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Mexico Health Reform

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Rafael Lozano, MSc, MD

Rafael Lozano, MSc, MD
Professor, IHME/Global Health

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  • Wise words from someone who knew what he was saying and because he said it. In Mexico we consider that Daniel Cosio Villegas is one of the greatest minds of the twentieth century and a wise man.

Mexico Health Reform Mexico Health Reform Presentation Transcript

  • Health Reform in Mexico in 2004: the origin of the Health Social Protection System
    Rafael Lozano MD MSc
    Global Health Seminar, “Aid and Health”
    November 13 2009
  • Outline
    Background
    Current Mexican´s facts
    Health reforms in Mexico 1943-2004
    How evidence did help in the design of the 2004 Health Reform in Mexico?
    Empowerment and action
    Ethical component
    Legal process to get approval
    Democratizing the health System in Mexico : Innovations
    Stewardship
    Financing
    Services delivery
    Lessons Learned
  • 3
    GDP PPP UDS per capita
    • Almost 2 mill Km2 (14th largest) View slide
    • 11,000 Km of littorals View slide
    • 3,000 km border in the north and 1,000 south
    • Huge biodiversity
    • 108 mill pop in 2009 (11th largest)
    • 75% in Urban areas
    • 56% in metropolitan areas
    • Rural means marginality, exclusion
    • 12% indigenous disperse
    • Administrative division:
    • 31 states and Federal District
    • 2,455 municipalities
    • 199 thousand localities
  • 4
    100
    90
    1994 Gini = 0.511
    2005 Gini = 0.489
    80
    70
    60
    % Income
    50
    40
    30
    20
    10
    0
    10
    1
    2
    3
    4
    5
    6
    7
    8
    9
    Income Distribution Mexico, 1994 and 2005
    Distribution of population by marginality Level
    Source: ENIGH, 1994, 2005
    Percent of Population living in Poverty, Mexico 1992-2008
  • 5
    DEMOGRAPHIC INDICATORS
    2009
    100
    90
    80
    Male
    Female
    70
    Rates x 1000 pop
    60
    50
    50
    45
    40
    Births rate
    30
    40
    20
    10
    35
    0
    Progress (years)
    Life expectancy
     
    30
    1.2
    1.0
    0.8
    0.6
    0.4
    0.2
    0.0
    0.2
    0.4
    0.6
    0.8
    1.0
    1.2
    Migrants to USA
    Millions
    Millions
    -
    35.9
    1930
    25
    30.0
    13
    49.0
    1950
    18.2 millions
    1st. - 3rd. generation
    20
    25.0
    12
    60.9
    1970
    10
    71.2
    1990
    15
    20.0
    5
    76.6
    2010
    10
    15.0
    Mortality
    11.1 millions
    Born in
    Mexico
    10.0
    5
    5.0
    0
    0.8
    4.5
    1930
    1940
    1950
    1960
    1970
    1980
    1990
    2000
    2010
    2020
    2030
    2040
    2050
    1900
    1910
    1920
    1930
    1940
    1950
    1960
    1970
    1980
    1990
    2006
    Year
    Mexican Origin
    Born in Mexico
    Life expectancy at birth
    Years
    85
    Female
    80
    75
    Male
    70
    65
    60
    55
    50
    45
    40
    35
    1930
    40
    50
    60
    70
    80
    90
    2000
    10
    20
    30
    40
    2050
    Sources: INEGI, CONAPO, DGIS,
  • 200.0
    Tasa x 1000 ajs edad
    Diarrheas
    180.0
    Respiratory Infections
    160.0
    Diabetes Mellitus
    140.0
    Ischemic Heart Disease
    120.0
    Cirrhosis
    100.0
    80.0
    60.0
    40.0
    20.0
    0.0
    1955
    1960
    1965
    1970
    1975
    1980
    1985
    1990
    1995
    2000
    2005
    Fuentes: Lozano R, 2008. Basada en INEGI y CONAPO varios años
    70 years of mortality transitions in Mexico: ages and causes
    Deaths by age
    Fuentes: Lozano R, 2008. Basada en INEGI y CONAPO variosaños
  • 20.0
    18.0
    17.3
    16.0
    15.1
    14.0
    Diabetes
    53%
    Ischaemic
    Heart Dis
    21%
    Hyperntensive
    Heart Dis
    13%
    Cerebro vascular
    Dis
    8%
    11.4
    Diabetes
    70%
    Ischaemic
    Heart Dis
    22%
    Cerebro vascular
    Dis
    8%
    12.0
    Ischaemic
    Heart Dis
    22%
    Cerebro vascular
    Dis
    8%
    Hyperntensive
    Heart Dis
    13%
    10.0
    8.0
    5.3
    6.0
    5.0
    4.5
    4.3
    4.1
    COPD
    Malnutrition
    Diarrhea
    HIV/AIDS
    Diabetes
    52%
    I.H.D
    10%
    Stroke
    10%
    4.0
    3.3
    I.H.D
    74%
    Stroke
    16%
    COPD
    43%
    I.H.D.
