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Garcia-Diaz R, Sosa-Rubí SG, Lozano R, Serván-Mori E. Equity in out-of-pocket health expenditure: Evidence from a health insurance program reform in Mexico. J Glob Health 2023; 13:04134. [PMID: 37994845 PMCID: PMC10666565 DOI: 10.7189/jogh.13.04134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Abstract
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.
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Affiliation(s)
- Rocío Garcia-Diaz
- Tecnologico de Monterrey, School of Social Science and Government, Monterrey, N.L., México
| | - Sandra G Sosa-Rubí
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Rafael Lozano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA
- School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Edson Serván-Mori
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
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Garcia-Diaz R. Effective access to health care in Mexico. BMC Health Serv Res 2022; 22:1027. [PMID: 35962375 PMCID: PMC9373534 DOI: 10.1186/s12913-022-08417-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
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. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08417-0.
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Affiliation(s)
- Rocio Garcia-Diaz
- Tecnologico de Monterrey, Ave. Eugenio Garza Sada 2501, Monterrey, N.L., Mexico.
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Colchero MA, Gómez R, Bautista-Arredondo S. A systematic review of the literature on the impact of the Seguro Popular. Health Res Policy Syst 2022; 20:42. [PMID: 35436938 PMCID: PMC9014564 DOI: 10.1186/s12961-022-00839-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/09/2022] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The Seguro Popular (SP) was launched in 2004 to increase access to healthcare and reduce catastrophic expenditures among the Mexican population. To document the evidence on its effectiveness, we conducted a systematic review of impact evaluations of the SP. METHODS We included papers using rigorous quasi-experimental designs to assess the effectiveness of the SP. We evaluated the quality of each study and presented the statistical significance of the effects by outcome category. RESULTS We identified 26 papers that met the inclusion criteria. Sixteen studies that evaluated the impact of SP on financial protection found consistent and statistically significant positive effects in 55% of the 65 outcomes analyzed. Nine studies evaluating utilization of health services for the general and infant populations found effectiveness on 40% of 30 outcomes analyzed. Concerning screening services for hypertension, diabetes, and cervical and prostate cancer, we found three studies evaluating 14 outcomes and finding significant effects on 50% of them. Studies looking at the impact of SP on diabetes, hypertension, and general health care and treatment evaluated 19 outcomes and found effects on 21% of them. One study assessed five diabetes monitoring services and found positive effects on four of them. The only study on morbidity and mortality found positive results on three of the four outcomes of interest. CONCLUSION We found mixed evidence on the impact of SP on financial protection, healthcare utilization, morbidity and mortality. In the 26 studies included in this review, researchers found positive effects in roughly half of the outcomes and null results on the rest.
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Affiliation(s)
- M A Colchero
- Center for Health Systems Research, Instituto Nacional de Salud Pública, Universidad No. 655 Colonia Santa María Ahuacatitlán, Cerrada Los Pinos y Caminera, C.P. 62100, Cuernavaca, Morelos, Mexico
| | - R Gómez
- Center for Health Systems Research, Instituto Nacional de Salud Pública, Universidad No. 655 Colonia Santa María Ahuacatitlán, Cerrada Los Pinos y Caminera, C.P. 62100, Cuernavaca, Morelos, Mexico
| | - S Bautista-Arredondo
- Center for Health Systems Research, Instituto Nacional de Salud Pública, Universidad No. 655 Colonia Santa María Ahuacatitlán, Cerrada Los Pinos y Caminera, C.P. 62100, Cuernavaca, Morelos, Mexico.
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Fernández Guerrico S. The effects of trade-induced worker displacement on health and mortality in Mexico. JOURNAL OF HEALTH ECONOMICS 2021; 80:102538. [PMID: 34634695 DOI: 10.1016/j.jhealeco.2021.102538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 08/23/2021] [Accepted: 09/20/2021] [Indexed: 06/13/2023]
Abstract
Recent research in the U.S. links trade-induced job displacement to deaths of despair. Should we expect the same mortality response in developing countries? This paper analyzes the effect of a trade-induced negative shock to manufacturing employment on leading causes of mortality in Mexico between 1998 and 2013. I exploit cross-municipality variation in trade exposure based on differences in industry specialization before China's accession to the WTO in 2001 to identify labor-demand shocks that are concentrated in manufacturing. I find trade-induced job loss increased mortality from diabetes, raised obesity rates, reduced physical activity, and lowered access to health insurance. These deaths were offset by declines in mortality from ischemic heart disease and chronic pulmonary disease. These findings highlight that negative employment shocks have heterogeneous impacts on mortality in developing countries, where falling incomes lead to less access to health care and nutritious food, but also reduce alcohol and tobacco use.
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Affiliation(s)
- Sofía Fernández Guerrico
- Université Libre de Bruxelles, Department of Applied Economics (Dulbea), Avenue Franklin Roosevelt 50, Brussels 1050, Belgium.
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Serván-Mori E, Orozco-Núñez E, Heredia-Pi I, Armenta-Paulino N, Wirtz VJ, Meneses-Navarro S, Nigenda G. Public health insurance and ethnic disparities in maternal health care: the case of vulnerable Mexican women over the last 25 years. Health Policy Plan 2021; 36:1671-1680. [PMID: 34557904 DOI: 10.1093/heapol/czab119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 09/14/2021] [Accepted: 09/23/2021] [Indexed: 11/13/2022] Open
Abstract
This article examines the coverage in the continuum of antenatal-postnatal care for vulnerable women in Mexico according to indigenous status and assesses the influence of public health insurance strategies on the evolution of coverage over the last 25 years. We studied a total of 19 613 567 Mexican women, aged 12-54 years at last birth, based on a pooled cross-sectional analysis of data from the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics. After describing sociodemographic characteristics and maternal-health coverage by indigenous status, we constructed a pooled fixed-effects and interaction multivariable regression model to assess the influence of the Seguro Popular programme on continuum of care. We estimated adjusted continuum of care coverage between 1994 and 2018 according to Seguro Popular affiliation and indigenous status. Prior to the Seguro Popular programme, crude coverage in the continuum of care for non-indigenous women stood at 14.5% [95% confidence interval (CI): 13.2-15.8%] or 11 percentage points higher than for indigenous women. During the last period of the programme, it rose to 46.5% [95% CI: 45.6-47.5%] and 34.1% [95% CI: 30.7-37.4%], respectively. Our regression analysis corroborated findings that, on average, indigenous women faced lower odds of benefiting from continuum of care [adjusted odds ratio (aOR) = 0.48, 95% CI: 0.40-0.57] than did their non-indigenous counterparts. It also revealed that coverage for indigenous women without Seguro Popular affiliation was 26.7% [95% CI: 23.3-30.1%] or 12 percentage points lower than for those with Seguro Popular affiliation (38.6%, 95% CI: 35.7-41.4%). Our regression results confirmed that the latter benefited from higher odds of continuum of care (aOR = 1.67, 95% CI: 1.36-2.26). Gaps between those of indigenous and non-indigenous status have persisted, but the Seguro Popular clearly contributed to reducing the coverage gaps between these two groups of women. Strategies yielding better outcomes are required to improve the structural conditions of indigenous populations.
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Affiliation(s)
- Edson Serván-Mori
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico
| | - Emanuel Orozco-Núñez
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico
| | - Ileana Heredia-Pi
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico
| | - Nancy Armenta-Paulino
- International Center for Equity in Health, Federal University of Pelotas, Pelotas 96020-220, Brazil
| | - Veronika J Wirtz
- Department of Global Health, Boston University School of Public Health, Boston, MA 02118, USA
| | - Sergio Meneses-Navarro
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico
| | - Gustavo Nigenda
- National School of Nursing and Obstetrics, National Autonomous University of Mexico, Mexico City 14370, Mexico
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Genberg BL, Wachira J, Steingrimsson JA, Pastakia S, Tran DNT, Said JA, Braitstein P, Hogan JW, Vedanthan R, Goodrich S, Kafu C, Wilson-Barthes M, Galárraga O. Integrated community-based HIV and non-communicable disease care within microfinance groups in Kenya: study protocol for the Harambee cluster randomised trial. BMJ Open 2021; 11:e042662. [PMID: 34006540 PMCID: PMC8137246 DOI: 10.1136/bmjopen-2020-042662] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION In Kenya, distance to health facilities, inefficient vertical care delivery and limited financial means are barriers to retention in HIV care. Furthermore, the increasing burden of non-communicable diseases (NCDs) among people living with HIV complicates chronic disease treatment and strains traditional care delivery models. Potential strategies for improving HIV/NCD treatment outcomes are differentiated care, community-based care and microfinance (MF). METHODS AND ANALYSIS We will use a cluster randomised trial to evaluate integrated community-based (ICB) care incorporated into MF groups in medium and high HIV prevalence areas in western Kenya. We will conduct baseline assessments with n=900 HIV positive members of 40 existing MF groups. Group clusters will be randomised to receive either (1) ICB or (2) standard of care (SOC). The ICB intervention will include: (1) clinical care visits during MF group meetings inclusive of medical consultations, NCD management, distribution of antiretroviral therapy (ART) and NCD medications, and point-of-care laboratory testing; (2) peer support for ART adherence and (3) facility referrals as needed. MF groups randomised to SOC will receive regularly scheduled care at a health facility. Findings from the two trial arms will be compared with follow-up data from n=300 matched controls. The primary outcome will be VS at 18 months. Secondary outcomes will be retention in care, absolute mean change in systolic blood pressure and absolute mean change in HbA1c level at 18 months. We will use mediation analysis to evaluate mechanisms through which MF and ICB care impact outcomes and analyse incremental cost-effectiveness of the intervention in terms of cost per HIV suppressed person-time, cost per patient retained in care and cost per disability-adjusted life-year saved. ETHICS AND DISSEMINATION The Moi University Institutional Research and Ethics Committee approved this study (IREC#0003054). We will share data via the Brown University Digital Repository and disseminate findings via publication. TRIAL REGISTRATION NUMBER NCT04417127.
