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Krakauer EL, Kwete XJ, Rassouli M, Arreola-Ornelas H, Ashrafizadeh H, Bhadelia A, Liu YA, Méndez-Carniado O, Osman H, Knaul FM. Palliative care need in the Eastern Mediterranean Region and human resource requirements for effective response. PLOS Glob Public Health 2023; 3:e0001980. [PMID: 37922240 PMCID: PMC10624269 DOI: 10.1371/journal.pgph.0001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/01/2023] [Indexed: 11/05/2023]
Abstract
Integration of palliative care into health care systems is considered an ethical responsibility, yet no country in the Eastern Mediterranean Region (EaMReg) has achieved integration. Data on palliative care need and cost are crucial forEaMReg health care planners and implementers in the region. Using data from the Lancet Commission on Palliative Care and Pain Relief, we estimated the number of people in each EaMReg country who needed palliative care in 2015 and their degree of access. In three countries, we estimated the number of days during which an encounter for palliative care was needed at each level of the health care system. This enabled calculation of the number of full-time equivalents (FTEs) of clinical and non-clinical staff members needed at each level to administer the essential package of palliative care recommended by WHO. In 2015, 3.2 million people in the EaMReg needed palliative care, yet most lacked access to it. The most common types of suffering were pain, fatigue, weakness, anxiety or worry, and depressed mood. To provide safe, effective palliative care at all levels of health care systems, between 5.4 and 11.1 FTEs of trained and supervised community health workers per 100,000 population would be needed in addition to 1.0-1.9 FTEs of doctors, 2.2-4.3 FTEs of nurses, and 1.4-2.9 FTEs of social workers. Data from our study enables design of palliative care services to meet the specific needs of each EaMReg country and to calculate the cost or cost savings.
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Affiliation(s)
- Eric L. Krakauer
- Program in Global Palliative Care, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Palliative Care & Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Xiaoxiao J. Kwete
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Maryam Rassouli
- School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Héctor Arreola-Ornelas
- Fundación Mexicana para la Salud, Mexico City, Mexico
- Institute for Obesity Research, Tecnologico de Monterrey, Mexico, Mexico
| | | | - Afsan Bhadelia
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | | | - Hibah Osman
- Program in Global Palliative Care, Harvard Medical School, Boston, Massachusetts, United States of America
- Balsam Lebanese Center for Palliative Care, Beirut, Lebanon
- Dana Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Felicia M. Knaul
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, Florida, United States of America
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Knaul FM, Arreola-Ornelas H, Touchton M, McDonald T, Blofield M, Avila Burgos L, Gómez-Dantés O, Kuri P, Martinez-Valle A, Méndez-Carniado O, Nargund RS, Porteny T, Sosa-Rubí SG, Serván-Mori E, Symes M, Vargas Enciso V, Frenk J. Setbacks in the quest for universal health coverage in Mexico: polarised politics, policy upheaval, and pandemic disruption. Lancet 2023; 402:731-746. [PMID: 37562419 DOI: 10.1016/s0140-6736(23)00777-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/21/2023] [Accepted: 04/11/2023] [Indexed: 08/12/2023]
Abstract
2023 marks the 20-year anniversary of the creation of Mexico's System of Social Protection for Health and the Seguro Popular, a model for the global quest to achieve universal health coverage through health system reform. We analyse the success and challenges after 2012, the consequences of reform ageing, and the unique coincidence of systemic reorganisation during the COVID-19 pandemic to identify strategies for health system disaster preparedness. We document that population health and financial protection improved as the Seguro Popular aged, despite erosion of the budget and absent needed reforms. The Seguro Popular closed in January, 2020, and Mexico embarked on a complex, extensive health system reorganisation. We posit that dismantling the Seguro Popular while trying to establish a new programme in 2020-21 made the Mexican health system more vulnerable in the worst pandemic period and shows the precariousness of evidence-based policy making to political polarisation and populism. Reforms should be designed to be flexible yet insulated from political volatility and constructed and managed to be structurally permeable and adaptable to new evidence to face changing health needs. Simultaneously, health systems should be grounded to withstand systemic shocks of politics and natural disasters.
