& health spending in Mexico: Health insurance & health spending in Mexico: Families receiving remittances ACADEMY HEALTH Orlando; June 5, 2007 Felicia M. Knaul Fundación Mexicana para la Salud

OUTLINE Mexico: basic data Demographic and epidemiological transition The health system Health reform, 2003 Health spending, health insurance and remittances

Mexico: Basic indicators, 2003 & 2005. 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 103 million 24% 187,931 157,958; 84% 21,572; 96% $7,310 $US372; $PPP582 >20% 7.9 years 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

Rapid social transition: ej: Dramatic increase in education Average years of schooling 8.1 8 7.6 2.8 Women 2 2.4 Men 1960 1970 1980 1990 2000 2002 Source: INEGI, SISEMIN and DIE/INEE Panorama educativo de México 2004.

OUTLINE Mexico: basic data Demographic and epidemiological transition The health system Health reform, 2003 Health spending, health insurance and remittances

Chronic, Non-communicable 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. 72% 73% Communicable La otra opción es poner este cuadro Chronic, Non-communicable Injuries 22% 17% 10% 6% 1955 2005 Source: Sepúlveda et al. ,2006

Overweight and Obesity Mexico, 5 to 11, 2006 ¨Painful double burden of disease¨: e.g.: obesity affects all populations, but for the poor it co-exists alongside malnutrition Child malnutrition Mexico, 1988 and 2006 Overweight and Obesity Mexico, 5 to 11, 2006 Under height Under weight Emaciation 26% 23 20% 18 14 13 12% National Urban 8 6 5 Rural 2 2 1988 1999 2006 Source: Instituto Nacional de Salud Pùblica, 2006

OUTLINE Mexico: basic data Demographic and epidemiological transition The health system Health reform, 2003 Health spending, health insurance and remittances

Insurance (and health care) coverage in Mexico All persons, in the United States of Mexico, have the right to health protection. ART. 4, CONSTITUTION 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

Contrasts in health care and access

Effective coverage of select interventions (Lozano, 2006) 98 93 92 86 67 66 41 22 % BCG immunization Skilled birth attendance Measles immunization DTP3 immunization Antenatal care Diarrhea treatment (children) Cervical cancer screening Breast cancer screening Source: 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%+ India 80 Vietnam 60 Congo China Mexico % OOP Ethiopia El Salvador Paraguay Thailand Malaysia LAC 40 Brazil Korea Venezuela Peru Chile Argentina Bolivia Costa Rica Spain Colombia Italy 20 Uruguay Panama France Germany GDP per capita OECD GDP per capita vs. OOP as a % of health system finance Source: Authors own estimations based on data from WHO 2006

=1.5 millions of families per trimester Absolute and/or relative impoverishment due to health expenditure, 2000 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% Impoverishment (Knaul et al., 2005): -absolute: fall below or further below the poverty line -relative: spend 30%+ of disposable income on health Source: authors own estimations based on data from the ENIGH 2000

OUTLINE Mexico: basic data Demographic and epidemiological transition The health system Health reform, 2003 Health spending, health insurance and remittances

Seguro Popular System for Social Protection in Health 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 1943 Social Security Public and private, Formal sector workers and their families: ~50% of population Poor, informal sector, non-salaried, rural areas: ~ 50% of population 2001/3: Pilot of PHI 2003: Law Jan. 1, 2004: SSPH 2010: Universal coverage with Seguro Popular Seguro Popular System for Social Protection in Health Frenk et al., 2004.

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 that is expanding over time. 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) UNINSURED IMSS 32% 28% 53% 60% 11% 10.5 SEGURO POPULAR Seguro Popular, administrative data, end of 2006: 5.1 million families (~23,000,000 people) 28% of the population w/o social security Source: INSP, Encuesta Nacional de Salud, 2000; Encuesta Nacional de Salud y Nutrición, 2006.

OUTLINE Mexico: basic data Demographic and epidemiological transition The health system Health reform, 2003 Health spending, health insurance and remittances

Families with remittances, by insurance coverage URBAN RURAL TOTAL IMSS ISSSTE SEG. POPULAR WITHOUT INSURANCE 24 6 3 67 9 1 8 82 16 4 5 74 TOTAL: FAMILIES WITH REMITTANCES 3.6 12.3 5.6 Source: Authors`own estimations based on data from the ENIGH 2004

5.6% of families receive income transfers; Health spending as a proportion of total disposable household spending*, by remittances 12 6 1992 2005 With remittances Without remittances 5.6% of families receive income transfers; these families account for about 9.7% of total out-of-pocket health spending *Disposable household spending: total spending – spending on food Source: Authors`own estimations based on data from the ENIGH 1992-2005

Catastrophic health expenditure in families with and without remittances, by quintile 10 With remittances Without remittances 5 Perhaps the text would be better left in the notes: 5.6% of families receive income transfers, these account for about 9.7% of total out-of-pocket health financing. Average / capita health spending by households with remittances is 121 pesos ; compared to 75 pesos for households without remittances. Families who receive income transfers are significantly more likely to suffer catastrophic health expenditure. This holds true across all income quintiles. QUINTILE I QUINTILE V TOTAL Total Household Expenditure (as a proxy for perm. Income) Average/capita health spending by households with remittances is 121 pesos; compared to 75 pesos for households without remittances. Source: Authors own estimations based on data from the ENIGH 1992-2005

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. Beneficiaries Spouse, 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 400,000 Families affiliated to IMSS through ´Health Insurance for the Family´ 1997 2000 2003 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. Source: Authors own estimations based on data from the Memoria Estadistica del IMSS, 2006

Affiliation and location of care, most recent health problem Insured by IMSS Insured by Seguro Popular HEALTH CARE SERVICE REC´D FROM: 24% 18% IMSS 66% 78% PRIVATE 4% 11% OTHERS MINISTRY OF HEALTH 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. Source: Authors own estimations based on data from the Encuesta Nacional de Nutrición y Salud, 2006.

Municipalities with insured population, by level of ´poverty´ and institution, 2005 97% 100% 100% 100 87% 92% % 78% 60 20 These data were taken from the Conteo de Poblaciòn y Vivienda 2005. Very high High Medium Low Very low Total % OF MUNICIPALITIES WITH AT LEAST ONE FAMILY W/ IMSS AND/OR SEGURO POPULAR IMSS ISSSTE SEG.POP PRIVADOS Source: Authors own estimations based on data from INEGI 2005.

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-payment Develop specialized, ?integrated?, insurance products – IMSS, Seguro Popular, private - for migrants and families Centre for Health System Research, INSP Health 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