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Affiliation(s)
- Becky L Genberg
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Juddy Wachira
- Behavioral Sciences, Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Jon A Steingrimsson
- Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Sonak Pastakia
- Center for Health Equity and Innovation, Purdue University College of Pharmacy, Indianapolis, Indiana, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Dan N Tina Tran
- Center for Health Equity and Innovation, Purdue University College of Pharmacy, Indianapolis, Indiana, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jamil AbdulKadir Said
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Internal Medicine, Moi University School of Medicine, Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Epidemiology, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Joseph W Hogan
- Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Rajesh Vedanthan
- Global Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Suzanne Goodrich
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Catherine Kafu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Marta Wilson-Barthes
- Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Omar Galárraga
- Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main St. Box G-S121-2 Providence, Rhode Island, USA
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Del Valle A. The effects of public health insurance in labor markets with informal jobs: Evidence from Mexico. JOURNAL OF HEALTH ECONOMICS 2021; 77:102454. [PMID: 33784539 DOI: 10.1016/j.jhealeco.2021.102454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 02/05/2021] [Accepted: 03/17/2021] [Indexed: 05/24/2023]
Abstract
This paper studies the labor market effects of the most significant public health insurance expansion in the Americas: Mexico's Seguro Popular (SP). To identify its impact, I exploit the staggered rollout of SP across municipalities. I find that SP increases labor supply by reducing the likelihood of informal workers exiting the labor market. This reduction is driven by women, who experience a 15% decrease in the probability of transitioning from informal employment to inactivity. I also find that this reduction is concentrated among female secondary earners residing in households with dependents. These findings suggest that SP may operate through a novel channel, namely that health insurance enables caregivers to continue working by reducing health shocks among dependents.
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Affiliation(s)
- Alejandro Del Valle
- Georgia State University, Department of Risk Management and Insurance, 35 Broad Street NW, Atlanta, GA 30303, United States.
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Mahé C. Publicly provided healthcare and migration. ECONOMICS AND HUMAN BIOLOGY 2020; 39:100924. [PMID: 32966954 DOI: 10.1016/j.ehb.2020.100924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/14/2020] [Accepted: 09/02/2020] [Indexed: 06/11/2023]
Abstract
Publicly provided healthcare has received growing attention. Debates have been fuelled by evidence on improved health and reduced poverty, and concerns over adverse labour market effects; concerns that are, to date, only supported by mixed empirical findings. This article examines whether publicly provided healthcare influences the decision to migrate. The spatial and temporal variation in the expansion of a non-contributory health insurance programme in Mexico, combined with the panel dimension and the timing of household survey data allows causal identification of the effect of increased coverage on migration. Difference-in-differences estimates reveal that accessing healthcare for free raises internal migration. The effect on international migration, costlier by nature, is statistically insignificant. Potential mechanisms include better health, the alleviation of financial constraints and a greater propensity to work. Results point to the relevance of including household members who have migrated in assessing the impacts of social health policies. They suggest that publicly provided healthcare could have multiplier effects on economic development and welfare by enabling labour force detachment of working-age members in affiliated households.
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Affiliation(s)
- Clotilde Mahé
- Department of Economics and Management, University of Luxembourg, 6, rue Richard Coudenhove-Kalergi, L-1359 Luxembourg, Luxembourg
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Yuan H, Li H, Hou Z. Is it worth outsourcing essential public health services in China?-Evidence from Beilin District of Xi'an. Int J Health Plann Manage 2020; 35:1486-1502. [PMID: 32895984 DOI: 10.1002/hpm.3051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/28/2020] [Accepted: 08/07/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Essential public health services (EPHS) is general welfare public health interventions led by the Chinese government and provided by the primary medical institutions to all residents. In Beilin District, Xi'an, EPHS producers can be divided into outsourced institutions and public institutions. OBJECTIVE Can outsourcing EPHS reduce costs and improve efficiency and quality? There is still no definite answer to this question. This paper compares the performance of outsourced institutions and public institutions in terms of efficiency and quality, explains the reasons for this phenomenon. METHODS This paper uses a theoretical and two-stage DEA model Based on a "triple subject" research framework. RESULTS The results show that the difference between public institutions and outsourced institutions is mainly reflected in service quality. When the quality is not measured, outsourced institutions' production efficiency is higher than that of public institutions. When there are quality measurements, the production efficiency of outsourced institutions is lower than that of public institutions. CONCLUSIONS Outsourced institutions perform worse than public institutions. The reason is that a bilateral monopolistic market structure has formed between local governments and outsourced institutions. This situation makes it difficult for the government to replace poor quality outsourced institutions under the constraints of a limited budget.
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Affiliation(s)
- Hai Yuan
- International Business School, Shaanxi Normal University, Xi'an, China
| | - Hang Li
- International Business School, Shaanxi Normal University, Xi'an, China
| | - ZhaoWei Hou
- School of Public Health, Xi'an Jiaotong University, Xi'an, China
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Serván-Mori E, Chivardi C, Fene F, Heredia-Pi I, Mendoza MÁ, Nigenda G. Tackling maternal mortality by improving technical efficiency in the production of primary health services: longitudinal evidence from the Mexican case. Health Care Manag Sci 2020; 23:571-584. [PMID: 32720200 DOI: 10.1007/s10729-020-09503-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 02/06/2020] [Indexed: 10/23/2022]
Abstract
Ensuring regular and timely access to efficient and quality health services reduces the risk of maternal mortality. Specifically, improving technical efficiency (TE) can result in improved health outcomes. To date, no studies in Mexico have explored the connection of TE with either the production of maternal health services at the primary-care level or the maternal-mortality ratio (MMR) in populations without social security coverage. The present study combined data envelopment analysis (DEA), longitudinal data and selection bias correction methods with the purpose of obtaining original evidence on the impact of TE on the MMR during the period 2008-2015. The results revealed that MMR fell 0.36% (P < 0.01) for every percentage point increase in TE at the jurisdictional level or elasticity TE-MMR. This effect proved lower in highly marginalized jurisdictions and disappeared entirely in those with low- or medium-marginalization levels. Our findings also highlighted the relevance of certain social and economic aspects in the attainment of TE by jurisdictions. This clearly demonstrates the need for comprehensive, cross-cutting policies capable of modifying the structural conditions that generate vulnerability in specific population groups. In other words, achieving an effective and sustainable reduction in the MMR requires, inter alia, that the Mexican government review and update two essential elements: the criteria behind resource allocation and distribution, and the control mechanisms currently in place for executing and ensuring accountability in these two functions.
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Affiliation(s)
- Edson Serván-Mori
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Carlos Chivardi
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Fato Fene
- School of Public Health, National Institute of Public Health of Mexico, Cuernavaca, Morelos, Mexico
| | - Ileana Heredia-Pi
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Miguel Ángel Mendoza
- School of Economics, National Autonomous University of Mexico, Mexico City, Mexico
| | - Gustavo Nigenda
- National School of Nursing and Obstetrics, National Autonomous University of Mexico, Mexico City, Mexico.
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Urquieta-Salomón J, Lamadrid-Figueroa H, Angeles G, Montoya A, Rojas-Martínez R, Martínez-Nolasco A, Torres-Pereda P, O'Shea G, Villagrán VM, Halley E, Delgado-Sánchez V, Lazcano-Ponce E. Impact of the 'Seguro Médico Siglo XXI' medical insurance programme on neonatal and infant mortality in Mexico, 2006-14: an ecological approach to estimation. Health Policy Plan 2020; 35:609-615. [PMID: 32236544 DOI: 10.1093/heapol/czaa013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2020] [Indexed: 11/13/2022] Open
Abstract
The 'Seguro Médico Siglo XXI' (SMSXXI), a universal coverage medical insurance programme for children under 5 years of age, started in 2006 to help avoid catastrophic health expenditures in poor families without social security in Mexico. The study used information from the National Health Information System for the 2006-14 period. An ecological approach was followed with a panel of the 2457 municipalities of Mexico as the units of analysis. The outcome variables were the municipality-level neonatal mortality and infant mortality rates in population without access to social security. The programme variable was the coverage of the SMSXXI programme at the municipality level, expressed as a proportion. Demographic and economic variables defined at the municipality level were included as covariates. Impact was estimated by fitting a fixed-effects negative binomial regression model. Results reveal that the SMSXXI significantly reduced both infant and neonatSal mortality in the target population, although in a non-linear fashion, with minimum mortality levels found around the 70% coverage range. The effect is mostly given by the transition from the first quintile to the fourth quintile of coverage (<13% vs 70.5-93.7% coverage), and it is attenuated significantly at coverage levels very close to or at 100%. The observed risk reduction amounted to an estimated total of 11 358 infant deaths being avoided due to the SMSXXI during the 2006-14 period, of which 48% were neonatal. In conclusion, we found a significant impact of the SMSXXI programme on both infant mortality and neonatal mortality. An attenuation of the effect of the insurance on mortality rates at levels close to 100% coverage may reflect the saturation of health units in detriment of the quality of care.