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Affiliation(s)
- Felicia Marie Knaul
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA; Fundación Mexicana para la Salud, Mexico City, Mexico; Tómatelo a Pecho, Mexico City, Mexico
| | - Hector Arreola-Ornelas
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; Fundación Mexicana para la Salud, Mexico City, Mexico; Tómatelo a Pecho, Mexico City, Mexico; Institute for Obesity Research and School of Government and Public Transformation, Tecnológico de Monterrey, Nuevo León, México
| | - Michael Touchton
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; Department of Political Science, College of Arts, and Sciences, University of Miami, Coral Gables, FL, USA.
| | - Tim McDonald
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; RAND Corporation, Santa Monica, CA, USA
| | - Merike Blofield
- Department of Political Science, University of Hamburg, Hamburg, Germany
| | - Leticia Avila Burgos
- Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública de México, Cuernavaca, México
| | - Octavio Gómez-Dantés
- Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública de México, Cuernavaca, México
| | - Pablo Kuri
- Proyecto OriGen, Instituto Tecnológico y de Estudios Superiores de Monterrey, Nuevo León, México
| | - Adolfo Martinez-Valle
- Centro de Investigación en Políticas Población y Salud, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | | | - Renu Sara Nargund
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; Vilcek Institute for Biomedical Sciences, New York University, New York, NY, USA
| | - Thalia Porteny
- Department of Health Policy and Management, Columbia University, New York, NY, USA
| | - Sandra Gabriela Sosa-Rubí
- Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública de México, Cuernavaca, México
| | - Edson Serván-Mori
- Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública de México, Cuernavaca, México
| | - Maya Symes
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Julio Frenk
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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Arreola-Ornelas H, Merino-Juárez GA, Contreras-Loya D, Méndez-Carniado O, Morales-Juárez L, Bernal-Serrano D, Arizmendi-Barrera KA, Vargas-Martínez C, Razo C, Knaul FM, Gakidou E, Dai X, Cogen R, Ahmad NS. Burden of overweight and obesity in Mexico from 1990 to 2021. GAC MED MEX 2023; 159:543-556. [PMID: 38386886 DOI: 10.24875/gmm.m24000836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 10/31/2023] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Overweight and obesity (OW/OB) represent a serious challenge in Mexico, with effects on health, society and economy. Demographic, epidemiological, nutritional, social and economic factors have exacerbated this problem. OBJECTIVE To analyze mortality and years of healthy life lost in Mexico due to OW/OB in the 1990-2021 period. MATERIAL AND METHODS The Global Burden of Disease and Risk Factors 2021 study was used to analyze data on elevated body mass index (BMI) as a risk factor and its evolution in Mexico. RESULTS In 2021, 118 thousand deaths attributable to high BMI were recorded, which accounted for 10.6% of total deaths and more than 4.2 million disability-adjusted life years lost. CONCLUSIONS The obesogenic environment, influenced by social determinants of health, has had a significant impact on mortality, burden of disease, and economic costs. Addressing OW/OB requires multisector interventions to strengthen the Mexican health system.