    14%
    I.H.D
    86%
    Stroke
    14%
    I.H.D
    56%
    Cirrhosis
    14%
    2.0
    0.0
    High
    Cholesterol
    High Blood
    Glucose
    High Body
    Mass Index
    High Blood
    Pressure
    Physical
    Inactivity
    Low Fruit &
    Veget. Intake
    Alcohol
    Others
    Tobacco
    Main killers of women in Mexico, 2006
    Source: MOH/DGIS, HIGH, 2006
  • Leading causes of DALYs by sex, Mexico 2005
    Women
    Men
    %
    %
  • Predicted Infant Mortality by Municipality and Level of Marginality, 2005
    90.0
    Very Low
    Low
    Medium
    High
    Very High
    80.0
    70.0
    Infantl mortality per 1000 lb
    60.0
    4.5
    50.0
    4.0
    Diarrheas
    40.0
    3.5
    Low resp Infec
    Under nutrition
    30.0
    3.0
    20.0
    2.5
    8.0
    2.0
    10.0
    Source: CONAPO, 2008
    TM < 5 años x 1000 nv
    7.0
    1.5
    0.0
    6.0
    -3.0
    -2.0
    -1.0
    0.0
    1.0
    2.0
    3.0
    Birth Asphyxia
    Marginality
    1.0
    Congenital Anomalies
    5.0
    0.5
    Prematurity
    0.0
    4.0
    Very Low
    Very High
    Hugh
    Median
    low
    TM < 5 años x 1000 nv
    3.0
    2.0
    1.0
    0.0
    Very High
    High
    Media
    Low
    Very low
    Source: Lozano R,2008
  • Mexican Health System (before reform)
    30%
    15%
    55%
    40%
    30%
    30%
    45%
    45%
    10%
    Source: Frenk J. et al 2003
  • Outline
    Background
    Current Mexican´s facts
    Health reforms in Mexico 1943-2004
    How evidence did help in the design of the 2004 Health Reform in Mexico?
    Empowerment and action
    Ethical component
    Legal process to get approval
    Democratizing the health System in Mexico : Innovations
    Stewardship
    Financing
    Services delivery
    Lessons Learned
  • Reform
    From Latin “reformare” … “form or shape again” (re-form)
    “…make changes in (something) in order to improve it…”
    to remove abuse and injustices
    reclaim, regenerate, rectify
    Synonymous: better, improve, amend, ameliorate, meliorate, innovation, transform, modification, etc.
    Can we put adjectives to the word “Reform”?
    Radical, minimalist, moderate, progressive
    For Public Policy, Public Health and Social Analysis Purposes
    aim to improve the system
    describe changes to public services
    reform may be:
    no more than fine tuning
    Redressing serious wrongs without altering the fundamentals of the system
    Reform seeks to improve the system as it stands, never to overthrow it wholesale
  • Health reform typically attempts to
    Broaden the population that receives health care coverage through either public sector insurance programs or private sector insurance companies
    Expand the array of health care providers consumers
    Improve the access to health care facilities Improve the quality of health care
    Decrease the cost of health care
    Increase the financial resources for health
    etc., etc.,
  • Three generations of Health Reform in Mexico
    14
    2004
    1982
    1943
    Million of population
    1943 Foundation of the Modern Health System
    1982 Toward a National Health System
    2004 Health Social Protection
    Source: Frenk J. et al 2003
  • Health Reforms in Mexico: three generations
    1943 Foundation of the Modern Health System
    Ministry of Health
    Social Security for all workers
    1982 Toward a National Health System
    Change of the Mexican Constitution
    Article 4: Health protection is a right of the population and an obligation of the government
    General Health Law
    Decentralization of the health system (state level)
    Coordination and Integration of health providers
    Administrative Modernization
    2004 Health Social Protection
    Separation of financing from the provision of services to stimulate competition and accountability;
    Evaluation of health interventions with the goal of designing cost-effective benefit packages;
    Programs for the continuous improvement of quality of care; and
    Increased participation of citizens in their care.
