Equity in out-of-pocket health expenditure: Evidence from a health insurance program reform in Mexico.

Background: The fragmentation of health systems in low- and middle-income countries (LMICs) deepens health inequities and shifts the economic burden of health care to families via out-of-pocket spending (OOPHE). This problem has been addressed by introducing public health insurance programs for poor people; however, there is a lack of knowledge about how equitable these programs are. We aimed to analyse the long-term effects of the Seguro Popular (SP) voluntary health insurance program, recently phased out and replaced by the Health Institute for Welfare (Instituto de Salud para el Bienestar (INSABI)), on OOPHE equity in the poor Mexican population. Methods: We conducted a pooled cross-sectional analysis using eleven waves of the National Household Income and Expenditure Survey (2002-2020). We identified the effect of SP by selecting households without social security (with SP or without health insurance (n = 169 766)) and matched them by propensity score to reduce bias in the decision to enrol in SP. We estimated horizontal and vertical equity metrics and assessed their evolution across subpopulations. Results: The program's entry years (2003-2010) show a positive redistributive effect associated with a focalised stage of the program, while oversaturation could have diluted these effects during 2010-2014, with adverse results in terms of vertical equity and re-ranking among insured families. SP is more horizontally inequitable than for those uninsured. Within SP, the redistributive effect could improve up to 13% if all families with similar expenditures were spending equal OOPHE and horizontal equity was eliminated. Regarding vertical equity, SP outperforms the insured population with middle-range coverage some years after the implementation, but this progress disappears. Conclusions: To achieve universal health coverage, health authorities need to create and execute financial protection mechanisms that effectively address structural inequalities. This involves implementing a more comprehensive risk-pooling mechanism that makes social insurance sustainable in the long-run by increasing the social-economic influx of resources. It is essential to monitor oversaturation and financial sustainability to achieve optimal results. The replacement of the SP with INSABI highlights the complexity of maintaining a social insurance program where the ideology of different governments can influence the program structure, regulation, financing, and even its existence.

Inequitable Financial Protection in Health for Indigenous Populations: the Mexican Case.

BACKGROUND: There is an important gap in the literature concerning the level, inequality, and evolution of financial protection for indigenous (IH) and non-indigenous (NIH) households in low- and middle-income countries. This paper offers an assessment of the level, socioeconomic inequality and middle-term trends of catastrophic (CHE), impoverishing (IHE), and excessive (EHE) health expenditures in Mexican IHs and NIHs during the period 2008-2020. METHODS: We conducted a pooled cross-sectional analysis using the last seven waves of the National Household Income and Expenditure Survey (n = 315,829 households). We assessed socioeconomic inequality in CHE, IHE, and EHE by estimating their Wagstaff concentration indices according to indigenous status. We adjusted the CHE, IHE, and EHE by estimating a maximum-likelihood two-stage probit model with robust standard errors. RESULTS: We observed that, during the period analyzed, CHE, IHE, and EHE were concentrated in the poorest IHs. CHE decreased from 5.4% vs. 4.7% in 2008 to 3.4% vs. 2.9% in 2014 in IHs and NIHs, respectively, and converged at 2008 levels towards 2020. IHE remained unchanged from 2008 to 2014 (1.6% for IHs vs. 1.0% for NIHs) and increased by 40% in IHs and NIHs during 2016-2020. EHE plunged in 2014 (4.6% in IHs vs. 3.8% in NIHs), then rose, and remained unchanged during 2016-2020 (6.7% in IHs and 5.6% in NIHs). CONCLUSION: In pursuit of universal health coverage, health authorities should formulate and implement effective financial protection mechanisms to address structural inequalities, especially forms of discrimination including racialization, that vulnerable social groups such as indigenous peoples have systematically faced. Doing so would contribute to closing the persistent ethnic gaps in health.

Remote ophthalmology with a smartphone adapter handled by nurses for the diagnosis of eye posterior pole pathologies during the COVID-19 pandemic.

INTRODUCTION: The use of smartphones to provide specialist ophthalmology services is becoming a more commonly used method to support patients with eye pathologies. During the COVID-19 pandemic, demand for telehealth services such as tele-ophthalmology, is increasing rapidly. METHODS: In 2019, the agreement between diagnostic tests was investigated by comparing the diagnostic performance for eye posterior pole pathologies of the images obtained by a smartphone coupled to a medical device known as open retinoscope (OR), handled by a nurse and subsequently assessed by an ophthalmologist versus the images obtained by an ophthalmologist using a slit lamp associated to a 76 diopter indirect ophthalmic lens (Volk Super FieldVR ) (SL-IOL) at the outpatient department of a hospital. The OR used in this study worked with a 28 diopter indirect lens. RESULTS: An examination of 151 dilated eyes (79 adult patients, mean age of 66.7 years, 59.5% women) was conducted. Sensitivity was 98.9%, specificity was 89.8%, the positive predictive value was 93.8% and the negative predictive value was 98.2%. The kappa index between both tests was 0.90 (95% CI: 0.83-0.97) in basic diagnosis, 0.81 (95% CI: 0.74-0.89) in syndromic diagnosis (13 categories) and 0.70 (95% CI: 0.62-0.77) in advanced diagnosis (23 categories). DISCUSSION: Images obtained by a nurse using a smartphone coupled to the OR and subsequently assessed by an ophthalmologist showed a high diagnostic performance for eye posterior pole pathologies, which could pave the way for remote ophthalmology systems for this patient group.

Effective access to health care in Mexico.

