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Mexico’s Seguro Popular: Achievements and Challenges

Mexico’s Seguro Popular: Achievements and Challenges Health Systems & Reform, 4(3):194–202, 2018 © 2018 Taylor & Francis ISSN: 2328-8604 print / 2328-8620 online DOI: 10.1080/23288604.2018.1488505 Commentary Mexico’s Seguro Popular: Achievements and Challenges Antonio Chemor Ruiz, Anette Elena Ochmann Ratsch* and Gloria Araceli Alamilla Martínez National Commission for Social Protection in Health (Seguro Popular), Mexico City, Mexico CONTENTS Abstract—In Mexico, Seguro Popular is a landmark government program aimed to guarantee universal access to health services, Introduction especially for the most vulnerable populations. Since its adoption Financial Structure in 2004, important changes have been made to improve the perfor- Conclusions mance of Seguro Popular. In this article, we present the main References changes that have been implemented in Seguro Popular during the current administration (2012–2018) and propose a series of consid- erations to improve its performance in the immediate future and thus contribute to achieving the goal of universal health coverage in Mexico. INTRODUCTION Mexico’s landmark Seguro Popular health insurance program was adopted in 2004 in order to address the nation’s unequal distribution of the financial, physical, and human resources in public health services. The purpose was to provide a universal social health protection system for the most vulnerable popula- tions; that is, persons of low socioeconomic status who have no formal employment and thus have no access to Mexico’sexten- sive social security health services provided by the Instituto Mexicano del Seguro Social (IMSS), Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (the social security system for state workers), and other similar institutions. The goals of Seguro Popular (SP) were to grant ample access to public health services through a voluntary, universal insurance instrument, bound to a “catalog” or benefit inven- tory called CAUSES (Catálogo Universal de Servicios de Salud), which today includes 294 interventions (equivalent Keywords: health reform, health system, Mexico, Seguro Popular, universal to 1,807 diagnoses of the International Classification of health coverage 2 Diseases) plus treatment for 65 catastrophic pathologies Received 1 May 2018; accepted 10 June 2018. paid through a special fund, named Fondo de Protección *Correspondence to: Anette Elena Ochmann Ratsch; Email: aochmann1@g- contra Gastos Catastróficos (FPGC), and, finally, a fund mail.com 194 Chemor Ruiz et al.: Mexico’s Seguro Popular 195 that covers 100% of all health conditions in children under negligent expenditures, fraud, corruption, nonlegitimate five years of age through Seguro Médico Siglo XXI resources. expenses, and price fixing, among others). Since its establishment, SP was able to increase Mexico’s Likewise, other adverse conditions prevailed, such as health expenditure by one point of gross domestic product inconsistencies in the census of affiliates, which defines the (GDP). This increase in health expenditure allowed for a resources allocated for each person and are transferred to the major extension of coverage and utilization, which, in turn, states. Problems also existed in medication shortages, in reduced catastrophic and impoverishing health expenditures addition to a lack of efficiency and quality in the provision and also improved equity for nearly 43.5% of Mexico’s of health services. Nigenda et al. identified three important 3,4 population who previously lacked social security and had findings in relation to the transfer and allocation of funds in to finance their health care mostly out of pocket. Though Seguro Popular: (1) delays in the transfer of the funds at great advances were more evident during the first years of different points in the system, (2) some states did not adhere Seguro Popular, the gradual introduction of coverage for to the negotiated expenditure targets, and (3) unauthorized more interventions that trigger catastrophic expenses has use of financial resources. been maintained, so that continuous positive impacts, mainly Consequently, during the present administration (2012– related to reduced out-of-pocket spending, are expected. 2018), important efforts have been made to address these The financing of Seguro Popular is made through both conditions and improve Seguro Popular. This article sum- federal and state government funds, whose origin is mainly marizes the main changes accomplished for this important from general tax revenues but also includes, in some cases, program in the last few years and describes their impacts and personal or family premium payments, although these latter further directions. represent a very small share of the total. The federal govern- ment pays the so-called social contribution and a federal FINANCIAL STRUCTURE solidarity quota, and each state makes its own payment, called the state solidarity quota. At the beginning of Seguro One of the first steps taken to improve Seguro Popular’s Popular, this last contribution could be provided in kind; financial system was the separation of functions to break during the current administration, it was established that at the connection between the financial and service provision least 30% of the state contribution must be paid in cash. The entities. Starting in 2014, Seguro Popular promoted a reform amount of financing provided has been based on the calcula- that established that the responsible state organizations, called tion of a capitation payment, like the premium for an insur- Regímenes Estatales de Protección Social en Salud (REPSS) ance plan, which is then paid, according to the number of and until then were dependent on the state health ministries, affiliated persons who were registered for Seguro Popular,to were transformed into public decentralized bodies, with their each state of the Mexican republic. own legal personalities and patrimonies. This reform allowed Health care provision for the SP-affiliated population was the REPSS to function as autonomous administrative entities defined as the responsibility of each federal entity (state) in in each Mexican state. The REPSS had the responsibility of Mexico through their own and already available infrastruc- supervising health care provision services, managing the