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Affiliation(s)
- José Urquieta-Salomón
- Directorate of Indicators and Analysis of Governmental Information, National Institute of Statistics and Geography, Av. Patriotismo 711A, Benito Juárez, 03730, Ciudad de México, México
| | - Héctor Lamadrid-Figueroa
- Department of Perinatal Health, National Institute of Public Health (INSP), Av. Universidad 655, 62440, Cuernavaca, MOR, Mexico
| | - Gustavo Angeles
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC 27599, USA
| | - Alejandra Montoya
- Department of Perinatal Health, National Institute of Public Health (INSP), Av. Universidad 655, 62440, Cuernavaca, MOR, Mexico
| | - Rosalba Rojas-Martínez
- Department of Perinatal Health, National Institute of Public Health (INSP), Av. Universidad 655, 62440, Cuernavaca, MOR, Mexico
| | - Alejandro Martínez-Nolasco
- Department of Perinatal Health, National Institute of Public Health (INSP), Av. Universidad 655, 62440, Cuernavaca, MOR, Mexico
| | - Pilar Torres-Pereda
- Department of Perinatal Health, National Institute of Public Health (INSP), Av. Universidad 655, 62440, Cuernavaca, MOR, Mexico
| | - Gabriel O'Shea
- Secretaría de Salud del Estado de México, Av. Independencia 5 Ote. 1009, Reforma y FFCC Nacionales, 50070 Toluca de Lerdo, México
| | - Victor M Villagrán
- Comisión Nacional de Protección Social en Salud, Secretaría de Salud, Calle Gustavo E. Campa 54, Guadalupe Inn, Álvaro Obregón, 01020 Ciudad de México, CDMX, México
| | - Elizabeth Halley
- Comisión Nacional de Protección Social en Salud, Secretaría de Salud, Calle Gustavo E. Campa 54, Guadalupe Inn, Álvaro Obregón, 01020 Ciudad de México, CDMX, México
| | - Verónica Delgado-Sánchez
- Comisión Nacional de Protección Social en Salud, Secretaría de Salud, Calle Gustavo E. Campa 54, Guadalupe Inn, Álvaro Obregón, 01020 Ciudad de México, CDMX, México
| | - Eduardo Lazcano-Ponce
- Department of Perinatal Health, National Institute of Public Health (INSP), Av. Universidad 655, 62440, Cuernavaca, MOR, Mexico
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Serván-Mori E, Cerecero-García D, Heredia-Pi IB, Pineda-Antúnez C, Sosa-Rubí SG, Nigenda G. Improving the effective maternal-child health care coverage through synergies between supply and demand-side interventions: evidence from Mexico. J Glob Health 2020; 9:020433. [PMID: 32257178 PMCID: PMC7101510 DOI: 10.7189/jogh.09.020433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Over the last two decades, the Mexican government has released several efforts to achieve universal health coverage (UHC), based on the principles of fairness and social protection, to reduce the inequities in utilization, access, and quality of care existing in the health system. Two of the most important social public policies that have targeted the population without access to social security include the 1997 conditional cash transfers (CCT) program known as Prospera (formerly Oportunidades or Progresa) and the Seguro Popular de Salud (SPS by its Spanish initials), launched in 2003. These two programs, so far, have survived changes in the federal administrations being the most longstanding social programs targeting poor (or unprotected) populations ever in the history of modern Mexico. We tested the existence of positive synergies between demand-side (or CCT-Prospera) and supply-side (or Seguro Popular de Salud, SPS) social programs in the achievement of effective coverage (EC) of maternal-child health interventions in Mexico. Methods We performed a retrospective-cohort analysis to 6413 women aged 12-49 years who participated in a probabilistic survey conducted in 2012. We calculated EC as the product of three indexes: need, utilization and quality of health care. Correlates of EC were identified estimating a logistic regression model. We also presented adjusted EC by specific women groups. Results EC among beneficiaries of both programs was similar to estimates in Social Security affiliates (54%). For those not affiliated to any of the programs or those who received benefits for only one of them, the EC was 47.6% and 45.5% respectively. Adjusted estimates of EC suggest that overall, having both programs (Prospera + SPS) has a positive effect on maternal and child care coverage, which makes the observed differences in EC not statistically significant between those affiliated to both programs in comparison with the observed in the population with social security. Conclusions Results support positive synergies between Prospera and SPS in the reduction of the gaps in EC. The most vulnerable population groups need to be reached by the combination of these programs so that public health efforts translate into greater EC of maternal health services and better maternal-child outcomes.
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Affiliation(s)
- Edson Serván-Mori
- Center for Health Systems Research. National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Diego Cerecero-García
- Center for Health Systems Research. National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Ileana B Heredia-Pi
- Center for Health Systems Research. National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Carlos Pineda-Antúnez
- Center for Health Systems Research. National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Sandra G Sosa-Rubí
- Center for Health Systems Research. National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Gustavo Nigenda
- National School of Nursing and Obstetrics. National Autonomous University of Mexico, Mexico City, Mexico
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Riumallo-Herl C, Aguila E. The effect of old-age pensions on health care utilization patterns and insurance uptake in Mexico. BMJ Glob Health 2019; 4:e001771. [PMID: 31798987 PMCID: PMC6861075 DOI: 10.1136/bmjgh-2019-001771] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/05/2019] [Accepted: 10/12/2019] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION As old-age pensions continue to expand around the world in response to population ageing, policymakers increasingly wish to understand their impact on healthcare demand. In this paper, we examine the effects of supplemental income to older adults on healthcare use patterns, expenditures and insurance uptake in Yucatan, Mexico. METHOD We use a longitudinal survey for individuals aged 70 or older and an individual fixed-effects difference-in-difference approach to understand the effect of an income supplement on healthcare use patterns, out-of-pocket expenditures and health insurance uptake patterns. RESULTS The implementation of the old-age pension was associated with increased use of healthcare with nuanced effects on the type of care. Old-age pensions increase the use of formal healthcare by 15 percentage points (95% CI 6.1 to 23.9) for those with healthcare use at baseline and by 7.5 percentage points (95% CI 3.7 to 11.3) for those without healthcare use at baseline. We find no evidence of greater out-of-pocket expenditures, likely because old-age pensions were associated with a 4.2 percentage point (95% CI 1.5 to 6.9) increase in use of public health insurance. CONCLUSION Old-age pensions can shift healthcare demand towards formal services and eliminate financial barriers to basic care. Pension benefits can also increase the uptake of insurance programmes. These results demonstrate how social programmes can complement each other This highlights the potential role of old-age pensions in achieving universal health coverage for individuals at older ages.
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Affiliation(s)
| | - Emma Aguila
- Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
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Celhay P, Martinez S, Muñoz M, Perez M, Perez-Cuevas R. Long-term effects of public health insurance on the health of children in Mexico: a retrospective study. LANCET GLOBAL HEALTH 2019; 7:e1448-e1457. [DOI: 10.1016/s2214-109x(19)30326-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 05/18/2019] [Accepted: 06/14/2019] [Indexed: 11/29/2022]
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15
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Serván‐Mori E, Mendoza MÁ, Chivardi C, Pineda‐Antúnez C, Rodríguez‐Franco R, Nigenda G. A spatio‐temporal cluster analysis of technical efficiency in the production of outpatient maternal health services and its structural correlates in México. Int J Health Plann Manage 2019; 34:e1417-e1436. [DOI: 10.1002/hpm.2785] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
| | | | - Carlos Chivardi
- Center for Health Systems Research National Institute of Public Health Cuernavaca Morelos México
| | - Carlos Pineda‐Antúnez
- Center for Health Systems Research National Institute of Public Health Cuernavaca Morelos México
| | - Roxana Rodríguez‐Franco
- Center for Health Systems Research National Institute of Public Health Cuernavaca Morelos México
| | - Gustavo Nigenda
- National School of Nursing and Obstetrics National Autonomous University of Mexico Mexico City México
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Medina-Solís CE, Ávila-Burgos L, Márquez-Corona MDL, Medina-Solís JJ, Lucas-Rincón SE, Borges-Yañez SA, Fernández-Barrera MÁ, Pontigo-Loyola AP, Maupomé G. Out-Of-Pocket Expenditures on Dental Care for Schoolchildren Aged 6 to 12 Years: A Cross-Sectional Estimate in a Less-Developed Country Setting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16111997. [PMID: 31195612 PMCID: PMC6603907 DOI: 10.3390/ijerph16111997] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/03/2019] [Accepted: 06/03/2019] [Indexed: 12/20/2022]
Abstract
Aim: The objective of this study was to estimate the Out-Of-Pocket Expenditures (OOPEs) incurred by households on dental care, as well as to analyze the sociodemographic, economic, and oral health factors associated with such expenditures. Method: A cross-sectional study was conducted among 763 schoolchildren in Mexico. A questionnaire was distributed to parents to determine the variables related to OOPEs on dental care. The amounts were updated in 2017 in Mexican pesos and later converted to 2017 international dollars (purchasing power parities-PPP US $). Multivariate models were created: a linear regression model (which modeled the amount of OOPEs), and a logistic regression model (which modeled the likelihood of incurring OOPEs). Results: The OOPEs on dental care for the 763 schoolchildren were PPP US $53,578, averaging a PPP of US $70.2 ± 123.7 per child. Disbursements for treatment were the principal item within the OOPEs. The factors associated with OOPEs were the child's age, number of dental visits, previous dental pain, main reason for dental visit, educational level of mother, type of health insurance, household car ownership, and socioeconomic position. Conclusions: The average cost of dental care was PPP US $70.2 ± 123.7. Our study shows that households with higher school-aged children exhibiting the highest report of dental morbidity-as well as those without insurance-face the highest OOPEs. An array of variables were associated with higher expenditures. In general, higher-income households spent more on dental care. However, the present study did not estimate unmet needs across the socioeconomic gradient, and thus, future research is needed to fully ascertain disease burden.
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Affiliation(s)
- Carlo Eduardo Medina-Solís
- The Academic Area of Dentistry in the Health Sciences Institute, the Autonomous University of the State of Hidalgo, Pachuca 42039, Mexico.
- The Center for Advanced Studies and Research in Dentistry "Keisaburo Miyata", Faculty of Dentistry, the Autonomous University of the State of Mexico, Toluca 50000, Mexico.
| | - Leticia Ávila-Burgos
- The Center for Health Systems Research, the National Institute of Public Health, Cuernavaca 62100, Mexico.
| | - María de Lourdes Márquez-Corona
- The Academic Area of Dentistry in the Health Sciences Institute, the Autonomous University of the State of Hidalgo, Pachuca 42039, Mexico.
| | - June Janette Medina-Solís
- Ministry of Education of Campeche, Sub-secretary of Educational Coordination, Direction of Coordination and Budgetary Management, Campeche 24095, Mexico.
| | - Salvador Eduardo Lucas-Rincón
- The Center for Advanced Studies and Research in Dentistry "Keisaburo Miyata", Faculty of Dentistry, the Autonomous University of the State of Mexico, Toluca 50000, Mexico.
- School of Dentistry, the Ixtlahuaca University Centre, Ixtlahuaca 50080, Mexico.
| | | | - Miguel Ángel Fernández-Barrera
- The Academic Area of Dentistry in the Health Sciences Institute, the Autonomous University of the State of Hidalgo, Pachuca 42039, Mexico.
| | - América Patricia Pontigo-Loyola
- The Academic Area of Dentistry in the Health Sciences Institute, the Autonomous University of the State of Hidalgo, Pachuca 42039, Mexico.
| | - Gerardo Maupomé
- Richard M. Fairbanks School of Public Health, Indiana University/Purdue University in Indianapolis, Indianapolis, IN 46202, USA.
