Presentacin de PowerPoint

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External Finance to Promote Global Evidence for
National Policy-making
CASE Analysis of financial protection and
the Mexican Health Reform 2003
Felicia Marie Knaul, Health and
Competitiveness, Mexican Health Foundation
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OUTLINE

• External Finance for health in Mexico
• Overview of the health reform
• The application of evidence on financial
  protection in the reform
• Conclusions

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External Finance in Mexico

• Context
• Large country, large economy
• Health budget per capita 475US per year
• Total health budget of MOH US 8 billion
• no-additionality

External finance must focus on strategic
investments to catalyze and stimulate innovation

• Evidence
• Global
• Lessons-learned application and evaluation
• Tools and methodologies

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OUTLINE

• External Finance in Mexico
• Overview of the health reform
• The application of evidence on financial
  protection in the reform
• Conclusions

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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
Social Security
1943
Public and private, Formal sector workers and
their families 50 of population
Poor, informal sector, non-salaried, rural areas
50 of population
Frenk et al., 2004.
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The 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
• Budgeting for states based on a formula using
  affiliation as the main criteria to introduce
  demand-side incentives into a supply-side model

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Expected benefit of the Reform

• Reduction in out-of-pocket spending and the
  incidence of impoverishing health expenditures,
  and hence
• EQUITY
• EFFICIENCY

8
There has been important progress since 2001 in
affiliation, coverage, and budgets
of uninsured families covered
Increase in budget of the MOH (rel. 2001)
States
Year
Families
2001
5
89,960
0.8
--
Pilot phase
2002
20
295,210
2.7
6.1
2003
25
613,938
5.5
7.5
Reform and new system
2004
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1,563,572
14.1
33.5
2005
32.1
59.6
ALL 32
3,555,977
Affiliation is progressive
Concentrated in Quintile 1 in 2004-6
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OUTLINE

• External Finance in Mexico
• Overview of the health reform
• The application of evidence on financial
  protection in the reform
• Conclusions

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Analysis of financial protection as evidence for
policy making, 1992-2006

• Work by the Mexican Health Foundation with
  Harvard University and the World Bank that showed
  that public funding did not dominate the health
  system, 1992-7
• Evidence to catalyse research and awareness
• Development of the WHO framework for health
  system performance assessment including Fairness
  of Finance and financial protection, 1998-2000
• Global rankings and evidence
• Transition Team of President Elect Fox identifies
  health and health sector priorities and
  formulates proposals for universal social
  insurance in health, 2000
• Global Evidence as a catalyst for a national
  reform, priority-setting and policy
• Incorporation of the Popular Insurance Program as
  a strategy in the National Health Program 2001-6,
  2001
• Evidence for policy design
• Large-scale piloting of the Popular Health
  Insurance, 2002-2003
• Incorporation into an evaluation scheme
• The reform of the General Health Law, 2003
• Evidence for advocacy and concensus-building
• The reform goes into effect, January 1st 2004
• Evidence for policy design-specifics, budgeting,
  evaluation
• Implementation and extension of coverage,
  2004-2006
• Monitoring and disseminating of progress
• Impact and policy evaluation by international
  organizations and academic groups

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Health system objectives
Level
Distribution
Health
Responsiveness
Fairness of finance/ Financial protection
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Mexico ranked low infairness of finance
in the W.H.O. (2000) evaluation of
health system performance.
13
Before the Reform, insurance coverage in Mexico
was highly inequitable and regressive by state,
in terms of health needs, and by income quintile.
Insurance coverage by quintile
Epidemiological backlog (mortality rate)
100
48 a 68
69 a 95
96 a 195
60
rate X 10,000
45 uninsured
20
Covered by Social Security
I
II
IV
V
TOTAL
III
Uninsured
Insured
51 a 70
35 a 50
18 a 49
Distribution of federal funds -2.4 times more
for the insured
Source Authors estimates using data from the
2000 Census ENIGH, 2000 and Salud México 2002,
Ssa (2003).
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Health finance in Mexico was heavily concentrated
in out of pocket spending and as a means of
financing health,
O.O.P. is inequitable and inefficient.
India
OOP as a of health system finance by GDP
80
Vietnam
China
60
Congo
Mexico
El Salvador
Ethiopia
Thailand
Paraguay
LAC
Malaysia
OOP
40
Brazil
Korea
Venezuela
Peru
Chile
Argentina
Bolivia
Costa Rica
Spain
Colombia
Italy
20
Uruguay
Panama
France
Germany
OECD
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Methodologies for measuring fairness of finance
and financial protection

• WHO-World Health Report 2000
• Guarantee that each household pays a fair share
  for health, based on a measure relative to
  capacity to contribute
• Eliminate the risk of impoverishment from health
  spending
• Progressivity of contributions (vertical equity)
• Households with similar incomes make similar
  contributions (horizontal equity)

• Index of Fairness in Financial Contributions
• of households with catastrophic payments
  (relative, gt 30 of disposible income)

Mexico/MOH-Funsalud, Wagstaff and VanDoorslaer
3. of households driven below, or deeper
below, the poverty line b/c of health spending 4.
(2)(3)Excessive health spending
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The incidence of absolute and relative
impoverishment from health spending is higher
among the uninsured and the poor.
Absolute and/or relative
6.3,
1.5 million families per trimester
2.2
Insured
9.6
Uninsured
19.6 910,000 families
Poorest quintile
Quintiles 2,3,4 and 5
3.1
In the poorest quintile, 2/3 of families are
below the poverty line and spend less than 30 of
disposable income, and 22 cross the poverty line
due to health spending.
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Among poor households, impoverishing health
expenditure is concentrated in medicines and
ambulatory care among the rich, in
hospitalization
Medicines
Hospitalization
Maternity
Other
Ambulatory care
poor
II
III
IV
wealthy
Source Authors calculations based on ENIGH,
2000.
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Key results from the simulated coverage of the
Popular Health Insurance, projections
The greatest impact on absolute and relative
impoverishment from health spending can be
achieved by extending public, subsidized health
insurance coverage

