Estimating the indirect costs associated with the expected number of cancer cases in Mexico by 2020.

OBJECTIVE: To estimate the indirect costs generated by adults with cancer in Mexico from 2002-2020. MATERIALS AND METHODS: Using information from national sources and the national cancer incidence from GLOBOCAN, we estimated income lost due to premature death (ILPD), short-term benefits (STBs), disability pensions (DPs), and opportunity costs for the carer (OCCs) generated by patients with cancer. Amounts were reported in Mexican pesos. RESULTS: We estimated 23 359 deaths and 216 679 new cases of cancer by 2020, which would be associated with a total indirect cost of 20.15 billion Mexican pesos. Men are expected to generate 54.9% of these costs. ILPD is expected to comprise the highest percentage of the cost (60%), followed by OCCs (22%), STBs (17%) and DPs (1%). CONCLUSIONS: From an economic perspective, the results emphasize the need to strengthen preventive interventions and early detection of cancer among adults to reduce its effect on the productivity of Mexico.

EQ-5D-5L Health-State Values for the Mexican Population.

OBJECTIVE: To generate a value set for the Mexican adult general population to support and facilitate the inclusion of quality-adjusted life years (QALYs) into the health technology assessment process of the Mexican healthcare authorities. METHODS: A representative sample of the Mexican adult population stratified by age, sex and socio-economic status was used. Following version 2.0 of the EuroQol EQ-5D-5L valuation protocol, trained interviewers guided participants in completing composite time trade-off (cTTO) and discrete-choice experiment (DCE) tasks included in the EQ-VT software. Generalized least squares, Tobit and Bayesian models were used for cTTO data. The choice of value set model was based on criteria that included: theoretical considerations, parsimony, logical ordering of coefficients, and statistical significance. RESULTS: Based on quality control criteria and interviewer judgment, 1000 out of 1032 participants provided useable responses. Participants' demographic characteristics were similar to the 2010 Mexican Population Census and followed the socioeconomic structure defined by the Mexican Association of Marketing Research and Public Opinion Agencies (AMAI). The predicted index values in the final cTTO model (a heteroscedastic censored model with Bayesian estimation) ranged from - 0.5960 to 1, with 19.7% of all predicted health state scores less than 0 (i.e., worse than dead). CONCLUSION: This study has generated the first value set representing the stated preferences of the Mexican adult population for use in estimating QALYs. The resulting EQ-5D-5L value set is technically robust and will facilitate health economic analyses as well as quality-of-life studies.

[Impact of size of families in Mexico's Popular Health Insurance Program]. / Impacto del tamaño de las familias afiliadas al Seguro Popular de Salud de México, experiencia 2004-2006.

OBJECTIVE: To compare the average size of families affiliated with Popular Health Insurance (SPS, abbrev. in Spanish) and identify variables that best predict single-person affiliation. MATERIAL AND METHODS: Average sizes of families in the SPS are compared using 2004-2006 enrollment records and other sources. Logistic models are used to identify explanatory variables for affiliation as a single-person family. RESULTS: SPS families on average are composed of one member less in comparison with other sources. The logistic models indicate that the more recent the affiliation year the more probable is affiliation as a single-person family. CONCLUSIONS: The smaller number of family members implies an over-financing by the SPS. It is recommended to change the unit of financing to the individual to help the operational and financial sustainability of the SPS over the mid- to long-term.

[Generalized cost-effectiveness of preventive interventions against cervical cancer in Mexican women: results of a Markov model from the public sector perspective]. / Relación costo-efectividad de las intervenciones preventivas contra el cáncer cervical en mujeres mexicanas.

OBJECTIVE: To develop a generalized cost-effectiveness analysis (GCEA) of the HPV vaccine, hybrid capture screening (HC) and Papanicolaou screening (Pap) in the Mexican context. MATERIALS AND METHODS: From April to August 2007, in Mexico, a GCEA of the interventions was developed for 10 possible scenarios using a Markov model from the public sector perspective as payer. RESULTS: Scenarios considering 80% coverage show an ACER per DALY averted of $16678 pesos for Pap of women between ages 25 and 64, $17277 pesos for HC of women between ages 30 and 64, and $84008 pesos for vaccination of 12-year-old girls. Annual financing of $621, $741 and $2255 million pesos, respectively, is needed for these scenarios. CONCLUSIONS: A selective, combined introduction of Pap-HC screening that considers the comparative advantages of application in different populations and geographical areas is suggested. Additionally, it is suggested to introduce the vaccine once a threshold price of $181 pesos per dose -when the vaccine becomes equal in terms of cost-effectiveness to HC- has been achieved.

