families receiving remittances families receiving remittances health insurance & health spending...
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Families receiving
remittances
Families receiving
remittances
Health insurance & health spending in Mexico:
Health insurance & health spending in Mexico:
Felicia M. KnaulFundación Mexicana para la Salud
ACADEMY HEALTH
Orlando; June 5, 2007
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Mexico: basic dataDemographic and epidemiological transitionThe health systemHealth reform, 2003Health spending, health insurance and remittances
Population % Rural
Localities 250 inhabitants or less 1,000 inhabitants or less
GDP per capita (current US$)
Health spending /capita
Poverty: <$2 per day
Average years of schooling
Mexico: Basic indicators, 2003 & 2005.
2003 data, World Health Organization, 2006.Source: INEGI. Conteo de Población y Vivienda 2005, World Bank, Key Development Data & Statistics; and World Health Organization, 2006
103 million 24%
187,931157,958; 84%21,572; 96%
$7,310
$US372; $PPP582
>20%
7.9 years
Rapid social transition: ej: Dramatic increase in education
Source: INEGI, SISEMIN and DIE/INEE Panorama educativo de México 2004.
Men
Women
Average years of schooling 8.1
2.8
7.6
2.42
8
1970 1980 1990 2000 20021960
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Mexico: basic dataDemographic and epidemiological transitionThe health systemHealth reform, 2003Health spending, health insurance and remittances
New challenges are associated with the rapid advance of profound demographic and epidemiologic transition.
Over 50 years, Mexico will complete an aging process that took two centuries in most European countries.
In 2050, one-in-four Mexicans will be 65 or over – a four-fold increase.
Costly, chronic, non-communicable illnesses now dominate the burden
of disease.
Costly, chronic, non-communicable illnesses now dominate the burden
of disease.
1955 2005
72%
22%
6%
73%
17%10%
Communicable
Chronic, Non-communicable
Injuries
Source: Sepúlveda et al. ,2006
¨Painful double burden of disease¨: e.g.: obesity affects all populations, but for the poor it co-exists alongside malnutrition
Overweight and ObesityMexico, 5 to 11, 2006
Overweight and ObesityMexico, 5 to 11, 2006
26%
12%
20%
Urb
an
Ru
ral
Nat
ion
al
Child malnutritionMexico, 1988 and 2006
Child malnutritionMexico, 1988 and 2006
Under height
Emaciation
Under weight
23
14
18
286
1988 1999
13
25
2006Source: Instituto Nacional de Salud Pùblica, 2006
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Mexico: basic dataDemographic and epidemiological transitionThe health systemHealth reform, 2003Health spending, health insurance and remittances
Insurance (and health care) coverage in Mexico
• Social Security: ~40% – IMSS: ~30-35%; formal-sector employees and family.– ISSSTE: ~5-7%; public sector employees and family.– Others: 3%; workers in specific industries
• Private insurance (first insurer): 1-2%– with capacity-to-pay; some public and private employees
• Ministry of Health (federal and state): 50+%– ´residual or ´open´ population without access to social security; poor– Lowest per capita investment in health
• Seguro Popular: health reform of 2003• Current coverage: 10 -15%• LAW: 100% of families without social security by 2010
All persons, in the United States of Mexico, have the right to health protection. ART. 4, CONSTITUTION
Contrasts in health care and access
Effective coverage of select interventions (Lozano, 2006)
% BCG immunization
Skilled birth attendance
Measles immunization
DTP3 immunization
Antenatal care
Diarrhea treatment (children)
Cervical cancer screening
Breast cancer screening
98
93
92
86
67
66
41
22Source: Lozano et al, 2006
Reliance on out-of-pocket spending to finance health systems is inversely related to GDP: Mexico is an exception at 50%+
FranceGermany
PanamaUruguay
ItalyColombia SpainBolivia Costa RicaArgentina
VenezuelaPeruBrazil Korea
ThailandMalaysiaParaguay
Ethiopia El Salvador
Congo China
Vietnam
India
20
40
60
80
Chile
MexicoLAC
OECD
GDP per capita vs. OOP as a % of health system finance
GDP per capita
% O
OP
Source: Authors own estimations based on data from WHO 2006
6.3% =1.5 millions of families per trimester
=~ 4 million per year
Insured: 2.2% Uninsured:
9.6% Poorest quintile: 9.6%
Quintiles 2-5: 3.1%
Absolute and/or relative impoverishment due to health expenditure, 2000
Source: authors own estimations based on data from the ENIGH 2000
Impoverishment (Knaul et al., 2005): -absolute: fall below or further below the poverty line
-relative: spend 30%+ of disposable income on health
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Mexico: basic dataDemographic and epidemiological transitionThe health systemHealth reform, 2003Health spending, health insurance and remittances
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
Social Security
Public and private, Formal sector workers and their families: ~50% of population
Ministry of Health with residual
funding
Poor, informal sector, non-salaried, rural areas: ~ 50% of population
1943
2001/3: Pilot of PHI
2003: Law
Jan. 1, 2004: SSPH
2010: Universal coverage with Seguro Popular
System for Social
Protection in
Health
Seguro Popular
Frenk et al., 2004.
