Presentacin de PowerPoint

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General Health Insurance in Financing of Health
Services in Turkey and Restructuring of the
Ministry of Health
Structural Reform of Health Systems Stewardship
for Universal Social Protection -The Case of
Mexico-
Julio Frenk, M.D., PhD. Minister of Health
Mexico
Instanbul, Turkey April 1st, 2006
México
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Key Messages

• To be successful we must move beyond false
  dilemmas
• Analysis versus advocacy
• Global versus national
• To reform we must inform or else we may deform
• Turkey and Mexico share similar challenges to
  their health systems
• Therefore, we can engage in a process of share
  learning.

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Outline

• Emerging challenges to health systems financing
• The Structural Reform in Mexico

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Emerging challenges
Epidemiological and demographic transition
Health system
Technological innovation
Patient empowerment
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Health poverty The unacceptable paradox
fair financing
Poverty alleviaton
Health care financing
Health care services
trough 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
• The Structural Reform in Mexico
• 2.1 Ethical basis

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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
• The Structural Reform in Mexico
• 2.1 Ethical basis
• 2.2 Political basis

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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
• The Structural Reform in Mexico
• 2.1 Ethical basis
• 2.2 Political basis
• 2.3 Technical basis
• 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) 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 health system.
• Regulation setting fair rules of the game with a
  level playing field.
• Intelligence assessing performance and sharing
  information.

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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

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

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New financial architecture for health
Innovations Allocation of funding for personal
health services
Health goods
Resources
Federal
Stewarship
MOH budget
State
Public goods
Contributory fund for CHS
Community health services
Essential services
Contributory fund for PHS
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
Management
Evaluation
Information
Human resources
Supply
Technology
Infrastructure
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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
Investment plan to strengthen service supply
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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

• The Structural Reform in Mexico
• 2.1 Ethical basis
• 2.2 Political basis
• 2.3 Technical basis
• 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.
• Sustain increasing investment 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.
• Institutionalizing 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

• The Structural Reform in Mexico
• 2.1 Ethical basis
• 2.2 Political basis
• 2.3 Technical basis
• 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 a strategy to solve
  similar problems out-of-pocket predominance,
  financial inequality, and catastrophic and
  impoverishing health spending.
• Reforming in a context of budgetary constraint
  and the role of incentives, efficency, consumer
  satisfation and accountability aspects.
• Stressing the role of health in the process of
  economic transition and changing the views of
  policy makers.
• 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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Selected Indicators
Total population 103.5 millions GDP per
capita (Intl , 2002) 8,979 Life expectancy at
birth m/f (years) 72.0/77.0 Healthy life
expectancy at birth m/f (years, 2002)
63.4/67.6 Child mortality m/f (per 1000)
31/25 Adult mortality m/f (per 1000)
166/95 Total health expenditure per capita (Intl
, 2002) 583 Total health expenditure as
of GDP (2002) 6.2 Practicing
physicians per 1000 population 1.5
Total population 71.3 millions GDP per capita
(Intl , 2002) 6,448 Life expectancy at birth
m/f (years) 68.0/73.0 Healthy life expectancy
at birth m/f (years, 2002) 61.2/62.8 Child
mortality m/f (per 1000) 40/38 Adult mortality
m/f (per 1000) 176/111 Total health
expenditure per capita (Intl , 2002)
452 Total health expenditure as of GDP (2002)
6.6 Practicing physicians per 1000
population 1.4