fed- ture, supplies, and human resources. Additional specific eral and state financial resources paid to the health services funds were also available for financing hospital construction providers, performing promotion and affiliation activities, as well as for the acquisition of medical equipment. and, finally, generating information regarding the operation, By the end of 2012, at the start of the current federal supervision, and follow-up of the whole process. administration, some of Seguro Popular’s original objectives Mexico has serious problems of fragmentation in its health had been achieved, mainly an increase in public heath expen- system. In the previous administration, in 2006, the govern- diture, resulting in improved equity of public health spending, ment sought to reduce fragmentation through the National a reduction in out-of-pocket expenditure and catastrophic Agreement Towards the Universalization of Health Care outlays, and important progress in financial equity, as well Services that was signed by different health care providers as the affiliation of a substantial sector of Mexico’s most within the system. In 2012, additional actions were taken vulnerable populations. through agreements that made it operationally possible to Despite these great achievements, a number of challenges reduce fragmentation. One of these agreements was aimed to remained. The most outstanding problems included an bring major providers closer together and to create coordina- uncontrolled, unspecific, incomplete, and untimely expendi- tion mechanisms to achieve a system of universal health cover- ture of resources, which also lacked transparency. These age in Mexico. Although Seguro Popular is not a service problems in turn might have allowed illegal acts (such as provider per se, its participation is important as a key role to 196 Health Systems & Reform, Vol. 4 (2018), No. 3 this goal. Therefore, recent efforts have been made to increase Payment Regulation (Methods to Pay (Use of Coercive the service exchanges between providers, and it is expected Health Care Efforts by the State to that Mexico will have the first promising results soon. Financing Providers, Such as Alter the Behavior of Some other amendments to the Seguro Popular system (Mobilizing Funds Fees, Capitation, and Actors in the Health were enacted in 2014, including the following: regularization for the Health Sector) Budgets) System) of resource transferences (cash and in-kind) for the local A system for In each state, new For cases of illegal management of funds; facilitation of interstate health care interstate and financial accounts acts associated portability; establishment of a compulsory financial informa- intersystem were established with Seguro tion mechanism that was required to be used by the states; payment of health (federal treasury Popular resources, and the institution of a specific felony for resource diversion. care services for accounts) to new penalties and Implementation of a major policy reform (like Seguro affiliates was allocate 50% of even punishment Popular) always requires changes and adjustments over created, also the total Seguro with imprisonment termed portability, Popular were established. time. Over the years, with the actual execution of reform through the resources, which Since 2016, a new programs, the original policy design often becomes inade- capacity of Seguro subsequently had management quate, old problems persist, and new problems arise. As system, called Popular to to be spent mainly Seguro Popular was implemented, it was recognized that establish a on the acquisition SIGEFI, was regulations had to be improved to avoid mismanagement of compensation of introduced to funds and to make spending more efficient as well as trans- mechanism called pharmaceuticals, control the annual parent. Therefore, in 2014, changes and adjustments were Sistema de health-related budget of more performed, organized according to three of the health system Compensación materials, and than 40 billion Económica de outsourcing MXN (about two “control knobs” proposed by Roberts et al. (Table 1). Servicios services, as well billion USD), 40% Other central innovations were introduced to prevent dis- Interestatales de as on salary of which was crepancies in the affiliate census, by matching the database of Salud to defray the payments allocated for IMSS (the largest social security institute in Mexico, with costs of services paying wages and nearly 50% of the total Mexican population affiliated ) with between states or 30% for the the databank of Seguro Popular. This database merge allowed between major acquisition of Seguro Popular to remove more than three million registries health insurance medication and from its listings that were duplicate affiliations (Figure 1), institutions health-related materials leading to more accurate financing of the whole system. Two results of these policy adjustments were promptly TABLE 1. Actions Taken to Improve Seguro Popular, Organized noticed: Sistema de Compensación Económica de Servicios According to Three Health System Control Knobs Interestatales de Salud allowed patients unrestricted access to health care regardless of their location, and health care pro- In addition, based on these adjustments, and despite viders were willing to supply the corresponding health care national financial constraints, Seguro Popular was able to knowing that the expenses would later be reimbursed. achieve several important improvements during the present The allocation of 50% of the total SP resources provided by administration. In January 2018, it possessed a reasonably the federal treasury, which had to be spent in a timely manner, accurate listing that included 53.5 million affiliates (23.1 according to specific rules, and only for specific budget items, million families), or 43.3% of Mexico’snational made it possible for these public resources to be sufficient for population (Figure 1). The share of public health health care provided in a majority of Mexico’sstates. expenses increased considerably, rising from 2.2% to A new finance management system was implemented 3.0% of the Mexican GDP (2000–2016) according to the (Sistema de Gestión Financiera, SIGEFI), which forced Organization for Economic Co-operation and Development REPSS to provide a stricter report of expenses that, in parallel and, on the other hand, out-of-pocket