The shift to primary care: PRONAM and the reconstruction of the Mexican health system

In a country where public hospitals are overwhelmed by complications from chronic diseases such as diabetes and hypertension, the General Health Council (CSG) is promoting structural change with the National Health Care Protocols (PRONAM).

This isn't just a technical adjustment, but a profound shift in the health policy outlined by Secretary David Kershenobich and his team. Dr. Patricia Clark, technical secretary of the CSG, who granted me an interview, explains that the PRONAMs seek to reestablish a vertical order in the system, both public and private, fostering fluid interaction between levels of care to alleviate the overload in specialized hospitals.

Let's imagine the current scenario: a patient with diabetes arrives at the National Institute of Nutrition with serious complications, such as gangrene or retinopathy that could lead to blindness. "Detecting prediabetes at the primary level, with promotion and prevention, is not the same as detecting it at a tertiary hospital where amputation is necessary," explains Dr. Clark. This shift to primary care—the gateway to healthcare—is not new globally, but in Mexico it had been postponed. With PRONAM, they seek to make it a reality by standardizing early care, resolving problems in health centers before they escalate. This relieves pressure on secondary and tertiary care, which are overwhelmed by advanced cases that could have been prevented. The goal: a unified system where IMSS, ISSSTE, IMSS-Bienestar, Sedena, Semar, and even private health care providers operate under the same guidelines, progressing toward a Unified Health System.

The key difference between PRONAM and older clinical guidelines lies in their prescriptive approach. "Guidelines provide flexible recommendations, such as 'you can use A or B,'" explains Clark, who comes from a research background rather than a civil service background, bringing fresh processes and methodological rigor. "A protocol provides specific guidelines: if blood sugar is high, do 1, 2, 3." This eliminates variability and ensures efficiency. He notes that outdated guidelines, which focused on cost-intensive, catastrophic diseases, were eliminated, and that six primary care protocols are now prioritized, covering 80% of the disease burden in Mexico.

These protocols focus on six areas: diabetes mellitus and metabolic syndrome, systemic arterial hypertension, chronic kidney disease, obesity, and overweight—the four main chronic conditions—plus two preventive ones: care in the first thousand days (from pregnancy to the child's second birthday) and lifelong vaccinations. Developed by multidisciplinary committees with experts from all institutions, these documents are not extensive—ranging from 20 to 25 pages—and include national data, indicating diagnostic criteria, pharmacological and non-pharmacological treatment, as well as clarifying when referral to specialized care is warranted. "What I resolve at the primary level and when I refer to higher levels," Clark emphasizes, promoting this vertical integration.

To make them accessible, "beautiful and understandable" infographics have already been designed for doctors and patients. "You can use them in consultations: 'Look, your blood sugar is high, let's do this.'" Additionally, they have QR codes—taking advantage of the fact that 90% of the population uses smartphones—that link to resources such as books for patients. The PRONAMs were launched on April 3, 2025, and are available at pronamsalud.csg.gob.mx.

The challenge now is implementation.

Patricia Clark plans to train general practitioners from 9,300 primary care public units (4,900 from IMSS, 930 from ISSSTE, 3,500 from IMSS-Bienestar) and also the physicians of the 18,000 offices adjacent to pharmacies. "It's not easy; the challenge is enormous," she admits, but envisions 95% coverage by the end of 2026. They will begin with self-managed and evaluated asynchronous courses, which will be piloted before scaling up to the field with physicians. The first prototype is for diabetes, and is expected to be ready by October. It will be supported by existing training platforms, such as the Carlos Slim Foundation, the Best Foundation, and others like Anafarmex, to ensure reach. "I don't want to burden the doctor further, but rather give them tools for efficiency and updating with the best scientific evidence," she notes.

And a crucial point here is the planned link with the National Compendium of Health Supplies (CNIS), also managed by the CSG. "We want to ensure that medications in PRONAMs have a CNIS key for government purchases and availability in pharmacies," Clark explains. This closes the loop: standardized protocols with available supplies, strengthening primary care and reducing inequalities. The path is gradual, he says, but the transformative potential is immense.

In short, it seems that PRONAMs are not just protocols; they are the linchpin of a reform that reorganizes the system vertically, prioritizing prevention and equity. As Dr. Clark Peralta says, "the population must make them their own." If we are optimistic and they are implemented well, Mexico could see fewer amputations, fewer blind people due to diabetes, and a sustainable system moving forward. We can only hope for their success.

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