Increase of catastrophic and impoverishing health expenditures in Mexico associated to policy changes and the COVID-19 pandemic.

Background: In 2003, the Mexican Congress approved a major reform to provide health care services to the poor population through the public insurance scheme Seguro Popular. This program was dismantled in 2019 as part of a set of health system reforms and substituted with the Health Institute for Welfare (INSABI). These changes were implemented during the initial phases of the coronavirus (COVID-19) pandemic. We aimed to examine the impact of these reforms and the COVID-19 pandemic on financial risk protection in Mexico between 2018 and 2020. Methods: We performed a population-based analysis using cross-sectional data from the 2018 and 2020 rounds of the National Household Income and Expenditures Survey. We used a pooled fixed-effects multivariable two-stage probit model to determine the likelihood of catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and excessive health expenditure (EHE) among Mexican households. We also mapped the quintiles of changes in EHE in households without health insurance by state. Results: The percentage of households without health insurance almost doubled from 8.8% (three million households) in 2018 to 16.5% (5.8 million households) in 2020. We also found large increases in the proportion of households incurring in CHE (18.4%; 95% confidence interval (CI) = 6.1, 30.7) and EHE (18.7%; 95% CI = 7.9, 29.5). Significant increases in CHE, IHE, and EHE were only observed among households without health insurance (CHE: 90.7%; 95% CI = 31.6, 149.7, EHE: 73.5%; 95% CI = 25.3, 121.8). Virtually all Mexican states (n/N = 31/32) registered an increase in EHE among households without health insurance. This increase has a systematic territorial component affecting mostly central and southern states (range = -1.0% to 194.4%). Conclusions: The discontinuation of the Seguro Popular Program and its substitution with INSABI during the first stages of the COVID-19 pandemic reduced the levels of health care coverage in Mexico. This reduction and the pandemic increased out-of-pocket expenditure in health and the portion of CHE and EHE in the 2018-2020 period. The effect was higher in households without health insurance and households in central and southern states of the country. Further studies are needed to determine the specific effect both of recent policy changes and of the COVID-19 pandemic on the levels of financial protection in health in Mexico.

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.

Setbacks in the quest for universal health coverage in Mexico: polarised politics, policy upheaval, and pandemic disruption.

2023 marks the 20-year anniversary of the creation of Mexico's System of Social Protection for Health and the Seguro Popular, a model for the global quest to achieve universal health coverage through health system reform. We analyse the success and challenges after 2012, the consequences of reform ageing, and the unique coincidence of systemic reorganisation during the COVID-19 pandemic to identify strategies for health system disaster preparedness. We document that population health and financial protection improved as the Seguro Popular aged, despite erosion of the budget and absent needed reforms. The Seguro Popular closed in January, 2020, and Mexico embarked on a complex, extensive health system reorganisation. We posit that dismantling the Seguro Popular while trying to establish a new programme in 2020-21 made the Mexican health system more vulnerable in the worst pandemic period and shows the precariousness of evidence-based policy making to political polarisation and populism. Reforms should be designed to be flexible yet insulated from political volatility and constructed and managed to be structurally permeable and adaptable to new evidence to face changing health needs. Simultaneously, health systems should be grounded to withstand systemic shocks of politics and natural disasters.

Origin, impacts, and potential solutions to the fragmentation of the Mexican health system: a consultation with key actors.