• The rural areas
• The poorest quintiles
• Medicines and ambulatory care
• Families with older adults, and families with
  young children

19
All indicators of impoverishment and fairness of
finance deteriorated during the economic crisis
of 1994-6, then improved continuously to 2004
Pre-economic crisis
Post economic crisis
Economic Crisis
With PHI and reform
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0.94
Absolute and /or relative
Absolute
of households
Index of fairness of finance
Relative
0
0.88
1992
1994
1996
1998
2000
2002
2004
Absolute impoverishment was more common until
2001. Relative is now more common.
20
Improvement since 2000, including the P.H.I.
period, is concentrated among the uninsured and
the poor.
of households with relative and/or absolute
impoverishment
12
35
Uninsured and PHI (after 2001)
DECILE 1
of households
DECILE 2
Insured (w/ Social Security)
0
0
1992
1996
2000
2004
2004
1992
1996
2000
DECILE 3, 4, 5

FuenteKnaul F, Arreola H, Mendez O. Tendencias
en la protección financiera en salud en México.
México, D. F. FUNSALUD, documento de trabajo,
2005.
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The highest rates of relative and absolute
impoverishment from health spending are among
families with older adults and young children,
and since 2000 particularly among families with
older adults
of households with relative and/or absolute
impoverishment
Older adults and children
30
Children, no older adults
of households
older adults, no children
Neither children or older adults
5
0
1992
1994
1996
1998
2000
2002
2004
Source Knaul F, Arreola H, Mendez O. Tendencias
en la protección financiera en salud en México.
México, D. F. FUNSALUD,documento de trabajo,
2005.
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Data National, household income and expenditure
surveys (NHIES), 1992 to 2004, including periods
of economic crisis, pilot of the P.H.I. And
introduction of the new health insurance system
Households in the sample
Year
10,503
1992
12,815
1994
Economic Crisis
14,042
1996
10,952
1998
10,108
2000
Pilot of Popular Insurance (PHI)
17,167
2002
22,595
2004
New health insurance law goes into effect
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Official indicators and publicionations on
financial protection in Mexico

• Salud México 2001, 2002, 2003 and 2004.
• Annual publications by the Ministry of Health
  that include indicators at the state level (not
  ranking, but does permit an analysis of relative
  performance). State budgets are partially based
  on these results.
• 2001
• IFFC and of households that spent 30 or more
  on health. National
• 2002
• IFFC and of households that spent 30 or more
  on health. By state.
• 2003
• IFFC, of households that spent 30 or more on
  health, of households with absolute
  impoverishment. National.
• 2004
• IFFC, of households that spent 30 or more on
  health, of households with absolute
  impoverishment. Time series, 1992-2004.

http//evaluacion.salud.gob.mx/saludmexico/saludme
xico.htm
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Evidence in the policy dialogue as advocacy for
reform

• each year almost 2 million households face
  catastrophic expenditures, because lacking access
  to social security and health insurance, caring
  for a sick family member becomes a cause of
  impoverishment due to the failure of our health
  system
• Dr. Julio Frenk Mora. Mexico, April 2001
• The extension of financial protection in health
  is generating important advances. According to
  published data, the number of families that
  suffered catastrophic or impoverishing health
  expenditure in Mexico fell from 3.7 million per
  year in 2000 to 2.6 million in 2004This notable
  improvement is almost exclusively concentrated
  among familieswhere the Popular Health Insurance
  is focused. Because these are the poorest
  families, the extension of financial protection
  in health has become a powerful instrument for
  fighting poverty and promoting social justice.
• Dr. Julio Frenk Mora, México, August 2005

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OUTLINE

• External Finance in Mexico
• Overview of the health reform
• The application of evidence on financial
  protection in the reform
• Conclusions

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Successful incorporation of evidence into policy
making strategic elements

• Build local research capacity to stimulate links
  between research and policy
• Collect data that are comparable over time
• Invest in research
• Participate in international research initiatives
  
• Translate research results into policy messages
• The importance of timing, collaboration and
  objectivity in integrating international
  frameworks and evidence produced by international
  agencies
• Link health and economic policy
• Use evidence and impact evaluation to guarantee
  continuity in the face of administrative and
  political turnover

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Future research

• Analyze the conditions under which international
  rankings are most useful to evoke policy
  responses
• Extrapolation from the case of health financing
  to other areas of health and health systems, and
  to other social sectors and systems where
  international rankings are heavily used (e.g.
  education)
• Analyze the causal relationship between changes
  in fairness of finance and changes in policy?
• Solve measurement and definition issues to
  generate better analytic tools

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External inputs of evidence, and for
evidence-building, on financial protection 2006

• Mexican Commission on Macroeconomics and Health
• OECD Towards High-Performing Health Systems,
  (2004) and Reviews of Health Systems México
  (2005)
• Global Development Network, Award 2005-6
• Harvard University Initiative for Global Health,
  Mexican Ministry of Health and The National
  Institute of Public Health. Evaluation of the
  System for Social Protection In Health.
• Health Financing Task Force

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Consejo Promotor Salud y Competitividad
Fundación Mexicana para la Salud
http//www.funsalud.org.mx/competitividad/principa
l.html