- The Indiana University Network Science Institute, Bloomington, IN 47408, USA.
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Pérez-Pérez E, Serván-Mori E, Nigenda G, Ávila-Burgos L, Mayer-Foulkes D. Government expenditure on health and maternal mortality in México: A spatial-econometric analysis. Int J Health Plann Manage 2019; 34:619-635. [PMID: 30615218 DOI: 10.1002/hpm.2722] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/20/2018] [Accepted: 11/21/2018] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVE To assess the relationship between government expenditure on maternal health (GE) and maternal mortality (MM) in Mexican poor population between 2000 and 2015 in the 2457 Mexican municipalities. METHODS Using administrative data, we performed the analysis in three stages: First, we tested the presence of selection bias in MM. Next, we assessed the presence of spatial dependence in the incidence and severity of MM. Finally, we estimated a spatial error model considering the correction of estimates for the spatial dependence and selection bias assessed before. RESULTS MM and GE were not randomly distributed throughout the Mexican territory; the most socially vulnerable municipalities exhibited the highest levels of MM severity but the lowest levels of GE and available human and physical resources for maternal health; the incidence of MM was independent of GE; elasticity of GE-severity in MM was -4% (P < 0.01). CONCLUSIONS Resource allocation for maternal health must move towards a more comprehensive vision, and efforts to achieve an effective delivery of universal health services must improve, particularly regarding the most vulnerable municipalities.
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Affiliation(s)
- Eduardo Pérez-Pérez
- National Center for Health Technology Excellence, Ministry of Health, México
| | | | - Gustavo Nigenda
- National School of Nursing and Obstetrics, National Autonomous University of México, México City, México
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18
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García-Díaz R, Sosa-Rubí SG, Serván-Mori E, Nigenda G. Welfare effects of health insurance in Mexico: The case of Seguro Popular de Salud. PLoS One 2018; 13:e0199876. [PMID: 29965976 PMCID: PMC6028097 DOI: 10.1371/journal.pone.0199876] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 06/18/2018] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Rocío García-Díaz
- Department of Economics, Monterrey Institute of Technology and Higher Education, Nuevo León, México
| | - Sandra G. Sosa-Rubí
- Center for Health Systems Research, National Institute of Public Health, Morelos, México
| | - Edson Serván-Mori
- Center for Health Systems Research, National Institute of Public Health, Morelos, México
| | - Gustavo Nigenda
- National School of Nursing and Obstetrics, National Autonomous University of México, México City, México
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19
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Parker SW, Saenz J, Wong R. Health Insurance and the Aging: Evidence From the Seguro Popular Program in Mexico. Demography 2018; 55:361-386. [PMID: 29357097 PMCID: PMC5829015 DOI: 10.1007/s13524-017-0645-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Aimed at covering the large fraction of workers in the informal sector without access to a social security program, the Mexican public health insurance program Seguro Popular began in 2002 and now reaches more than 50 million individuals. We estimate impacts of Seguro Popular for the population aged 50 and older on a set of indicators related to health care including utilization, diagnostic/preventive tests, and treatment conditional on being ill. Using the longitudinal Mexican Health and Aging Study over the period 2001-2012, we conduct before and after difference-in-difference matching impact estimators. Our results suggest large and important effects of the Program on utilization and diagnostic tests. We find overall smaller effects on the probability of being in treatment for individuals with chronic diseases, but these effects are concentrated in rural areas with relatively more health services versus rural areas with lower levels of health services. These results suggest that, to the extent that health services become more available in rural areas lacking services, effects of health insurance may increase.
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Affiliation(s)
- Susan W Parker
- School of Public Policy, University of Maryland, 2101 Van Munching Hall, College Park, MD, 20742, USA.
- Centro de Investigación y Docencia Económicas (CIDE), Carretera Mexico Toluca 3655, Mexico, DF, Mexico.
| | - Joseph Saenz
- University of Southern California, 3715 McClintock Avenue, Los Angeles, CA, 90089-0191, USA
| | - Rebeca Wong
- University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555-0177, USA
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20
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Das D. Public expenditure and healthcare utilization: the case of reproductive health care in India. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2017; 17:473-494. [PMID: 28702922 DOI: 10.1007/s10754-017-9219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 06/24/2017] [Indexed: 06/07/2023]
Abstract
An important reason for public intervention in health in developing countries is to address the issue of accessibility. However, numerous studies have found inconclusive evidence of the effect of public expenditure on health outcomes. Here, I revisit the debate by examining the effect of public expenditure on the use of health services, which is an important link between expenditure and outcomes. I use data from two recent waves of the National Family Health Survey of India to study the role of public expenditure on the use of healthcare services during pregnancy and childbirth. India has high state-level variations in the use of prenatal care and delivery by skilled personnel as well as levels of public expenditure. I exploit the variation in public expenditure to identify its effect on the use of healthcare services, controlling for other confounding factors. The results show a significant effect of public expenditure at the state level on the use of both prenatal and delivery care at the individual level. Also, there is no evidence of public expenditure crowding out private expenditure. Further, there is strong evidence that public expenditure reaches the desired targets. The results highlight the positive implications of raising public expenditure for healthcare use of pregnancy and childbirth services in the Indian context.
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Affiliation(s)
- Dhiman Das
- Asia Research Institute, National University of Singapore, Singapore, Singapore.
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21
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Serván-Mori E, Contreras-Loya D, Gomez-Dantés O, Nigenda G, Sosa-Rubí SG, Lozano R. Use of performance metrics for the measurement of universal coverage for maternal care in Mexico. Health Policy Plan 2017; 32:625-633. [PMID: 28453712 DOI: 10.1093/heapol/czw161] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2016] [Indexed: 11/12/2022] Open
Abstract
This study provides evidence for those working in the maternal health metrics and health system performance fields, as well as those interested in achieving universal and effective health care coverage. Based on the perspective of continuity of health care and applying quasi-experimental methods to analyse the cross-sectional 2009 National Demographic Dynamics Survey (n = 14 414 women), we estimated the middle-term effects of Mexico's new public health insurance scheme, Seguro Popular de Salud (SPS) (vs women without health insurance) on seven indicators related to maternal health care (according to official guidelines): (a) access to skilled antenatal care (ANC); (b) timely ANC; (c) frequent ANC; (d) adequate content of ANC; (e) institutional delivery; (f) postnatal consultation and (g) access to standardized comprehensive antenatal and postnatal care (or the intersection of the seven process indicators). Our results show that 94% of all pregnancies were attended by trained health personnel. However, comprehensive access to ANC declines steeply in both groups as we move along the maternal healthcare continuum. The percentage of institutional deliveries providing timely, frequent and adequate content of ANC reached 70% among SPS women (vs 64.7% in the uninsured), and only 57.4% of SPS-affiliated women received standardized comprehensive care (vs 53.7% in the uninsured group). In Mexico, access to comprehensive antenatal and postnatal care as defined by Mexican guidelines (in accordance to WHO recommendations) is far from optimal. Even though a positive influence of SPS on maternal care was documented, important challenges still remain. Our results identified key bottlenecks of the maternal healthcare continuum that should be addressed by policy makers through a combination of supply side interventions and interventions directed to social determinants of access to health care.
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Affiliation(s)
| | | | | | | | | | - Rafael Lozano
- National Institute of Public Health, Cuernavaca, Mexico.,School of Medicine, State of Morelos Autonomous University, Morelos, Mexico
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Rios-Zertuche D, Blanco LC, Zúñiga-Brenes P, Palmisano EB, Colombara DV, Mokdad AH, Iriarte E. Contraceptive knowledge and use among women living in the poorest areas of five Mesoamerican countries. Contraception 2017; 95:549-557. [PMID: 28126542 PMCID: PMC5493184 DOI: 10.1016/j.contraception.2017.01.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 01/13/2017] [Accepted: 01/16/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To identify factors associated with contraceptive use among women in need living in the poorest areas in five Mesoamerican countries: Guatemala, Honduras, Nicaragua, Panama and State of Chiapas (Mexico). STUDY DESIGN We analyzed baseline data of 7049 women of childbearing age (15-49 years old) collected for the Salud Mesoamérica Initiative. Data collection took place in the 20% poorest municipalities of each country (July, 2012-August, 2013). RESULTS Women in the poorest areas were very poorly informed about family planning methods. Concern about side effects was the main reason for nonuse. Contraceptive use was lower among the extremely poor (<$1.25 USD PPP per day) [odds ratio (OR): 0.75; confidence interval (CI): 0.59-0.96], those living more than 30 min away from a health facility (OR 0.71, CI: 0.58-0.86), and those of indigenous ethnicity (OR 0.50, CI: 0.39-0.64). Women who were insured and visited a health facility also had higher odds of using contraceptives than insured women who did not visit a health facility (OR 1.64, CI: 1.13-2.36). CONCLUSIONS Our study showed low use of contraceptives in poor areas in Mesoamerica. We found the urgent need to improve services for people of indigenous ethnicity, low education, extreme poverty, the uninsured, and adolescents. It is necessary to address missed opportunities and offer contraceptives to all women who visit health facilities. Governments should aim to increase the public's knowledge of long-acting reversible contraception and offer a wider range of methods to increase contraceptive use. IMPLICATIONS We show that unmet need for contraception is higher among the poorest and describe factors associated with low use. Our results call for increased investments in programs and policies targeting the poor to decrease their unmet need.
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Affiliation(s)
- Diego Rios-Zertuche
- Salud Mesoamérica Initiative/Inter-American Development Bank, Calle 50, Edificio Tower Financial Center (Towerbank), Piso 23, Panama, Panama.
| | | | - Paola Zúñiga-Brenes
- Salud Mesoamérica Initiative/Inter-American Development Bank, Calle 50, Edificio Tower Financial Center (Towerbank), Piso 23, Panama, Panama.
| | - Erin B Palmisano
- Institute for Health Metrics and Evaluation, 2301 5th Ave, Suite 600, Seattle, WA, USA.
| | - Danny V Colombara
- Institute for Health Metrics and Evaluation, 2301 5th Ave, Suite 600, Seattle, WA, USA.