BACKGROUND: One of the central debates in health policy is related to the fragmentation of health systems. Fragmentation is perceived as a major obstacle to UHC. This article presents the results of a consultation with a group of actors of the Mexican policy arena on the origins and impacts of the fragmentation of the Mexican health system. METHODS: We used a consultation to nine key actors to collect thoughts on the fragmentation of the Mexican health system. The group included national and local decision makers with experience in health care issues and researchers with background in health systems and/or public policies. The sessions were recorded, transcribed verbatim and analyzed thematically. RESULTS: Participants defined the term 'fragmentation' as the separation of the various groups of the population based on characteristics which define their access to health care services. This is a core characteristic of health systems in Latin America (LA). In general, those affiliated to social security institutions have a higher per capita expenditure than those without social security, which translates into differential health benefits. According to the actors in this consultation, fragmentation is the main structural problem of the Mexican health system. Actors agreed that the best way to end fragmentation is through the creation of a universal health system. Defragmentation plans should include a research component to document the impacts of fragmentation, and design and test the instruments needed for the integration process. CONCLUSIONS: First, health system fragmentation in Mexico has created problems of equity since different population groups have unequal access to public resources and different health benefits. Second, Mexico needs to move beyond the fragmentation of its health system and guarantee, through its financial integration, access to the same package of health services to all its citizens. Third, defragmentation plans should include a research component to document the impacts of fragmentation, and design and test the instruments needed for the integration process. Fourth, defragmentation of health systems is not an easy task because there are vested interests that oppose its implementation. Political strategies to meet the resistance of these groups are an essential component of any defragmentation plan.

An assessment of the performance of the Mexican health system between 2000 and 2018.

This paper offers a comprehensive picture of the performance of the Mexican health system during the period 2000-18. Using high-quality and periodical data from the Organization for Economic Cooperation and Development, the World Bank, the Institute for Health Metrics and Evaluation and Mexico's National Survey of Household Income and Expenditure, we assess the evolution of seven types of indicators (health expenditure, health resources, health services, quality of care, health care coverage, health conditions and financial protection) over a period of 18 years during three political administrations. The reform implemented in Mexico in the period 2004-18-which includes the creation of 'Seguro Popular'-and other initiatives helped improve the financial protection levels of the Mexican population, expressed in the declining prevalence of catastrophic and impoverishing health expenditures, and various health conditions (consumption of tobacco in adults and under-five, maternal, cervical cancer and human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) mortality rates). We conclude that policies intended to move towards universal health coverage should count on strong financial mechanisms to guarantee the consistent expansion of health care coverage and the sustainability of reform efforts. However, the mobilization of additional resources for health and the expansion of health care coverage do not guarantee by themselves major improvements in health conditions. Interventions to deal with specific health needs are also needed.

Challenges of Guaranteeing Access to Medicines in Mexico: Lessons from Recent Changes in Pharmaceuticals Procurement.

During the last two decades, Mexico adopted policies intended to increase the efficiency and effectiveness of medicines procurement in its nationally fragmented health system. In this policy report, we review Mexico's efforts to guarantee access to medicines during three national administrations (from 2000 to 2018), and then examine major health system changes introduced by the current government (2018-2024), which have created significant setbacks in guaranteeing access to medicines in Mexico. These recent changes are having important consequences in the levels of satisfaction of health care users and citizens, household expenditure on health, and health conditions. We suggest key lessons for Mexico and other countries seeking to improve pharmaceutical procurement as part of guaranteeing access to medicines.

Hospitalisation and mortality from COVID-19 in Mexican indigenous people: a cross-sectional observational study.

BACKGROUND: Despite having a large indigenous population, little is known about the differences in COVID-19-related health outcomes between indigenous and non-indigenous patients in Mexico. The aim of this study is to analyse the variation in hospitalisation and death between indigenous and non-indigenous patients with COVID-19 to guide future policies and clinical practice. METHODS: We used data from the Mexican Ministry of Health (MoH) to study the hospitalisation and death of adults with laboratory-confirmed SARS-CoV-2 in MoH facilities between 1 March 2020 and 28 February 2021. Predicted probabilities of hospitalisation and death were adjusted for sociodemographic and presentation to care characteristics as well as municipal social deprivation index and health jurisdiction-level index of human resource and hospital equipment availability. RESULTS: Of 465 676 hospitalised adults with COVID-19, 5873 (1.3%) were identified as indigenous. Indigenous patients had higher odds of hospitalisation (adjusted OR (aOR)=1.9, 95% CI 1.8 to 2.0), death (aOR=1.3, 95% CI 1.1 to 1. 3) and early mortality (aOR=1.2, 95% CI 1.0 to 1.4), compared with non-indigenous patients. Living in municipalities with high social deprivation was associated with a higher risk of hospitalisation and early death. Living in areas with low healthcare resources was associated with a higher risk of hospitalisation but not death. Being male, aged 51 years or older, having diabetes, hypertension and obesity were associated with an incremental probability of hospitalisation and death among indigenous patients. CONCLUSIONS: Indigenous patients with COVID-19 in Mexico have a higher risk of hospitalisation and death than non-indigenous individuals. Our findings can guide future efforts to protect this population from SARS-CoV-2 infection and associated outcomes.

