More Money For Health, Better Health for the Money

David Garcia-Junco Machado was recently appointed as the Mexican National Commissioner for Social Protection in Health by the Minister of Health, Salomon Chertorivski Woldenberg, on behalf of President Felipe Calderon Hinojosa. In this role, Mr. Garcia-Junco oversees Seguro Popular, a national health insurance program established in 2003 and has brought the number of uninsured people in the country from roughly 50 million down to 3 million, with a commitment to providing coverage to the remaining 3 million people by the end of 2012.

Seguro Popular started in 2003 and has grown from 3 million to almost 50 million. That’s a lot of growth in a short time. How has the system managed to scale up so quickly?

In 2010, the mechanism of registering membership change from the number of families to individuals, this change raised the previous yearly records of the “Seguro Popular” affiliation since 2003. This is the main cause of the elevation of the figures from 2010 compared to previous ones.

Additionally, since 2009 the membership has been growing every year, due to the efforts of coordination between the states of the federation and “State Regimes of Social Protection in Health” to try to incorporate new people as members and comply with the agreement for achieving the goal of universal membership coverage in health for2011.

Are there adverse selection issues with the program? If not, how has it been structured against them?

This kind of problem doesn’t exist, because the scheme for medical coverage is for the whole population which lacks medical health insurance proportionated by social security institutions and other medical insurance schemes. This means that almost the entire population that is likely to require the service from “Seguro Popular” is currently affiliated with it, instead of just people with more information about the “Seguro Popular” benefits, or interest. In 2011, the “Seguro Popular” should be insuring virtually all people who need health services.

Some people have criticized Seguro Popular for being insurance for people in the informal sector that aren’t paying taxes, so they aren’t paying into the system. Is this characterization of the recipients accurate? If so, is there a justice issue here?

The “Seguro Popular” is financed through resources that come from general taxation. In this way the whole population pays both a direct and an indirect sense. Needless to say, the ”Seguro Popular” is intended also as a mechanism of protection for those segments of the population with heavy conditions of vulnerability and poverty. This part of the population needs to have access to the right of health care without payment or other kind of co-payments. In this sense, for these specific segments of the population the “Seguro Popular” is being an agent for delivering distributive justice.

What can other countries—including the U.S.—learn from the successes and failures of the Seguro Popular Program?

One of the main achievements obtained by the “Seguro Popular” that even advanced countries like the USA can learn from is the creation of a safety net that prevents the impoverishment of families for elevated payments in the health service. This is the main contribution of the “Seguro Popular”.

This fact is especially important in those diseases and interventions that require longer treatment which would destabilize any family budget leading to poverty to all the family members (e.g. cancer and HIV). Another success is related to the way for creating a budgetary mechanism able to sustain a system of national health from both local and federal contributions. These allocations are with the purpose of creating a funding mechanism that allows access the whole uninsured population to medical services.

The problems which “Seguro Popular” currently has are common to other health systems with universal protection in the world that are concerned about maintaining the quality of services and constantly improving them.

How does the program manage the relationship between state and the federal government funding? What audit mechanisms are in place to ensure funding is spent appropriately, and are they stronger than comparable mechanism in ISSSTE of IMSS?

The financial and resource management is done through active coordination between the National Commission of Social Health Protection (CNPSS) and the State Regimes of Social Health Protection (REPSS), which are responsible in the joint efforts for coordinating with their respective authorities in each state all around in the country. This is to maintain the control resources through monitoring, validation, and authorization for payment of medical services for the various ailments of the enrolled population.

Is there any evidence in terms of how Seguro Popular has improved national health outcomes?

The main evidence of the impact produced by the “Seguro Popular” is found in several sources.

One of them is concerning with the reduction of catastrophic health spending. The most important result in this area measured by the National Survey of Household Incomes and Expenses (ENIGH) gives the following result. The reduction of the percentage of households with catastrophic health expenditure in the country was 2.88% in 2002: by 2010 it had fallen to 2.23%.

There has also been a reduction in the dropout rates in childhood cancer. Before the entry into operation of the “Seguro Popular”, 7 of 10 children stopped treatment: currently, only 2 out of 10 drop out to the treatment.

Has the public health infrastructure grown at the pace that the list of beneficiaries has? If not, do you have any estimate of the investment required to fill that gap?

The increased membership has led simultaneously to a steady increase in both local and federal budgets for the construction of hospital and medical units. The construction of new medical facilities which are not provided for different levels of medical care is carried out by the Provident Fund Budget (“Fondo de Previsión Presupuestal”). This fund is included into the 2% of the “Seguro Popular” budget, which has as one of its main objectives the creation of infrastructure for new hospitals.