Mariana Barraza-Lloréns

The Quest for Universal Health Coverage: Achieving Social Protection for All in Mexico

Mexico is reaching universal health coverage in 2012. A national health insurance programme called Seguro Popular, introduced in 2003, is providing access to a package of comprehensive health services with financial protection for more than 50 million Mexicans previously excluded from insurance. Universal coverage in Mexico is synonymous with social protection of health. This report analyses the road to universal coverage along three dimensions of protection: against health risks, for patients through quality assurance of health care, and against the financial consequences of disease and injury. We present a conceptual discussion of the transition from labour-based social security to social protection of health, which implies access to effective health care as a universal right based on citizenship, the ethical basis of the Mexican reform. We discuss the conditions that prompted the reform, as well as its design and inception, and we describe the 9-year, evidence-driven implementation process, including updates and improvements to the original programme. The core of the report concentrates on the effects and impacts of the reform, based on analysis of all published and publically available scientific literature and new data. Evidence indicates that Seguro Popular is improving access to health services and reducing the prevalence of catastrophic and impoverishing health expenditures, especially for the poor. Recent studies also show improvement in effective coverage. This research then addresses persistent challenges, including the need to translate financial resources into more effective, equitable and responsive health services. A next generation of reforms will be required and these include systemic measures to complete the reorganisation of the health system by functions. The paper concludes with a discussion of the implications of the Mexican quest to achieve universal health coverage and its relevance for other low-income and middle-income countries.Mexico is reaching universal health coverage in 2012. A national health insurance programme called Seguro Popular, introduced in 2003, is providing access to a package of comprehensive health services with financial protection for more than 50 million Mexicans previously excluded from insurance. Universal coverage in Mexico is synonymous with social protection of health. This report analyses the road to universal coverage along three dimensions of protection: against health risks, for patients through quality assurance of health care, and against the financial consequences of disease and injury. We present a conceptual discussion of the transition from labour-based social security to social protection of health, which implies access to effective health care as a universal right based on citizenship, the ethical basis of the Mexican reform. We discuss the conditions that prompted the reform, as well as its design and inception, and we describe the 9-year, evidence-driven implementation process, including updates and improvements to the original programme. The core of the report concentrates on the effects and impacts of the reform, based on analysis of all published and publically available scientific literature and new data. Evidence indicates that Seguro Popular is improving access to health services and reducing the prevalence of catastrophic and impoverishing health expenditures, especially for the poor. Recent studies also show improvement in effective coverage. This research then addresses persistent challenges, including the need to translate financial resources into more effective, equitable and responsive health services. A next generation of reforms will be required and these include systemic measures to complete the reorganisation of the health system by functions. The paper concludes with a discussion of the implications of the Mexican quest to achieve universal health coverage and its relevance for other low-income and middle-income countries.

Priority setting for health interventions in Mexico's System of Social Protection in Health

Explicit priority setting presents Mexico with the opportunity to match the pressure and complexity of an advancing epidemiological transition with evidence-based policies driven by a fundamental concern for how to make the best use of scarce resources to improve population health. The Mexican priority-setting experience describes how standardised analytical approaches to decision making, mainly burden of disease and cost-effectiveness analyses, combine with other criteria--eg, being responsive to the legitimate non-health expectations of patients and ensuring fair financing across households--to design and implement a set of three differentiated health intervention packages. This process is a key element of a wider set of reform components aimed at extending health insurance, especially to the poor. The most relevant policy implications include lessons on the use of available and proven analytical tools to set national health priorities, the usefulness of priority-setting results to guide long-term capacity development, the importance of favouring an institutionalised approach to cost-effectiveness analysis, and the need for local technical capacity strengthening as an essential step to balance health-maximising arguments and other non-health criteria in a transparent and systematic process.

Definición de prioridades para las intervenciones de salud en el Sistema de Protección Social en Salud de México

La definicion explicita de prioridades en intervenciones de salud representa una oportunidad para Mexico de equilibrar la presion y la complejidad de una transicion epidemiologica avanzada, con politicas basadas en evidencias generadas por la inquietud de como optimizar el uso de los recursos escasos para mejorar la salud de la poblacion. La experiencia mexicana en la definicion de prioridades describe como los enfoques analiticos estandarizados en la toma de decisiones, principalmente los de analisis de la carga de la enfermedad y de costo-efectividad, se combinan con otros criterios -tales como dar respuesta a las expectativas legitimas no medicas de los pacientes y asegurar un financiamiento justo para los hogares-, para disenar e implementar un grupo de tres paquetes diferenciados de intervenciones de salud. Este es un proceso clave dentro de un conjunto mas amplio de elementos de reforma dirigidos a extender el aseguramiento en salud, especialmente a los pobres. Las implicaciones mas relevantes en el ambito de politicas publicas incluyen lecciones sobre el uso de las herramientas analiticas disponibles y probadas para definir prioridades nacionales de salud; la utilidad de resultados que definan prioridades para guiar el desarrollo de capacidades a largo plazo; la importancia de favorecer un enfoque para institucionalizar el analisis ex-ante de costo-efectividad; y la necesidad del fortalecimiento de la capacidad tecnica local como un elemento esencial para equilibrar los argumentos sobre maximizacion de la salud con criterios no relacionados con la salud en el marco de un ejercicio sistematico y transparente.

