Presentacin de PowerPoint

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The Centre for International Health Faculty of
Medicine, University of Toronto 4th Annual Global
Health Research Conference 15th Annual GHEC
Conference
Health financing and the dual challenge of
infectious and chronic diseases -The Case of
Mexico-
Julio Frenk, M.D., PhD. Minister of Health
Mexico
Toronto, Canada April 20, 2006
México
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Outline

• Emerging challenges to health systems financing
• Structural reform in Mexico

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Emerging challenges
Epidemiological and demographic transition
Health system
Technological innovation
Patient empowerment
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Selected causes of deathMexico, 1955-2005
Infectiuos and Parasitic
Diarroheal Dis.
Respiratory Inf.
Perinatal Dis.
Malnutrition
Maternal Cond.
Cardiovascular Dis.
Injuries
Malignant Neoplasms
Chronic Respiratory Dis.
Genitourinary Dis.
Neuropsychiatric Cond
Congenital A.
Diabetes
Ill-defined
Source INEGI/Sec Salud. Mortality Database
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Epidemiological transition
deaths
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The dual challenge index (Non Communicable
Injuries / Communicable, Reproductive and
Nutritional)World Regions and Mexico by State
Coahuila
Nuevo León
Distrito Federal
Colima
EAs P
Chihuahua
Tamaulipas
Sinaloa
LAC
Durango
Nayarit
Michoacán
ME NA
Aguascalientes
Morelos
Hidalgo
WORLD
Zacatecas
Jalisco
San Luis Potosí
SAs
Sonora
Querétaro
Veracruz
SSA
Mexico
Yucatán
Campeche
-1.0
1.0
2.0
4.0
6.0
8.0
Guanajuato
Tabasco
Baja California Sur
Ratio
Baja California
Edo de México
Tlaxcala
EAsP East Asia Pacific LAC Latin America
Caribbean MENA Middle East North Africa Sas
South Asia SSA Sub-Saharan Africa
Guerrero
Puebla
Quintana Roo
Oaxaca
Chiapas
1.0
2.0
4.0
6.0
8.0
10.0
Word
LAC
Sources DCP2, 2006 INEGI, 2004 CONAPO, 2002
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Health poverty The unacceptable paradox
fair financing
Poverty alleviaton
Health care financing
Health care services
through out-of-pocket payment
Poverty trap
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The three pillars of public policy
Public policies
Ethical
Political
Technical
Evidence on best practice
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Outline

• Emerging challenges to health systems financing
• Structural reform in Mexico
• 2.1 Ethical pillar

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Ethical basis of reform
Values
Principles
Key concept
Social inclusion
Universality
National portability
Equal opportunity
Explicit prioritization
Free at point of delivery
Financial justice
Democratization of Health
Financial solidarity
Corresponsibility
Subsidiarity
Autonomy
Democratic budgeting
Accountability
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The vision
Social Insurance
Ministry of Health
1943
Independent workers, poor, mainly rural
Salaried workers, mainly urban
2003
Universal Social Protection for Health
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Outline

• Emerging challenges to health systems financing
• Structural reform in Mexico
• 2.1 Ethical pillar
• 2.2 Political pillar

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Consensus building

• Between branches of government legislative and
  executive.
• Between levels of government state and federal.
• Over time more than one Administration.

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Outline

• Emerging challenges to health systems financing
• Structural reform in Mexico
• 2.1 Ethical pillar
• 2.2 Political pillar
• 2.3 Technical pillar
• 2.3.1 The problem

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Problem
Almost half of Mexican households lack health
insurance, which limits access to care, reduces
opportunities for risk pooling, and generates
catastrophic expenditures.
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Global public goods as an input to national
policy making
Types of knowledge-related on public
goods Concepts Methods InstrumentsEvidenc
e

• Examples
• WHO framework for health system performance
  assessment
• National health accounts
• Priority setting methods
• Household Income and Expenditure Surveys
• World Health Survey
• Cross-national comparisons

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Financial imbalances in 2000
1. Level insufficient investment (5.7 of GDP)
vis-a-vis the dual challenge 2. Source
predominance of out-of-pocket payments (55) 3.
Distribution 3.1. Among populations more than
three times between insured and uninsured 3.2.
Among states 5 to 1 between the state with the
highest and the lowest per capita federal
expenditure
4. State contributions 89 to 1 5. Allocation
items current expenditure versus investment
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Impoverishment due to health care expenditure
1.5 million families
2 million catastrophic expenditures
.5 million families
1.8 million families
2.3 million impoverishing expenditures
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Before the reform Organization by population
groups
Social Groups
Insured
Uninsured
Middle class
Poor Urban/Rural
Functions
Stewarship Financing Delivery
Federal and State Governments
Private sector
IMSS/ISSSTE
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After the reform Organization by functions
Social Groups
Insured
Uninsured
Poor Urban/Rural
Middle class
Functions
Ministry of Health
Stewarship Financing Delivery
Universal Social Protection
Pluralism
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Components of stewardship

• Health policy formulation defining the vision
  and direction for the entire health system
  setting priorities, and advocating intersectorial
  action for healthy policies.
• Regulation setting fair rules of the game with a
  level playing field and protecting comsumers.
• Intelligence assessing performance and sharing
  information.

