The document summarizes health reforms in Mexico from 1943-2004, with a focus on the 2004 reform that established the Health Social Protection System. It overviews declining mortality rates and increasing life expectancy over time. Key aspects of the 2004 reform included establishing universal health care coverage, separating financing from service provision, defining an essential benefits package, and increasing accountability through performance measurement. The reform reorganized Mexico's health system to improve access, quality, and financial protection for all citizens.

1. Health Reform in Mexico in 2004: the origin of the Health Social Protection System Rafael Lozano MD MSc Global Health Seminar, “Aid and Health” November 13 2009

2. Outline Background Current Mexican´s facts Health reforms in Mexico 1943-2004 How evidence did help in the design of the 2004 Health Reform in Mexico? Empowerment and action Ethical component Legal process to get approval Democratizing the health System in Mexico : Innovations Stewardship Financing Services delivery Lessons Learned

4. 11,000 Km of littorals

5. 3,000 km border in the north and 1,000 south

6. Huge biodiversity

7. 108 mill pop in 2009 (11th largest)

8. 75% in Urban areas

9. 56% in metropolitan areas

10. Rural means marginality, exclusion

11. 12% indigenous disperse

12. Administrative division:

13. 31 states and Federal District

14. 2,455 municipalities

16. 5 DEMOGRAPHIC INDICATORS 2009 100 90 80 Male Female 70 Rates x 1000 pop 60 50 50 45 40 Births rate 30 40 20 10 35 0 Progress (years) Life expectancy 30 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 0.4 0.6 0.8 1.0 1.2 Migrants to USA Millions Millions - 35.9 1930 25 30.0 13 49.0 1950 18.2 millions 1st. - 3rd. generation 20 25.0 12 60.9 1970 10 71.2 1990 15 20.0 5 76.6 2010 10 15.0 Mortality 11.1 millions Born in Mexico 10.0 5 5.0 0 0.8 4.5 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2006 Year Mexican Origin Born in Mexico Life expectancy at birth Years 85 Female 80 75 Male 70 65 60 55 50 45 40 35 1930 40 50 60 70 80 90 2000 10 20 30 40 2050 Sources: INEGI, CONAPO, DGIS,

17. 200.0 Tasa x 1000 ajs edad Diarrheas 180.0 Respiratory Infections 160.0 Diabetes Mellitus 140.0 Ischemic Heart Disease 120.0 Cirrhosis 100.0 80.0 60.0 40.0 20.0 0.0 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Fuentes: Lozano R, 2008. Basada en INEGI y CONAPO varios años 70 years of mortality transitions in Mexico: ages and causes Deaths by age Fuentes: Lozano R, 2008. Basada en INEGI y CONAPO variosaños

18. 20.0 18.0 17.3 16.0 15.1 14.0 Diabetes 53% Ischaemic Heart Dis 21% Hyperntensive Heart Dis 13% Cerebro vascular Dis 8% 11.4 Diabetes 70% Ischaemic Heart Dis 22% Cerebro vascular Dis 8% 12.0 Ischaemic Heart Dis 22% Cerebro vascular Dis 8% Hyperntensive Heart Dis 13% 10.0 8.0 5.3 6.0 5.0 4.5 4.3 4.1 COPD Malnutrition Diarrhea HIV/AIDS Diabetes 52% I.H.D 10% Stroke 10% 4.0 3.3 I.H.D 74% Stroke 16% COPD 43% I.H.D. 14% I.H.D 86% Stroke 14% I.H.D 56% Cirrhosis 14% 2.0 0.0 High Cholesterol High Blood Glucose High Body Mass Index High Blood Pressure Physical Inactivity Low Fruit & Veget. Intake Alcohol Others Tobacco Main killers of women in Mexico, 2006 Source: MOH/DGIS, HIGH, 2006