expenditures declined with the established penalties, made it possible from 2013 to from 52.2% to 41.4% (2000–2015) of total health spending the present (May 2018) to create prompt reporting of spend- between 2000 and 2015. In our view, the most important ing and prevent the misuse of resources. accomplishments were the reforms that led to a more Ensuring that the list of SP affiliates does not contain transparent way to substantiate health expenditures within duplicates has allowed Seguro Popular to stick to the author- the states, which favored more accurate accounting and ized budget and to avoid the funding of unauthorized rational spending. individuals. Chemor Ruiz et al.: Mexico’s Seguro Popular 197 57.3 57.1 55.6 54.9 53.5 52.9 51.8 43.5 31.1 27.2 21.8 15.7 11.4 5.3 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year FIGURE 1. Evolution of Affiliates to Seguro Popular over Time (Modified from Knaul et al. ) These achievements have also been felt at the family and security and affiliated with Seguro Popular in 2013, com- personal levels. A reduction in catastrophic expenses began pared to MXN 3,505 and 3,945 for IMSS and Instituto de in previous administrations, showing a decrease from 2.7% to Seguridad y Servicios Sociales de los Trabajadores del 12 13 1.7% (2004–2014) of households (representing a note- Estado, respectively. worthy decrease of 36%). More efficient resource manage- Despite the achievements of these reforms, several core ment promoted in recent years favors a continuation of these challenges of Seguro Popular remain and are worth positive trends. The same situation occurs with the impover- highlighting: ishing expenses, which fell from 3.3% to 0.8% of the popula- tion from 2004 to 2014, resulting in a significant reduction Scope of services covered: The provision of health care of more than 83% in outlays for the most vulnerable families. has improved significantly, mainly due to the expansion In addition, as the National Board of Political and Social of interventions included in CAUSES (the benefit pack- Development notes, the indicator for “lack of access to health age), which have risen from 90 in 2004 to 294 in 2018. services” (defined as no formal insurance affiliation) declined During the current administration, 142 medicines and from 29.2% of the population to 15.5% between 2010 and materials as well as nine interventions were added to 2016 (Figure 2). this catalog, making it possible to address the main Seguro Popular has also advanced equity in Mexico. In causes of hospital discharges in Mexico. Regarding 1995, IMSS accounted for 69% of total health expenditure in this issue, to date, there are still significant challenges Mexico; from 2005 to 2017, this share has declined because that must be overcome to match the health services of Seguro Popular. Today, because the SP capitation payment provided by Seguro Popular to those delivered to the is the same for every affiliate, throughout the country, federal population with access to social security and then be able resources have been spent in a more equitable manner among to reduce the outlay of personal expenses. Though, pro- the states. The administrative reforms undertaken in recent gressively, high-cost health interventions have been years have made it possible to improve proper allocation of added (i.e., liver, heart, and lung transplantation, as resources. Seguro Popular has reduced, to a great degree, the well as treatment for esophageal cancer in 2018), there previously existing gap in per person government spending are some conditions that are still not financially feasible between individuals with and without social security, result- to incorporate, such as myocardial infarction for indivi- a 15 ing in MXN 2,734.8 per capita for people without social duals older than 65 years, as well as the management of Million people 198 Health Systems & Reform, Vol. 4 (2018), No. 3 4.00 3.77 3.27 3.34 2.88 2.52 2.23 2.06 2.08 2.00 1.57 1.53 1.52 1.28 1.19 0.98 0.95 1.10 0.66 0.58 0.56 0.64 0.42 0.34 0.33 0.34 0.00 2002 2004 2005 2006 2008 2010 2012 2014 Year Hous eholds with cata strophic e xpendi ture s Households with impover ishing expe nditures Hous eholds with cata strophic a nd impover ishing expenditures FIGURE 2. Households with Catastrophic and Impoverishing Expenditures, Mexico 2002–2014 (Modified from de Salud ) Percentage Chemor Ruiz et al.: Mexico’s Seguro Popular 199 chronic renal failure with dialysis (which alone would year. This turnover in IMSS affiliation makes it neces- collapse the system) (Figure 3). Moreover, the provision sary to establish tools that would allow Seguro Popular of ambulatory medical services at the primary-care level to have access to the databases of the social security medicine must increase significantly, first to provide organizations, so that these institutions can be charged more preventive services and, second, to expand access for services provided and paid for by Seguro Popular. to medical care, mainly to the most vulnerable popula- tions, such as indigenous communities, where effective Seguro Popular is the first public insurance program in the history access remains very poor. of Mexico aimed at the most vulnerable populations, seeking to Health impoverishment: Although the share of public grant them access to health services. This massive effort to health expenditure has increased, consequently lowering affiliate 54 million inhabitants with Seguro Popular has brought out-of-pocket expenses and thus improving financial the country close to achieving universal health coverage. equity for the Mexican population, it is important to For the near future, the Mexican health system, and there- continue to seek an increase in the percentage of GDP fore Seguro Popular, faces two major additional challenges: allocated to the public health system in order to approach at least the average of Organization for Economic Co- a. Financial sustainability is not guaranteed in the long operation and Development countries. term because: Access to health services: According to the 2015 inter- i. The health system is becoming more expensive by censal survey from the Instituto Nacional de Estadística the day due to epidemiologic changes in the y Geografía, 17.8% of the Mexican population is not Mexican population, which combine the character- affiliated with any health care service or social security