    Source: Frenk J. et al 2003
  • Outline
    Background
    Current Mexican´s facts
    Health reforms in Mexico 1943-2004
    How evidence did help in the design of the 2004 Health Reform in Mexico?
    Empowerment and action
    Ethical component
    Legal process to get approval
    Democratizing the health System in Mexico : Innovations
    Stewardship
    Financing
    Services delivery
    Lessons Learned
  • Priorities for research
    and development
    (the intelligence)
    National Health
    Accounts
    (the means)
    National Burden
    of Disease
    (the problem)
    Universal package
    of health services
    (the solutions)
    Proposals for
    reform
    (the vehicle)
    Cost-
    effectiveness
    analysis
    Financing
    (the require-
    ments)
    Analysis of system
    performance
    (the capacity)
    Building the evidence
    Frenk J., Lozano R., González MA, et al 1994
  • Public Politics
    Political
    Ethical
    Technical
    Evidence andInformation
    The Pillars of Public Politics on Health
    Source: Frenk, J. 2005
  • The challenges of the Mexican Health System
    Equity: change in the health pattern with more social and regional inequalities
    Quality: heterogeneous performance by provider and lack of responsiveness
    Financial Protection: the uncertainty risk to have catastrophic expenditures
  • Financial Protection
    Motivation
    Almost half the families have no health insurance, which leads to postpone care and to be incurred in catastrophic expenditures, as well as generating a deep injustice
  • Financial Unbalances
    Level: investment: 5.8% of GDP
    Source of funds: the predominance out of pocket payments (55%)
    Distribution 3.1 Among populations: 1.5 times between insured and uninsured 3.2. Between states: 8 to 1 in the state with the highest per capita federal spending and the state with the lowest per capita federal spending
    State effort on health expenses: 119 to 1 between higher and lower
    Destination: increasing the payroll, with a fall in infrastructure investment
  • Financial imbalances Underinvestment
    Health expenditure as percentage of GDP
    16
    13.9
    14
    12
    10.9
    Latin America average:
    10
    9.3
    $ 36,948 mills. de USD
    $ 356 USD per capita
    Percent
    8
    7.2
    6.9
    5.8
    6
    5.3
    4
    2
    0
    Bolivia
    Mexico
    USA
    Uruguay
    Colombia
    Costa Rica
  • Financial imbalances
    Source of funds
    Social Security
    61%
    States
    7%
    Federal
    32%
    Private
    Insurances
    3%
    Public
    Expenses
    42%
    Out of
    Pocket
    55%
  • Financial imbalances
    Unequal effort from the states
    Federal
    States
    Percentage of federal and state expenses on health for uninsured population
    100%
    80%
    60%
    40%
    20%
    0%
    AGS.
    B.C.
    B.C.S.
    COL.
    D.F.
    HGO.
    JAL.
    MICH.
    NAY.
    PUE.
    QRO.
    S.L.P.
    SON.
    VER.
    TLAX.
    YUC.
    ZAC.
    CAM.
    COAH.
    CHIS.
    CHIH.
    DGO.
    GTO.
    GRO.
    MEX.
    MOR.
    N.L.
    OAX.
    Q.ROO
    SIN.
    TAB.
    TAMPS.