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, 2301 5th Ave, Suite 600, Seattle, WA, USA.
| | - Emma Iriarte
- Salud Mesoamérica Initiative/Inter-American Development Bank, Calle 50, Edificio Tower Financial Center (Towerbank), Piso 23, Panama, Panama.
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Rivera-Hernandez M, Rahman M, Mor V, Galarraga O. The Impact of Social Health Insurance on Diabetes and Hypertension Process Indicators among Older Adults in Mexico. Health Serv Res 2017; 51:1323-46. [PMID: 27417264 DOI: 10.1111/1475-6773.12404] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the impact of Seguro Popular (Mexican social health insurance for the poor; SP) on diabetes and hypertension care, intermediate process indicators for older adults (>50 years): pharmacological treatment, blood glucose tests, the use of complementary and alternative medicine (CAM), and adherence to their nutrition and exercise program. (CAM was defined as products or practices that were not part of the medical standard of care.) DATA SOURCES/STUDY SETTING Repeated cross-sectional surveys from Encuesta Nacional de Salud y Nutrición (Mexican Health and Nutrition Survey, ENSANUT), a nationally representative health and nutrition survey sampling N = 45,294 older adults in 2000, N = 45,241 older adults in 2005-2006, and N = 46,277 older adults in 2011-2012. STUDY DESIGN Fixed-effects instrumental variable (FE-IV) repeated cross-sectional at the individual level with municipality fixed-effects estimation was performed. PRINCIPAL FINDINGS We found a marginally significant effect of SP on the use of insulin and oral agents (40 percentage points). Contrary to that expected, no other significant differences were found for diabetes or hypertension treatment and care indicators. CONCLUSIONS Social health insurance for the poor improved some but not all health care process indicators among diabetic and hypertensive older people in Mexico.
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Affiliation(s)
| | - Momotazur Rahman
- Department of Health Services, Policy and Practice, Brown University, Providence, RI
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University, Providence, RI
| | - Omar Galarraga
- Department of Health Services, Policy and Practice, Brown University, Providence, RI
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Guendelman S, Gemmill A, Thornton D, Walker D, Harvey M, Walsh J, Perez-Cuevas R. Prevalence, Disparities, And Determinants Of Primary Cesarean Births Among First-Time Mothers In Mexico. Health Aff (Millwood) 2017; 36:714-722. [PMID: 28373338 DOI: 10.1377/hlthaff.2016.1084] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mexico has the second-highest prevalence of cesarean deliveries in the Americas, behind Brazil. Having had a previous cesarean delivery is highly predictive of having subsequent cesarean deliveries, yet evidence on the drivers of primary (that is, first-time) cesarean deliveries is sparse. Using 2014 Mexican birth certificate data and performing population-level analyses of data on 600,124 first-time mothers giving birth after at least thirty-seven weeks of gestation, we examined the prevalence and determinants of primary cesarean deliveries. We found a very high prevalence of cesarean deliveries among these women-48.7 percent-and wide variations across insurance coverage types. Enrollees in Seguro Popular, the public health insurance program introduced in 2003 for the previously uninsured and gradually rolled out nationally, had a cesarean rate of 40 percent, while women insured through the Social Security Institute for Civil Servants had a rate of 78 percent. The lower risk of primary cesarean deliveries among Seguro Popular enrollees persisted after adjustment for covariates. Rates of primary cesarean deliveries were particularly high in private birthing facilities for all first-time mothers. Reducing the rate of cesarean deliveries in Mexico will require interventions across types of insurance and birthing facilities and will also require targeted public health messaging.
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Affiliation(s)
- Sylvia Guendelman
- Sylvia Guendelman is a professor and chair of the Maternal and Child Health Program, Division of Community Health Sciences, School of Public Health, University of California, Berkeley
| | - Alison Gemmill
- Alison Gemmill is a PhD candidate in demography at the University of California, Berkeley
| | - Dorothy Thornton
- Dorothy Thornton is an independent researcher in Berkeley, California
| | - Dilys Walker
- Dilys Walker is a professor of obstetrics, gynecology, and reproductive health sciences and global sciences at the University of California, San Francisco
| | - Michael Harvey
- Michael Harvey is a PhD candidate in the School of Public Health, University of California, Berkeley
| | - Julia Walsh
- Julia Walsh is an adjunct professor in the Division of Community Health Sciences, School of Public Health, University of California, Berkeley
| | - Ricardo Perez-Cuevas
- Ricardo Perez-Cuevas is social protection and health senior specialist in the Division of Social Protection and Health at the Inter-American Development Bank, in Mexico City
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Strouse C, Perez-Cuevas R, Lahiff M, Walsh J, Guendelman S. Mexico's Seguro Popular Appears To Have Helped Reduce The Risk Of Preterm Delivery Among Women With Low Education. Health Aff (Millwood) 2017; 35:80-7. [PMID: 26733704 DOI: 10.1377/hlthaff.2015.0594] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Beginning in 2001 Mexico established Seguro Popular, a health insurance scheme aimed at providing coverage to its large population of uninsured people. While recent studies have evaluated the health benefits of Seguro Popular, evidence on perinatal health outcomes is lacking. We conducted a population-based study using Mexican birth certificate data for 2010 to assess the relationship between enrollment in Seguro Popular and preterm delivery among first-time mothers with singleton births in Mexico. Seguro Popular enrollees with no formal education had a far greater reduction in risk of preterm delivery, while enrollees with any formal education experienced only slight reduction in risk, after maternal age, marital status, education level, mode of delivery, and trimester in which prenatal care was initiated were controlled for. Seguro Popular appears to facilitate access to health services among mothers with low levels of education, reducing their risk for preterm delivery. Providing broad-scale health insurance coverage may help improve perinatal health outcomes in this vulnerable population.
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Affiliation(s)
- Carly Strouse
- Carly Strouse is a doctoral candidate in the School of Public Health at the University of California, Berkeley
| | - Ricardo Perez-Cuevas
- Ricardo Perez-Cuevas is a social protection and health senior specialist in the Division of Social Protection and Health at the Inter-American Development Bank, in Mexico City, Mexico
| | - Maureen Lahiff
- Maureen Lahiff is a lecturer in the Division of Biostatistics, School of Public Health, University of California, Berkeley
| | - Julia Walsh
- Julia Walsh is an adjunct professor in the Division of Community Health and Human Development, School of Public Health, University of California, Berkeley
| | - Sylvia Guendelman
- Sylvia Guendelman is a professor in the Division of Community Health and Human Development and chair of the Maternal and Child Health Program in the School of Public Health, University of California, Berkeley
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Brooks MI, Thabrany H, Fox MP, Wirtz VJ, Feeley FG, Sabin LL. Health facility and skilled birth deliveries among poor women with Jamkesmas health insurance in Indonesia: a mixed-methods study. BMC Health Serv Res 2017; 17:105. [PMID: 28148258 PMCID: PMC5288898 DOI: 10.1186/s12913-017-2028-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 01/17/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia's strategy to achieve the goal of UHC, large investments have been made to increase health access for the poor, resulting in the implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jamkesmas program. In the backdrop of Indonesia's aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. The objective of this study was to evaluate the association of health facility and skilled birth deliveries among poor women with and without Jamkesmas and explore perceived barriers to health insurance membership and maternal health service utilization. METHODS We used a mixed-methods design. Utilizing data from the 2012 Indonesian Demographic and Health Survey (n = 45,607), secondary analysis using propensity score matching was performed on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). In-depth interviews (n = 51) were conducted in the provinces of Jakarta and Banten among poor women, midwives, and government representatives. Thematic framework analysis was performed on qualitative data to explore perceived barriers. RESULTS In 2012, 63.0% of women did not have health insurance; 19.1% had Jamkesmas. Poor women with Jamkesmas were 19% (OR = 1.19 [1.03-1.37]) more likely to have HFD and 17% (OR = 1.17 [1.01-1.35]) more likely to have SBD compared to poor women without insurance. Qualitative interviews highlighted key issues, including: lack of proper documentation for health insurance registration; the preference of pregnant women to deliver in their parents' village; the use of traditional birth attendants; distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation. CONCLUSIONS Poor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings are consistent with economic theory that health insurance coverage can reduce financial barriers to care and increase service uptake. However, factors such as socio-cultural beliefs, accessibility, and quality of care are important elements that need to be addressed as part of the national UHC agenda to improve maternal health services in Indonesia.
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Affiliation(s)
- Mohamad I. Brooks
- Pathfinder International, 9 Galen St, Suite 217, Watertown, 02472 MA USA
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118 MA USA
| | - Hasbullah Thabrany
- Center for Health Economics and Policy Studies, University of Indonesia School of Public Health, Building G Room 311, Depok, 16424 West Java Indonesia
| | - Matthew P. Fox
- Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, Talbot T2C, Boston, 02118 MA USA
- Center for Global Health and Development, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118 MA USA
| | - Veronika J. Wirtz
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118 MA USA
- Center for Global Health and Development, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118 MA USA
| | - Frank G. Feeley
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118 MA USA
- Center for Global Health and Development, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118 MA USA
| | - Lora L. Sabin
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118 MA USA
- Center for Global Health and Development, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118 MA USA
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Sosa-Rubí SG. Is Being Insured Sufficient to Ensure Effective Access to Health Care among Poor People in Mexico in the Long Term? Health Serv Res 2016; 51:1319-22. [PMID: 27396344 DOI: 10.1111/1475-6773.12541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Sandra G Sosa-Rubí
- National Bureau of Economic Research, 1050 Massachusetts Ave., Cambridge, MA
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Servan-Mori E, Avila-Burgos L, Nigenda G, Lozano R. A Performance Analysis of Public Expenditure on Maternal Health in Mexico. PLoS One 2016; 11:e0152635. [PMID: 27043819 PMCID: PMC4820121 DOI: 10.1371/journal.pone.0152635] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/16/2016] [Indexed: 11/19/2022] Open
Abstract
We explore the relationship between public expenditure, coverage of adequate ANC (including timing, frequent and content), and the maternal mortality ratio--adjusted by coverage of adequate ANC--observed in Mexico in 2012 at the State level. Additionally, we examine the inequalities and concentration of public expenditure between populations with and without Social Security. Results suggest that in the 2003-2011 period, the public expenditure gap between women with and without Social Security decreased 74%, however, the distribution is less equitable among women without Social Security, across the States. Despite high levels of coverage on each dimension of ANC explored, coverage of adequate ANC was lower among Social Security than non-Social Security women. This variability results in differences up to 1.5 times in State-adjusted maternal mortality rate at the same level of expense and maternal mortality rate, respectively. The increase in the economic resources is only a necessary condition for achieving improved health outcomes. Providing adequate health services and achieving efficient, effective and transparent use of resources in health, are critical elements for health systems performance. The attainment of universal effective coverage of maternal health and reducing maternal mortality in Mexico, requires the adjustment of policy innovations including the rules of allocation and execution of health resources. Health policies should be designed on a more holistic view promoting a balance between accessibility, effective implementation and rigorous stewardship.