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Affiliation(s)
- Héctor Arreola-Ornelas
- Public Policies Unit, Institute of Research on Obesity, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
- Fundación Mexicana para la Salud, A. C., Mexico City, Mexico
| | - Gustavo A Merino-Juárez
- Public Policies Unit, Institute of Research on Obesity, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
- School of Government and Public Transformation, Tecnológico de Monterrey, Mexico City, Mexico
| | - David Contreras-Loya
- Public Policies Unit, Institute of Research on Obesity, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
- School of Government and Public Transformation, Tecnológico de Monterrey, Mexico City, Mexico
| | | | - Linda Morales-Juárez
- Public Policies Unit, Institute of Research on Obesity, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
- School of Government and Public Transformation, Tecnológico de Monterrey, Mexico City, Mexico
| | - Daniel Bernal-Serrano
- School of Government and Public Transformation, Tecnológico de Monterrey, Mexico City, Mexico
| | - Klaudia A Arizmendi-Barrera
- Public Policies Unit, Institute of Research on Obesity, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
- School of Government and Public Transformation, Tecnológico de Monterrey, Mexico City, Mexico
| | - Carolina Vargas-Martínez
- Public Policies Unit, Institute of Research on Obesity, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
- School of Government and Public Transformation, Tecnológico de Monterrey, Mexico City, Mexico
| | - Christian Razo
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Felicia M Knaul
- Tómatelo a Pecho, A. C., Mexico City, Mexico
- Fundación Mexicana para la Salud, A. C., Mexico City, Mexico
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, Florida, United States of America
| | - Emmanuela Gakidou
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Xiaochen Dai
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Rebecca Cogen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Noah S Ahmad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
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Knaul FM, Arreola-Ornelas H, Rodriguez NM, Méndez-Carniado O, Kwete XJ, Puentes-Rosas E, Bhadelia A. Avoidable Mortality: The Core of the Global Cancer Divide. J Glob Oncol 2019; 4:1-12. [PMID: 30096010 PMCID: PMC6223530 DOI: 10.1200/jgo.17.00190] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose The incidence of infection-associated cancers and lethality of cancers amenable to treatment are closely correlated with the income of countries. We analyzed a core part of this global cancer divide—the distribution of premature mortality across country income groups and cancers—applying novel approaches to measure avoidable mortality and identify priorities for public policy. Methods We analyzed avoidable cancer mortality using set lower- and upper-bound age limits of 65 and 75 years (empirical approach), applying cancer-specific and country income group–specific ages of death (feasibility approach), and applying cancer-specific ages of death of high-income countries to all low- and middle-income countries (LMICs; social justice approach). We applied these methods to 2015 mortality data on 16 cancers for which prevention is possible and/or treatment is likely to result in cure or significant increase in life expectancy. Results At least 30% and as much as 50% of cancer deaths are premature, corresponding to between 2.6 and 4.3 million deaths each year, and 70% to 80% are concentrated in LMICs. Using the feasibility approach, 36% of cancer deaths are avoidable; with the social justice approach, 45% of cancer deaths are avoidable. Five cancer types—breast, colorectal, lung, liver, and stomach—account for almost 75% of avoidable cancer deaths in LMICs and worldwide. Conclusion Each year, millions of premature cancer deaths could be avoided with interventions focused on four priority areas: infection-associated cancers, lifestyle and risk factors, women’s cancers, and children’s cancers. Our analysis of the global burden and the specific cancer types associated with avoidable cancer mortality suggests significant opportunities for health systems to redress the inequity of the global cancer divide.
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Affiliation(s)
- Felicia Marie Knaul
- Felicia Marie Knaul, Sylvester Comprehensive Cancer Center at the University of Miami; Felicia Marie Knaul and Natalia M. Rodriguez, University of Miami Institute for Advanced Study of the Americas; Hector Arreola-Ornelas, Afsan Bhadelia, and Xiaoxiao Jiang Kwete, University of Miami, Miami, FL; Felicia Marie Knaul, Hector Arreola-Ornelas, and Oscar Méndez-Carniado, Fundación Mexicana para la Salud, A.C.; Felicia Marie Knaul and Hector Arreola-Ornelas, Tómateloa a Pecho A.C., Mexico City; and Esteban Puentes-Rosas, Sanofi Pasteur, LATAM Region, Mexico