19. Leading causes of DALYs by sex, Mexico 2005 Women Men % %

20. Predicted Infant Mortality by Municipality and Level of Marginality, 2005 90.0 Very Low Low Medium High Very High 80.0 70.0 Infantl mortality per 1000 lb 60.0 4.5 50.0 4.0 Diarrheas 40.0 3.5 Low resp Infec Under nutrition 30.0 3.0 20.0 2.5 8.0 2.0 10.0 Source: CONAPO, 2008 TM < 5 años x 1000 nv 7.0 1.5 0.0 6.0 -3.0 -2.0 -1.0 0.0 1.0 2.0 3.0 Birth Asphyxia Marginality 1.0 Congenital Anomalies 5.0 0.5 Prematurity 0.0 4.0 Very Low Very High Hugh Median low TM < 5 años x 1000 nv 3.0 2.0 1.0 0.0 Very High High Media Low Very low Source: Lozano R,2008

21. Mexican Health System (before reform) 30% 15% 55% 40% 30% 30% 45% 45% 10% Source: Frenk J. et al 2003

22. Outline Background Current Mexican´s facts Health reforms in Mexico 1943-2004 How evidence did help in the design of the 2004 Health Reform in Mexico? Empowerment and action Ethical component Legal process to get approval Democratizing the health System in Mexico : Innovations Stewardship Financing Services delivery Lessons Learned

23. Reform From Latin “reformare” … “form or shape again” (re-form) “…make changes in (something) in order to improve it…” to remove abuse and injustices reclaim, regenerate, rectify Synonymous: better, improve, amend, ameliorate, meliorate, innovation, transform, modification, etc. Can we put adjectives to the word “Reform”? Radical, minimalist, moderate, progressive For Public Policy, Public Health and Social Analysis Purposes aim to improve the system describe changes to public services reform may be: no more than fine tuning Redressing serious wrongs without altering the fundamentals of the system Reform seeks to improve the system as it stands, never to overthrow it wholesale

24. Health reform typically attempts to Broaden the population that receives health care coverage through either public sector insurance programs or private sector insurance companies Expand the array of health care providers consumers Improve the access to health care facilities Improve the quality of health care Decrease the cost of health care Increase the financial resources for health etc., etc.,

25. Three generations of Health Reform in Mexico 14 2004 1982 1943 Million of population 1943 Foundation of the Modern Health System 1982 Toward a National Health System 2004 Health Social Protection Source: Frenk J. et al 2003

26. Health Reforms in Mexico: three generations 1943 Foundation of the Modern Health System Ministry of Health Social Security for all workers 1982 Toward a National Health System Change of the Mexican Constitution Article 4: Health protection is a right of the population and an obligation of the government General Health Law Decentralization of the health system (state level) Coordination and Integration of health providers Administrative Modernization 2004 Health Social Protection Separation of financing from the provision of services to stimulate competition and accountability; Evaluation of health interventions with the goal of designing cost-effective benefit packages; Programs for the continuous improvement of quality of care; and Increased participation of citizens in their care. Source: Frenk J. et al 2003

27. Outline Background Current Mexican´s facts Health reforms in Mexico 1943-2004 How evidence did help in the design of the 2004 Health Reform in Mexico? Empowerment and action Ethical component Legal process to get approval Democratizing the health System in Mexico : Innovations Stewardship Financing Services delivery Lessons Learned

28. Priorities for research and development (the intelligence) National Health Accounts (the means) National Burden of Disease (the problem) Universal package of health services (the solutions) Proposals for reform (the vehicle) Cost- effectiveness analysis Financing (the require- ments) Analysis of system performance (the capacity) Building the evidence Frenk J., Lozano R., González MA, et al 1994

29. Public Politics Political Ethical Technical Evidence andInformation The Pillars of Public Politics on Health Source: Frenk, J. 2005

30. The challenges of the Mexican Health System Equity: change in the health pattern with more social and regional inequalities Quality: heterogeneous performance by provider and lack of responsiveness Financial Protection: the uncertainty risk to have catastrophic expenditures