istic illnesses of a developing country with the system. This situation indicates that universal financial chronic degenerative diseases of an aging health protection has not been achieved in full in population. Mexico, remaining a task still to accomplish. ii. The FPGC is losing its financial basis and is pre- ● Efficiency of financial management: Although a dicted to run out of money in ten years. separation of functions (financing from provision) within b. Mexico faces potential political challenges and changes in Seguro Popular was effectively achieved and the subse- the July 2018 presidential election, and the results of that quent enforcement of the transparency of the manage- election could endanger the continuity of Seguro Popular. ment of resources was well executed, the system continues to face a significant challenge related to effi- Mexico needs to execute financial strategies and public poli- cient financial resources management. Mechanisms are cies that will guarantee the financial sustainability and con- needed to allow REPSS, for example, to exercise more tinuity of Seguro Popular in the long term. Measures to do cost-effective strategies for service purchasing and sup- this could include the following: plies procurement, as well as to have more authority in the decision-making process. Positive and specific health impacts will have to be Quality of services: With respect to the quality of health linked to financing in order to drive the system to more services, recent measures have been introduced by efficient resource administration and allocation. Seguro Popular to drive resources toward the “accred- Seguro Popular possesses a contributive premium-based itation” process, rather than to operations, as occurred in membership regime and a subsidized membership the past. For example, state health services are now regime, although only the second one is applied in required to invest in infrastructure development and practice. It is estimated that almost 30% of affiliated equipment acquisition, as well as the hiring of human households are able to pay a personal or familiar resources, but mechanisms still need to be developed in contribution as a premium but do not currently do order to make these tasks permanent. so. This source of funding, if collected, could provide ● Listing of affiliates: To maintain the affiliate registry significant new revenues for Seguro Popular. with no duplication (for any social security organization) is a major undertaking. The formal workforce in Mexico is very unstable and the SP affiliation period is three CONCLUSIONS years (but ceases to be valid when a person enters another health insurance system). A significant propor- The most significant results of Seguro Popular are the ability tion of the total workforce enters or leaves IMSS every to maintain positive trends of in reducing in catastrophic/ 200 Health Systems & Reform, Vol. 4 (2018), No. 3 I nterv entions Me dicines 600 642 312 315 284 285 285 285 287 287 275 275 266 266 249 255 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 YEAR FIGURE 3. Evolution of CAUSES over Time (Modified from Comisión Nacional de Protección Social en Salud, Secretaría de Salud and Unidad de Análisis Económico, Secretaría de Salud ) # ITEMS COVERED Chemor Ruiz et al.: Mexico’s Seguro Popular 201 is affiliated with SP gets a formal job and joins IMSS, hospitals and impoverishing costs, in reducing lack of access to health care clinics have no way to know this and therefore the patient is covered services, and decreasing out-of-pocket expenses. under SP benefits. As a result, patients who seek medical care for In recent years (from 2013 to 2018), Seguro Popular CAUSES interventions, using SP, are not recognized if they are affiliated coverage has been expanded, with the addition of 61 pathol- with IMSS or ISSTE. On the other hand, because catastrophic expenses are charged after services are delivered, it is possible for “active” affili- ogies grouped into nine interventions and 61 medicines and ates with IMSS or ISSTE to be considered for reimbursement to SP. materials to the CAUSES catalog; the FPGC component, during the same period of time, also increased to include [c] This article was accepted in June 2018, before Mexico’s presidential election occurred. six new pathologies. The most important changes were those regarding the reforms to the law in 2014, which promoted a more transpar- DISCLOSURE OF POTENTIAL CONFLICTS OF ent administration of the federal resources allocated to the INTEREST states. These reforms included methods to transfer money to No potential conflicts of interest were disclosed. the REPSS, limiting how they spend the resources, introdu- cing ways to render, validate, and substantiate expenses through the SIGEFI system and establishing mechanisms ACKNOWLEDGMENTS with penalties for illegal acts. In addition, the listing of The authors thank Editor-in-Chief Michael Reich for his help affiliates was revised, removing duplicate memberships with and input. other programs or institutions. The results of these reforms were improved administrative adherence to a legal framework, which promotes better man- REFERENCES agement of resources. During the current administration, 1. Secretaria de Salud Decreto por el que se reforma y adiciona la Seguro Popular resources have been provided and used in a Ley General de Salud. [accessed 2018 Feb 08]. http://dof.gob. timely, orderly, as well as a correct manner; this, in addition mx/nota_detalle.php?codigo=695626&fecha=15/05/2003. to the elimination of three million affiliates who held dupli- 2. Comisión Nacional de Protección Social en Salud, Secretaría de cate affiliation with other institutions, made it possible to Salud. Catálogo Universal de Servicios de Salud (CAUSES). adhere to the authorized budget. [accessed 2018 Feb 08]. http://www.documentos.seguro-popu lar.gob.mx/dgss/CAUSES2016.pdf. There are many challenges for Seguro Popular in the 3. Instituto Nacional de Estadística y Geografía (INEGI). future. These include ensuring financial sustainability and Derechohabiencia y uso de servicios de salud. Población pro- promoting the allocation of more resources for the health tegida por los servicios de salud, 2000 a 2014. [accessed 2018 system to increase the proportion of GDP destined to this Feb 08]. http://www3.inegi.org.mx/sistemas/sisept/default. area. In addition, the provision of health care has to increase aspx?t=msoc01&s=est&c=22594. 4. Consejo Nacional de Poblacion (CONAPO). Indicadores and improve in terms of quality, so that out-of-pocket demográficos de México, periodo 1990-2030. [accessed 2018 expenses may decrease and access to health care increases. Feb 08]. https://datos.gob.mx/herramientas/indicadores-demo In the coming years, the Mexican health system will face graficos-de-mexico-periodo-1990-2030?category=web&tag= significant epidemiological and financial challenges, economia. described above, as well as political challenges of who wins 5. Ávila-Burgos L, Serván-Mori E, Wirtz VJ, Sosa-Rubí SG, the upcoming presidential election. The next administration Salinas-Rodríguez A. 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Mexico’s Seguro Popular: Achievements and Challenges