  • Financial imbalances
    Imbalance destination of the expenditure
    Federal expenses by chapter
    100%
    80%
    60%
    40%
    20%
    0%
    1995
    1996
    1997
    1998
    1999
    2000
    2001
    2002
    2003
    Health care
    Administrative
    Investment on Infrastruc
  • Financial imbalances
    Impoverishment due to health spending
    2 millions:
    Catastrophic expenses (more
    of 30% of
    income available)
    1.5 millions of families
    .5 millions of families
    1.8 millions of families
    2.3 millions:
    immiserizing spending ( "Medical indigence")
    Source: Encuesta Nacional de Ingresos y Gastos de los Hogares, 2000.
    Estimaciones CASESALUD
  • Universality
    Social Inclusion
    NationalPortability
    Equal opportunities
    Explicit Priorization
    Fair Finance
    Free of Charge in the moment of use
    Financial Solidarity
    Co-respon-sability
    Subsidiarity
    Democratic Budgeting
    Individual Autonomy
    Accountability
    Ethical foundations of the reform
    Principles
    Key Concept
    Values
    Democratization of Health
  • Democratizing the health System in Mexico
    Empower people making them aware about their entitlements
    Transparency and accountability
    Objectives of the Reform
    Ordering the health financing and increasing public budget gradually, fiscally responsible and financially sustainable
    To protect investments in prevention and health services to the community
    To provide financial protection in health care to the population, especially the poorest
    To transform the Incentives in order to achieve a democratic budgeting, which allows to increase the satisfaction of population's expectations
  • More than a Legal process to get the change in the Law
    Foundation of The National Institute of Public Health, January 1987
    The Health and the Economy 1994, Frenk et al.
    Beginning of the administrative period, Dec 2000
    Release of the National Health Program 2000-2006, July 2001
    Initiative sent to the congress, Nov 2002
    Approval in the Congress, April 2003 (92% of votes in the senate house and 79% in the representatives house)
    The Official Gazette published the decree that reforms and adds the General Health Law, May 2003
    Started the System of Social Protection in Health, January 2004
    29
  • State Reform
    • Collaboration between congress and presidency
    • Two level of government were involved (state and national)
    • Transcendence of more than one administrative period (2004 to 2010)
  • Outline
    Background
    Current Mexican´s facts
    Health reforms in Mexico 1943-2004
    How evidence did help in the design of the 2004 Health Reform in Mexico?
    Empowerment and action
    Ethical component
    Legal process to get approval
    Democratizing the health System in Mexico: Innovations
    Stewardship
    Financing
    Services delivery
    Lessons Learned
  • Structural reform of the health systemfinancing
    Innovations
    Universalization of social security on health
    Establishment of the System on Social Protection in Health
    Master Plan for Health infrastructure
    Protection against catastrophic expenses
    Budget priority for public health
    New plan for democratic budgeting
    Affiliation with explicit rights for all people
  • Reorganization of the Mexican Health System
    Source: Frenk J. et al 2003
  • Stewardship
    Key function, mother function
    “…To do that others do what they must do…”
    Tools and rules
    Coordination, regulation, monitoring and evaluation
    Create instruments with explicit rules for financial transfers
    Priority setting to a package
    Certification of health infrastructure
    Orient financial flows Demand instead supply
    Accountability
  • Stewardship
    IV. How do we measured the advances
    Accountability as part of the democratic process
    - Outcomes measurement and Health System performance assessment
    • Accountability
  • Relation Between types of goods and financing funds in the System of Social Protection on Health
  • New structure to provide universal financial protection
    Contributors
    Public Insurances
    Co-responsible
    contributor
    Federal Government
    Beneficiary
    IMSS salaried employees in the private sector
    Private Employer
    employee taxes
    Social
    contribution
    Public Employer
    Social
    contribution
    Employee
    taxes
    ISSSTE salaried employees in the public sector
    Seguro Popular non-salaried workers,self-employees, families outside of the formal labour force
    Family
    Solidarity contribution
    Social
    contribution
    State
    Federal
    Gov
  • Service Delivery
    Master plans
    Investment in infrastructure
    Medical equipment
    Human resources
    Universal Coverage
    Essential package (249)
    Catastrophic expenses (17)
    Improving the Quality of care
    Accreditation of health facilities
  • Dimensions of
    Universal Coverage
    Type of coverage
    Criteria
    Reference
    Gender and socioeconomic Equity
    Target Population
    • Horizontal
    Type of Health Intervention
    Explicit for
    Setting Priorities
    • Vertical
  • Toward universal coverage
    ACELERETED COVERAGE
    GASTOS CATASTROFICOS
    Package of Interventions
    Benefits
    Family
    Insurance
    PREVENTIVE ACTIONS FINANCED BY SEGURO POPULAR
    COMUNITY HEALTH SERVICES
    poor
    I II III IV V VI VII VIII IX X
    Rich
    Income deciles
  • Seguro Popular
    Accelerated Vertical Coverage
    New vaccines
    Equal start of life
    New vaccines
    Children & adolescents Cancer
    Cervix Cancer
    Children Cancer
    Cataracts
    HIV/AIDS
    < 9 months
    2 years
    5 years
    18 years
    60 years
    Life line
  • Outline
    Background
    Current Mexican´s facts
    Health reforms in Mexico 1943-2004
    How evidence did help in the design of the 2004 Health Reform in Mexico?
