A Diagonal Approach to
analyzing UHC: Cancer and the
Mexico Seguro Popular
Felicia Marie Knaul,Director, Harvard Global
Equity Initiativeand Mexican Health
FoundationAnd
Héctor Arreola Ornelas and Oscar Méndez,Mexican Health
Foundation
NEW CHALLENGE DISEASES
(NCD)Chronicity
+ Polarized and protacted epidemiological transtion
#2 cause of death in wealthy countries #3 in upper middle-income#4 in lower middle-income and # 8 in low-income countries
For children & adolescents 5-14cancer is
In developing regions,breast cancer…
• Most common cancer in developed and developing regions
• Most frequent cause of cancer-related death in developing and developed regions
• A leading cause if death especially for young women
• 268,000 of the 458,000 deaths per year are in LIMCs: 58%
• 4.4 million women alive (diagnosed): how many in developing regions?
(Globocan, 2010; Boyle y Levin, 2008; Beaulieu, Bloom, y Bloom, 2009).
Adults
BreastCervix Prostate
Testis
HL
N HL
Leukaemia
All cancers
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
Children
LOW INCOME
HIGH INCOME
Survival inequality gap
LOW INCOME
HIGH INCOME
100%
The opportunity to survive (M/I)should not be defined by income.
Yet it is.
Why a Diagonal Approach to Health System Strengthening and UHC
• Rather than focusing on disease-specific vertical programs or only horizontally on system constraints, harness synergies that provide opportunity to tackle disease-specific priorities while addressing systemic gaps.
• Optimize available resources so that the whole is more than the sum of the parts
• Bridge the divides as patients suffer diseases over a lifetime, most of it chronic
• Sepulveda et al., 2006.
Health system functions and diagonal integration
Diagonal, synergistic:
verticaland
horizontal integration
Disease Specific: vertical
integration, horizontal
segmentation
Generalized: vertical
segmentation, horizontalintegration
Atomized:vertical
and horizontal
segmentation
Stewardship
Financing Revenue collection Fund Pooling Purchasing
Provision
Revenue generation
FUC
TIO
NS
Adapted from Murray and Frenk; WHO Bulletin 2000
Disease 1Disease 2Disease 3
1. Harness platforms: Integrate disease prevention, screening and survivorship into MCH, SRH, HIV/AIDs, social welfare/anti-poverty programs
2. Delivery: Catalyze, employ and deploy community health workers and expert patients
3. Financing: social protection strategies that include horizontal and vertical coverage
4. Stewardship: Improve regulatory frameworks to remove non-price barriers to pain control
5. Developing effective health services research and indicators
Diagonal strategies for NCD
A Diagonal Approach toFinancial Protection
Vert
ical
Cov
erag
e: N
umbe
r of
Dis
ease
s an
d In
terv
entio
ns
The Diagonal Approach
:
Financing (a
nd delivery)
Horizontal Coverage: Number of Beneficiaries
Prevents impoverishm
ent and catastrophic expenditures:Pre-paid, subsidized, public
UHC: intersection between coverage and financial protection in the face of chronicity• Stages – lifecycle of interventions
for a chronic illness– Primary prevention– Secondary prevention (early detection)– Diagnosis– Treatment– Survivorship care– Palliative care
Depth of the package = effective coverage + effective financial protection
MEXICO: SEGURO POPULAR
Distribution of mortality,1-15 years Mexico, 1979-2008
0
40
1979 2008
1-4 5-14
Malignant tumors
40
5%16%
Respiratory infectionsInfectious and parasitic diseases
%
1979 20080
Source: Lozano, Knaul, Gómez-Dantés, Arreola-Ornelas y Méndez, 2008, Tendencias en la mortalidad por cáncer de mama en México, 1979-2007. FUNSALUD, Documento de trabajo. Observatorio de la Salud, con base en datos de la OMS y la Secretaría de Salud de México.