OBJECTIVES: This paper assesses the impact of effective access on out-of-pocket health payments and catastrophic health expenditure. Effective access cannot be attained unless both health services and financial risk protection are accessible, affordable, and acceptable. Therefore, it represents a key determinant in the transition from fragmented health systems to universal coverage that many low- and middle-income countries face. METHODS: We use a definition of effective access as the utilization of health insurance when available. We conducted a cross-sectional analysis using the 2018 Mexican National Health Survey (ENSANUT) at the household level. The analysis is performed in two stages. The first stage is a multinomial analysis that captures the factor associated with choosing effective access against the alternative of paying privately. The second stage consists of an impact analysis regarding the decision of not choosing effective access in terms of out-of-pocket (OOP) health payments and catastrophic health expenditures (CHE). The analysis corrects for both the decision to buy insurance and the decision to pay for health care. RESULTS: We found that, on average, not choosing effective access increases OOP health payments by around 2300 pesos annually. Medicine payments are the most common factor in this increase. Nevertheless, outpatient and medicines health care are the main drivers of the increase in OOP health payments in all insurance beneficiaries. Not having effective access increases the probability of CHE health expenditures by 2.7 p.p. for the case of Social Security Insurance and 4.0 p.p. for Social Government insurance. Household enrolled in Prospera program for the poor are more likely to choose effective access while having household heads with more education and assets value does the opposite. Diabetes illnesses are associated with a higher probability of effective access. CONCLUSION: Improving effective access is a middle step that cannot be disregarded when seeking universal coverage because OOP health payments and catastrophic outcomes are direct consequences. Public insurance in general, has around 50% effective access which remains a challenge in terms of health services utilization and health public policy design, calling for the need of better coordination across insurance types and pooling mechanisms to increase sustainability of needed health services.

Welfare effects of health insurance in Mexico: The case of Seguro Popular de Salud.

This study contributes with original empirical evidence on the distributional and welfare effects of one of the most important health policies implemented by the Mexican government in the last decade, the Seguro Popular de Salud (SPS). We analyze the effect of SPS on households' welfare using a decomposable index that considers insured and uninsured households' response to out-of-pocket (OOP) payments using both social welfare weights and inequality aversion. The disaggregation of the welfare index allows us to explore the heterogeneity of the SPS impact on households' welfare. We applied propensity score matching to reduce the self-selection bias of being SPS insured. Overall results suggest non-conclusive results of the impact of SPS on households' welfare. When we disaggregated the welfare index by different sub-population groups, our results suggest that households' beneficiaries of SPS with older adults or living in larger cities are better protected against OOP health care payments than their uninsured counterparts. However, no effect was found among SPS-insured households living in rural and smaller cities, which is a result that could be attributed to limited access to health resources in these regions. Scaling up health insurance coverage is a necessary but not sufficient condition to ensure the protection of SPS coverage against financial risks among the poor.

Doctors Adjacent to Private Pharmacies: The New Ambulatory Care Provider for Mexican Health Care Seekers.

BACKGROUND: In 2010 Mexican health authorities enacted an antibiotic sale, prescription, and dispensation bill that increased the presence of a new kind of ambulatory care provider, the doctors adjacent to private pharmacies (DAPPs). OBJECTIVES: To analyze how DAPPs' presence in the Mexican ambulatory care market has modified health care seekers' behavior following a two-stage health care provider selection decision process. METHODS: The first stage focuses on individuals' propensity to captivity to the health care system structure before 2010. The second stage analyzes individuals' medical provider selection in a health system including DAPPs. This two-stage process analysis allowed us not only to show the determinants of each part in the decision process but also to understand the overall picture of DAPPs' impact in both the Mexican health care system and health care seekers, taking into account conditions such as the origins, evolution, and context of this new provider. We used data from individuals (N = 97,549) participating in the Mexican National Survey of Health and Nutrition in 2012. RESULTS: We found that DAPPs have become not only a widely accepted but also a preferred option among the Mexican ambulatory care providers that follow no specific income-level population user group (in spite of its original low-income population target). Our results showed DAPPs as an urban and rapidly expanded phenomenon, presumably keeping the growing pace of new communities and adapting to demographic changes. CONCLUSIONS: Individuals opt for DAPPs when they look for health care: in a nearby provider, for either the most recent or common ailments, and in an urban setting; regardless of most socioeconomic background. The relevance of location and accessibility variables in our study provides evidence of the role taken by this provider in the Mexican health care system.

Analysis of the distributional impact of out-of-pocket health payments: evidence from a public health insurance program for the poor in Mexico.

Many governments have health programs focused on improving health among the poor and these have an impact on out-of-pocket health payments made by individuals. Therefore, one of the objectives of these programs is to reach the poorest and reduce their out-of-pocket expenditure. In this paper we propose the distributional poverty impact approach to measure the poverty impact of out-of-pocket health payments of different health financing policies. This approach is comparable to the impoverishment methodology proposed by Wagstaff and van Doorslaer (2003) that compares poverty indices before and after out-of-pocket health payments. In order to escape the specification of a particular poverty index, we use the marginal dominance approach that uses non-intersecting curves and can rank poverty reducing health financing policies. We present an empirical application of the out-of-pocket health payments for an innovative social financing policy implemented in Mexico named Seguro Popular. The paper finds evidence that Seguro Popular program has a better distributional poverty impact when families face illness when compared to other poverty reducing policies. The empirical dominance approach uses data from Mexico in 2006 and considers international poverty standards of $2 per person per day.