Key elements of the reform:
1. Access to publicly-funded health insurance – Popular Health Insurance (PHI) - for all families excluded from Social Security.
2. Progressive pre-payment through a sliding-scale subsidy based on disposable income and zero family contribution for the poorest two deciles.
3. Separate budgeting and funds for public health goods with universal coverage.
4. Package of personal health services based on cost-effectiveness and burden of disease that is expanding over time.
5. Elimination of fees and co-payments at point-of-service for health care and medications.
Evolution of Health Coverage in Mexico by Institution; National Surveys: 2000-2005/6
2005(4)/6(1)2000
Source: INSP, Encuesta Nacional de Salud, 2000; Encuesta Nacional de Salud y Nutrición, 2006.
32%60%
28%
10.5
53%
11%
Seguro Popular, administrative data, end of 2006: •5.1 million families (~23,000,000 people)•28% of the population w/o social security
UN
INS
UR
ED
IMSS
SEGURO
POPULAR
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Mexico: basic dataDemographic and epidemiological transitionThe health systemHealth reform, 2003Health spending, health insurance and remittances
Families with remittances, by insurance coverage
TOTAL: FAMILIES WITH REMITTANCES 3.6 12.3 5.6
IMSS
ISSSTE
SEG. POPULAR
WITHOUT INSURANCE
URBAN RURAL TOTAL
24
6
3
67
9
1
8
82
16
4
5
74
Source: Authors`own estimations based on data from the ENIGH 2004
Health spending as a proportion of total disposable household spending*, by remittances
0
6
12
1992 2005
•5.6% of families receive income transfers;• these families account for about 9.7% of total
out-of-pocket health spending
With remittances Without remittances
Source: Authors`own estimations based on data from the ENIGH 1992-2005*Disposable household spending: total spending – spending on food
Catastrophic health expenditure in families with and without remittances, by quintile
0
5
10
QUINTILE I QUINTILE V TOTAL
With remittances
Without remittances
Source: Authors own estimations based on data from the ENIGH 1992-2005
Average/capita health spending by households with remittances is 121 pesos; compared to 75
pesos for households without remittances.
Total Household Expenditure (as a proxy for perm. Income)
Insurance options for Mexicans living abroad FOR HEALTH CARE IN MEXICO
Health Insurance for the Family
(IMSS)
Popular Health Insurance for
Migrant Families
Private insurance (examples)
Coverage
consultations, medications, lab work, basic dental, hospitalization, surgery, and maternity.
consultation, hospitalization, medications, lab work, surgery and maternity.
consultations,Hospitalization, laboratory work, surgery and maternity.
BeneficiariesSpouse, children, parents, and extended family
Nuclear family: Spouse and Children
Whomever is included in the quota.
Price
Paid once a year, cost per person: $101 to $266 USD
Family quota is a function of the family’s capacity to pay.
individual cost based on age and sex.
Restrictions
Serious, pre-existing illnesses: Cancer, diabetes, cardiovascular illness
Cannot be covered by other social security institution
Pre-existing illnesses are not covered.Maternity and pregnancy if insurance was contracted less than 10 months prior
Evolution of IMSS health insurance coverage
Families affiliated to IMSS through ´Health Insurance for the Family´
Source: Authors own estimations based on data from the Memoria Estadistica del IMSS, 2006
Health Insurance for the Family, the only voluntary, non-employment-based option for IMSS coverage,
has grown from 20,000 to ~380,000 families over the past decade, but remains tiny compared to overall
coverage and reportedly difficult to contract.
1997 2000 2003 2006
400,000
Affiliation and location of care, most recent health problem
Insured by IMSS
Insured bySeguro Popular
Source: Authors own estimations based on data from the Encuesta Nacional de Nutrición y Salud, 2006.
66% 24%11%
IMSS
4%
78% 18%
MINISTRY OF HEALTH
PRIVATE
OTHERS
A large proportion of people with health insurance coverage use private services and pay out-of-pocket. This is true for IMSS, ISSSTE and Seguro Popular.
HEALTH CARE SERVICE REC´D FROM:
0
20
60
100
IMSS ISSSTE
SEG.POP PRIVADOS
78%87%
97% 100% 100%
% OF MUNICIPALITIES WITH AT LEAST ONE FAMILY W/ IMSS AND/OR SEGURO POPULAR
%
Municipalities with insured population, by level of ´poverty´ and institution, 2005
Source: Authors own estimations based on data from INEGI 2005.
Very high High Medium Low Very low Total
92%
Conclusions and future research The level and catastrophic nature of health spending
by families with remittances, and the current situation of the health system and the reform in Mexico, suggest an important opportunity – health, equity and efficiency – for converting OOP into pre-paymentDevelop specialized, ?integrated?, insurance products – IMSS, Seguro Popular, private - for migrants and families
Centre for Health System Research, INSPHealth Initiative of the Americas, U of California
Analyze the nature and determinants – qualitative and quantitative – of remittances sent to finance health care
Funsalud; INSP; Estudio sobre Migración, Salud y Seguro Popular, 2007 (Nigenda et al)
Compare and contrast with Canadian bi-national programs (SAW) and policy on migration, work and health insurance