    Empowerment and action
    Ethical component
    Legal process to get approval
    Democratizing the health System in Mexico: Innovations
    Stewardship
    Financing
    Services delivery
    Lessons Learned
  • Lessons Learned
    The ABCDE of the successful reform
    Agenda
    Budget
    Capacity
    Deliverables
    Evidence
    Healthy Policies
    National Commission for Risk Protection
    Global Public Goods for local decision-making
  • Report 2009 1stsem(NCSPH)
    Affiliation
    9.6 millions of families (28.5 millions of people)
    Almost all Municipalities
    Increase in the number of people of the first and second deciles (including indigenous population)
    New generation program (2.2 million)
    Healthy pregnancy (380 K)
    90.9% of re-affiliation
    Services Delivery
    39 million of visits
    Half a million of hospital discharges (245 K of deliveries)
    Waiting time 58 min (?)
    78% of patients have received all drugs from doctor prescription (?)
    Financial imbalances follow up
    Source: Frenk J., et.al. 2006
  • Critical aspects
    Summary of findings
    • Increasing health funding in Mexico is important, but independent evaluations suggest that SP is not the most successful model to achieve equity, efficiency, and quality care.
    • Promote privatization of health services
    • Federal government funding below promised levels
    • Bureaucratic rigidity and slow implementation of contracts
    • Limited progress in signing SP portability agreements among states
    • The use of funds for purposes other than those for which they were intended
    The poor are affiliating to Seguro Popular
    More resources are available for the uninsured and the distribution of resources across states is more equal
    Mixed results for utilization of health services among SP affiliates
    Composite coverage has increased for the country and for the uninsured
    Inequalities in coverage have decreased across states and across wealth deciles
    Catastrophic spending is lower among SP affiliates than the uninsured, especially within subgroup that use health services
  • 46
    National Health System (2007)
    Physicians
    %
    Beds
    %
    Population Affiliated
    %
    Health Expenses per capita
    USD
    Hospitals
    %
    87.9
    34.5
    33.3
    42.4
    No Medical Insurance
    26.8
    325.6
    36.0
    36.5
    27.9
    Medical Insurance
    73.2
    324.8
    25.0
    27.6
    16.3
    IMSS
    35.8
    231.9
    7.7
    5.9
    6.4
    ISSSTE
    7.5
    216.8
    Seguro Popular (Health Reform)
    25.5
    910.0
    3.2
    3.2
    5.0
    Others
    1.5
    1,000.0
    29.5
    30.2
    29.7***
    Private
    2.9
    534.2
    218**
    115**
    1,664
    Total (absolute)
    106*
    * Millions ** thousands *** Includes Hospitals over 15 beds. Private Sector has more than 2.5 thousand small hospitals
  • Lesson Learned
    Money matters. More money better result, but just at the beginning, after, strong management is needed
    Health reform is more complicate that a change of the law. Besides the need of lobby is necessary to build good stakeholders
    How do get ownership of the reform?
    More that the inner circle
    Institutionalization of the change
    How do get the achieved the goals offered?
    Affiliation
    Increase the budget
    Change the predominance of private money
    Increase the quality of care
    Decrease inequalities
  • Daniel Cosio Villegas
    Those that are inside of the government know what is going on, but they don't have time to write anything; however who is out the government write many things, but they don't have any idea of what is going on
    48