services of doctors, nurses and dentists. A policy of expanding health insurance coverage to the indigenous people, as part of a policy of universalizing health insurance policy, could greatly improve their health care.

Fifth, improved water supply and greater control of public health threats like dengue and malaria reduce self-reported illness, raises health well being and saves curative resources. This finding illustrates the continued national importance of public health. It also underlines the importance of ensuring that the indigenous population has easier access to potable water supply and that the health system has sufficient resources for better control of public health threats. To illustrate the importance of this issue, a Bank analysis of the Chiapas health sector reveals a serious under-funding of public health activities to control vector-borne diseases, which are largely concentrated in indigenous communities.

The effectiveness of health care services depends on the extent to which they are tailored to the needs, constraints and priorities of individuals and local communities. These factors in turn are determined by historical and socio-cultural conditioning. For this reason, it makes sense to ensure that health programs are sensitive to the distinctive cultural differences among the various demographic groups. There are two approaches to achieve this sensitivity in the choice and design of health services. The first approach is the development of special interventions that are specifically directed to particular issues facing target ethnic groups without changing the structural features of the health system. These interventions are programs that are specially tailored to the diverse traditions and beliefs of target ethnic groups. Many of the current ideas to promote indigenous health to date are generally of this variety. The second approach is to promote reform of the health system structures to give communities and health providers the capability and incentive to tailor their programs to the economic and socio-cultural realities of the target population groups.

It is arguable that to achieve sustained reduction in the health gap between the indigenous and the mainstream population, Mexico needs to follow both approaches. The purpose of the systemic approach is to change the rules governing the public finance and delivery of health services at the federal, state and local levels so that health providers will be enabled and rewarded for reaching out to their intended beneficiaries and tailoring their health services to the needs and cultural background of said consumers.

This approach calls for the support of the following reform ideas: (i) the deepening of the process of decentralization, pushing down more decision rights to local communities, health care providers and consumers; (ii) the transformation of supply to demand-based subsidy (money follows the intended beneficiaries); (iii) use of public and private competition for the delivery of a defined package of basic health services; (iv) expansion of subsidized health insurance coverage of the indigenous and other disadvantaged groups, initially employing public funds currently being used to finance public delivery of services for the open population; and (v) measures that promotes equalization of health subsidy per open population, not to mention increased subsidy for 14