1. March 13, 2015 Improving health coverage for the poor in Mexico: the role of Seguro Popular 1 Rabat, Morroco

2. 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. 3 1. Why was Seguro Popular created?

4. 4 It was unfair that half of the population was not protected by a public insurance scheme Social security Formal workers & not poor Assistance 1943 Informal workers & poor 2003 IMSS & ISSSTE Seguro Popular

5. 5 CHALLENGESOBJECTIVES 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. 6 More money for health Health expenditure as percentage of GDP % LA average : 6.9 13.9 9.6 9.3 7.2 5.8 4.0 0 2 4 6 8 10 12 14 16 EUAArgentinaColombiaCosta Rica Perú México $ 36,948 US $ 356 US per cápita

7. 7 Out-of-pocket was the main source of health care funding 42% 3% 55% Gasto público Pago de bolsillo Seguros privados Seguridad social 61% Federal 32% Estados 7%

8. 8 Federal employee fee Family fee Seguro Popular ISSSTE medical insurance Sickness and maternity funds of IMSS State Federal government fee Employers fee Workers fee Financial resources Public insurance schemes Federal Solidary fee Beneficiary Employer Federal government Social fee $150 US $200 US $100 US Financial inequities within the system

9. 9 2. What were its main goals?

10. 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. 11 3. How was it implemented ?

12. 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. 13 3. Implementation: social security institutions were untouchable

14. 3. Implementation: defining an explicit benefit package 14 I II III IV V VI VII VIII IX X Más pobre Beneficios 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)

15. 3. Implementation: criteria for defining coverage Intervention typeIinterventions Preventiva20 Detección temprana 20 Familiar60 Salud reproductiva20 Rehabilitación12 Odontología08 Urgencias40 Hospitalización26 Embarazo20 Cirugías20 Total246 15 Criteria MorbilityMorbility UtilizationUtilization EfectivenessEfectiveness Social demandSocial demand

16. 3. Implementation: evidence-based coverage 16 Focus groups: Qualitative approach National survey: Quantitative approach IssueFindings 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

17. 3. Implementation: a negotiation process with Congress 7327 Por ciento

18. 3.Implementation: governance at the state level

19. 19 3. What did Seguro Popular achieved?

20. It has nearly affiliated its targeted population Fuente: Elaboración propia con base en CNPSS (2012)

21. Seguro Popular has increased public health expenditures Gasto público en salud (pesos 2012) Miles de millones Fuente : PEF y cuenta pública /1 Presupuestado.

22. Effective access to prescribed drugs has improved in most states 22 Fuente: ENSANUT 2012. Estudio de satisfacción de usuarios del Sistema de Protección Social en Salud 2014. 25 of 32 states need to improve to achieve the 90% goal

23. 23 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. 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

25. ¿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. 26 5.What are the main challenges ahead?

27. 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. 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 Percent change 1980-2011

29. 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

30. 30 Secondly, to achieve universal health coverage, the Mexican system needs to Overcome the fragmented health care system Ensure effective access with quality

31. 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

32. 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

33. 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. 34 Thank you very much