| | - Hector Arreola-Ornelas
- Felicia Marie Knaul, Sylvester Comprehensive Cancer Center at the University of Miami; Felicia Marie Knaul and Natalia M. Rodriguez, University of Miami Institute for Advanced Study of the Americas; Hector Arreola-Ornelas, Afsan Bhadelia, and Xiaoxiao Jiang Kwete, University of Miami, Miami, FL; Felicia Marie Knaul, Hector Arreola-Ornelas, and Oscar Méndez-Carniado, Fundación Mexicana para la Salud, A.C.; Felicia Marie Knaul and Hector Arreola-Ornelas, Tómateloa a Pecho A.C., Mexico City; and Esteban Puentes-Rosas, Sanofi Pasteur, LATAM Region, Mexico
| | - Natalia M Rodriguez
- Felicia Marie Knaul, Sylvester Comprehensive Cancer Center at the University of Miami; Felicia Marie Knaul and Natalia M. Rodriguez, University of Miami Institute for Advanced Study of the Americas; Hector Arreola-Ornelas, Afsan Bhadelia, and Xiaoxiao Jiang Kwete, University of Miami, Miami, FL; Felicia Marie Knaul, Hector Arreola-Ornelas, and Oscar Méndez-Carniado, Fundación Mexicana para la Salud, A.C.; Felicia Marie Knaul and Hector Arreola-Ornelas, Tómateloa a Pecho A.C., Mexico City; and Esteban Puentes-Rosas, Sanofi Pasteur, LATAM Region, Mexico
| | - Oscar Méndez-Carniado
- Felicia Marie Knaul, Sylvester Comprehensive Cancer Center at the University of Miami; Felicia Marie Knaul and Natalia M. Rodriguez, University of Miami Institute for Advanced Study of the Americas; Hector Arreola-Ornelas, Afsan Bhadelia, and Xiaoxiao Jiang Kwete, University of Miami, Miami, FL; Felicia Marie Knaul, Hector Arreola-Ornelas, and Oscar Méndez-Carniado, Fundación Mexicana para la Salud, A.C.; Felicia Marie Knaul and Hector Arreola-Ornelas, Tómateloa a Pecho A.C., Mexico City; and Esteban Puentes-Rosas, Sanofi Pasteur, LATAM Region, Mexico
| | - Xiaoxiao Jiang Kwete
- Felicia Marie Knaul, Sylvester Comprehensive Cancer Center at the University of Miami; Felicia Marie Knaul and Natalia M. Rodriguez, University of Miami Institute for Advanced Study of the Americas; Hector Arreola-Ornelas, Afsan Bhadelia, and Xiaoxiao Jiang Kwete, University of Miami, Miami, FL; Felicia Marie Knaul, Hector Arreola-Ornelas, and Oscar Méndez-Carniado, Fundación Mexicana para la Salud, A.C.; Felicia Marie Knaul and Hector Arreola-Ornelas, Tómateloa a Pecho A.C., Mexico City; and Esteban Puentes-Rosas, Sanofi Pasteur, LATAM Region, Mexico
| | - Esteban Puentes-Rosas
- Felicia Marie Knaul, Sylvester Comprehensive Cancer Center at the University of Miami; Felicia Marie Knaul and Natalia M. Rodriguez, University of Miami Institute for Advanced Study of the Americas; Hector Arreola-Ornelas, Afsan Bhadelia, and Xiaoxiao Jiang Kwete, University of Miami, Miami, FL; Felicia Marie Knaul, Hector Arreola-Ornelas, and Oscar Méndez-Carniado, Fundación Mexicana para la Salud, A.C.; Felicia Marie Knaul and Hector Arreola-Ornelas, Tómateloa a Pecho A.C., Mexico City; and Esteban Puentes-Rosas, Sanofi Pasteur, LATAM Region, Mexico
| | - Afsan Bhadelia
- Felicia Marie Knaul, Sylvester Comprehensive Cancer Center at the University of Miami; Felicia Marie Knaul and Natalia M. Rodriguez, University of Miami Institute for Advanced Study of the Americas; Hector Arreola-Ornelas, Afsan Bhadelia, and Xiaoxiao Jiang Kwete, University of Miami, Miami, FL; Felicia Marie Knaul, Hector Arreola-Ornelas, and Oscar Méndez-Carniado, Fundación Mexicana para la Salud, A.C.; Felicia Marie Knaul and Hector Arreola-Ornelas, Tómateloa a Pecho A.C., Mexico City; and Esteban Puentes-Rosas, Sanofi Pasteur, LATAM Region, Mexico
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Knaul FM, Arreola-Ornelas H, Wong R, Lugo-Palacios DG, Méndez-Carniado O. Efecto del Seguro Popular de Salud sobre los gastos catastróficos y empobrecedores en México, 2004-2012. ACTA ACUST UNITED AC 2018; 60:130-140. [DOI: 10.21149/9064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 01/25/2018] [Indexed: 11/06/2022]
Abstract
Objetivos. Determinar el impacto del Seguro Popular (SPS) en los gastos catastróficos y empobrecedores de los hogares y la protección financiera del sistema de salud en México. Material y métodos. Se aplicó el método de pareo por puntaje de propensión sobre la afiliación al SPS y se determinó el efecto atribuible en el gasto en salud. Se hizo uso de la Encuesta Nacional de Ingresos y Gastos de los Hogares (ENIGH) de 2004 a 2012, del Instituto Nacional de Estadística y Geografía. Resultados. El SPS tiene un efecto significativo reductor en la probabilidad de sufrir gastos empobrecedores. En lo que respecta a los gastos catastróficos hubo reducción sin ser significativa entre grupos. Conclusión. Este estudio demuestra el efecto que el SPS, y en particular el aseguramiento en salud, tiene como un instrumento de protección financiera. Para futuros estudios se propone analizar la persistencia del alto porcentaje del gasto de bolsillo aprovechando series de tiempo más largas de la ENIGH.