31. Financial Protection Motivation Almost half the families have no health insurance, which leads to postpone care and to be incurred in catastrophic expenditures, as well as generating a deep injustice

32. Financial Unbalances Level: investment: 5.8% of GDP Source of funds: the predominance out of pocket payments (55%) Distribution 3.1 Among populations: 1.5 times between insured and uninsured 3.2. Between states: 8 to 1 in the state with the highest per capita federal spending and the state with the lowest per capita federal spending State effort on health expenses: 119 to 1 between higher and lower Destination: increasing the payroll, with a fall in infrastructure investment

33. Financial imbalances Underinvestment Health expenditure as percentage of GDP 16 13.9 14 12 10.9 Latin America average: 10 9.3 $ 36,948 mills. de USD $ 356 USD per capita Percent 8 7.2 6.9 5.8 6 5.3 4 2 0 Bolivia Mexico USA Uruguay Colombia Costa Rica

34. Financial imbalances Source of funds Social Security 61% States 7% Federal 32% Private Insurances 3% Public Expenses 42% Out of Pocket 55%

35. Financial imbalances Unequal effort from the states Federal States Percentage of federal and state expenses on health for uninsured population 100% 80% 60% 40% 20% 0% AGS. B.C. B.C.S. COL. D.F. HGO. JAL. MICH. NAY. PUE. QRO. S.L.P. SON. VER. TLAX. YUC. ZAC. CAM. COAH. CHIS. CHIH. DGO. GTO. GRO. MEX. MOR. N.L. OAX. Q.ROO SIN. TAB. TAMPS.

36. Financial imbalances Imbalance destination of the expenditure Federal expenses by chapter 100% 80% 60% 40% 20% 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 Health care Administrative Investment on Infrastruc

37. Financial imbalances Impoverishment due to health spending 2 millions: Catastrophic expenses (more of 30% of income available) 1.5 millions of families .5 millions of families 1.8 millions of families 2.3 millions: immiserizing spending ( "Medical indigence") Source: Encuesta Nacional de Ingresos y Gastos de los Hogares, 2000. Estimaciones CASESALUD

38. Universality Social Inclusion NationalPortability Equal opportunities Explicit Priorization Fair Finance Free of Charge in the moment of use Financial Solidarity Co-respon-sability Subsidiarity Democratic Budgeting Individual Autonomy Accountability Ethical foundations of the reform Principles Key Concept Values Democratization of Health

39. Democratizing the health System in Mexico Empower people making them aware about their entitlements Transparency and accountability Objectives of the Reform Ordering the health financing and increasing public budget gradually, fiscally responsible and financially sustainable To protect investments in prevention and health services to the community To provide financial protection in health care to the population, especially the poorest To transform the Incentives in order to achieve a democratic budgeting, which allows to increase the satisfaction of population's expectations

40. More than a Legal process to get the change in the Law Foundation of The National Institute of Public Health, January 1987 The Health and the Economy 1994, Frenk et al. Beginning of the administrative period, Dec 2000 Release of the National Health Program 2000-2006, July 2001 Initiative sent to the congress, Nov 2002 Approval in the Congress, April 2003 (92% of votes in the senate house and 79% in the representatives house) The Official Gazette published the decree that reforms and adds the General Health Law, May 2003 Started the System of Social Protection in Health, January 2004 29

42. Two level of government were involved (state and national)

44. Structural reform of the health systemfinancing Innovations Universalization of social security on health Establishment of the System on Social Protection in Health Master Plan for Health infrastructure Protection against catastrophic expenses Budget priority for public health New plan for democratic budgeting Affiliation with explicit rights for all people

45. Reorganization of the Mexican Health System Source: Frenk J. et al 2003

46. Stewardship Key function, mother function “…To do that others do what they must do…” Tools and rules Coordination, regulation, monitoring and evaluation Create instruments with explicit rules for financial transfers Priority setting to a package Certification of health infrastructure Orient financial flows Demand instead supply Accountability