Priority setting for health interventions in Mexico's System of Social Protection in Health.

Explicit priority setting presents Mexico with the opportunity to match the pressure and complexity of an advancing epidemiological transition with evidence-based policies driven by a fundamental concern for how to make the best use of scarce resources to improve population health. The Mexican priority-setting experience describes how standardised analytical approaches to decision making, mainly burden of disease and cost-effectiveness analyses, combine with other criteria--eg, being responsive to the legitimate non-health expectations of patients and ensuring fair financing across households--to design and implement a set of three differentiated health intervention packages. This process is a key element of a wider set of reform components aimed at extending health insurance, especially to the poor. The most relevant policy implications include lessons on the use of available and proven analytical tools to set national health priorities, the usefulness of priority-setting results to guide long-term capacity development, the importance of favouring an institutionalised approach to cost-effectiveness analysis, and the need for local technical capacity strengthening as an essential step to balance health-maximising arguments and other non-health criteria in a transparent and systematic process.

Cancer Trends in Mexico: Essential Data for the Creation and Follow-Up of Public Policies.

Purpose Cancer in a country like Mexico is a challenge for the current health system and for public health. However, the statistics about cancer in Mexico are scarce, so epidemiologic surveillance needs to be improved. The objectives of this article were to describe the extent of cancer and to estimate the national burden of cancer through 2020. Materials and Methods To meet this objective, an analysis of secondary official sources was performed. The cancer cases through 2020 were estimated on the basis of trends in mortality and the projection of incident cases reported by GLOBOCAN. Results In 2013, cancer was the cause of 12.84% of all deaths in Mexico. It is projected that the prevalence of cancer will be 904,581 by 2017 and will reach 1,262,861 by early in the next decade (ie, 2020). Conclusion Available data for cancer are incomplete. The development and implementation of population-based cancer registries in Mexico are essential. Assessment of the future outlook of cancer in Mexico will provide awareness of future challenges and can help health systems prepare to face them.

Cost-effectiveness of breast cancer control strategies in Central America: the cases of Costa Rica and Mexico.

This paper reports the most cost-effective policy options to support and improve breast cancer control in Costa Rica and Mexico. Total costs and effects of breast cancer interventions were estimated using the health care perspective and WHO-CHOICE methodology. Effects were measured in disability-adjusted life years (DALYs) averted. Costs were assessed in 2009 United States Dollars (US$). To the extent available, analyses were based on locally obtained data. In Costa Rica, the current strategy of treating breast cancer in stages I to IV at a 80% coverage level seems to be the most cost-effective with an incremental cost-effectiveness ratio (ICER) of US$4,739 per DALY averted. At a coverage level of 95%, biennial clinical breast examination (CBE) screening could improve Costa Rica's population health twofold, and can still be considered very cost-effective (ICER US$5,964/DALY). For Mexico, our results indicate that at 95% coverage a mass-media awareness raising program (MAR) could be the most cost-effective (ICER US$5,021/DALY). If more resources are available in Mexico, biennial mammography screening for women 50-70 yrs (ICER US$12,718/DALY), adding trastuzumab (ICER US$13,994/DALY) or screening women 40-70 yrs biennially plus trastuzumab (ICER US$17,115/DALY) are less cost-effective options. We recommend both Costa Rica and Mexico to engage in MAR, CBE or mammography screening programs, depending on their budget. The results of this study should be interpreted with caution however, as the evidence on the intervention effectiveness is uncertain. Also, these programs require several organizational, budgetary and human resources, and the accessibility of breast cancer diagnostic, referral, treatment and palliative care facilities should be improved simultaneously. A gradual implementation of early detection programs should give the respective Ministries of Health the time to negotiate the required budget, train the required human resources and understand possible socioeconomic barriers.

