Mexico Health Reform

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)
11,000 Km of littorals
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
Ethical component
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

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.

Outline
Background
Ethical component
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%

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.

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

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
Ethical component
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

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
Ethical component
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