Mexico's path towards the Sustainable Development Goal for health: an assessment of the feasibility of reducing premature mortality by 40% by 2030.

BACKGROUND: The United Nations Sustainable Development Goal for health (SDG3) poses complex challenges for signatory countries that will require clear roadmaps to set priorities over the next 15 years. Building upon the work of the Commission on Investing in Health and published estimates of feasible global mortality SDG3 targets, we analysed Mexico's mortality to assess the feasibility of reducing premature (0-69 years) mortality and propose a path to meet SDG3. METHODS: We developed a baseline scenario applying 2010 age-specific and cause-specific mortality rates from the Mexican National Institute of Statistics and Geography (INEGI) to the 2030 UN Population Division (UNPD) population projections. In a second scenario, INEGI age-specific and cause-specific trends in death rates from 2000 to 2014 were projected to 2030 and adjusted to match the UNPD 2030 mortality projections. A third scenario assumed a 40% reduction in premature deaths across all ages and causes. By comparing these scenarios we quantified shortfalls in mortality reductions by age group and cause, and forecasted life expectancy pathways for Mexico to converge to better performing countries. FINDINGS: UNPD-projected death rates yield a 25·9% reduction of premature mortality for Mexico. Accelerated reductions in adult mortality are necessary to reach a 40% reduction by 2030. Mortality declines aggregated across all age groups mask uneven gains across health disorders. Injuries, particularly road traffic accidents and homicides, are the main health challenge for young adults (aged 20-49 years) whereas unabated diabetes mortality is the single most important health concern for older adults (aged 50-69 years). INTERPRETATION: Urgent action is now required to control non-communicable diseases and reduce fatal injuries in Mexico, making a 40% reduction in premature mortality by 2030 feasible and putting Mexico back on a track of substantial life expectancy convergence with better performing countries. Our study provides a roadmap for setting national health priorities. Further analysis of the equity implications of following the suggested pathway remains a subject of future research. FUNDING: Mexico's Ministry of Health, University of California, San Francisco, and Bill & Melinda Gates Foundation.

Hacia la cobertura universal en salud: protección social para todos en México

México alcanzará la cobertura universal en salud en 2012. El seguro nacional de salud denominado Seguro Popular, introducido en 2003, garantiza el acceso a un paquete de servicios de salud integrales con protección financiera a más de 50 millones de mexicanos previamente excluidos de la seguridad social. La cobertura universal en México es sinónimo de protección social en salud. Este informe analiza el camino hacia la cobertura universal en sus tres dimensiones de protección: a) contra riesgos para la salud, b) de los pacientes a través de la garantía de calidad de la atención a la salud y c) contra las consecuencias financieras de la enfermedad y las lesiones. Se presenta una discusión conceptual sobre la transición de una seguridad social basada en la condición laboral a la protección social en salud, que implica el acceso a una atención integral de la salud como derecho universal basado en la ciudadanía, plataforma ética de la reforma mexicana. Se describen asimismo las condiciones que llevaron a la reforma, así como su diseño y puesta en marcha, y se discute el proceso de implantación a nueve años de iniciado y las evidencias que dieron origen a actualizaciones y mejoras del programa original. El núcleo del informe se centra en los efectos e impactos de la reforma que se desprenden de la literatura sobre el tema, que incluye artículos científicos y otras publicaciones disponibles. La evidencia indica que el Seguro Popular está mejorando el acceso a los servicios de salud y reduciendo la prevalencia de los gastos en salud catastróficos y empobrecedores, especialmente entre los pobres. Estudios recientes muestran asimismo una mejora en la cobertura efectiva. También se discuten los desafíos prevalentes, incluyendo la necesidad de traducir los recursos financieros en servicios de salud más efectivos, equitativos y sensibles a las expectativas de los usuarios. Se requiere una nueva generación de reformas que incluya medidas sistémicas para consolidar la reorganización del sistema de salud por funciones. El artículo concluye con una discusión sobre las implicaciones de la búsqueda de la cobertura universal de salud en México y su importancia para otros países de ingresos bajos y medios.

Income-related inequalities and inequities in health and health care utilization in Mexico, 2000-2006.