Intervention strategies to reduce the burden of non-communicable diseases in Mexico: cost effectiveness analysis.

OBJECTIVE: To inform decision making regarding intervention strategies against non-communicable diseases in Mexico, in the context of health reform. DESIGN: Cost effectiveness analysis based on epidemiological modelling. INTERVENTIONS: 101 intervention strategies relating to nine major clusters of non-communicable disease: depression, heavy alcohol use, tobacco use, cataracts, breast cancer, cervical cancer, chronic obstructive pulmonary disease, cardiovascular disease, and diabetes. DATA SOURCES: Mexican data sources were used for most key input parameters, including administrative registries; disease burden and population estimates; household surveys; and drug price databases. These sources were supplemented as needed with estimates for Mexico from the WHO-CHOICE unit cost database or with estimates extrapolated from the published literature. MAIN OUTCOME MEASURES: Population health outcomes, measured in disability adjusted life years (DALYs); costs in 2005 international dollars ($Int); and costs per DALY. RESULTS: Across 101 intervention strategies examined in this study, average yearly costs at the population level would range from around ≤$Int1m (such as for cataract surgeries) to >$Int1bn for certain strategies for primary prevention in cardiovascular disease. Wide variation also appeared in total population health benefits, from <1000 DALYs averted a year (for some components of cancer treatments or aspirin for acute ischaemic stroke) to >300,000 averted DALYs (for aggressive combinations of interventions to deal with alcohol use or cardiovascular risks). Interventions in this study spanned a wide range of average cost effectiveness ratios, differing by more than three orders of magnitude between the lowest and highest ratios. Overall, community and public health interventions such as non-personal interventions for alcohol use, tobacco use, and cardiovascular risks tended to have lower cost effectiveness ratios than many clinical interventions (of varying complexity). Even within the community and public health interventions, however, there was a 200-fold difference between the most and least cost effective strategies examined. Likewise, several clinical interventions appeared among the strategies with the lowest average cost effectiveness ratios-for example, cataract surgeries. CONCLUSIONS: Wide variations in costs and effects exist within and across intervention categories. For every major disease area examined, at least some strategies provided excellent value for money, including both population based and personal interventions.

Estimating the indirect costs associated with the expected number of cancer cases in Mexico by 2020 / Estimación del costo indirecto asociado con el número esperado de casos de cáncer en México al año 2020

Abstract Objective: To estimate the indirect costs generated by adults with cancer in Mexico from 2002-2020. Materials and methods: Using information from national sources and the national cancer incidence from GLOBOCAN, we estimated income lost due to premature death (ILPD), short-term benefits (STBs), disability pensions (DPs), and opportunity costs for the carer (OCCs) generated by patients with cancer. Amounts were reported in Mexican pesos. Results: We estimated 23 359 deaths and 216 679 new cases of cancer by 2020, which would be associated with a total indirect cost of 20.15 billion Mexican pesos. Men are expected to generate 54.9% of these costs. ILPD is expected to comprise the highest percentage of the cost (60%), followed by OCCs (22%), STBs (17%) and DPs (1%). Conclusions: From an economic perspective, the results emphasize the need to strengthen preventive interventions and early detection of cancer among adults to reduce its effect on the productivity of Mexico.

Resumen Objetivo: Estimar el costo indirecto generado por población mexicana adulta con cáncer en el periodo 2002-2020. Material y métodos: Utilizando información 2002-2013 de fuentes nacionales y de incidencia de GLOBOCAN, se estiman para 2002-2020 los ingresos perdidos por muerte prematura (IPMP), subsidios de corto plazo (SCP), pensiones de invalidez (PD) y costo de oportunidad del cuidador (COC) generados por pacientes con cáncer, reportándose montos en millones de pesos (mdp) mexicanos. Resultados: Se estiman 23 359 muertes y 216 679 casos nuevos de cáncer para 2020, con un costo indirecto total de 20 148 mdp, del cual 54.9% corresponde a hombres. IPMP contribuye en mayor medida (60%), seguida por COC (22%), SCP (17%) y PD (1%). Conclusiones: Los resultados apoyan, desde la perspectiva económica, la necesidad de robustecer el proceso de prevención y detección temprana de los cánceres en adultos para reducir su impacto en la productividad del país.