Conceptual foundations of the new public health.

This paper discusses the origins and content of the framework that guided the creation of the Center for Public Health Research in 1984 and the modernization of the School of Public of Health of Mexico, established in 1922. These two institutions eventually merged with the Center for Research in Infectious Disease to create, in 1987, the National Institute of Public Health of Mexico, one of the leading institutions of higher education and research in public health in the developing world.

Stakeholder analysis of the deliberation of an increase to the excise tax on sweetened beverages in Mexico / Análisis de grupos de interés sobre la deliberación del incremento al impuesto a bebidas azucaradas en México

Abstract Objective: To present the results of a stakeholder analysis used to construct a map of the actors involved in the delib- eration of a proposal to increase the tax on sugar-sweetened beverages (SSB) in Mexico from 10 to 20 percent per liter. Materials and methods: A literature review and in- terviews to key actors were implemented. The analysis of the actors' power and position was made using Policymaker. Results: There was concern for the obesity epidemic among all stakeholders, but little consensus on the way to solve it. Researchers and non-governmental organizations (NGO) support an increase in the tax on SSB, while government officials and industry representatives oppose this measure. Conclusión: Supporters of an increase to the tax on SSB need to build a coalition in order to force government officials to support this policy and successfully confront the soda industry, which has a solid opposing strategy and enormous financial resources to influence public opinion and congressmen.

Resumen Objetivo: Presentar los resultados de un análisis de grupos de interés para definir un mapa de los actores involucrados en la deliberación de una propuesta para incrementar el impuesto a bebidas azucaradas (BA) en México del 10 al 20% por litro. Material y métodos: Se revisó la literatura y se entrevistó a actores clave. El análisis del poder y posición de los actores se realizó con el programa Policymaker. Resultados: Se identificó una amplia preocupación por la epidemia de obesidad, pero poco consenso sobre cómo resolverla. Los investigadores y las Organizaciones No Gubernamentales (ONG) apoyan un incremento en el impuesto a las BA, mientras que los funcionarios gubernamentales y los representantes de la industria se oponen a dicha medida. Conclusión: Quienes apoyan un incremento al impuesto deben crear una coalición que fuerce a los funcionarios gubernamentales a apoyar el aumento y confrontar exitosa- mente a la industria, la cual cuenta con una estrategia sólida y recursos financieros abundantes para influir en la opinión pública y en los legisladores.

Stakeholder analysis of the deliberation of an increase to the excise tax on sweetened beverages in Mexico.

OBJECTIVE: To present the results of a stakeholder analysis used to construct a map of the actors involved in the delib-eration of a proposal to increase the tax on sugar-sweetened beverages (SSB) in Mexico from 10 to 20 percent per liter. MATERIALS AND METHODS: A literature review and in-terviews to key actors were implemented. The analysis of the actors' power and position was made using Policymaker. RESULTS: There was concern for the obesity epidemic among all stakeholders, but little consensus on the way to solve it. Researchers and non-governmental organizations (NGO) support an increase in the tax on SSB, while government officials and industry representatives oppose this measure. CONCLUSION: Supporters of an increase to the tax on SSB need to build a coalition in order to force government officials to support this policy and successfully confront the soda industry, which has a solid opposing strategy and enormous financial resources to influence public opinion and congressmen.