48. New structure to provide universal financial protection Contributors Public Insurances Co-responsible contributor Federal Government Beneficiary IMSS salaried employees in the private sector Private Employer employee taxes Social contribution Public Employer Social contribution Employee taxes ISSSTE salaried employees in the public sector Seguro Popular non-salaried workers,self-employees, families outside of the formal labour force Family Solidarity contribution Social contribution State Federal Gov

49. Service Delivery Master plans Investment in infrastructure Medical equipment Human resources Universal Coverage Essential package (249) Catastrophic expenses (17) Improving the Quality of care Accreditation of health facilities

51. Seguro Popular Accelerated Vertical Coverage New vaccines Equal start of life New vaccines Children & adolescents Cancer Cervix Cancer Children Cancer Cataracts HIV/AIDS < 9 months 2 years 5 years 18 years 60 years Life line

52. Outline Background Current Mexican´s facts Health reforms in Mexico 1943-2004 How evidence did help in the design of the 2004 Health Reform in Mexico? Empowerment and action Ethical component Legal process to get approval Democratizing the health System in Mexico: Innovations Stewardship Financing Services delivery Lessons Learned

53. Lessons Learned The ABCDE of the successful reform Agenda Budget Capacity Deliverables Evidence Healthy Policies National Commission for Risk Protection Global Public Goods for local decision-making

54. Report 2009 1stsem(NCSPH) Affiliation 9.6 millions of families (28.5 millions of people) Almost all Municipalities Increase in the number of people of the first and second deciles (including indigenous population) New generation program (2.2 million) Healthy pregnancy (380 K) 90.9% of re-affiliation Services Delivery 39 million of visits Half a million of hospital discharges (245 K of deliveries) Waiting time 58 min (?) 78% of patients have received all drugs from doctor prescription (?) Financial imbalances follow up Source: Frenk J., et.al. 2006

56. Promote privatization of health services

57. Federal government funding below promised levels

58. Bureaucratic rigidity and slow implementation of contracts

59. Limited progress in signing SP portability agreements among states

60. The use of funds for purposes other than those for which they were intendedThe poor are affiliating to Seguro Popular More resources are available for the uninsured and the distribution of resources across states is more equal Mixed results for utilization of health services among SP affiliates Composite coverage has increased for the country and for the uninsured Inequalities in coverage have decreased across states and across wealth deciles Catastrophic spending is lower among SP affiliates than the uninsured, especially within subgroup that use health services

61. 46 National Health System (2007) Physicians % Beds % Population Affiliated % Health Expenses per capita USD Hospitals % 87.9 34.5 33.3 42.4 No Medical Insurance 26.8 325.6 36.0 36.5 27.9 Medical Insurance 73.2 324.8 25.0 27.6 16.3 IMSS 35.8 231.9 7.7 5.9 6.4 ISSSTE 7.5 216.8 Seguro Popular (Health Reform) 25.5 910.0 3.2 3.2 5.0 Others 1.5 1,000.0 29.5 30.2 29.7*** Private 2.9 534.2 218** 115** 1,664 Total (absolute) 106* * Millions ** thousands *** Includes Hospitals over 15 beds. Private Sector has more than 2.5 thousand small hospitals

62. Lesson Learned Money matters. More money better result, but just at the beginning, after, strong management is needed Health reform is more complicate that a change of the law. Besides the need of lobby is necessary to build good stakeholders How do get ownership of the reform? More that the inner circle Institutionalization of the change How do get the achieved the goals offered? Affiliation Increase the budget Change the predominance of private money Increase the quality of care Decrease inequalities

63. Daniel Cosio Villegas Those that are inside of the government know what is going on, but they don't have time to write anything; however who is out the government write many things, but they don't have any idea of what is going on 48