018 was accompanied by a distribution strategy not focused solely on journalists. Prior to the release of the special report, the team contacted legislators from various political parties to share the main findings of the investigation, leading to requests for explanations and information access requests from across the political spectrum.
Next steps for Salud, Dinero y Corrupción
Thanks to a combination of journalism, evidence analysis and patient voice, it was possible to show the link between overpaying for medicines and shortages. In other words, it brought to public attention how the problems observed in procurement systems affect real people, namely patients.
The team that worked on Salud, Dinero y Corrupción will now analyze what is being purchased through the new mechanisms and compare these with previous procurement processes. This can only be achieved if more open data is available so that journalists, civil society organizations, doctors, hospitals and patient groups can work with each other, see purchases in real time and anticipate shortages.
But in seeking to achieve this next goal, PODER México and Nosotrxs face new technical challenges. Since the publication of the special report, the IMSS procurement portal has been suffering from intermittent technical problems. In response to an information access request submitted by PODER México, the IMSS reported that these problems are due to changes made to the administrative procurement system. In addition, the data on new purchases does not include the “description” field, which is a key element for comparing the items purchased.
Greater transparency and robust accountability mechanisms will be essential to ensure the continued oversight of medicines procurement in the future. The challenges will not stop a team that has found a way of combining different skills to tell the story, supported by data, of how Mexicans are not able to access the medicines they need, when they need them.