Incremental Risk of Developing Severe COVID-19 Among Mexican Patients With Diabetes Attributed to Social and Health Care Access Disadvantages.

OBJECTIVE: Diabetes is an important risk factor for severe coronavirus disease 2019 (COVID-19), but little is known about the marginal effect of additional risk factors for severe COVID-19 among individuals with diabetes. We tested the hypothesis that sociodemographic, access to health care, and presentation to care characteristics among individuals with diabetes in Mexico confer an additional risk of hospitalization with COVID-19. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study using public data from the General Directorate of Epidemiology of the Mexican Ministry of Health. We included individuals with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 between 1 March and 31 July 2020. The primary outcome was the predicted probability of hospitalization, inclusive of 8.5% of patients who required intensive care unit admission. RESULTS: Among 373,963 adults with COVID-19, 16.1% (95% CI 16.0-16.3) self-reported diabetes. The predicted probability of hospitalization was 38.4% (37.6-39.2) for patients with diabetes only and 42.9% (42.2-43.7) for patients with diabetes and one or more comorbidities (obesity, hypertension, cardiovascular disease, and chronic kidney disease). High municipality-level of social deprivation and low state-level health care resources were associated with a 9.5% (6.3-12.7) and 17.5% (14.5-20.4) increased probability of hospitalization among patients with diabetes, respectively. In age-, sex-, and comorbidity-adjusted models, living in a context of high social vulnerability and low health care resources was associated with the highest predicted probability of hospitalization. CONCLUSIONS: Social vulnerability contributes considerably to the probability of hospitalization among individuals with COVID-19 and diabetes with associated comorbidities. These findings can inform mitigation strategies for populations at the highest risk of severe COVID-19.

Precursores, promotores y artífices del servicio social de medicina en México / Precursors, promoters and architects of social service in medicine in Mexico

Resumen: Una de las primeras iniciativas para llevar atención médica a las comunidades rurales de México fue el servicio social de medicina, el cual se implantó en la Universidad Nacional Autónoma de México y en la Universidad Michoacana de San Nicolás de Hidalgo en 1936, y cuya paternidad se atribuyeron diversos ilustres médicos mexicanos. Este texto precisa las contribuciones de varios actores a la promoción, diseño e implantación de esta importante innovación educativa y de atención a la salud. La principal conclusión de este artículo es que la prestación de servicios de salud a las comunidades rurales por estudiantes de medicina en su último año de carrera en México no fue idea de una sola persona, sino resultado de varios esfuerzos encabezados por diversos actores, entre ellos estudiantes y profesores de medicina, sanitaristas y funcionarios universitarios y gubernamentales.

Abstract: One of the first attempts to provide medical care to rural populations in Mexico was the social service in medicine, established at the National Autonomous University of Mexico and the Michoacán University of San Nicolás de Hidalgo in 1936, the paternity of which has been disputed by several prestigious Mexican physicians. This text identifies the precise contributions made by various actors to the promotion, design, and implementation of this important training and health care delivery innovation. The main conclusion of this article is that the provision of health care to rural communities by medical students in their last year of training was not the idea of a single person but the result of several efforts headed by multiple actors, including medicine students and professors, public health professionals, and university and government decision-makers.

Ethics and Public Health: definition of priorities in the Mexican Health Reform / Ética y salud pública: definición de prioridades en la Reforma Sanitaria mexicana / Ética e saúde pública: definição de prioridades na Reforma Sanitária mexicana

Abstract The purpose of this paper is to discuss one of the most common ethical predicaments faced by public health practitioners: the distribution of limited resources for health. The question we address is the following: If there are limited resources to provide necessary health care, how can we reasonably establish priorities? We discuss this question using as reference a real-life situation, which was the establishment of priorities in the design of a package of high-cost interventions for Seguro Popular in Mexico, a public insurance scheme that extended social protection in health to over 50 million people between 2003 and 2018. The main conclusion of this paper is that the use of explicit ethical assumptions in the design of public policies contribute to their acceptability and eventual success.

