1. MÉXICO Department of Family Medicine UANL / Mexican College of Family Physicians. José M Ramírez-Aranda MD, PhD Professor - Researcher Family Medicine Department, UANL Mexican College of Family Medicine, AC

2. Department of Family Medicine UANL / Mexican College of Family Physicians. Demographics of Mexico´s population Population: 112 336 530 inhabitants (2010) Distribution: 78% Urban 22% rural Ethnicity: 7.1% indigenous population Náhuatl – 23% Maya – 11.% Mixteco – 7.1% Tetzal – 6.9% Others – 52% Unemployment rate: 5.2 (2011)

3. Overall health system design Mixed system: Public -Insured: IMSS. ISSSTE, PEMEX, SEDENA, SEMAR. Not insured: SP, SSa, SESA Popular Health Insurance (PHI) since 2003. Explicit service package Free Public Hospitals (small recovery fee) Available private insurance Specialist, hospital care and elective surgery. Direct payment Primary Care based on public system (out-of-pocket expenses) Subsidized drugs

4. How primary care is delivered in Mexico Public Health System. (Complex and expensive financing and administration) Family Physicians (IMSS) & General Physicians (Others) Multidisciplinary team Physicians, Nurses, medical Collaborators Mixed Financing Insured: Federal Government, employer, Out-of-pocket expense: Worker Uninsured : Federal, state government Pay for: Health services package (PHI, IMSS) Medical care Disability insurance, Retirement plan Few preventive interventions

5. Access to primary health care in Mexico Public System: No unique regulation Free: Medical consultation, preventive services, drugs, x-rays, imaging studies. Secondary and tertiary care. Out-of-pocket expenses: 45.2% of total health expenses (2012)

6. Department of Family Medicine UANL / Mexican College of Family Physicians. What are the benefits? Wide coverage and health services (PHI) Free service package Preventive programs, curative services, referral to 2nd & 3rd level of care Results NOT SURE WHAT THIS MEANS?

7. What are the drawbacks? Curative model Limited service package Isolated and vertical implementation in institutions No health regulation Complex financing Out-of-pocket expenses: 1.4% GDP; 35% of health cost

8. Department of Family Medicine UANL / Mexican College of Family Physicians. Impact on patient care Improvement in medical coverage Barriers: Some populations are not cared for (rural) Service quality (Personnel, Drugs) Financial protection (selective)

9. Epidemiological & demographic transition Chronic diseases: diabetes (15%); ischemic heart disease; HT Unhealthy life style diseases: Child obesity (6th place worldwide); Adults (2nd) OECD Department of Family Medicine UANL / Mexican College of Family Physicians. Growing health care burden in Mexico

10. Ability of health system to respond to challenge Prevention: Pillar of health system reform: FP Sugar, soda and bread taxes Government prevention program (very little success) National Universal Health System

11. Popular Health Insurance Gradual implementation (less pressure on budget) Primary medical care (normative vs. reality) Department of Family Medicine UANL / Mexican College of Family Physicians. Lessons for other countries

12. Thank you

13. Transition of the national health system Federal fundsContributionsHome funds Federal Services State Services IMSS Opportunities IMSS ISSSTE Private Services Past Federal fundsContributionsHome funds PHI expenses Catastrophic PHI CAUSES State Services IMSS Opportunities Federal Services IMSS ISSSTE Private Services Present Unique Federal FundComplementary funds Public Articulation Agencies Private Articulation Agencies Federal Services State Services IMSS Opportunities IMSS ISSSTE Private Services ¿Future?