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Components of financing

• Revenue collection mobilizing money from
  households, firms and donors.
• Fund pooling accumulating revenues for the
  common advantage of participants by sharing
  financial risks.
• Purchasing allocating money to providers in
  order to deliver interventions.

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Objectives of the reform

• Create a legal framework to increase public
  expenditure for health in a gradual, fiscally
  responsible, and sustainable manner.
• Achieve greater allocative efficiency by
  protecting funding for cost-effective
  community-based preventive interventions.
• Protect families from health expenditures by a
  collective mechanism to manage risks in a fair
  way.
• Transform incentives from supply-side to
  demand-side in order to promote quality,
  efficiency, and responsiveness to users.
• Restructure the Ministry of Health away from
  direct provision of care for the poor and towards
  stewardship of the entire health system.

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Outline

• Structural reform in Mexico
• 2.1 Ethical pillar
• 2.2 Political pillar
• 2.3 Technical pillar
• 2.3.1 The problem
• 2.3.2 Key features

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New financial architecture for health
Health goods
Resources
Federal
Stewarship
MOH budget
State
Public goods
Contributory fund for CHS
Community health services
Contributory fund for PHS
Essential services
Personal services (Popular Health Insurance)
Fund for protection against catastrophic
expenditures
High- specialty interventions
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Structure of financial contributions
Contributions
Public insurance scheme
Federal government
Co-responsible contributor
Beneficiary
IMSS (salaried employees in the private sector)
Social contribution
Private employer
Employee
ISSSTE (salaried employees in the public sector)
Social contribution
Federal employer
Employee
Solidarity contribution
Popular Health Insurance (non-salaried workers,
self- employed and persons outside of the labor
force)
Family
Social contribution
State- level Govern-ment
Federal Government
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Strenghthening the supply side The other half of
the reform
Quality improvement
Management reform
Performance evaluation
Information systems
Human resource development
Drug supply
Technology assessment
Infrastructure planning
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Innovations of the reform
Universal health insurance
Social protection system for health
Protection against catastrophic expenses
Budgetary priority to public health
Democratic budgeting
Affiliation with explicit rights for all
Plan to strengthen supply of resources and
services
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Coverage strategy Horizontal and vertical
ACCELERATED COVERAGE
High specialty interventions
Catastrophic expenses coverage
Benefits
Comprehen-sive package of essential health
services
Community health services
I II III IV
V VI VII VIII
IX X
Decile
Beneficiaries
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Horizontal coverage
Enrollment of families
Families (000)
14,000
11,500
12,000
10,000
8,000
6,000
5,000
4,000
3,555
2,000
295.5
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year
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Progressive vertical coverage
Not covered
1
9
High specialty
Fund for Protection against Catastrophic
Expenditures
Complexity levels
Basic specialities
90
ComprehensivePackage of Essential Services
Ambulatory
Demand for services
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Outline

• Structural reform in Mexico
• 2.1 Ethical pillar
• 2.2 Political pillar
• 2.3 Technical pillar
• 2.3.1 The problem
• 2.3.2 Key features
• 2.3.3 Implementation results and challenges

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Health expenditure as percentage of GDP
Imbalance Insufficient investment
/1
Latin American Average 20026.6 20006.5
/1 USA. 2003, Uruguay, Colombia and Costa Rica
2002
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Insured population by income
Percentage
Income Quintile
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Incidence of excessive health expenditure
Excessive health expenditure trend by income
quintile 1992-2004
Excessive health expenditure trend by insuring
condition 1992-2004
of households
of households
Year
Year
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Progressivity of benefits

19.6
20
15
10
5
2.1
I
II
III
IV
V
VI
VII
VIII
IX
X
Income
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Challenges

• Maintaining the pace of enrollment and improving
  quality of care.
• Sustaining investment expansion in the health
  sector.
• Converting the system into being more
  client-oriented and responsive.
• Strengthening provider incentives and developing
  a more competitive environment on the
  supply-side.
• Converging towards a single national risk pool,
  especially for protection against catastrophic
  expenditures.
• Mainstreaming evidence and information as key
  tools for implementation.
• Involving the diversity of actors to maintain
  broad support base and assure continuity in the
  face of political transition.

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Outline

• Structural reform in Mexico
• 2.1 Ethical pillar
• 2.2 Political pillar
• 2.3 Technical pillar
• 2.3.1 The problem
• 2.3.2 Key features
• 2.3.3 Implementation results and challenges
• 2.3.4 Relevance to other countries

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Relevance to other countries

• Reorganizing financing as an strategy to solve
  similar problems out-of-pocket predominance,
  financial injustice, and catastrophic
  expenditures, in the context of the dual
  challenge.
• Reforming in a context of budgetary constraints
  and the central role of incentives, efficency,
  consumer satisfaction, and accountability.
• Stressing the value of health for economic
  performance and changing the views of policy
  makers in other sectors.
• Restructuring the Ministry of Health for better
  stewardship of a health care system oriented
  towards universal access to high-quality care
  with fair financing.

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• All progress is precarious, and the solution of
  one problem brings us face to face with another
  problem.
• Martin Luther King, Jr.
• Strength to Love, 1963

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