The double burden of disease in developing countries: the Mexican experience.

OBJECTIVE: To present the challenges arising from the double burden of disease in developing countries, focusing on the case of Mexico, and to propose a strategy for addressing these challenges. METHODOLOGY/APPROACH: Mortality and morbidity data are presented for selected countries and groups of diseases. Specific examples of the pressures faced by the public health services in Mexico to provide and finance treatment for communicable and non-communicable diseases are used to illustrate the extent of the challenges in the context of a country with limited resources. FINDINGS: Public health systems in developing countries face strong pressure to provide and finance treatment for both communicable and non-communicable diseases, inevitably producing competition among diseases and conditions and requiring trade-offs between equity and efficiency goals. IMPLICATIONS FOR POLICY: In developing countries, addressing the challenges presented by the double burden of disease requires a multidisciplinary approach to develop and strengthen the policymaking process. This involves the use of analytical tools applied to each stage of the planning cycle, in particular the use of an explicit priority setting process together with monitoring and assessment to strengthen decision making under limited resources.

[Priority setting for health interventions in Mexico's System of Social Protection in Health]. / Definición de prioridades para las intervenciones de salud en el Sistema de Protección Social en Salud de Mexico.

Explicit priority setting presents Mexico with the opportunity to match the pressure and complexity of an advancing epidemiological transition with evidence-based policies driven by a fundamental concern for how to make the best use of scarce resources to improve population health. The Mexican priority-setting experience describes how standardised analytical approaches to decision making, mainly burden of disease and cost-effectiveness analyses, combine with other criteria -eg, being responsive to the legitimate non-health expectations of patients and ensuring fair financing across households- to design and implement a set of three differentiated health intervention packages. This process is a key element of a wider set of reform components aimed at extending health insurance, especially to the poor. The most relevant policy implications include lessons on the use of available and proven analytical tools to set national health priorities, the usefulness of priority-setting results to guide long-term capacity development, the importance of favouring an institutionalised approach to cost-effectiveness analysis, and the need for local technical capacity strengthening as an essential step to balance health-maximising arguments and other non-health criteria in a transparent and systematic process.

Impacto del tamaño de las familias afiliadas al Seguro Popular de Salud de México, experiencia 2004-2006 / Impact of size of families in Mexico's Popular Health Insurance Program

OBJETIVO: Comparar el tamaño promedio de las familias del Seguro Popular de Salud (SPS) e identificar las variables que mejor predicen la afiliación unipersonal. MATERIAL Y MÉTODOS: Se comparan tamaños promedios de familias según los Padrones 2004 a 2006 del SPS y otras fuentes. Se ajustan modelos logísticos para identificar las variables explicativas de la afiliación como familia unipersonal. RESULTADOS: Las familias del SPS en promedio tienen un miembro menos respecto de otras fuentes. Los modelos logísticos indican que cuanto más reciente es el año de afiliación tanto mayor es la probabilidad de afiliarse como familia unipersonal CONCLUSIONES: El menor número de miembros por familia afiliada implica un sobrefinanciamiento al SPS. Se recomienda cambiar la unidad de financiamiento hacia la persona, para apoyar el sostenimiento financiero y operativo del SPS en el mediano y largo plazos.

OBJECTIVE: To compare the average size of families affiliated with Popular Health Insurance (SPS, abbrev. in Spanish) and identify variables that best predict single-person affiliation. MATERIAL AND METHODS: Average sizes of families in the SPS are compared using 2004-2006 enrollment records and other sources. Logistic models are used to identify explanatory variables for affiliation as a single-person family. RESULTS: SPS families on average are composed of one member less in comparison with other sources. The logistic models indicate that the more recent the affiliation year the more probable is affiliation as a single-person family. CONCLUSIONS: The smaller number of family members implies an over-financing by the SPS. It is recommended to change the unit of financing to the individual to help the operational and financial sustainability of the SPS over the mid- to long-term.