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Abstract

Health Systems & Reform, 4(3):194–202, 2018 © 2018 Taylor & Francis ISSN: 2328-8604 print / 2328-8620 online DOI: 10.1080/23288604.2018.1488505 Commentary Mexico’s Seguro Popular: Achievements and Challenges Antonio Chemor Ruiz, Anette Elena Ochmann Ratsch* and Gloria Araceli Alamilla Martínez National Commission for Social Protection in Health (Seguro Popular), Mexico City, Mexico CONTENTS Abstract—In Mexico, Seguro Popular is a landmark government program aimed to guarantee universal access to health services, Introduction especially for the most vulnerable populations. Since its adoption Financial Structure in 2004, important changes have been made to improve the perfor- Conclusions mance of Seguro Popular. In this article, we present the main References changes that have been implemented in Seguro Popular during the current administration (2012–2018) and propose a series of consid- erations to improve its performance in the immediate future and thus contribute to achieving the goal of universal health coverage in Mexico. INTRODUCTION Mexico’s landmark Seguro Popular health insurance program was adopted in 2004 in order to address the nation’s unequal distribution of the financial, physical, and human resources in public health services. The purpose was to provide a universal social health protection system for the most vulnerable popula- tions; that is, persons of low socioeconomic status who have no formal employment and thus have no access to Mexico’sexten- sive social security health services provided by the Instituto Mexicano del Seguro Social (IMSS), Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (the social security system for state workers), and other similar institutions. The goals of Seguro Popular (SP) were to grant ample access to public health services through a voluntary, universal insurance instrument, bound to a “catalog” or benefit inven- tory called CAUSES (Catálogo Universal de Servicios de Salud), which today includes 294 interventions (equivalent Keywords: health reform, health system, Mexico, Seguro Popular, universal to 1,807 diagnoses of the International Classification of health coverage 2 Diseases) plus treatment for 65 catastrophic pathologies Received 1 May 2018; accepted 10 June 2018. paid through a special fund, named Fondo de Protección *Correspondence to: Anette Elena Ochmann Ratsch; Email: aochmann1@g- contra Gastos Catastróficos (FPGC), and, finally, a fund mail.com 194 Chemor Ruiz et al.: Mexico’s Seguro Popular 195 that covers 100% of all health conditions in children under negligent expenditures, fraud, corruption, nonlegitimate five years of age through Seguro Médico Siglo XXI resources. expenses, and price fixing, among others). Since its establishment, SP was able to increase Mexico’s Likewise, other adverse conditions prevailed, such as health expenditure by one point of gross domestic product inconsistencies in the census of affiliates, which defines the (GDP). This increase in health expenditure allowed for a resources allocated for each person and are transferred to the major extension of coverage and utilization, which, in turn, states. Problems also existed in medication shortages, in reduced catastrophic and impoverishing health expenditures addition to a lack of efficiency and quality in the provision and also improved equity for nearly 43.5% of Mexico’s of health services. Nigenda et al. identified three important 3,4 population who previously lacked social security and had findings in relation to the transfer and allocation of funds in to finance their health care mostly out of pocket. Though Seguro Popular: (1) delays in the transfer of the funds at great advances were more evident during the first years of different points in the system, (2) some states did not adhere Seguro Popular, the gradual introduction of coverage for to the negotiated expenditure targets, and (3) unauthorized more interventions that trigger catastrophic expenses has use of financial resources. been maintained, so that continuous positive impacts, mainly Consequently, during the present administration (2012– related to reduced out-of-pocket spending, are expected. 2018), important efforts have been made to address these The financing of Seguro Popular is made through both conditions and improve Seguro Popular. This article sum- federal and state government funds, whose origin is mainly marizes the main changes accomplished for this important from general tax revenues but also includes, in some cases, program in the last few years and describes their impacts and personal or family premium payments, although these latter further directions. represent a very small share of the total. The federal govern- ment pays the so-called social contribution and a federal FINANCIAL STRUCTURE solidarity quota, and each state makes its own payment, called the state solidarity quota. At the beginning of Seguro One of the first steps taken to improve Seguro Popular’s Popular, this last contribution could be provided in kind; financial system was the separation of functions to break during the current administration, it was established that at the connection between the financial and service provision least 30% of the state contribution must be paid in cash. The entities. Starting in 2014, Seguro Popular promoted a reform amount of financing provided has been based on the calcula- that established that the responsible state organizations, called tion of a capitation payment, like the premium for an insur- Regímenes