An article written by Professor Gary King, and his collaborators from Harvard University, Cambridge, MA, USA, published Online First and in an upcoming edition of The Lancet, discuss the findings of an evaluation made at random of Seguro Popular, Mexico’s newly-introduced pilot universal health insurance system. Results show that household-crippling* expenditure has declined for poor families, as well as the general population.
Reducing catastrophic* health expenditure by providing social health protection is the goal of Seguro Popular. The plan includes health policies and priorities with entitlements for affiliated families, as well as specific benefit packages coverage for 266 typical health interventions and 312 medications. More funds will also be given to State Health Ministries in proportion to the number of families affiliated to Seguro Popular, federal funds for personal and non-personal health services, and the creation of special federal funds for catastrophic medical expenditures linked to certain diseases is also included as part of the plan.
Researchers allocated treatment at random within seventy four matched pairs of communities, representing 118,569 households in seven Mexican states, in what has been the largest randomized health policy trial ever conducted. In fifty of these pairs, the outcomes of two surveys were measured: a baseline survey conducted from August to September 2005 and a follow-up survey ten months later, from July to August 2006.
The participants of Oportunidades** an anti-poverty program, were enrolled automatically by the State and informed them of their new rights of the Seguro Popular. This enrollment involved support and encouragement to join a health insurance program at no cost for the poor, as well as upgraded medical facilities and services. Funds to improve health facilities and to supply medications for services in treated communities were provided to participant states. Communities in the control group did not receive any additional funds.
Seguro Popular decreased the proportion of households with catastrophic expenditures by twenty-three percent, amongst all survey responders. The reduction among compliers*** was fifty-five percent. Across all responders, this translated in a drop in health spending of US$31 (426 pesos). Among compliers, the average reduction in health spending was US$66 (915 pesos). Against expectations and prior study, there were no changes in medication spending, health outcomes, or use of health care.
Innovative research designs and statistical methods in the study achieved the assessment of a large public policy program in a much lower cost approach than before. As the writers explain, using standard procedures “would have increased our standard errors by as much as 600%” and it would have been necessary to randomise many more communities to generate results with the same margin of error. Randomised public policy assessments are likely to be unsuccessful because of political and other interventions. The article introduces reliable procedures “designed to survive these types of interventions.” As a result, it is possible to submit other public policies in Mexico and elsewhere to scientific evaluation and evidence-based standards.
The authors write in conclusion: “That Mexico may now have a validated architecture for delivering health services to the poor seems to be the most surprising and encouraging result from this experiment. We found that the stewardship of Seguro Popular has been successful in reducing overall catastrophic and out-of-pocket expenditures for inpatient and outpatient medical procedures, especially in the poorest individuals.”
“Programme resources reached the poor. However, the programme did not show some other effects, possibly due to the short duration of treatment (10 months). Although Seguro Popular seems to be successful at this early stage, further experiments and follow-up studies, with longer assessment periods, are needed to ascertain the long-term effects of the programme.”
Professor Cesar G Victora, Universidade Federal de Pelotas, Brazil (CGV) and Johns Hopkins University, Baltimore, MD, USA, and Dr David Peters, Johns Hopkins University, Baltimore, MD, USA, say in a supplementary comment: “We welcome this contribution to the policy debate. Not so much because the study provides definitive answers, but because it raises the many challenges of doing real-life effectiveness evaluations, and because it proposes innovative approaches that might-or might not-prove to be useful.”
“Rigorous health-systems and policy research is much needed. For example, major experiences in financing health services in Latin America (the tax-based universal health system in Brazil, the Colombia health-system reform, and the Seguro Popular in Mexico) still await rigorous comparison.”
“Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme.”
Gary King, Emmanuela Gakidou, Kosuke Imai, Jason Lakin, Ryan T Moore, Clayton Nall, Nirmala Ravishankar, Manett Vargas, Martha María Téllez-Rojo, Juan Eugenio Hernández Ávila, Mauricio Hernández Ávila, Héctor Hernández Llamas
The Lancet DOI:10.1016/S0140-6736(09)60239-7
*Household-crippling/catastrophic expenditures are defined on the basis of the share of a household’s spending, after a minimal food budget that is allocated to health care. If a household’s health spending exceeded 30% of the capacity to pay, the household was regarded as suffering catastrophic health expenditures.
** Oportunidades is a government social assistance program in Mexico founded in 2002, designed to target poverty by providing cash payments to families in exchange for regular school attendance, health clinic visits, and nutritional support.
***A ‘complier’ is a person who signs up for Seguro Popular when in a treatment community and doesn’t sign up if they happen to be in a control community.
Written by Stephanie Brunner (B.A.)