OBJECTIVE: To measure income-related inequalities and inequities in the distribution of health and health care utilization in Mexico. METHODS: The National Health Survey (NHS) 2000 and the National Health and Nutrition Survey (NHNS) 2006 were used to estimate concentration indices for health outcomes and health care utilization variables before and after standardization. The study analyzed 110 460 individuals 18 years or older for NHS 2000 and 124 149 individuals for NHNS 2006. Health status variables were self-assessed health, physical limitations, and chronic illness. Health care utilization included curative visits and dental, hospital, and preventive care. Individuals were ranked by three standard-of-living measures: household income, wealth, and expenditure. Other independent variables were area of residence, geographic region, education, employment, ethnicity, and health insurance. Decomposition analysis allowed for assessing the contributions of independent variables to the distribution of health care among individuals. RESULTS: The worse-off population reports less good self-assessed health and more physical limitations, whereas better-off individuals report more chronic illnesses. Utilization of curative visits and hospitalization is more concentrated among the better-off population. No significant changes in these results can be established between 2000 and 2006. According to available evidence, standard of living, health insurance, and education largely contribute to the inequitable distribution of health care. CONCLUSIONS: Despite improvements in health care utilization patterns, income-related health and health care inequities prevail. Equity remains a challenge for Mexico.

Income-related inequalities and inequities in health and health care utilization in Mexico, 2000 - 2006 / Desigualdades e inequidades en la salud y en la utilización de la atención sanitaria relacionadas con los ingresos en México, 2000-2006

OBJECTIVE: To measure income-related inequalities and inequities in the distribution of health and health care utilization in Mexico. METHODS: The National Health Survey (NHS) 2000 and the National Health and Nutrition Survey (NHNS) 2006 were used to estimate concentration indices for health outcomes and health care utilization variables before and after standardization. The study analyzed 110 460 individuals 18 years or older for NHS 2000 and 124 149 individuals for NHNS 2006. Health status variables were self-assessed health, physical limitations, and chronic illness. Health care utilization included curative visits and dental, hospital, and preventive care. Individuals were ranked by three standard-of-living measures: household income, wealth, and expenditure. Other independent variables were area of residence, geographic region, education, employment, ethnicity, and health insurance. Decomposition analysis allowed for assessing the contributions of independent variables to the distribution of health care among individuals. RESULTS: The worse-off population reports less good self-assessed health and more physical limitations, whereas better-off individuals report more chronic illnesses. Utilization of curative visits and hospitalization is more concentrated among the better-off population. No significant changes in these results can be established between 2000 and 2006. According to available evidence, standard of living, health insurance, and education largely contribute to the inequitable distribution of health care. CONCLUSIONS: Despite improvements in health care utilization patterns, income-related health and health care inequities prevail. Equity remains a challenge for Mexico.

OBJETIVO: Medir las desigualdades y las inequidades en la salud y en la utilización de la atención sanitaria relacionadas con los ingresos en México. MÉTODOS: Se emplearon los datos de la Encuesta Nacional de Salud del año 2000 y la Encuesta Nacional de Salud y Nutrición de 2006 para calcular los índices de concentración de las variables de resultados en salud y de utilización de la atención sanitaria antes y después de su estandarización. El estudio analizó 110 460 individuos de 18 años o más de la primera encuesta y 124 149 de la segunda. Las variables de estado de salud consideradas fueron la salud autoevaluada, las limitaciones físicas y la enfermedad crónica. La utilización de la atención sanitaria incluyó las visitas curativas y la atención odontológica, hospitalaria y preventiva. Los individuos se agruparon según tres medidas de estándar de vida: ingresos, riqueza o patrimonio y gasto del hogar. Otras variables independientes fueron área de residencia, región geográfica, educación, empleo, grupo étnico y seguro de salud. El análisis de descomposición permitió estimar las contribuciones de las variables independientes a la distribución de la atención sanitaria entre los individuos. RESULTADOS: La población en peor situación económica refirió un peor nivel de salud autoevaluada y mayores limitaciones físicas, mientras que los individuos en mejor situación informaron más enfermedades crónicas y tuvieron más consultas curativas y hospitalizaciones. No se observaron cambios significativos en estos resultados entre 2000 y 2006. Según la evidencia disponible, el nivel de vida, el seguro de salud y la educación contribuyen en gran parte a la distribución desigual de la atención sanitaria. CONCLUSIONES: A pesar de las mejoras en los patrones de utilización de la atención sanitaria, persisten inequidades en la salud y en la atención sanitaria relacionadas con los ingresos. La equidad en salud sigue siendo un reto para México.