Resumen El propósito de este artículo es discutir uno de los dilemas éticos que con mayor frecuencia enfrentan quienes se dedican a la salud pública: la distribución de recursos limitados para la salud. La pregunta a la que se pretende responder es la siguiente: si existen recursos limitados para prestar los servicios de salud necesarios, ¿cómo podemos fijar prioridades? Intentamos responder a esta pregunta haciendo referencia a una situación de la vida real que fue el establecimiento de prioridades en el diseño de un paquete de intervenciones de alto costo para el Seguro Popular de México, un seguro público que extendió la protección social en salud a más de 50 millones de personas entre 2003 y 2018. La principal conclusión de este artículo es que el uso de un marco ético explícito en el diseño de las políticas públicas incrementa su aceptabilidad y favorece su eventual éxito.

Resumo O propósito deste artigo é discutir um dos dilemas éticos que com maior frequência aqueles que se dedicam à saúde pública enfrentam: a distribuição de recursos limitados para a saúde. A pergunta que se pretende responder é a seguinte: se existem recursos limitados para prestar os serviços de saúde necessários, como podemos fixar prioridades? Tentamos responder a esta pregunta fazendo referência a uma situação de vida real que foi o estabelecimento de prioridades na concepção de um pacote de intervenções de alto custo para o Seguro Popular do México, um seguro público que estendeu a proteção social em saúde a mais de 50 milhões de pessoas entre 2003 e 2018. A principal conclusão deste artigo é que o uso de um enquadramento ético explícito na concepção das políticas públicas aumenta sua aceitação e favorece seu eventual sucesso.

El "trancazo", la pandemia de 1918 en México / The "blow", the 1918 pandemic in Mexico

Resumen Después de ocho años de una cruenta lucha armada que dejó devastado al país, en octubre de 1918 llegó a México la gripe española, una de las peores pandemias en la historia de la humanidad. En este artículo se narra su llegada a Veracruz en buques procedentes de La Habana y Nueva York, su diseminación del Golfo al resto del país, incluyendo la ciudad de México, y las respuestas que implementaron las autoridades sanitarias federales y estatales. Dos hechos son particularmente destacables de la pandemia de 1918 en México, además del número insólito de decesos: la puesta a prueba de las disposiciones incorporadas a la Constitución de 1917 en materia sanitaria y el extraordinario papel que jugó la sociedad civil.

Abstract After eight years of a civil war which devastated the country, Spanish flu, one of the worst pandemics in the history of humankind, arrived in Mexico in October of 1918. This article discusses its arrival to the port of Veracruz in ships coming from Habana and New York City; its dissemination from the Gulf of Mexico area to the rest of the country, including Mexico City; and the responses of both federal and local health authorities. Two events associated to this pandemic are particularly relevant, in addition to the high number of deaths: the testing of the sanitary dispositions added to the 1917 Mexican Constitution and the extraordinary role played by civil society organizations.

[The "blow", the 1918 pandemic in Mexico]. / El "trancazo",la pandemia de 1918 en México.

After eight years of a civil war which devastated the country, Spanish flu, one of the worst pandemics in the history of humankind, arrived in Mexico in October of 1918. This article discusses its arrival to the port of Veracruz in ships coming from Habana and New York City; its dissemination from the Gulf of Mexico area to the rest of the country, including Mexico City; and the responses of both federal and local health authorities. Two events associated to this pandemic are particularly relevant, in addition to the high number of deaths: the testing of the sanitary dispositions added to the 1917 Mexican Constitution and the extraordinary role played by civil society organizations.