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Affiliation(s)
| | | | - Gustavo Nigenda
- School of Medicine, State of Morelos Autonomous University, Cuernavaca, Morelos, Mexico
| | - Rafael Lozano
- National Institute of Public Health, Cuernavaca, Morelos, Mexico
- Institute for Health Metrics and Evaluation, UW, Seattle, WA, United States of America
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Avila-Burgos L, Cahuana-Hurtado L, Montañez-Hernandez J, Servan-Mori E, Aracena-Genao B, del Río-Zolezzi A. Financing Maternal Health and Family Planning: Are We on the Right Track? Evidence from the Reproductive Health Subaccounts in Mexico, 2003-2012. PLoS One 2016; 11:e0147923. [PMID: 26812646 PMCID: PMC4728114 DOI: 10.1371/journal.pone.0147923] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 01/11/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To analyze whether the changes observed in the level and distribution of resources for maternal health and family planning (MHFP) programs from 2003 to 2012 were consistent with the financial goals of the related policies. MATERIALS AND METHODS A longitudinal descriptive analysis of the Mexican Reproductive Health Subaccounts 2003-2012 was performed by financing scheme and health function. Financing schemes included social security, government schemes, household out-of-pocket (OOP) payments, and private insurance plans. Functions were preventive care, including family planning, antenatal and puerperium health services, normal and cesarean deliveries, and treatment of complications. Changes in the financial imbalance indicators covered by MHFP policy were tracked: (a) public and OOP expenditures as percentages of total MHFP spending; (b) public expenditure per woman of reproductive age (WoRA, 15-49 years) by financing scheme; (c) public expenditure on treating complications as a percentage of preventive care; and (d) public expenditure on WoRA at state level. Statistical analyses of trends and distributions were performed. RESULTS Public expenditure on government schemes grew by approximately 300%, and the financial imbalance between populations covered by social security and government schemes decreased. The financial burden on households declined, particularly among households without social security. Expenditure on preventive care grew by 16%, narrowing the financing gap between treatment of complications and preventive care. Finally, public expenditure per WoRA for government schemes nearly doubled at the state level, although considerable disparities persist. CONCLUSIONS Changes in the level and distribution of MHFP funding from 2003 to 2012 were consistent with the relevant policy goals. However, improving efficiency requires further analysis to ascertain the impact of investments on health outcomes. This, in turn, will require better financial data systems as a precondition for improving the monitoring and accountability functions in Mexico.
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Affiliation(s)
- Leticia Avila-Burgos
- Center for Health Systems Research, National Institute of Public Health, Morelos, Mexico
| | - Lucero Cahuana-Hurtado
- Center for Health Systems Research, National Institute of Public Health, Morelos, Mexico
| | | | - Edson Servan-Mori
- Center for Health Systems Research, National Institute of Public Health, Morelos, Mexico
| | - Belkis Aracena-Genao
- Research Center for Evaluation and Surveys, National Institute of Public Health, Morelos, Mexico
| | - Aurora del Río-Zolezzi
- National Center for Gender Equity and Reproductive Health, Ministry of Health, Mexico City, Mexico
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Using ambulatory care sensitive hospitalisations to analyse the effectiveness of primary care services in Mexico. Soc Sci Med 2015; 144:59-68. [DOI: 10.1016/j.socscimed.2015.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 08/20/2015] [Accepted: 09/06/2015] [Indexed: 11/22/2022]
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Servan-Mori E, Heredia-Pi I, Montañez-Hernandez J, Avila-Burgos L, Wirtz VJ. Access to Medicines by Seguro Popular Beneficiaries: Pending Tasks towards Universal Health Coverage. PLoS One 2015; 10:e0136823. [PMID: 26407158 PMCID: PMC4583285 DOI: 10.1371/journal.pone.0136823] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 08/10/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE In the context of aiming to achieve universal health coverage in Mexico, this study compares access to prescribed medicines (ATPM) between Seguro Popular (SP) and non-SP affiliated outpatient health service users. MATERIALS AND METHODS ATPM by 6,123 users of outpatient services was analyzed using the National Health and Nutrition Survey 2012. Adjusted bi-probit models were performed incorporating instrumental variables. RESULTS 17.3% of SP and 10.1% of the non-SP population lacked ATPM. Two-thirds of all outpatient SP and 18.5% of all outpatient non-SP received health services at Ministry of Health facilities, among whom, 64.6 and 53.6% of the SP and non-SP population respectively reported ATPM at these facilities. Lack of medicines in health units, chronic health problems (compared to acute conditions) and prescription ≥3 medicines were risk factors for non-ATPM. Adjusted models suggest that when using Ministry of Health services, the SP population has a higher probability of ATMP compared to the non-SP population. CONCLUSION Given the aspirations of achieving universal health coverage in Mexico, it is important to increase ATPM in Ministry of Health facilities thereby ensuring basic rights to health care are met.
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Affiliation(s)
- Edson Servan-Mori
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Ileana Heredia-Pi
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Julio Montañez-Hernandez
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Leticia Avila-Burgos
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Veronika J. Wirtz
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
- Department for Global Health, Boston University School of Public Health, Boston, United States of America
- * E-mail:
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Rivera-Hernandez M, Galarraga O. Type of Insurance and Use of Preventive Health Services Among Older Adults in Mexico. J Aging Health 2015; 27:962-82. [PMID: 25804897 PMCID: PMC4720256 DOI: 10.1177/0898264315569457] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The main purpose of this article was to assess the differences between Seguro Popular (SP) and employer-based health insurance in the use of preventive services, including screening tests for diabetes, cholesterol, hypertension, cervical cancer, and prostate cancer among older adults at more than a decade of health care reform in Mexico. METHOD Logistic regression models were used with data from the Mexican Health and Nutrition Survey, 2012. RESULTS After adjusting for other factors influencing preventive service utilization, SP enrollees were more likely to use screening tests for diabetes, cholesterol, hypertension, and cervical cancer than the uninsured; however, those in employment-based and private insurances had higher odds of using preventive care for most of these services, except Pap smears. DISCUSSION Despite all the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in health care access and utilization still exist in Mexico.
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Affiliation(s)
| | - Omar Galarraga
- Department of Health Services, Policy and Practice Brown University, Providence, RI, USA
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Servan-Mori E, Wirtz V, Avila-Burgos L, Heredia-Pi I. Antenatal Care Among Poor Women in Mexico in the Context of Universal Health Coverage. Matern Child Health J 2015; 19:2314-22. [DOI: 10.1007/s10995-015-1751-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sood N, Bendavid E, Mukherji A, Wagner Z, Nagpal S, Mullen P. Government health insurance for people below poverty line in India: quasi-experimental evaluation of insurance and health outcomes. BMJ 2014; 349:g5114. [PMID: 25214509 PMCID: PMC4161676 DOI: 10.1136/bmj.g5114] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To evaluate the effects of a government insurance program covering tertiary care for people below the poverty line in Karnataka, India, on out-of-pocket expenditures, hospital use, and mortality. DESIGN Geographic regression discontinuity study. SETTING 572 villages in Karnataka, India. PARTICIPANTS 31,476 households (22,796 below poverty line and 8680 above poverty line) in 300 villages where the scheme was implemented and 28,633 households (21,767 below poverty line and 6866 above poverty line) in 272 neighboring matched villages ineligible for the scheme. INTERVENTION A government insurance program (Vajpayee Arogyashree scheme) that provided free tertiary care to households below the poverty line in about half of villages in Karnataka from February 2010 to August 2012. MAIN OUTCOME MEASURE Out-of-pocket expenditures, hospital use, and mortality. RESULTS Among households below the poverty line, the mortality rate from conditions potentially responsive to services covered by the scheme (mostly cardiac conditions and cancer) was 0.32% in households eligible for the scheme compared with 0.90% among ineligible households just south of the eligibility border (difference of 0.58 percentage points, 95% confidence interval 0.40 to 0.75; P<0.001). We found no difference in mortality rates for households above the poverty line (households above the poverty line were not eligible for the scheme), with a mortality rate from conditions covered by the scheme of 0.56% in eligible villages compared with 0.55% in ineligible villages (difference of 0.01 percentage points, -0.03 to 0.03; P=0.95). Eligible households had significantly reduced out-of-pocket health expenditures for admissions to hospitals with tertiary care facilities likely to be covered by the scheme (64% reduction, 35% to 97%; P<0.001). There was no significant increase in use of covered services, although the point estimate of a 44.2% increase approached significance (-5.1% to 90.5%; P=0.059). Both reductions in out-of-pocket expenditures and potential increases in use might have contributed to the observed reductions in mortality. CONCLUSIONS Insuring poor households for efficacious but costly and underused health services significantly improves population health in India.