Universalidad de los servicios de salud en México / Universal Coverage of Health Services in Mexico

Las reformas llevadas a cabo en años recientes al sistema de salud en México han reducido las inequidades en la atención a la salud de la población, pero han sido insuficientes para resolver todos los problemas del Sistema Nacional de Salud (SNS). Para que el derecho a la protección de la salud consagrado en la Constitución sea una realidad para todos los ciudadanos, México se encuentra ante la necesidad de garantizar el acceso universal y efectivo a los servicios de salud. En este trabajo se delinea una reforma de largo alcance para la consolidación de un sistema de salud, afín con estándares internacionales, que establezca las condiciones estructurales para reducir las desigualdades en cobertura. Esta reforma se plantea a partir de un "pluralismo estructurado" para evitar tanto el monopolio ejercido desde el sector público como la atomización en el sector privado, y no caer en los extremos de procedimientos autoritarios o ausencia de regulación. Esto implica sustituir la actual integración vertical con segregación de grupos sociales, por una organización horizontal con separación de funciones. Implica, asimismo, reformas de tipo jurídico y fiscal, fortalecimiento del SNS, reorganización de las instituciones de salud y formulación de los instrumentos normativos, técnicos y financieros que hagan operativo el esquema propuesto para hacer plenamente efectivo el derecho humano a la salud de los mexicanos.

The reforms made in recent years to the Mexican Health System have reduced inequities in the health care of the population, but have been insufficient to solve all the problems of the MHS. In order to make the right to health protection established in the Constitution a reality for every citizen, Mexico must warrant effective universal access to health services. This paper outlines a long-term reform for the consolidation of a health system that is akin to international standards and which may establish the structural conditions to reduce coverage inequity. This reform is based on a "structured pluralism" intended to avoid both a monopoly exercised within the public sector and fragmentation in the private sector, and to prevent falling into the extremes of authoritarian procedures or an absence of regulation. This involves the replacement of the present vertical integration and segregation of social groups by a horizontal organization with separation of duties. This also entails legal and fiscal reforms, the reinforcement of the MHS, the reorganization of health institutions, and the formulation of regulatory, technical and financial instruments to operationalize the proposed scheme with the objective of rendering the human right to health fully effective for the Mexican people.

The quest for universal health coverage: achieving social protection for all in Mexico.

Mexico is reaching universal health coverage in 2012. A national health insurance programme called Seguro Popular, introduced in 2003, is providing access to a package of comprehensive health services with financial protection for more than 50 million Mexicans previously excluded from insurance. Universal coverage in Mexico is synonymous with social protection of health. This report analyses the road to universal coverage along three dimensions of protection: against health risks, for patients through quality assurance of health care, and against the financial consequences of disease and injury. We present a conceptual discussion of the transition from labour-based social security to social protection of health, which implies access to effective health care as a universal right based on citizenship, the ethical basis of the Mexican reform. We discuss the conditions that prompted the reform, as well as its design and inception, and we describe the 9-year, evidence-driven implementation process, including updates and improvements to the original programme. The core of the report concentrates on the effects and impacts of the reform, based on analysis of all published and publically available scientific literature and new data. Evidence indicates that Seguro Popular is improving access to health services and reducing the prevalence of catastrophic and impoverishing health expenditures, especially for the poor. Recent studies also show improvement in effective coverage. This research then addresses persistent challenges, including the need to translate financial resources into more effective, equitable and responsive health services. A next generation of reforms will be required and these include systemic measures to complete the reorganisation of the health system by functions. The paper concludes with a discussion of the implications of the Mexican quest to achieve universal health coverage and its relevance for other low-income and middle-income countries.

[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.

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.

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.

Addressing inequity in health and health care In Mexico

This paper presents the inequities of the health care system and describes how it contributes to the status quo rather than redressing the situation. After tracing the origins of the present system, also discuss policy initiatives for moving toward universal health insurance.

Addressing inequity in health and health care in Mexico

It presents informations about the Mexican health care system has evolved into a series of disjointed subsystems that are incapable of delivering universal health insurance and inequities of the system and describes how the current system contributes to the status quo rather than redressing the situation.

Addressing inequity in health and health care in Mexico.

Despite the fact that life expectancy at birth in Mexico has improved from forty-two years in 1940 to seventy-three in 2000, major inequalities persist in health and access to health care. The Mexican health care system has evolved into a series of disjointed subsystems that are incapable of delivering universal health insurance. Without greatly restructuring the way health care is financed, performance with respect to equity will remain poor. This paper presents the inequities of the system and describes how the current system contributes to the status quo rather than redressing the situation. After tracing the origins of the present system, we discuss policy initiatives for moving toward universal health insurance.