Después de ocho años de una cruenta lucha armada que dejó devastado al país, en octubre de 1918 llegó a México la gripe española, una de las peores pandemias en la histo-ria de la humanidad. En este artículo se narra su llegada a Veracruz en buques procedentes de La Habana y Nueva York, su diseminación del Golfo al resto del país, incluyendo la ciudad de México, y las respuestas que implementaron las autoridades sanitarias federales y estatales. Dos hechos son particularmente destacables de la pandemia de 1918 en México, además del número insólito de decesos: la puesta a prueba de las disposiciones incorporadas a la Constitución de 1917 en materia sanitaria y el extraordinario papel que jugó la sociedad civil.

[Haitian health system]. / Sistema de salud de Haití.

The Haitian health system includes a public and a private sector. The public sector comprises the Ministry of Health and Population (MSPP) and a social security institution (Ofatma). The private sector includes private insurance agencies and providers. MSPP provides health services to the non-salaried population, while Ofatma provides services to the salaried population. Health expenditure in Haiti in 2016 was 5.4% of gross domestic product. Expenditure per capita in health was 38 American dollars. There is a great dependency on foreign resources. The MSPP is in charge of most stewardship functions. The main challenge faced by the Haitian health system is the provision of comprehensive health services with financial protection to all the population. This goal will not be met without additional financial resources, mostly public, and an effort to strengthen health institutions.

El sistema de salud haitiano se conforma por un sector público y un sector privado. El primero está compuesto por el Ministerio de Salud Pública y Población (MSPP) y la Caja de Seguro de Accidentes de Trabajo, Enfermedades y Maternidad (Ofatma). El sector privado incluye a los seguros y prestadores de servicios de salud privados. El MSPP ofrece servicios básicos a la población no asalariada (95% de la población total), mientras que la Ofatma ofrece seguros contra accidentes de trabajo, enfermedades y maternidad a los trabajadores del sector formal privado y público. El gasto total en salud enmHaití representó 5.4% del producto interno bruto en 2016 y el gasto en salud per cápita fue de 38 dólares estadunidenses. Hay una enorme dependencia de los recursos externos. El MSPP es el responsable de la mayor parte de las actividades de rectoría. El mayor reto que enfrenta el sistema de salud de Haití es ofrecer servicios integrales de salud con protección financiera a toda la población. Esta meta no podrá alcanzarse sin mayores recursos financieros, sobre todo públicos, y sin un importante esfuerzo de fortalecimiento institucional.

Sistema de salud de Haití / Haitian health system

Resumen: El sistema de salud haitiano se conforma por un sector público y un sector privado. El primero está compuesto por el Ministerio de Salud Pública y Población (MSPP) y la Caja de Seguro de Accidentes de Trabajo, Enfermedades y Maternidad (Ofatma). El sector privado incluye a los seguros y prestadores de servicios de salud privados. El MSPP ofrece servicios básicos a la población no asalariada (95% de la población total), mientras que la Ofatma ofrece seguros contra accidentes de trabajo, enfermedades y maternidad a los trabajadores del sector formal privado y público. El gasto total en salud en Haití representó 5.4% del producto interno bruto en 2016 y el gasto en salud per cápita fue de 38 dólares estadunidenses. Hay una enorme dependencia de los recursos externos. El MSPP es el responsable de la mayor parte de las actividades de rectoría. El mayor reto que enfrenta el sistema de salud de Haití es ofrecer servicios integrales de salud con protección financiera a toda la población. Esta meta no podrá alcanzarse sin mayores recursos financieros, sobre todo públicos, y sin un importante esfuerzo de fortalecimiento institucional.

Abstract: The Haitian health system includes a public and a private sector. The public sector comprises the Ministry of Health and Population (MSPP) and a social security institution (Ofatma). The private sector includes private insurance agencies and providers. MSPP provides health services to the non-salaried population, while Ofatma provides services to the salaried population. Health expenditure in Haiti in 2016 was 5.4% of gross domestic product. Expenditure per capita in health was 38 American dollars. There is a great dependency on foreign resources. The MSPP is in charge of most stewardship functions. The main challenge faced by the Haitian health system is the provision of comprehensive health services with financial protection to all the population. This goal will not be met without additional financial resources, mostly public, and an effort to strengthen health institutions.