1. Harvard University Initiative for Global Health Global Health Challenges Social Analysis 76: Lecture 24

2. Harvard University Initiative for Global Health

4. Mexican Health System before 2000 National Reform Debate Reform Law Interim Evaluation of Impact

5. Harvard University Initiative for Global Health

7. 1)High-income households largely use private outpatient and inpatient services funded by out-of- pocket payments or health insurance. For advanced specialist care, Ministry of Health tertiary facilities used. 2)Formal sector employees and their families covered by social insurance: Instituto Mexicano del Seguro Social (IMSS) since 1940s for most, civil servants by ISSTE, workers in PEMEX and military have their own insurance/provision systems. 3)Rest of population not covered by social insurance obtain services from Ministry of Health and private sector. Fragmented System

8. Harvard University Initiative for Global Health

10. Mexican Health System before 2000 National Reform Debate Reform Law Interim Evaluation of Impact

11. Harvard University Initiative for Global Health After more than 70 years of PRI control of Congress and the Presidency, Vicente Fox for PAN (right of center) won the Presidency in July 2000. Julio Frenk led health transition team and became Minister of Health on December 1 st, 2000. World Health Report 2000 rankings of health systems provided frame of reference for Fox to deliberate on new health policy directions. Fox Election

12. Harvard University Initiative for Global Health Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997

13. Harvard University Initiative for Global Health For the first time, the extent of catastrophic spending was documented and widely discussed. This previously ‘hidden’ issue became a major focus of policy debate. The importance of the issue both to low-income and middle-income households helped build a broad movement for reform. Catastrophic Health Spending on the Agenda

14. Harvard University Initiative for Global Health Mexican Health System before 2000 National Reform Debate Reform Law Interim Evaluation of Impact

15. Harvard University Initiative for Global Health Law passed April 2003 with majority support from all three parties (PRD, PAN, PRI). Over a seven year period from January 2004, a new health insurance, Seguro Popular will be extended to the entire population. Affiliation to Seguro Popular is voluntary. Reform Law

16. Harvard University Initiative for Global Health Public financing per family is linked to the social contribution—i.e. the amount allocated per family in the formal sector in the tax-financed part of social security. This creates an entitlement for families in Seguro Popular similar to that of families receiving social security benefits, and is predicted to increase public financing from 3·1% of the gross domestic product (GDP) in 2003 by 0·8–1·0% of GDP over 7 years. First Key Component

17. Harvard University Initiative for Global Health The packages of individual health services are explicit and are made known to all enrollees, the State Ministries of Health, and to the taxpayers. In principle, this practice gives affiliates an opportunity to demand the services and benefits provided by this programme. Second Key Component

18. Harvard University Initiative for Global Health

19. State Ministries of Health receive funds in proportion to the number of families that voluntarily affiliate each year. Affiliation expires after a year and families can opt to re-affiliate, creating a powerful incentive for states to improve service provision and encourage re-affiliation. This component of the reform is the critical linkage between the financing and supply- side issues. Third Key Component

20. Harvard University Initiative for Global Health Federal money flowing to the States is divided into two parts: a fund for non-personal services and a fund for personal services. This strategy aims to ensure that, in the long run, financing for public-health interventions cannot be diverted to clinical interventions. Fourth Key Component

21. Harvard University Initiative for Global Health Catastrophic fund was created from federal monies to directly finance care for specific conditions for which treatment often results in catastrophic expenditure and that are not included in the essential package of services. Conditions currently covered by the fund include treatment for HIV (antiretroviral therapy), childhood leukaemia, cervical cancer, and prematurely born babies. Fifth Key Component

22. Harvard University Initiative for Global Health Mexican Health System before 2000 National Reform Debate Reform Law Interim Evaluation of Impact

23. Harvard University Initiative for Global Health Affiliation goals To provide insurance to those uninsured by the social security sector About 50 million individuals in 2000 Profile of uninsured: Poor, indigenous, living in deprived communities, in rural areas

24. Harvard University Initiative for Global Health Gradual expansion of affiliation Goal: full coverage by 2010

25. Harvard University Initiative for Global Health Profile of affiliated population

26. Harvard University Initiative for Global Health Financing

27. Harvard University Initiative for Global Health Provision of services – Utilization conditional on need

28. Harvard University Initiative for Global Health

30. Changes in composite coverage by state, 2000-2006: Poorer states see larger increases

31. Harvard University Initiative for Global Health Reduction in wealth-related inequalities in composite coverage, 2000 to 2005-06

32. Harvard University Initiative for Global Health

34. Household financial contributions

35. Harvard University Initiative for Global Health Summary of findings Affiliation is reaching the poor More resources for the uninsured; more equal distribution of resources across states Use of health-care services has increased for SP affiliates and SP communities Composite coverage for 11 interventions 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, especially within subgroups that use health services

36. Harvard University Initiative for Global Health Challenges ahead Double challenge of expansion: –Expanding into the most deprived communities, while handling the growing demand for services –Expansion into higher income households which requires collection of family contribution Maintaining high level of satisfaction Encourage states to use resources to address existing infrastructure problems in deprived communities

37. Harvard University Initiative for Global Health Lessons for Mexico Monitoring effective coverage, with an emphasis on technical quality, will become very important Invest further in monitoring human and physical infrastructure – currently, a weak area of the health information system