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

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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

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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

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Secondly, to achieve universal health coverage, the Mexican system needs to

Overcome the fragmented health care system

Ensure effective access with quality

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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

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Thank you very much