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Affiliation(s)
- Neeraj Sood
- Department of Pharmaceutical Economics and Policy, School of Pharmacy, University of Southern California, Los Angeles, CA, USA Leonard D Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA National Bureau of Economic Research, Cambridge, MA, USA
| | - Eran Bendavid
- Division of General Medical Disciplines, Stanford University, Stanford, CA, USA Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | - Arnab Mukherji
- Center for Public Policy, Indian Institute of Management Bangalore, Bangalore, India
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Leyva-Flores R, Servan-Mori E, Infante-Xibille C, Pelcastre-Villafuerte BE, Gonzalez T. Primary health care utilization by the mexican indigenous population: the role of the Seguro popular in socially inequitable contexts. PLoS One 2014; 9:e102781. [PMID: 25099399 PMCID: PMC4123888 DOI: 10.1371/journal.pone.0102781] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 06/22/2014] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To analyze the relationship between primary health care utilization and extended health insurance coverage under the Seguro Popular (SP) among Mexican indigenous people. METHODOLOGY A cross-sectional analysis was conducted using data from the Mexican National Nutrition Survey 2012 (n = 194,758). Quasi-experimental matching methods and nonlinear regression probit models were used to estimate the influence of SP on primary health care utilization. RESULTS 25% of the Mexican population reported having no health insurance coverage, while 59% of indigenous versus 35% of non-indigenous reported having SP coverage. Health problems were reported by 13.9% of indigenous vs. 10.5% of non-indigenous; of these, 52.8% and 57.7% respectively, received primary health care (p<0.05). Economic barriers were the most frequent reasons for not using primary health care services. The probability of utilizing primary health care services was 11.5 percentage points higher (p<0.01) for indigenous SP affiliates in comparison with non-indigenous, in similar socioeconomic conditions. CONCLUSION Socioeconomic conditions, not ethnicity per-se, determine whether people utilize primary health care services. Therefore, SP can be conceived as a public policy strategy which acts as a social buffer by enhancing health care utilization regardless of ethnicity. Further analysis is required to explore the potential gaps as a result of SP coverage among socially vulnerable groups.
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Affiliation(s)
- Rene Leyva-Flores
- Centre for Health Systems Research of the National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Edson Servan-Mori
- Centre for Health Systems Research of the National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Cesar Infante-Xibille
- Centre for Health Systems Research of the National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | | | - Tonatiuh Gonzalez
- Centre for Health Systems Research of the National Institute of Public Health, Cuernavaca, Morelos, Mexico
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Biosca O, Brown H. Boosting health insurance coverage in developing countries: do conditional cash transfer programmes matter in Mexico? Health Policy Plan 2014; 30:155-62. [PMID: 24441284 DOI: 10.1093/heapol/czt109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Achieving universal health insurance coverage is a goal for many developing countries. Even when universal health insurance programmes are in place, there are significant barriers to reaching the lowest socio-economic groups such as a lack of awareness of the programmes or knowledge of the benefits to participating in the insurance market. Conditional cash transfer (CCT) programmes can encourage participation through mandatory health education classes, increased contact with the health care system and cash payments to reduce costs of participating in the insurance market. OBJECTIVE To explore if participation in a CCT programme in Mexico, Oportunidades, is significantly associated with self-reported enrolment in a public health insurance programme. METHODS Cross-sectional data from 2007 collected on 29 595 Mexican households where the household head is aged between ages 15 and 60 were analysed. A logit model was used to estimate the association between Oportunidades participation and awareness of enrolment in a public health insurance programme. RESULTS Participation in the Oportunidades programme is associated with a 25% higher likelihood of being actively aware of enrolment in Seguro Popular, a public health insurance scheme for the lowest socio-economic groups. CONCLUSIONS Participation in the Oportunidades CCT programme is positively associated with awareness of enrolment in public health insurance. CCT programmes may be used to promote participation of the lowest socio-economic groups in universal public health insurance systems. This is crucial to achieving universal health insurance coverage in developing countries.
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Affiliation(s)
- Olga Biosca
- Yunus Centre for Social Business and Health/Glasgow School for Business and Society, Glasgow Caledonian University, Glasgow G4 0BA, UK and Institute of Health and Society, Newcastle University, Newcastle upon Tyne NE2 4AA, UK
| | - Heather Brown
- Yunus Centre for Social Business and Health/Glasgow School for Business and Society, Glasgow Caledonian University, Glasgow G4 0BA, UK and Institute of Health and Society, Newcastle University, Newcastle upon Tyne NE2 4AA, UK
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Lyssenko N, Martínez-Espiñeira R. 'Been there done that': disentangling option value effects from user heterogeneity when valuing natural resources with a use component. ENVIRONMENTAL MANAGEMENT 2012; 50:819-836. [PMID: 22968477 DOI: 10.1007/s00267-012-9937-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 07/30/2012] [Indexed: 06/01/2023]
Abstract
Endogeneity bias arises in contingent valuation studies when the error term in the willingness to pay (WTP) equation is correlated with explanatory variables because observable and unobservable characteristics of the respondents affect both their WTP and the value of those variables. We correct for the endogeneity of variables that capture previous experience with the resource valued, humpback whales, and with the geographic area of study. We consider several endogenous behavioral variables. Therefore, we apply a multivariate Probit approach to jointly model them with WTP. In this case, correcting for endogeneity increases econometric efficiency and substantially corrects the bias affecting the estimated coefficients of the experience variables, by isolating the decreasing effect on option value caused by having already experienced the resource. Stark differences are unveiled between the marginal effects on WTP of previous experience of the resource in an alternative location versus experience in the location studied, Newfoundland and Labrador (Canada).
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Affiliation(s)
- Nikita Lyssenko
- Department of Economics, Memorial University of Newfoundland, St. John's, NL, Canada.
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Abstract
Many commentators, including WHO, have advocated progress towards universal health coverage on the grounds that it leads to improvements in population health. In this report we review the most robust cross-country empirical evidence on the links between expansions in coverage and population health outcomes, with a focus on the health effects of extended risk pooling and prepayment as key indicators of progress towards universal coverage across health systems. The evidence suggests that broader health coverage generally leads to better access to necessary care and improved population health, particularly for poor people. However, the available evidence base is limited by data and methodological constraints, and further research is needed to understand better the ways in which the effectiveness of extended health coverage can be maximised, including the effects of factors such as the quality of institutions and governance.
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Affiliation(s)
- Rodrigo Moreno-Serra
- Business School and Centre for Health Policy, Imperial College London, London, UK
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Dror DM, Vellakkal S. Is RSBY India's platform to implementing universal hospital insurance? Indian J Med Res 2012; 135:56-63. [PMID: 22382184 PMCID: PMC3307185 DOI: 10.4103/0971-5916.93425] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background & objectives: In 2008, India's Labour Ministry launched a hospital insurance scheme called Rashtriya Swasthya Bima Yojana (RSBY) covering ‘Below Poverty Line’ (BPL) households. RSBY is implemented through insurance companies; premiums are subsidized by Union and States governments (75 : 25%). We examined RSBY's enrolment of BPL, costs vs. budgets and policy ramifications. Methods: Numbers of BPL are obtained by following criteria of two committees appointed for this task. District-specific premiums are weighted to obtain national average premiums. Using the BPL estimates and national premiums, we calculated overall expected costs of full roll-out of the RSBY per annum, and compared it to Union government budget allocations. Results: By March 31, 2011, RSBY enrolled about 27.8 per cent of the number of BPL households following the Tendulkar Committee estimates (37.6% following the Lakdawala Committee criteria). The average national weighted premium was 530 per household per year in 2011. The expected cost of premium to the union government of enrolling the entire BPL population in financial year (FY) 2010-11 would be 33.5 billion using Tendulkar count of BPL (or 24.6 billion following Lakdawala count), representing about 0.3 per cent (or 0.2%, respectively) of the total union budget. The RSBY budget allocation for FY 2010-11 was only about 0.037 per cent of the total union budget, sufficient to pay premiums of only 34 per cent of the BPL households enrolled by March 31, 2011. Interpretation & conclusions: RSBY could be the platform for universal health insurance when (i) the budget allocation will match the required funds for maintenance and expansion of the scheme; (ii) the scheme would ensure that beneficiaries’ rights are legally anchored; and (iii) RSBY would attract large numbers of premium-paying (non-BPL) households.
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Affiliation(s)
- David M Dror
- Erasmus University Rotterdam (Institute of Health Policy & Management), The Netherlands.
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Spenkuch JL. Moral hazard and selection among the poor: evidence from a randomized experiment. JOURNAL OF HEALTH ECONOMICS 2012; 31:72-85. [PMID: 22307034 DOI: 10.1016/j.jhealeco.2011.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2011] [Revised: 11/03/2011] [Accepted: 12/15/2011] [Indexed: 05/31/2023]
Abstract
Not only does economic theory predict high-risk individuals to be more likely to purchase insurance, but insurance coverage is also thought to crowd out precautionary activities. In spite of stark theoretical predictions, there is conflicting empirical evidence on adverse selection, and evidence on ex ante moral hazard is very scarce. Using data from the Seguro Popular Experiment in Mexico, this paper documents patterns of selection on observables into health insurance as well as the existence of non-negligible ex ante moral hazard. More specifically, the findings indicate that (i) agents in poor self-assessed health prior to the intervention have, all else equal, a higher propensity to take up insurance; and (ii) insurance coverage reduces the demand for self-protection in the form of preventive care. Curiously, however, individuals do not sort based on objective measures of their health.
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Affiliation(s)
- Jörg L Spenkuch
- Department of Economics, University of Chicago, United States.
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Danese-dlSantos LG, Sosa-Rubí SG, Valencia-Mendoza A. Analysis of changes in the association of income and the utilization of curative health services in Mexico between 2000 and 2006. BMC Public Health 2011; 11:771. [PMID: 21978183 PMCID: PMC3203078 DOI: 10.1186/1471-2458-11-771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 10/07/2011] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND A common characteristic of health systems in most developing countries is unequal access to health services. As a result, members of the poorest population groups often do not receive formal attention for health services, because they cannot afford it. In 2001 in Mexico, to address income-related differences in the use of health services, the government launched a major healthcare reform, which includes a health insurance program called Seguro Popular, aimed at improving healthcare access among poor, uninsured residents. This paper analyzes the before and after changes in the demand for curative ambulatory health services focusing on the association of income-related characteristics and the utilization of formal healthcare providers vs. no healthcare service utilization. METHODS By using two nationally representative health surveys (ENSA-2000 and ENSANUT-2006), we modeled an individual's decision when experiencing an illness to use services provided by the (1) Ministry of Health (MoH), (2) social security, (3) private entities, or (4) to not use formal services (no healthcare service utilization). RESULTS Poorer individuals were more likely in 2006 than in 2000 to respond to an illness by using formal healthcare providers. Trends in provider selection differed, however. The probability of using public services from the MoH increased among the poorest population, while the findings indicated an increase in utilization of private health services among members of low- and middle-income groups. No significant change was seen among formal workers -covered by social security services-, regardless of socioeconomic status. CONCLUSIONS Overall, for 2006 the Mexican population appears less differentiated in using healthcare across economic groups than in 2000. This may be related, in part, to the implementation of Seguro Popular, which seems to be stimulating healthcare demand among the poorest and previously uninsured segment of the population. Still, public health authorities need to address the remaining income-related healthcare utilization differences, the differences in quality between public and private health services, and the general perception that MoH facilities offer inferior services.
