The parallel is unmistakable. Before the reforms that brought in health coverage for all, Mexico had 52 million residents who were not covered. We here in the big rich neighbor to the north have about the same number of people — roughly 48 million in a recent count — who lack health insurance. Mexico has shown over the last decade that it is possible to cover everyone. We — well, you know.
Just out in the medical journal The Lancet is a sweeping look at how Mexico brought in universal coverage, and the health benefits the country reaped, including significant drops in the death rates among babies and children and mothers. A Lancet editorial concludes that Mexico has demonstrated that universal coverage, “as well as being ethically the right thing to do, is the smart thing to do.”
I’m afraid my first question to the Lancet paper’s lead author came out a little plaintive: Why? Why could Mexico do it, reach universal coverage, while America seemingly can’t? Felicia Knaul is the director of the Harvard Global Equity Initiative and a senior economist for the Mexican Health Foundation. Her reply, by phone from Mexico City:
“First let me just say, i think the United States is moving forward in the right direction and we just have to keep that forward movement going, in all sorts of senses. I can tell you why Mexico did it; I can’t tell you why the United States didn’t until now.
This country chose to believe in the fact that people’s access to health care should not be defined by where they work but rather by their need for health care. Number two, in addition to this being a right, a social entitlement, it was good for human development, for social development, for economic development, to make sure people were not going bankrupt and suffering impoverishment and catastrophe from trying to figure out how to manage the cost of health care.”
Was it, I asked, a convergence of historical forces?
Several forces did converge, she said. “One very important one was evidence and data. This is a country that invested for decades in having data that allowed us to trace, for example, how families were spending on health.”
“Number two is a strong civil society that had been trained and was working in an evidence-based way that provided important impetus for the reform. It’s important to have those entities that can push forward and defend reform.”
Also, she noted, there had been a lot of investment in the training of people who could run a reform.
And finally, “I believe very strongly that we’ve had some leaders who believe in the good of the cause and worked toward that. I’m very biased because I’m married to one of them. I’m married to Julio Frenk [current dean of the Harvard School of Public Health, Mexican minister of health from 2000 to 2006]. But in my time here, I’ve met an incredible group of people who are committed at the highest levels to making sure that people don’t have to be impoverished to pay for their health care.
What would she highlight as the most impressive benefits of universal coverage?
“I think number one is the reduction in the proportion of families that are suffering catastrophic impoverishment from health care spending. There are also some very impressive numbers on improvement in effective coverage” — coverage of vaccinations, and cervical cancer screening, and more.
“I think the other incredibly impressive piece here is how the package of covered services and interventions expanded,” and that’s despite the triple whammy of H1N1 flu, violence and economic crisis that hit the country in recent years. It’s not just that health care is covered, she said, it’s that it’s covered well.
There are already some cases, she said — only anecdotal, but documented — “of Mexicans legally resident and working in the United States who came back to Mexico because they were diagnosed with a catastrophic illness, and their insurance wouldn’t cover them, so they came back to Mexico.”
From the press release:
Mexico has achieved universal health coverage in less than ten years, with more than 50 million previously uninsured Mexicans enrolling on a public medical insurance scheme since 2004.
Writing in The Lancet, a group of public health experts – including Julio Frenk, Dean of the Harvard School of Public Health and former Minister of Health of Mexico – highlight the progress that Mexico has made towards achieving comprehensive health coverage, as well discussing some of the healthcare challenges that remain for the country, which has a population of more than 100 million.
According to current Minister of Health of Mexico Salomón Chertorivski, a co-author on the report, “Mexico devised and implemented a reform and then demonstrated, with evidence, how a large, middle-income country can transform its health system and successfully achieve universal health coverage in one decade”.
Until 2004, adequate medical insurance was only available to Mexican citizens who could access social security schemes through their employment, or via expensive private insurance. Those people who were not in regular salaried employment and could not afford private health insurance were unable to access adequate health care, unless they were able to meet significant out-of-pocket expenses.
However, in 2003, the Mexican Congress approved reforms to Mexico’s health legislation, establishing the Sistema de Protección Social en Salud (‘System of Social Protection in Health’, or SSPH). These reforms enabled the introduction of Seguro Popular (‘popular health insurance’), an ambitious government-funded scheme which aimed to ensure that even the poorest Mexican citizens have access to an adequate standard of health care – from treatment for the most pressing chronic and catastrophic illnesses, to preventative healthcare such as vaccination and diabetes screening.
According to lead author Professor Felicia Knaul, of the Mexican Health Foundation and Director of the Harvard Global Equity Initiative, “In 2012, the 9th year of implementation, the country reached a major milestone in universal coverage. As of April, 52.6 million Mexicans, previously uninsured, were incorporated into the SSPH and the budgetary allocation for universal coverage was achieved. Every Mexican, regardless of their socio-economic situation, has access to the financial protection in health that shields them from facing the terrible choice between impoverishment and suffering or even death.”
According to Dr Julio Frenk, architect of the original reform, “The quest for universal health coverage in Mexico has produced remarkable progress and many valuable lessons. It shows the value of sound evidence in fuelling a virtuous upward spiral of policy formulation, implementation, evaluation and back to the formulation of new and improved policies on the basis of lessons learned. This experience is relevant to countries of both high and lower income.”
Examining the evidence for the effect that Seguro Popular has had on the nation’s health, the authors point out that it may be too soon to say whether specific successes in Mexican health care are due to the successful implementation of universal financial protection in health, but health indicators have steadily increased in the nine years since Seguro Popular was introduced. Coverage of several key interventions rose significantly since the implementation of the reform. Antenatal care increased 14% to cover more than 81% of women, treatment of acute respiratory infections in children under age 5 increased almost 6%, and cervical cancer screening in women 25 to 64 more than 7% to cover almost half of the population in addition to introducing HPV vaccination in 2011.
Significant challenges remain – there are still disparities between the quality of healthcare in different states due to the way funding is distributed, and ensuring that populations in remote rural areas have effective access to healthcare are just two ongoing difficulties. However, according to Professor Knaul, “Evidence indicates that Seguro Popular is improving access to health services and reducing the prevalence of catastrophic and impoverishing health bills for the poor.”