Relación costo-efectividad de las intervenciones preventivas contra el cáncer cervical en mujeres mexicanas / Generalized cost-effectiveness of preventive interventions against cervical cancer in Mexican women: results of a Markov model from the public sector perspective

OBJETIVO: Realizar un análisis de la relación costo-efectividad generalizada (ACEG) para la vacuna anti-VPH, el tamiz por captura de híbridos (CH) y el tamiz por Papanicolaou en el caso mexicano. MATERIAL Y MÉTODOS: Entre abril y agosto de 2007 se desarrolló en México un ACEG de las intervenciones relacionadas con 10 posibles escenarios en un modelo markoviano, bajo la perspectiva del sector público como pagador. RESULTADOS: Los escenarios con cobertura universal muestran un cociente costo-efectividad por AVISA ganado para el Papanicolaou en mujeres de 25 a 64 años de 16 678 pesos, para el tamiz por CH en mujeres de 30 a 64 años de 17 285 pesos y para la vacuna en niñas de 12 años de 84 008 pesos. El financiamiento anual necesario para estas intervenciones es de 621, 741 y 2 255 millones de pesos, respectivamente. CONCLUSIONES: Se sugiere introducir una combinación selectiva de tamices (Papanicolaou y CH) y considerar las ventajas comparativas de aplicación en distintas poblaciones y áreas geográficas. De manera complementaria, se aconseja introducir la vacuna con un precio umbral de 181 pesos por dosis, equiparable en términos del costo y la efectividad a la CH.

OBJECTIVE: To develop a generalized cost-effectiveness analysis (GCEA) of the HPV vaccine, hybrid capture screening (HC) and Papanicolaou screening (Pap) in the Mexican context. MATERIALS AND METHODS: From April to August 2007, in Mexico, a GCEA of the interventions was developed for 10 possible scenarios using a Markov model from the public sector perspective as payer. RESULTS: Scenarios considering 80 percent coverage show an ACER per DALY averted of $16678 pesos for Pap of women between ages 25 and 64, $17277 pesos for HC of women between ages 30 and 64, and $84008 pesos for vaccination of 12-year-old girls. Annual financing of $621, $741 and $2255 million pesos, respectively, is needed for these scenarios. CONCLUSIONS: A selective, combined introduction of Pap-HC screening that considers the comparative advantages of application in different populations and geographical areas is suggested. Additionally, it is suggested to introduce the vaccine once a threshold price of $181 pesos per dose -when the vaccine becomes equal in terms of cost-effectiveness to HC- has been achieved.

Implicaciones éticas y sociales de la introducción de la vacuna contra el virus del papiloma humano en México: reflexiones sobre una propuesta de intervención / Ethical and social implications of the introduction of the vaccine against the human papilloma virus in Mexico: reflections on a proposed intervention / Implicações éticas e sociais da introdução da vacina contra o virus do papiloma humano no México: reflexões sobre uma proposta de intervenção

El objetivo de este trabajo es identificar aspectos éticos y sociales relacionados con la introducción de la vacuna contra el virus del papiloma humano (VPH) en México para una decisión informada y justa que considere no sólo los aspectos financieros. De acuerdo con la información sobre eficiencia y costo de la vacuna, su introducción al sistema público mexicano puede acarrear consecuencias no previstas para las participantes y para toda la sociedad, por lo que debe examinarse en el contexto mexicano, reconociendo sus riesgos sin sobrestimar resultados comprobados o potenciales derivados de diversas políticas de vacunación. Exponer la evidencia científica y los motivos para la toma de decisiones es esencial. También, dirigirse de manera responsable hacia una decisión política sobre la implementación de programas de vacunación, tamizaje y tratamiento de cáncer cervical con base en el potencial para salvar vidas que tienen las nuevas tecnologías, siempre que se respeten los derechos, opiniones y preocupaciones de las mujeres a las que va dirigida la vacuna contra el VPH y que representen un valor agregado para la sociedad mexicana en su conjunto.

