Health insurance & health spending in Mexico: OUTLINE Mexico: basic data Demographic and epidemiological transition The health system Health reform, 2003 Health spending, health insurance and remittances Families receiving remittances ACADEMY HEALTH Orlando; June 5, 2007 Felicia M. Knaul Fundación Mexicana para la Salud Mexico: Basic indicators, 2003 & 2005. Rapid social transition: ej: Dramatic increase in education Population 103 million % Rural 24% Localities Average years of schooling 8.1 8 187,931 250 inhabitants or less 1,000 inhabitants or less GDP per capita (current US$) Health spending /capita Poverty: <$2 per day 7.6 157,958; 84% 21,572; 96% $7,310 $US372; $PPP582 Average years of schooling >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 OUTLINE Mexico: basic data Demographic and epidemiological transition The health system Health reform, 2003 Health spending, health insurance and remittances 2.8 2 Women 2.4 1960 Men 1970 1980 1990 2000 2002 Source: INEGI, SISEMIN and DIE/INEE Panorama educativo de México 2004. 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 1 ¨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 OUTLINE Overweight and Obesity Mexico, 5 to 11, 2006 Mexico: basic data Demographic and epidemiological transition The health system Under height Under weight Emaciation 26% 23 20% 2 1988 1999 5 2 12% Rural 8 6 Urban 13 Health reform, 2003 Health spending, health insurance and remittances National 18 14 2006 Source: Instituto Nacional de Salud Pùblica, 2006 Insurance (and health care) coverage in Mexico Contrasts in health care and access 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 Reliance on out-of-pocket spending to finance health systems is inversely related to GDP: Mexico is an exception at 50%+ Effective coverage of select interventions (Lozano, 2006) 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 India 80 Vietnam % OOP BCG immunization 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 2 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 OUTLINE Mexico: basic data Demographic and epidemiological transition The health system Health reform, 2003 Health spending, health insurance and remittances Source: authors own estimations based on data from the ENIGH 2000 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 SU IN UN D RE 60% 2005(4)/6(1) S IMS 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-ofFrenk et al., 2004. Evolution of Health Coverage in Mexico by Institution; National Surveys: 2000-2005/6 2000 Key elements of the reform: 28% 32% 53% 11% 10.5 SE PO GU PU RO LA Seguro Popular, administrative data, end of 2006: R •5.1 million families (~23,000,000 people) •28% of the population w/o social security service for health care and medications. OUTLINE Mexico: basic data Demographic and epidemiological transition The health system Health reform, 2003 Health spending, health insurance and remittances Source: INSP, Encuesta Nacional de Salud, 2000; Encuesta Nacional de Salud y Nutrición, 2006. 3 Families with remittances, by insurance coverage Health spending as a proportion of total disposable household spending*, by remittances 12 URBAN RURAL TOTAL IMSS 24 9 16 ISSSTE 6 1 4 3 8 5 SEG. POPULAR WITHOUT INSURANCE TOTAL: FAMILIES WITH REMITTANCES 67 3.6 82 6 0 74 12.3 5.6 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 200 Source: Authors`own estimations based on data from the ENIGH 1992-2005 Insurance options for Mexicans living abroad FOR HEALTH CARE IN MEXICO Catastrophic health expenditure in families with and without remittances, by quintile 10 Health Insurance for the Family (IMSS) With remittances Without remittances Coverage 5 Beneficiaries 0 QUINTILE I QUINTILE V TOTAL Price 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. 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 Source: Authors own estimations based on data from the ENIGH 1992-2005 Evolution of IMSS health insurance coverage Affiliation and location of care, most recent health problem Insured by IMSS 400,000 Families affiliated to IMSS through ´Health Insurance for the Family´ Insured by Seguro Popular HEALTH CARE SERVICE REC´D FROM: IMSS 66% 24% 78% 18% PRIVATE 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 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. 4 Municipalities with insured population, by level of ´poverty´ and institution, 2005 100 % 97% 87% 100% 100% 92% 78% 60 20 Conclusions and future research ¾ 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 ¾Develop specialized, ?integrated?, insurance products – IMSS, Seguro Popular, private - for migrants and families ¾Centre for Health System Research, INSP ¾Health Initiative of the Americas, U of California ¾ 0 Very high IMSS SEG.POP High Medium ISSSTE PRIVADOS Low Very low Total % OF MUNICIPALITIES WITH AT LEAST ONE FAMILY W/ IMSS AND/OR SEGURO POPULAR Analyze the nature and determinants – qualitative and quantitative – of remittances sent to finance health care ¾Funsalud; INSP; Estudio sobre Migración, Salud y Seguro Popular, 2007 (Nigenda et al) ¾ Compare and contrast with Canadian bi-national programs (SAW) and policy on migration, work and health insurance Source: Authors own estimations based on data from INEGI 2005. 5