Mortality from breast and cervical cancer in Mexico1955-2008: less death from cervical
#2 cause of death, women 30-54
Rate for100,000 women adjusted for age
0
4
8
12
16
1955
1965
1975
1985
1995
2005
CérvixMama
1979
0
4
8
12
16
1980 1985 1990 1995 2000 2005
Distrito FederalMR x 100,000 women
2008
0
Oaxaca
5
10
15
20
25 MR x 100,000 women
19791980 1985 1990 1995 2000 2005
2008
Key Financing Elementsof the 2003 Mexico Reform:
1. Access to publicly-funded, heavily subsidized, progressive health insurance –Seguro Popular- for all families excluded from Social Security
2. Separate budgeting and funds for public health goods with universal coverage
3. Package of personal health services based on cost-effectiveness and burden of disease – expands over time
4. Fund for Catastrophic Illness covering specific interventions for specific diseases – expands over time
# of covered services: personal
Source: Comisión Nacional de Protección Social en Salud, 2010
104 113146
249262 266
XX??
Increase in population coverage + expansion of package of services w/ increased MOH budget dedicated to SPS
Households affiliated to Seguro Popular
2006
2004
~100%
2012
2005
~17.
2 m
illon
es d
e fa
mili
as
3%
9%
30%
20%
42%
1.5 3.5
mill
ones
5.1
mill
ones
7.3
mill
ones
53%
0.6
9.1
mill
ones
2007
2008
2003
61%10
.5 m
illon
es20
09
85%
14.7
mill
ones
2010
2006
2004
2012
2005
2007
2008
2003
2009
2010
275
+
2011
282
Incorporation of Diseases in the Catastrophic Fund
Disease Category Initiation of CoverageCervical Cancer 2004
HIV-AIDS 2005
Intensive neonatal care 2005
Cataracts 2006
Childhood cancers 2006 – LLA 2008 - All cancer
Bone marrow transplants 2006
Transplants for congenital and acquired defects (Health Insurance for a New Generation)
All children born after December 2006
Breast Cancer 2007
Acute myocardial infarction, non-Hodgkin’s lymphona, lysosomal diseases, bone marrow transplant, corneal transplant and testicular tumor
2011
Rigorous evaluation• Rigorous evaluation processes have been underway since the SPS was
established and the results are encouraging.
• The incidence of catastrophic spending has decreased by more than 20% among those who have taken on Seguro Popular, as has overall out of pocket spending especially among the poorest households. (King , Gakidou , Imai et al, 2009)
• Since the incorporation of childhood cancers into the program in 2006, 30-month survival has increased from approximately 30% to almost 70% and adherence to treatment from 70% to 95%. (Pérez-Cuevas etal 2010)
• Another study of breast cancer begun in 2007, reported an 80% survival rate of 30-months after initiating treatment and an increase in adherence to treatment from 79% to 98%. (Lara Medina et al, 2010)
• A separate study showed that hypertensive adults insured through Seguro Popular had a significantly higher probability of accessing effective treatment and that this was associated with a greater supply of health professionals (Bleich et al., 2010)
Beneficiaries: Population covered
Ben
efits
: cov
ered
inte
rven
tions
Horizontal and vertical financial protection strategies: Seguro Popular in Mexico
Catastrophic IllnessACCELERATED VERTICAL COVERAGE: Ex: breast cancer,
AIDS
Package of essential personal
services
Community Health Services
Poor Rich
Health insurance for a new generation
Barrier: Lack of financialprotection for early detection.
Source: Groot et al, 2006. The Breast Journal
• Since February 2007, every Mexican woman has the right to ‘full’ financial protection for the treatment of breast cancer.
…Yet, early detection is only covered for those already insured, difficult to access and there is a threat of reducing the entitlement
… and early detection is unaffordable mammography, biopsy and pathology - at the most subsidized level in a public hospital - costs more than one month of subsistence income.
Effective financial coverage: breast cancer in Mexico
– Primary prevention– Secondary prevention (early detection)– Diagnosis– Treatment– Survivorship care– Palliative care
Large and exemplary investment in treatment for women and the health system
yet a low survival rate. By applying a diagonal approach, this can and is be
remedied.
Juanita
A Diagonal Approach to
analyzing UHC: Cancer and the
Mexico Seguro Popular
Felicia Marie Knaul,Director, Harvard Global
Equity Initiativeand Mexican Health
FoundationAnd
Héctor Arreola Ornelas and Oscar Méndez,Mexican Health
Foundation