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March 13, 2015
Improving health coverage for the poor in Mexico: the role of Seguro Popular
1
Rabat, Morroco
2
Contents
1. Why was Seguro Popular created?
2. What were its main goals?
3. How was it implemented?
4. What did Seguro Popular achieved?
5. What are the main challenges ahead?
3
1. Why was Seguro Popular created?
4
It was unfair that half of the population was not protected by a public insurance scheme
Social security
Formal workers & not poor
Assistance1943
Informal workers & poor
2003 IMSS & ISSSTE Seguro Popular
5
CHALLENGES OBJECTIVES STRATEGIES ACTIONS
5 estrategias instrumental
es
35
31
Equity
• Técnica
• Interper- sonal
Ensure justice in health financing
Strengthen health system
Reduce health inequalities
Improve health conditions
Ensure adequate care
5 estrategias sustantivas
Financial protection
Quality
Priorities of National Health Program 2001- 2006
6
More money for health
Health expenditure as percentage of GDP%
LA average :
6.9
13.9
9.6
9.3
7.2
5.84.0
0
2
4
6
8
10
12
14
16
EUA Argentina Colombia Costa Rica PerúMéxico
$ 36,948 US $ 356 US per cápita
7
Out-of-pocket was the main source of health care funding
42%
3%
55%
Gasto público
Pago de bolsillo
Segurosprivados
Seguridad social 61%
Federal32%
Estados 7%
8
Federal employee
fee
Family feeSeguro Popular
ISSSTE medical insurance
Sickness and maternity funds of IMSS
State
Federal government
fee
Employers fee
Workers fee
Financial resourcesPublic insurance
schemes
Federal
Solidary fee
Beneficiary Employer Federal government
Social fee
Social fee
Social fee
$150 US $200 US$100 US
Financial inequities within the system
9
2. What were its main goals?
1. Moving forward towards enforcing the right to universal health protection
2. Increasing public health expenditures gradually, fiscally responsibly, and financially sustainable
3. Providing health financial protection to everyone, specially the poor
4. Achieving a better allocation of resources between medical care and public health
5. Creating incentives to meet health expectations and needs of the population
Main goals were financial protection oriented
11
3. How was it implemented ?
Seguro Popular aimed to protect the population not covered by social security: both informal & poor
12
Source: Encuesta Nacional de Empleo y Encuesta Nacional de Ocupación y Empleo
Distribution of workers per wage bracket, formal and informal
Informal
Formal
• Almost two thirds of the working population do so in the informal market• Most of these workers are very poor: 61% earn less than $4 US daily
13
3. Implementation: social security institutions were untouchable
3. Implementation: defining an explicit benefit package
14
I II III IV V VI VII VIII IX XMás pobre
Ben
efi
cio
s
SERVICIOS DE SALUD A LA COMUNIDAD
Catálogo de servicios esenciales de salud
PLAN FAMILIAR
SEGURO POPULAR PREVENTIVO
Población según ingreso Más rico
COBERTURA ACELERADA
GASTOS CATASTROFICOS
78 ($221)
249($2700)
151($1025)
3. Implementation: criteria for defining coverage
Intervention type
Iinterventions
Preventiva 20
Detección temprana
20
Familiar 60
Salud reproductiva
20
Rehabilitación 12
Odontología 08
Urgencias 40
Hospitalización 26
Embarazo 20
Cirugías 20
Total 246 15
Criteria
•Morbility
•Utilization
•Efectiveness
•Social demand
3. Implementation: evidence-based coverage
16
Focus groups:
Qualitative approach
National survey:
Quantitative approach
Issue Findings
Benefits •Drugs
•Chronic illness
Quality of care
•Better treatment
•Timely care
•Longer hours of care
Physicians •Beter trained
•More specialists
Willingness
to affiliate
•According to need
•Related to benefits offered
Willingness
to pay
•Related to income & need
•$ 4 - 30 US monthly
3. Implementation: a negotiation process with Congress
Distribución de votos Cámara de Diputados
2003
0
50
100
150
200
PRI PAN PRD PVEM OTROS
Vot
os to
tale
s
FavorContra
73 27
Por ciento
3.Implementation: governance at the state level
19
3. What did Seguro Popular achieved?
It has nearly affiliated its targeted population
Fuente: Elaboración propia con base en CNPSS (2012)
Seguro Popular has increased public health expenditures
Gasto público en salud (pesos 2012)
Mile
s de
mill
ones
Fuente: PEF y cuenta pública/1 Presupuestado.
Effective access to prescribed drugs has improved in most states
22Fuente: ENSANUT 2012. Estudio de satisfacción de usuarios del Sistema de Protección Social en Salud 2014.
