1. & health spending in Mexico:
Health insurance
& health spending in Mexico:
Families
receiving
remittances
ACADEMY HEALTH
Orlando; June 5, 2007
Felicia M. Knaul
Fundación Mexicana para la Salud

2. OUTLINE Mexico: basic data Demographic and epidemiological transition
The health system
Health reform, 2003
Health spending, health insurance and remittances

3. Mexico: Basic indicators, 2003 & 2005.
Population
% Rural
Localities
250 inhabitants or less
1,000 inhabitants or less
GDP per capita (current US$)
Health spending /capita
Poverty: <$2 per day
Average years of schooling
103 million
24%
187,931
157,958; 84%
21,572; 96%
$7,310
$US372; $PPP582
>20%
7.9 years
2003 data, World Health Organization, 2006.
Source: INEGI. Conteo de Población y Vivienda 2005, World Bank, Key Development Data & Statistics; and World Health Organization, 2006

4. Rapid social transition: ej: Dramatic increase in education
Average years of schooling
8.1 8
7.6
2.8
Women 2
2.4
Men
1960
1970
1980
1990
2000
2002
Source: INEGI, SISEMIN and DIE/INEE Panorama educativo de México 2004.

5. OUTLINE Mexico: basic data Demographic and epidemiological transition
The health system
Health reform, 2003
Health spending, health insurance and remittances

6. Chronic, Non-communicable
New challenges are associated with the rapid advance of profound demographic and epidemiologic transition.
Over 50 years, Mexico will complete an aging process that took two centuries in most European countries.
In 2050, one-in-four Mexicans will be 65 or over – a four-fold increase.
Costly, chronic, non-communicable illnesses now dominate the burden of disease.
72%
73%
Communicable
La otra opción es poner este cuadro
Chronic, Non-communicable
Injuries
22%
17%
10% 6%
1955
2005
Source: Sepúlveda et al. ,2006

7. Overweight and Obesity Mexico, 5 to 11, 2006
¨Painful double burden of disease¨: e.g.: obesity affects all populations, but for the poor it co-exists alongside malnutrition
Child malnutrition Mexico, 1988 and 2006
Overweight and Obesity Mexico, 5 to 11, 2006
Under height
Under weight
Emaciation
26% 23
20% 18 14 13
12%
National
Urban 8 6 5
Rural 2 2
1988
1999
2006
Source: Instituto Nacional de Salud Pùblica, 2006

8. OUTLINE Mexico: basic data Demographic and epidemiological transition
The health system
Health reform, 2003
Health spending, health insurance and remittances

9. Insurance (and health care) coverage in Mexico
All persons, in the United States of Mexico, have the right to health protection. ART. 4, CONSTITUTION
Social Security: ~40%
IMSS: ~30-35%; formal-sector employees and family.
ISSSTE: ~5-7%; public sector employees and family.
Others: 3%; workers in specific industries
Private insurance (first insurer): 1-2%
with capacity-to-pay; some public and private employees
Ministry of Health (federal and state): 50+%
´residual or ´open´ population without access to social security; poor
Lowest per capita investment in health
Seguro Popular: health reform of 2003
Current coverage: %
LAW: 100% of families without social security by 2010

10. Contrasts in health care and access

11. Effective coverage of select interventions (Lozano, 2006)98 93 92 86 67 66 41 22 %
BCG immunization
Skilled birth attendance
Measles immunization
DTP3 immunization
Antenatal care
Diarrhea treatment (children)
Cervical cancer screening
Breast cancer screening
Source: Lozano et al, 2006

12. Reliance on out-of-pocket spending to finance health systems is inversely related to GDP: Mexico is an exception at 50%+
India 80
Vietnam 60
Congo
China
Mexico
% OOP
Ethiopia
El Salvador
Paraguay
Thailand
Malaysia
LAC 40
Brazil
Korea
Venezuela
Peru
Chile
Argentina
Bolivia
Costa Rica
Spain
Colombia
Italy 20
Uruguay
Panama
France
Germany
GDP per capita
OECD
GDP per capita vs. OOP as a % of health system finance
Source: Authors own estimations based on data from WHO 2006

13. =1.5 millions of families per trimester
Absolute and/or relative impoverishment due to health expenditure, 2000
6.3%
=1.5 millions of families per trimester
=~ 4 million per year
Insured: 2.2%
Uninsured: 9.6%
Poorest quintile: 9.6%
Quintiles 2-5: 3.1%
Impoverishment (Knaul et al., 2005):
-absolute: fall below or further below the poverty line
-relative: spend 30%+ of disposable income on health
Source: authors own estimations based on data from the ENIGH 2000

14. OUTLINE Mexico: basic data Demographic and epidemiological transition
The health system
Health reform, 2003
Health spending, health insurance and remittances

15. Seguro Popular System for Social Protection in Health
THE VISION BEHIND THE 2003 REFORM: ELIMINATE SEGMENTATION IN ACCESS TO HEALTH INSURANCE BY GENERATING A SYSTEM FOR SOCIAL PROTECTION IN HEALTH THAT INCLUDES POPULAR HEALTH INSURANCE FOR FAMILIES EXCLUDED FROM SOCIAL SECURITY
Ministry of Health with residual funding
1943
Social Security
Public and private, Formal sector workers and their families: ~50% of population
Poor, informal sector, non-salaried, rural areas: ~ 50% of population
2001/3: Pilot of PHI
2003: Law
Jan. 1, 2004: SSPH
2010: Universal coverage with Seguro Popular
Seguro Popular
System for Social Protection in Health
Frenk et al., 2004.