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Knaul FM, Arreola-Ornelas H, Méndez-Carniado O, Bryson-Cahn C, Barofsky J, Maguire R, Miranda M, Sesma S. Las evidencias benefician al sistema de salud: reforma para remediar el gasto catastrófico y empobrecedor en salud en México. Salud pública Méx 2007. [DOI: 10.1590/s0036-36342007000700010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Knaul FM, Arreola-Ornelas H, Méndez-Carniado O, Bryson-Cahn C, Barofsky J, Maguire R, Miranda M, Sesma S. [Evidence is good for your health system: policy reform to remedy catastrophic and impoverishing health spending in Mexico]. Salud Publica Mex 2007; 49 Suppl 1:S70-87. [PMID: 17469400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Abstract
Absence of financial protection in health is a recently diagnosed "disease" of health systems. The most obvious symptom is that families face economic ruin and poverty as a consequence of financing their health care. Mexico was one of the first countries to diagnose the problem, attribute it to lack of financial protection, and propose systemic therapy through health reform. In this article we assess how Mexico turned evidence on catastrophic and impoverishing health spending into a catalyst for institutional renovation through the reform that created Seguro Popular de Salud (Popular Health Insurance). We present 15-year trends on the evolution of catastrophic and impoverishing health spending, including evidence on how the situation is improving. The results of the Mexican experience suggest an important role for the organisation and financing of the health system in reducing impoverishment and protecting households during periods of individual and collective financial crisis.
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Affiliation(s)
- Felicia Marie Knaul
- Fundación Mexicana para la Salud, Periférico Sur No. 4809, CP 14610, México, DF.
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Knaul FM, Arreola-Ornelas H, Méndez-Carniado O, Bryson-Cahn C, Barofsky J, Maguire R, Miranda M, Sesma S. Evidence is good for your health system: policy reform to remedy catastrophic and impoverishing health spending in Mexico. Lancet 2006; 368:1828-41. [PMID: 17113432 DOI: 10.1016/s0140-6736(06)69565-2] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Absence of financial protection in health is a recently diagnosed "disease" of health systems. The most obvious symptom is that families face economic ruin and poverty as a consequence of financing their health care. Mexico was one of the first countries to diagnose the problem, attribute it to lack of financial protection, and propose systemic therapy through health reform. In this article we assess how Mexico turned evidence on catastrophic and impoverishing health spending into a catalyst for institutional renovation through the reform that created Seguro Popular (Popular Health Insurance). We present 15-year trends on the evolution of catastrophic and impoverishing health spending, including evidence on how the situation is improving. The results of the Mexican experience suggest an important role for the organisation and financing of the health system in reducing impoverishment and protecting households during periods of individual and collective financial crisis.
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Affiliation(s)
- Felicia Marie Knaul
- Mexican Health Foundation, Periferico Sur 4809, Col Arenal Tepepan, 14610 Mexico City, Mexico.
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