40 50 60 70 80 90 10040
50
60
70
80
90
100
NAY
QROO
HGODF CAM
COAH GROCOLVERMICH
OAXQROZAC
TLAXSLP
SIN NACL DGOAGS TAB TAMYUCBCSON CHIHMOR
BCSJALPUE GTO
MEXNLCHIA
% Surtimiento completo de recetas 2012
% S
urtim
ient
o co
mpl
eto
de r
ecet
as 2
014
25 of 32 states need to improve to achieve the 90% goal
23
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Año
Porc
enta
je
67.6
32.4
55.1
44.9
67.3
32.7
Seguro Popular begins
With social security
Without social security
Financial resources by type of population covered
It also has reduced financial health inequities between public health institutions
24
Coeficientes de concentración por programas e instituciones de salud pública, 2010
Seguro Popular has been evaluated as one of the more progressive social policies in Mexico
Fuente: CONEVAL 2011, Scott 2011
¿Were the goals achieved?
1. Moving forward towards enforcing the right to universal health protection
2. Increasing public health expenditures gradually, fiscally responsibly, and financially sustainable
3. Providing health financial protection to everyone, specially the poor
4. Achieving a better allocation of resources between medical care and public health
5. Creating incentives to meet health expectations and needs of the population
26
5. What are the main challenges ahead?
27
To achieve universal health coverage, the Mexican system needs to address three key structural challenges
Be more responsive to health care needs
Ensure effective access with quality
Overcome the fragmented health care system
28
To meet health care needs, the Mexican system must address the current burden of disease, in which chronic non communicable illnesses are becoming more prevalent
Source: Mortality Database 1980-2011 INEGI/SS
Leading causes of death, Mexico 1980-2011
1980 1990 2000 20110
20
40
60
80
100
120
Cardiovascular Cancer Diabetes mellitusInfectious and parasitic Intentional injuries Traffic accidents
Deat
hs p
er 1
00,0
00 p
opul
ation
106.8
106.8
93.6
16.4
39.561.7
21.9
69.9
21.4
28.5
14%
219%56%
33%
-82%
Percent change 1980-2011
-38%23.1
14.4
It should also address the needs of the highly deprived geographic regions where the most vulnerable population lives
Leading causes of death in states with very high and very low marginalization level, Mexico 2011
Notes: /1 Includes deformations and chromosomal abnormalities; /2 Except bronchitis, bronchiectasis, emphysema and asthma. According to CONAPO the states highly marginalized are Oaxaca, Chiapas and Guerrero. Distrito Federal, Nuevo León, Coahuila and Baja California are the states with vthe lowest marginalization. Fuente: Mortality Database1980-2011 INEGI/SS y CONAPO, Proyecciones de la Población de México por entidades federativas 2010-2030, versión Censo 2010 29
0 20 40 60 80 100
Heart diseasesDiabetes mellitus
Malignant neoplasmCardiovascular
AccidentLiver diseases
Assault (homicide)Chronic obstructive pulmonary diseases
Pneumonia and influenzaRenal failure
Certain conditions originated in the perinatal periodMalnutrition and other nutritional deficiencies
Disease by the human immunodeficiency virusChronic bronchitis, emphysema and asthma
Intentionally self-inflicted injuries (suicide)Intestinal infectious diseasesCongenital malformations /1
Septicemia
Deaths per 100,000 populationVery low marginalization Very high marginalization
30
Secondly, to achieve universal health coverage, the Mexican system needs to
Overcome the fragmented health care system
Ensure effective access with quality
31
People use private services even if they have public insurance coverage
Source: ENSANUT 2012
Ambulatory care Hospital care
It is essential to strengthen• Effective access• Primary care
Utilization of services by affiliation, Mexico 2012
IMSS ISSSTE Seguro Popular
PEMEX0
20
40
60
80
100
65.3 65.9 65.9 72.8
4.1 5.6 3.0
30.9 28.4 31.1 27.2
Institution of affiliationOther public institutionsPrivate institutions
%
IMSS ISSSTE Seguro Popular
PEMEX0
20
40
60
80
100
79.967.7 77.3
100.0
7.813.8
10.912.1 18.3 11.4
Institution of affiliationOther public institutionsPrivate institutions
%
32
Effective access to drugs prescribed has not improved enough
Drug supply prescribed by institution
ENSANUT, 2006
Drug supply prescribed by institution
ENSANUT, 2012
Source: ENSANUT 2006 and 2012
IMSS ISSSTE SeSa0
20
40
60
80
100
88.3 85.3
63.0
4.1 3.8
9.0
7.6 10.928.0
They got all drugs out of the place of consulta-tionThey got only some or none of the drugs
%
IMSS ISSSTE SeSa0
20
40
60
80
100
86.468.7 64.4
10.324.9
21.6
3.3 6.4 14.0
They got all drugs out of the place of consulta-tionThey got only some or none of the drugs
%
33
The Mexican health care system still needs to address its fragmented structure that discriminates care according to labour status
Social Security
Formal and higher income workers
Assistance
National Universal Health System regardless of labor condition
1943
2018
Informal and poor workers
2003 Right according to labor condition Seguro Popular
34
Thank you very much
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