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Affiliation(s)
- Laura G Danese-dlSantos
- Center for Evaluation Research and Surveys, Division of Health Economics, National Institute of Public Health (INSP), Av. Universidad 655, Cuernavaca 62508, Morelos, Mexico
| | - Sandra G Sosa-Rubí
- Center for Evaluation Research and Surveys, Division of Health Economics, National Institute of Public Health (INSP), Av. Universidad 655, Cuernavaca 62508, Morelos, Mexico
| | - Atanacio Valencia-Mendoza
- Center for Evaluation Research and Surveys, Division of Health Economics, National Institute of Public Health (INSP), Av. Universidad 655, Cuernavaca 62508, Morelos, Mexico
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Garcia-Diaz R, Sosa-Rubi SG. Analysis of the distributional impact of out-of-pocket health payments: evidence from a public health insurance program for the poor in Mexico. JOURNAL OF HEALTH ECONOMICS 2011; 30:707-718. [PMID: 21724281 DOI: 10.1016/j.jhealeco.2011.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 03/23/2011] [Accepted: 04/11/2011] [Indexed: 05/31/2023]
Abstract
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.
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Sosa-Rubí SG, Salinas-Rodríguez A, Galárraga O. [Impact of "Seguro Popular" on catastrophic and out-of-pocket health expenditures in rural and urban Mexico, 2005-2008]. SALUD PUBLICA DE MEXICO 2011; 53 Suppl 4:425-435. [PMID: 22282205 PMCID: PMC4791953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVE To estimate the effect of "Seguro Popular" (SP) on the incidence of catastrophic health expenditure (CHE) and out-of-pocket (OOP) health expenditure in the medium term. MATERIAL AND METHODS We used the 'Encuesta de Evaluación del SP' --SP Survey Evaluation-- (2005-2008). We analyzed the SP effect on the rural cohort during two years of follow-up (2006 and 2008) and in the urban cohort during one year of follow-up (2008). RESULTS At the local level (regional clusters) we did not find an effect of the SP. At the household level we found a protective effect of SP on CHE and the OOP health payments in outpatient and hospitalization in rural areas; and a significant effect on the reduction of OOP health payments in outpatient services in urban zones. CONCLUSIONS SP seems to be an effective program to protect poor household against out-of-pocket health expenditures in the medium term.
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Affiliation(s)
- Sandra G Sosa-Rubí
- Departamento de Servicios de Salud, Políticas y Práctica, Brown University, Providence, Rhode Island, USA
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Galárraga O, Sosa-Rubí SG, Salinas-Rodríguez A, Sesma-Vázquez S. Health insurance for the poor: impact on catastrophic and out-of-pocket health expenditures in Mexico. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2010; 11:437-447. [PMID: 19756796 PMCID: PMC2888946 DOI: 10.1007/s10198-009-0180-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Accepted: 08/18/2009] [Indexed: 05/28/2023]
Abstract
The goal of Seguro Popular (SP) in Mexico was to improve the financial protection of the uninsured population against excessive health expenditures. This paper estimates the impact of SP on catastrophic health expenditures (CHE), as well as out-of-pocket (OOP) health expenditures, from two different sources. First, we use the SP Impact Evaluation Survey (2005-2006), and compare the instrumental variables (IV) results with the experimental benchmark. Then, we use the same IV methods with the National Health and Nutrition Survey (ENSANUT 2006). We estimate naïve models, assuming exogeneity, and contrast them with IV models that take advantage of the specific SP implementation mechanisms for identification. The IV models estimated included two-stage least squares (2SLS), bivariate probit, and two-stage residual inclusion (2SRI) models. Instrumental variables estimates resulted in comparable estimates against the "gold standard." Instrumental variables estimates indicate a reduction of 54% in catastrophic expenditures at the national level. SP beneficiaries also had lower expenditures on outpatient and medicine expenditures. The selection-corrected protective effect is found not only in the limited experimental dataset, but also at the national level.
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Affiliation(s)
- Omar Galárraga
- Health Economics Unit, Center for Evaluation and Survey Research, Mexican School of Public Health, National Institute of Public Health (INSP), Av. Universidad 655, Cuernavaca, 62508 Mexico
- Institute of Business and Economic Research (IBER), University of California, Berkeley, CA USA
| | - Sandra G. Sosa-Rubí
- Health Economics Unit, Center for Evaluation and Survey Research, Mexican School of Public Health, National Institute of Public Health (INSP), Av. Universidad 655, Cuernavaca, 62508 Mexico
| | - Aarón Salinas-Rodríguez
- Statistics Unit, Center for Evaluation and Survey Research, Mexican School of Public Health, National Institute of Public Health (INSP), Av. Universidad 655, Cuernavaca, 62508 Mexico
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Sosa-Rubí SG, Galárraga O, López-Ridaura R. Diabetes treatment and control: the effect of public health insurance for the poor in Mexico. Bull World Health Organ 2009; 87:512-9. [PMID: 19649365 PMCID: PMC2704037 DOI: 10.2471/blt.08.053256] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 10/20/2008] [Accepted: 11/11/2008] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To analyse the effect of enrolment in the public health insurance scheme known as Seguro Popular [People's Insurance] on access to health resources, treatment and blood glucose control among poor adults with diabetes in Mexico. METHODS We analysed cross-sectional data from the 2006 National Health and Nutrition Survey and compared health care access and biological health outcomes, specifically glycosylated haemoglobin (HbA1c) levels, among adults with diabetes who were enrolled in the Seguro Popular (treatment group) and those who had no health insurance (control group). Standard propensity score matching was used to create a highly comparable control group. FINDINGS Adults with diabetes who were enrolled in the Seguro Popular had significantly more access than comparable uninsured adults to some type of blood glucose control test (by a difference of 9.5 percentage points; 95% confidence interval, CI: 2.4-16.6) and to insulin injections (3.13 more per week; 95% CI: 0.04-6.22). Those with insurance were also significantly more likely to have appropriately-controlled blood glucose levels (HbA1c 12%) was found in a significantly smaller proportion of adults in the insured group than in the uninsured group (by a difference of 17.5 percentage points; 95% CI: 6.5-28.5). CONCLUSION The Seguro Popular appears to have improved access to health care and blood glucose control among poor adults with diabetes in Mexico, and it may have had a positive effect on the management of other chronic health conditions, but its long-term effects are yet to be demonstrated. Although the findings are most relevant to Mexico, they may also be applicable to other developing countries seeking to improve health-care coverage for the poor by expanding their public health insurance programmes.
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Affiliation(s)
- Sandra G Sosa-Rubí
- National Institute of Public Health, Health Economics Division, Av. Universidad 655, Cuernavaca, CP 62100, Mexico
| | - Omar Galárraga
- Institute of Business and Economic Research, University of California, Berkeley, CA, United States of America
| | - Ruy López-Ridaura
- Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
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Sosa-Rubi SG, Galárraga O, Harris JE. Heterogeneous impact of the "Seguro Popular" program on the utilization of obstetrical services in Mexico, 2001-2006: a multinomial probit model with a discrete endogenous variable. JOURNAL OF HEALTH ECONOMICS 2009; 28:20-34. [PMID: 18824268 PMCID: PMC2790917 DOI: 10.1016/j.jhealeco.2008.08.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 08/03/2008] [Accepted: 08/13/2008] [Indexed: 05/26/2023]
Abstract
OBJECTIVE We evaluated the impact of Seguro Popular (SP), a program introduced in 2001 in Mexico primarily to finance health care for the poor. We focused on the effect of household enrollment in SP on pregnant women's access to obstetrical services, an important outcome measure of both maternal and infant health. DATA We relied upon data from the cross-sectional 2006 National Health and Nutrition Survey (ENSANUT) in Mexico. We analyzed the responses of 3890 women who delivered babies during 2001-2006 and whose households lacked employer-based health care coverage. METHODS We formulated a multinomial probit model that distinguished between three mutually exclusive sites for delivering a baby: a health unit specifically accredited by SP; a non-SP-accredited clinic run by the Department of Health (Secretaría de Salud, or SSA); and private obstetrical care. Our model accounted for the endogeneity of the household's binary decision to enroll in the SP program. RESULTS Women in households that participated in the SP program had a much stronger preference for having a baby in a SP-sponsored unit rather than paying out of pocket for a private delivery. At the same time, participation in SP was associated with a stronger preference for delivering in the private sector rather than at a state-run SSA clinic. On balance, the Seguro Popular program reduced pregnant women's attendance at an SSA clinic much more than it reduced the probability of delivering a baby in the private sector. The quantitative impact of the SP program varied with the woman's education and health, as well as the assets and location (rural vs. urban) of the household. CONCLUSIONS The SP program had a robust, significantly positive impact on access to obstetrical services. Our finding that women enrolled in SP switched from non-SP state-run facilities, rather than from out-of-pocket private services, is important for public policy and requires further exploration.
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Affiliation(s)
- Sandra G. Sosa-Rubi
- Center for Evaluation Research and Surveys, Division of Health Economics, National Institute of Public Health (Instituto Nacional de Salud Pública), Cuernavaca, Morelos 62508, México
| | - Omar Galárraga
- Center for Evaluation Research and Surveys, Division of Health Economics, National Institute of Public Health (Instituto Nacional de Salud Pública), Cuernavaca, Morelos 62508, México; and Institute of Business and Economic Research (IBER), University of California, Berkeley, California 94720, USA
| | - Jeffrey E. Harris
- Department of Economics, Massachusetts Institute of Technology, Cambridge, Massachusetts 02142, USA
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