Estatales de Protección Social en Salud (REPSS) ance plan, which is then paid, according to the number of and until then were dependent on the state health ministries, affiliated persons who were registered for Seguro Popular,to were transformed into public decentralized bodies, with their each state of the Mexican republic. own legal personalities and patrimonies. This reform allowed Health care provision for the SP-affiliated population was the REPSS to function as autonomous administrative entities defined as the responsibility of each federal entity (state) in in each Mexican state. The REPSS had the responsibility of Mexico through their own and already available infrastruc- supervising health care provision services, managing the fed- ture, supplies, and human resources. Additional specific eral and state financial resources paid to the health services funds were also available for financing hospital construction providers, performing promotion and affiliation activities, as well as for the acquisition of medical equipment. and, finally, generating information regarding the operation, By the end of 2012, at the start of the current federal supervision, and follow-up of the whole process. administration, some of Seguro Popular’s original objectives Mexico has serious problems of fragmentation in its health had been achieved, mainly an increase in public heath expen- system. In the previous administration, in 2006, the govern- diture, resulting in improved equity of public health spending, ment sought to reduce fragmentation through the National a reduction in out-of-pocket expenditure and catastrophic Agreement Towards the Universalization of Health Care outlays, and important progress in financial equity, as well Services that was signed by different health care providers as the affiliation of a substantial sector of Mexico’s most within the system. In 2012, additional actions were taken vulnerable populations. through agreements that made it operationally possible to Despite these great achievements, a number of challenges reduce fragmentation. One of these agreements was aimed to remained. The most outstanding problems included an bring major providers closer together and to create coordina- uncontrolled, unspecific, incomplete, and untimely expendi- tion mechanisms to achieve a system of universal health cover- ture of resources, which also lacked transparency. These age in Mexico. Although Seguro Popular is not a service problems in turn might have allowed illegal acts (such as provider per se, its participation is important as a key role to 196 Health Systems & Reform, Vol. 4 (2018), No. 3 this goal. Therefore, recent efforts have been made to increase Payment Regulation (Methods to Pay (Use of Coercive the service exchanges between providers, and it is expected Health Care Efforts by the State to that Mexico will have the first promising results soon. Financing Providers, Such as Alter the Behavior of Some other amendments to the Seguro Popular system (Mobilizing Funds Fees, Capitation, and Actors in the Health were enacted in 2014, including the following: regularization for the Health Sector) Budgets) System) of resource transferences (cash and in-kind) for the local A system for In each state, new For cases of illegal management of funds; facilitation of interstate health care interstate and financial accounts acts associated portability; establishment of a compulsory financial informa- intersystem were established with Seguro tion mechanism that was required to be used by the states; payment of health (federal treasury Popular resources, and the institution of a specific felony for resource diversion. care services for accounts) to new penalties and Implementation of a major policy reform (like Seguro affiliates was allocate 50% of even punishment Popular) always requires changes and adjustments over created, also the total Seguro with imprisonment termed portability, Popular were established. time. Over the years, with the actual execution of reform through the resources, which Since 2016, a new programs, the original policy design often becomes inade- capacity of Seguro subsequently had management quate, old problems persist, and new problems arise. As system, called Popular to to be spent mainly Seguro Popular was implemented, it was recognized that establish a on the acquisition SIGEFI, was regulations had to be improved to avoid mismanagement of compensation of introduced to funds and to make spending more efficient as well as trans- mechanism called pharmaceuticals, control the annual parent. Therefore, in 2014, changes and adjustments were Sistema de health-related budget of more performed, organized according to three of the health system Compensación materials, and than 40 billion Económica de outsourcing MXN (about two “control knobs” proposed by Roberts et al. (Table 1). Servicios services, as well billion USD), 40% Other central innovations were introduced to prevent dis- Interestatales de as on salary of which was crepancies in the affiliate census, by matching the database of Salud to defray the payments allocated for IMSS (the largest social security institute in Mexico, with costs of services paying wages and nearly 50% of the total Mexican population affiliated ) with between states or 30% for the the databank of Seguro Popular. This database merge allowed between major acquisition of Seguro Popular to remove more than three million registries health insurance medication and from its listings that were duplicate affiliations (Figure 1), institutions health-related materials leading to more accurate financing of the whole system. Two results of these policy adjustments were promptly TABLE 1. Actions Taken to Improve Seguro Popular, Organized noticed: Sistema de Compensación Económica de Servicios According to Three Health System Control Knobs Interestatales de Salud allowed patients unrestricted access to health care regardless of their location, and health care pro- In addition, based on these adjustments, and despite viders were willing to supply the corresponding health care national financial constraints, Seguro Popular was able to knowing that the expenses would later be reimbursed. achieve several important improvements during the present The allocation of 50% of the total SP resources provided by administration. In January 2018, it possessed a reasonably the federal