Hacia la cobertura universal en salud: protección social para todos en México

Mexico alcanzara la cobertura universal en salud en 2012. El seguro nacional de salud denominado Seguro Popular, introducido en 2003, garantiza el acceso a un paquete de servicios de salud integrales con proteccion financiera a mas de 50 millones de mexicanos previamente excluidos de la seguridad social. La cobertura universal en Mexico es sinonimo de proteccion social en salud. Este informe analiza el camino hacia la cobertura universal en sus tres dimensiones de proteccion: a) contra riesgos para la salud, b) de los pacientes a traves de la garantia de calidad de la atencion a la salud y c) contra las consecuencias financieras de la enfermedad y las lesiones. Se presenta una discusion conceptual sobre la transicion de una seguridad social basada en la condicion laboral a la proteccion social en salud, que implica el acceso a una atencion integral de la salud como derecho universal basado en la ciudadania, plataforma etica de la reforma mexicana. Se describen asimismo las condiciones que llevaron a la reforma, asi como su diseno y puesta en marcha, y se discute el proceso de implantacion a nueve anos de iniciado y las evidencias que dieron origen a actualizaciones y mejoras del programa original. El nucleo del informe se centra en los efectos e impactos de la reforma que se desprenden de la literatura sobre el tema, que incluye articulos cientificos y otras publicaciones disponibles. La evidencia indica que el Seguro Popular esta mejorando el acceso a los servicios de salud y reduciendo la prevalencia de los gastos en salud catastroficos y empobrecedores, especialmente entre los pobres. Estudios recientes muestran asimismo una mejora en la cobertura efectiva. Tambien se discuten los desafios prevalentes, incluyendo la necesidad de traducir los recursos financieros en servicios de salud mas efectivos, equitativos y sensibles a las expectativas de los usuarios. Se requiere una nueva generacion de reformas que incluya medidas sistemicas para consolidar la reorganizacion del sistema de salud por funciones. El articulo concluye con una discusion sobre las implicaciones de la busqueda de la cobertura universal de salud en Mexico y su importancia para otros paises de ingresos bajos y medios.

Mexico's path towards the Sustainable Development Goal for health: an assessment of the feasibility of reducing premature mortality by 40% by 2030

Summary Background The United Nations Sustainable Development Goal for health (SDG3) poses complex challenges for signatory countries that will require clear roadmaps to set priorities over the next 15 years. Building upon the work of the Commission on Investing in Health and published estimates of feasible global mortality SDG3 targets, we analysed Mexicos mortality to assess the feasibility of reducing premature (0–69 years) mortality and propose a path to meet SDG3. Methods We developed a baseline scenario applying 2010 age-specific and cause-specific mortality rates from the Mexican National Institute of Statistics and Geography (INEGI) to the 2030 UN Population Division (UNPD) population projections. In a second scenario, INEGI age-specific and cause-specific trends in death rates from 2000 to 2014 were projected to 2030 and adjusted to match the UNPD 2030 mortality projections. A third scenario assumed a 40% reduction in premature deaths across all ages and causes. By comparing these scenarios we quantified shortfalls in mortality reductions by age group and cause, and forecasted life expectancy pathways for Mexico to converge to better performing countries. Findings UNPD-projected death rates yield a 25·9% reduction of premature mortality for Mexico. Accelerated reductions in adult mortality are necessary to reach a 40% reduction by 2030. Mortality declines aggregated across all age groups mask uneven gains across health disorders. Injuries, particularly road traffic accidents and homicides, are the main health challenge for young adults (aged 20–49 years) whereas unabated diabetes mortality is the single most important health concern for older adults (aged 50–69 years). Interpretation Urgent action is now required to control non-communicable diseases and reduce fatal injuries in Mexico, making a 40% reduction in premature mortality by 2030 feasible and putting Mexico back on a track of substantial life expectancy convergence with better performing countries. Our study provides a roadmap for setting national health priorities. Further analysis of the equity implications of following the suggested pathway remains a subject of future research. Funding Mexicos Ministry of Health, University of California, San Francisco, and Bill & Melinda Gates Foundation.