Health insurance
& health spending in
Mexico:
Families
receiving
remittances
ACADEMY HEALTH
Orlando; June 5, 2007
Felicia M. Knaul
Fundación Mexicana para la Salud
OUTLINE
Mexico: basic data
Demographic and
epidemiological transition
The health system
Health reform, 2003
Health spending, health
insurance and remittances
Mexico: Basic indicators,
2003 & 2005.
Population
103 million
% Rural
24%
Localities
187,931
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
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
Rapid social transition: ej:
Dramatic increase in education
Average years of schooling
8
8.1
7.6
2.8
2
Women
2.4
1960
Men
1970
1980
Source: INEGI, SISEMIN and DIE/INEE Panorama educativo de México 2004.
1990 2000 2002
OUTLINE
Mexico: basic data
Demographic and
epidemiological transition
The health system
Health reform, 2003
Health spending, health
insurance and remittances
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-infour Mexicans
will be 65 or
over – a fourfold increase.
Source: Sepúlveda et al. ,2006
Costly, chronic, non-communicable
illnesses now dominate the burden
of disease.
73%
72%
Communicable
Chronic, Noncommunicable
Injuries
22%
17%
10%
6%
1955
2005
¨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
18
6
1988
8
2
1999
Source: Instituto Nacional de Salud Pùblica, 2006
Urban
13
5
2
2006
12%
Rural
14
National
20%
OUTLINE
Mexico: basic data
Demographic and
epidemiological transition
The health system
Health reform, 2003
Health spending, health
insurance and remittances
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: 10 -15%
• LAW: 100% of families without social security by 2010
Contrasts in
health care
and access
Effective coverage of select
interventions (Lozano, 2006)
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
98
93
92
86
67
66
41
22
Reliance on out-of-pocket spending to
finance health systems is inversely related to
GDP: Mexico is an exception at 50%+
India
80
% OOP
Vietnam
60
China
Congo
Mexico
El Salvador
Paraguay Thailand
Malaysia
Brazil
Peru Venezuela
Chile
Argentina
Costa
Rica
Bolivia
Colombia
Ethiopia
40
20
Uruguay
Panama
GDP per capita
Korea
LAC
Spain
Italy
France
Germany
OECD
GDP per capita vs. OOP as a % of health system finance
Source: Authors own estimations based on data from WHO 2006
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
OUTLINE
Mexico: basic data
Demographic and
epidemiological transition
The health system
Health reform, 2003
Health spending, health
insurance and remittances
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
1943
Ministry of Health
with residual
funding
Social Security
Public and private,
Formal sector workers
and their families:
~50% of population
2001/3: Pilot of PHI
2003: Law
Jan. 1, 2004: SSPH
2010: Universal
coverage with
Seguro Popular
Poor, informal
sector, non-salaried,
rural areas:
~ 50% of population
System for Social
Protection in
Health
Seguro
Popular
Frenk et al., 2004.
Key elements of the reform:
1. Access to publicly-funded health insurance –
Popular Health Insurance (PHI) - for all families
excluded from Social Security.
2. Progressive pre-payment through a sliding-scale
subsidy based on disposable income and zero
family contribution for the poorest two deciles.
3. Separate budgeting and funds for public health
goods with universal coverage.
4. Package of personal health services based on
cost-effectiveness and burden of disease that is
expanding over time.
5. Elimination of fees and co-payments at point-ofservice for health care and medications.
Evolution of Health Coverage in Mexico by
Institution; National Surveys: 2000-2005/6
2000
2005(4)/6(1)
28%
32%
60%
53%
11%
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.
10.5
OUTLINE
Mexico: basic data
Demographic and
epidemiological transition
The health system
Health reform, 2003
Health spending, health
insurance and remittances
Families with remittances,
by insurance coverage
URBAN
RURAL TOTAL
IMSS
24
9
16
ISSSTE
6
1
4
3
8
5
67
82
74
SEG. POPULAR
WITHOUT
INSURANCE
TOTAL: FAMILIES WITH
REMITTANCES
3.6
12.3
5.6
Source: Authors`own estimations based on data from the ENIGH 200
Health spending as a proportion of total
disposable household spending*, by remittances
12
6
0
1992
With remittances
Without remittances
2005
• 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 1992-2005
Catastrophic health expenditure in families with
and without remittances, by quintile
10
With remittances
Without remittances
5
0
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 1992-2005
Insurance options for Mexicans living
abroad FOR HEALTH CARE IN MEXICO
Health Insurance
for the Family
(IMSS)
Coverage
Beneficiaries
Price
Restrictions
Popular Health
Insurance for
Migrant Families
consultations,
medications, lab
work, basic dental,
hospitalization,
surgery, and
maternity.
Spouse, children,
parents, and
extended family
consultation,
hospitalization,
medications, lab
work, surgery and
maternity.
Paid once a year,
cost per person:
$101 to $266 USD
Family quota is a
function of the
family’s capacity to
pay.
Cannot be covered
by other social
security institution
Serious, preexisting illnesses:
Cancer, diabetes,
cardiovascular
illness
Private insurance
(examples)
consultations,
Hospitalization,
laboratory work,
surgery and maternity.
Nuclear family:
Whomever is included
Spouse and Children in the quota.
individual cost based
on age and sex.
Pre-existing illnesses
are not covered.
Maternity and
pregnancy if
insurance was
contracted less than
10 months prior
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
Affiliation and location of care,
most recent health problem
Insured by
IMSS
Insured by
Seguro Popular
HEALTH CARE
SERVICE
REC´D FROM:
IMSS
66%
24%
78%
18%
PRIVATE
OTHERS
MINISTRY
OF HEALTH
11%
4%
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.
Municipalities with insured population,
by level of ´poverty´ and institution, 2005
100
%
87%
97%
100%
100%
92%
78%
60
20
0
Very high
IMSS
SEG.POP
High
ISSSTE
PRIVADOS
Source: Authors own estimations based on data from INEGI 2005.
Medium
Low
Very low
Total
% OF MUNICIPALITIES WITH AT
LEAST ONE FAMILY W/ IMSS
AND/OR SEGURO POPULAR
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