treasury, which had to be spent in a timely manner, accurate listing that included 53.5 million affiliates (23.1 according to specific rules, and only for specific budget items, million families), or 43.3% of Mexico’snational made it possible for these public resources to be sufficient for population (Figure 1). The share of public health health care provided in a majority of Mexico’sstates. expenses increased considerably, rising from 2.2% to A new finance management system was implemented 3.0% of the Mexican GDP (2000–2016) according to the (Sistema de Gestión Financiera, SIGEFI), which forced Organization for Economic Co-operation and Development REPSS to provide a stricter report of expenses that, in parallel and, on the other hand, out-of-pocket expenditures declined with the established penalties, made it possible from 2013 to from 52.2% to 41.4% (2000–2015) of total health spending the present (May 2018) to create prompt reporting of spend- between 2000 and 2015. In our view, the most important ing and prevent the misuse of resources. accomplishments were the reforms that led to a more Ensuring that the list of SP affiliates does not contain transparent way to substantiate health expenditures within duplicates has allowed Seguro Popular to stick to the author- the states, which favored more accurate accounting and ized budget and to avoid the funding of unauthorized rational spending. individuals. Chemor Ruiz et al.: Mexico’s Seguro Popular 197 57.3 57.1 55.6 54.9 53.5 52.9 51.8 43.5 31.1 27.2 21.8 15.7 11.4 5.3 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year FIGURE 1. Evolution of Affiliates to Seguro Popular over Time (Modified from Knaul et al. ) These achievements have also been felt at the family and security and affiliated with Seguro Popular in 2013, com- personal levels. A reduction in catastrophic expenses began pared to MXN 3,505 and 3,945 for IMSS and Instituto de in previous administrations, showing a decrease from 2.7% to Seguridad y Servicios Sociales de los Trabajadores del 12 13 1.7% (2004–2014) of households (representing a note- Estado, respectively. worthy decrease of 36%). More efficient resource manage- Despite the achievements of these reforms, several core ment promoted in recent years favors a continuation of these challenges of Seguro Popular remain and are worth positive trends. The same situation occurs with the impover- highlighting: ishing expenses, which fell from 3.3% to 0.8% of the popula- tion from 2004 to 2014, resulting in a significant reduction Scope of services covered: The provision of health care of more than 83% in outlays for the most vulnerable families. has improved significantly, mainly due to the expansion In addition, as the National Board of Political and Social of interventions included in CAUSES (the benefit pack- Development notes, the indicator for “lack of access to health age), which have risen from 90 in 2004 to 294 in 2018. services” (defined as no formal insurance affiliation) declined During the current administration, 142 medicines and from 29.2% of the population to 15.5% between 2010 and materials as well as nine interventions were added to 2016 (Figure 2). this catalog, making it possible to address the main Seguro Popular has also advanced equity in Mexico. In causes of hospital discharges in Mexico. Regarding 1995, IMSS accounted for 69% of total health expenditure in this issue, to date, there are still significant challenges Mexico; from 2005 to 2017, this share has declined because that must be overcome to match the health services of Seguro Popular. Today, because the SP capitation payment provided by Seguro Popular to those delivered to the is the same for every affiliate, throughout the country, federal population with access to social security and then be able resources have been spent in a more equitable manner among to reduce the outlay of personal expenses. Though, pro- the states. The administrative reforms undertaken in recent gressively, high-cost health interventions have been years have made it possible to improve proper allocation of added (i.e., liver, heart, and lung transplantation, as resources. Seguro Popular has reduced, to a great degree, the well as treatment for esophageal cancer in 2018), there previously existing gap in per person government spending are some conditions that are still not financially feasible between individuals with and without social security, result- to incorporate, such as myocardial infarction for indivi- a 15 ing in MXN 2,734.8 per capita for people without social duals older than 65 years, as well as the management of Million people 198 Health Systems & Reform, Vol. 4 (2018), No. 3 4.00 3.77 3.27 3.34 2.88 2.52 2.23 2.06 2.08 2.00 1.57 1.53 1.52 1.28 1.19 0.98 0.95 1.10 0.66 0.58 0.56 0.64 0.42 0.34 0.33 0.34 0.00 2002 2004 2005 2006 2008 2010 2012 2014 Year Hous eholds with cata strophic e xpendi ture s Households with impover ishing expe nditures Hous eholds with cata strophic a nd impover ishing expenditures FIGURE 2. Households with Catastrophic and Impoverishing Expenditures, Mexico 2002–2014 (Modified from de Salud ) Percentage Chemor Ruiz et al.: Mexico’s Seguro Popular 199 chronic renal failure with dialysis (which alone would year. This turnover in IMSS affiliation makes it neces- collapse the system) (Figure 3). Moreover, the provision sary to establish tools that would allow Seguro Popular of ambulatory medical services at the primary-care level to have access to the databases of the social security medicine must increase significantly, first to provide organizations, so that these institutions can be charged more preventive services and, second, to expand access for services provided and paid for by Seguro Popular. to medical care, mainly to the most vulnerable popula- tions, such as indigenous communities, where effective Seguro Popular is the first public insurance program in the history access remains very poor. of Mexico aimed at the most vulnerable populations, seeking to Health impoverishment: Although the share of public grant them access to health services. This massive effort to health expenditure has increased, consequently lowering affiliate 54 million inhabitants with Seguro Popular has brought out-of-pocket expenses and thus improving financial the country close to achieving universal health coverage. equity for the Mexican population, it is important to For the near