The objective of this work is to identify ethical and social aspects related to the introduction of the vaccine against the human papillomavirus (HPV) in Mexico for an informed and just decision that considers not only financial aspects. According to information about the efficiency and cost of the vaccine, its introduction to the public health system of Mexico can lead to unforeseen consequences for the participants and for society as a whole. The introduction of the vaccine should examine the Mexican context, recognizing its risks without overestimating potential or proven results derived from diverse vaccine policies. Exposing scientific evidence and the motives for decision making is essential. Also, it is essential to take a responsible stand toward political decisions on the implementation of vaccine programs, screening and treatment for cervical cancer based on the potential for new technologies to save lives, always with respect for the rights, opinions and preoccupations of women, the recipients of the HPV vaccine, and that represent an added value for Mexican society as a whole.

O objetivo deste trabalho é identificar aspectos éticos e sociais relacionados com a introdução da vacina contra o vírus do papiloma humano (HPV) no México para uma decisão informada e justa que considere não somente os aspectos financeiros. De acordo com a informação sobre eficiência e custo da vacina, sua introdução no sistema público mexicano pode carrear conseqüências não previstas para as participantes e para toda a sociedade, pelo que deve ser examinada no contexto mexicano, reconhecendo seus riscos sem superestimar resultados comprovados ou potenciais derivados de diversas políticas de vacinação. Expor a evidência científica e os motivos para a tomada de decisões é essencial. Também, dirigir-se de maneira responsável para uma decisão política sobre a implementação de programas de vacinação, tamisação e tratamento de câncer cervical com base no potencial para salvar vidas que têm as novas tecnologias, sempre que se respeitam direitos, opiniões e preocupações das mulheres às quais é destinada a vacina contra o HPV e que representam um valor agregado para a sociedade mexicana em seu conjunto.

Definición de prioridades para las intervenciones de salud en el Sistema de Protección Social en Salud de México / Priority setting for health interventions in Mexico's System of Social Protection in Health

La definición explícita de prioridades en intervenciones de salud representa una oportunidad para México de equilibrar la presión y la complejidad de una transición epidemiológica avanzada, con políticas basadas en evidencias generadas por la inquietud de cómo optimizar el uso de los recursos escasos para mejorar la salud de la población. La experiencia mexicana en la definición de prioridades describe cómo los enfoques analíticos estandarizados en la toma de decisiones, principalmente los de análisis de la carga de la enfermedad y de costo-efectividad, se combinan con otros criterios -tales como dar respuesta a las expectativas legítimas no médicas de los pacientes y asegurar un financiamiento justo para los hogares-, para diseñar e implementar un grupo de tres paquetes diferenciados de intervenciones de salud. Éste es un proceso clave dentro de un conjunto más amplio de elementos de reforma dirigidos a extender el aseguramiento en salud, especialmente a los pobres. Las implicaciones más relevantes en el ámbito de políticas públicas incluyen lecciones sobre el uso de las herramientas analíticas disponibles y probadas para definir prioridades nacionales de salud; la utilidad de resultados que definan prioridades para guiar el desarrollo de capacidades a largo plazo; la importancia de favorecer un enfoque para institucionalizar el análisis ex-ante de costo-efectividad; y la necesidad del fortalecimiento de la capacidad técnica local como un elemento esencial para equilibrar los argumentos sobre maximización de la salud con criterios no relacionados con la salud en el marco de un ejercicio sistemático y transparente.

Explicit priority setting presents Mexico with the opportunity to match the pressure and complexity of an advancing epidemiological transition with evidence-based policies driven by a fundamental concern for how to make the best use of scarce resources to improve population health. The Mexican priority-setting experience describes how standardised analytical approaches to decision making, mainly burden of disease and cost-effectiveness analyses, combine with other criteria -eg, being responsive to the legitimate non-health expectations of patients and ensuring fair financing across households- to design and implement a set of three differentiated health intervention packages. This process is a key element of a wider set of reform components aimed at extending health insurance, especially to the poor. The most relevant policy implications include lessons on the use of available and proven analytical tools to set national health priorities, the usefulness of priority-setting results to guide long-term capacity development, the importance of favouring an institutionalised approach to cost-effectiveness analysis, and the need for local technical capacity strengthening as an essential step to balance health-maximising arguments and other non-health criteria in a transparent and systematic process.