16. Key elements of the reform:
Access to publicly-funded health insurance – Popular Health Insurance (PHI) - for all families excluded from Social Security.
Progressive pre-payment through a sliding-scale subsidy based on disposable income and zero family contribution for the poorest two deciles.
Separate budgeting and funds for public health goods with universal coverage.
Package of personal health services based on cost-effectiveness and burden of disease that is expanding over time.
Elimination of fees and co-payments at point-of-service for health care and medications.

17. Evolution of Health Coverage in Mexico by Institution; National Surveys: 2000-2005/6
2005(4)/6(1)
UNINSURED
IMSS
32%
28%
53%
60%
11%
10.5
SEGURO
POPULAR
Seguro Popular, administrative data, end of 2006:
5.1 million families (~23,000,000 people)
28% of the population w/o social security
Source: INSP, Encuesta Nacional de Salud, 2000; Encuesta Nacional de Salud y Nutrición, 2006.

18. OUTLINE Mexico: basic data Demographic and epidemiological transition
The health system
Health reform, 2003
Health spending, health insurance and remittances

19. Families with remittances, by insurance coverage
URBAN
RURAL
TOTAL
IMSS
ISSSTE
SEG. POPULAR
WITHOUT
INSURANCE 24 6 3 67 9 1 8 82 16 4 5 74
TOTAL: FAMILIES WITH REMITTANCES
Source: Authors`own estimations based on data from the ENIGH 2004

20. 5.6% of families receive income transfers;
Health spending as a proportion of total disposable household spending*, by remittances 12 6
1992
2005
With remittances
Without remittances
5.6% of families receive income transfers;
these families account for about 9.7% of total
out-of-pocket health spending
*Disposable household spending: total spending – spending on food
Source: Authors`own estimations based on data from the ENIGH

21. Catastrophic health expenditure in families with and without remittances, by quintile10
With remittances
Without remittances 5
Perhaps the text would be better left in the notes:
5.6% of families receive income transfers, these account for about 9.7% of total out-of-pocket health financing.
Average / capita health spending by households with remittances is 121 pesos ; compared to 75 pesos for households without remittances.
Families who receive income transfers are significantly more likely to suffer catastrophic health expenditure. This holds true across all income quintiles.
QUINTILE I
QUINTILE V
TOTAL
Total Household Expenditure (as a proxy for perm. Income)
Average/capita health spending by households with remittances is 121 pesos; compared to 75 pesos for households without remittances.
Source: Authors own estimations based on data from the ENIGH

22. Insurance options for Mexicans living abroad FOR HEALTH CARE IN MEXICO
Health Insurance for the Family (IMSS)
Popular Health Insurance for Migrant Families
Private insurance (examples)
Coverage
consultations, medications, lab work, basic dental, hospitalization, surgery, and maternity.
consultation, hospitalization, medications, lab work, surgery and maternity.
consultations,
Hospitalization, laboratory work, surgery and maternity.
Beneficiaries
Spouse, children, parents, and extended family
Nuclear family: Spouse and Children
Whomever is included in the quota.
Price
Paid once a year, cost per person: $101 to $266 USD
Family quota is a function of the family’s capacity to pay.
individual cost based on age and sex.
Restrictions
Serious, pre-existing illnesses: Cancer, diabetes, cardiovascular illness
Cannot be covered by other social security institution
Pre-existing illnesses are not covered.
Maternity and pregnancy if insurance was contracted less than 10 months prior

23. Evolution of IMSS health insurance coverage
400,000
Families affiliated to IMSS through ´Health Insurance for the Family´
1997
2000
2003
2006
Health Insurance for the Family, the only voluntary, non-employment-based option for IMSS coverage, has grown from 20,000 to ~380,000 families over the past decade, but remains tiny compared to overall coverage and reportedly difficult to contract.
Source: Authors own estimations based on data from the Memoria Estadistica del IMSS, 2006

24. Affiliation and location of care, most recent health problem
Insured by IMSS
Insured by
Seguro Popular
HEALTH CARE SERVICE REC´D FROM:
24%
18%
IMSS
66%
78%
PRIVATE 4%
11%
OTHERS
MINISTRY OF HEALTH
A large proportion of people with health insurance coverage use private services and pay out-of-pocket. This is true for IMSS, ISSSTE and Seguro Popular.
Source: Authors own estimations based on data from the Encuesta Nacional de Nutrición y Salud, 2006.

25. Municipalities with insured population, by level of ´poverty´ and institution, 2005
97%
100%
100%
100
87%
92% %
78% 60 20
These data were taken from the Conteo de Poblaciòn y Vivienda 2005.
Very high
High
Medium
Low
Very low
Total
% OF MUNICIPALITIES WITH AT LEAST ONE FAMILY W/ IMSS AND/OR SEGURO POPULAR
IMSS
ISSSTE
SEG.POP
PRIVADOS
Source: Authors own estimations based on data from INEGI 2005.

26. Conclusions and future research
The level and catastrophic nature of health spending by families with remittances, and the current situation of the health system and the reform in Mexico, suggest an important opportunity – health, equity and efficiency – for converting OOP into pre-payment
Develop specialized, ?integrated?, insurance products – IMSS, Seguro Popular, private - for migrants and families
Centre for Health System Research, INSP
Health Initiative of the Americas, U of California
Analyze the nature and determinants – qualitative and quantitative – of remittances sent to finance health care
Funsalud; INSP; Estudio sobre Migración, Salud y Seguro Popular, 2007 (Nigenda et al)
Compare and contrast with Canadian bi-national programs (SAW) and policy on migration, work and health insurance