future, the Mexican health system, and there- continue to seek an increase in the percentage of GDP fore Seguro Popular, faces two major additional challenges: allocated to the public health system in order to approach at least the average of Organization for Economic Co- a. Financial sustainability is not guaranteed in the long operation and Development countries. term because: Access to health services: According to the 2015 inter- i. The health system is becoming more expensive by censal survey from the Instituto Nacional de Estadística the day due to epidemiologic changes in the y Geografía, 17.8% of the Mexican population is not Mexican population, which combine the character- affiliated with any health care service or social security istic illnesses of a developing country with the system. This situation indicates that universal financial chronic degenerative diseases of an aging health protection has not been achieved in full in population. Mexico, remaining a task still to accomplish. ii. The FPGC is losing its financial basis and is pre- ● Efficiency of financial management: Although a dicted to run out of money in ten years. separation of functions (financing from provision) within b. Mexico faces potential political challenges and changes in Seguro Popular was effectively achieved and the subse- the July 2018 presidential election, and the results of that quent enforcement of the transparency of the manage- election could endanger the continuity of Seguro Popular. ment of resources was well executed, the system continues to face a significant challenge related to effi- Mexico needs to execute financial strategies and public poli- cient financial resources management. Mechanisms are cies that will guarantee the financial sustainability and con- needed to allow REPSS, for example, to exercise more tinuity of Seguro Popular in the long term. Measures to do cost-effective strategies for service purchasing and sup- this could include the following: plies procurement, as well as to have more authority in the decision-making process. Positive and specific health impacts will have to be Quality of services: With respect to the quality of health linked to financing in order to drive the system to more services, recent measures have been introduced by efficient resource administration and allocation. Seguro Popular to drive resources toward the “accred- Seguro Popular possesses a contributive premium-based itation” process, rather than to operations, as occurred in membership regime and a subsidized membership the past. For example, state health services are now regime, although only the second one is applied in required to invest in infrastructure development and practice. It is estimated that almost 30% of affiliated equipment acquisition, as well as the hiring of human households are able to pay a personal or familiar resources, but mechanisms still need to be developed in contribution as a premium but do not currently do order to make these tasks permanent. so. This source of funding, if collected, could provide ● Listing of affiliates: To maintain the affiliate registry significant new revenues for Seguro Popular. with no duplication (for any social security organization) is a major undertaking. The formal workforce in Mexico is very unstable and the SP affiliation period is three CONCLUSIONS years (but ceases to be valid when a person enters another health insurance system). A significant propor- The most significant results of Seguro Popular are the ability tion of the total workforce enters or leaves IMSS every to maintain positive trends of in reducing in catastrophic/ 200 Health Systems & Reform, Vol. 4 (2018), No. 3 I nterv entions Me dicines 600 642 312 315 284 285 285 285 287 287 275 275 266 266 249 255 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 YEAR FIGURE 3. Evolution of CAUSES over Time (Modified from Comisión Nacional de Protección Social en Salud, Secretaría de Salud and Unidad de Análisis Económico, Secretaría de Salud ) # ITEMS COVERED Chemor Ruiz et al.: Mexico’s Seguro Popular 201 is affiliated with SP gets a formal job and joins IMSS, hospitals and impoverishing costs, in reducing lack of access to health care clinics have no way to know this and therefore the patient is covered services, and decreasing out-of-pocket expenses. under SP benefits. As a result, patients who seek medical care for In recent years (from 2013 to 2018), Seguro Popular CAUSES interventions, using SP, are not recognized if they are affiliated coverage has been expanded, with the addition of 61 pathol- with IMSS or ISSTE. On the other hand, because catastrophic expenses are charged after services are delivered, it is possible for “active” affili- ogies grouped into nine interventions and 61 medicines and ates with IMSS or ISSTE to be considered for reimbursement to SP. materials to the CAUSES catalog; the FPGC component, during the same period of time, also increased to include [c] This article was accepted in June 2018, before Mexico’s presidential election occurred. six new pathologies. The most important changes were those regarding the reforms to the law in 2014, which promoted a more transpar- DISCLOSURE OF POTENTIAL CONFLICTS OF ent administration of the federal resources allocated to the INTEREST states. These reforms included methods to transfer money to No potential conflicts of interest were disclosed. the REPSS, limiting how they spend the resources, introdu- cing ways to render, validate, and substantiate expenses through the SIGEFI system and establishing mechanisms ACKNOWLEDGMENTS with penalties for illegal acts. In addition, the listing of The authors thank Editor-in-Chief Michael Reich for his help affiliates was revised, removing duplicate memberships with and input. other programs or institutions. The results of these reforms were improved administrative adherence to a legal framework, which promotes better man- REFERENCES agement of resources. During the current administration, 1. Secretaria de Salud Decreto por el que se reforma y adiciona la Seguro Popular resources have been provided and used in a Ley General de Salud. 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Journal

Health Systems & ReformTaylor & Francis

Published: Jul 3, 2018

Keywords: health reform; health system; Mexico; Seguro Popular; universal health coverage

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