A Diagonal Approach to analyzing UHC: Cancer and the Mexico

Seguro Popular
Felicia Marie Knaul, Director, Harvard Global Equity Initiative and Mexican Health Foundation
And

Hctor Arreola Ornelas and Oscar Mndez,Mexican Health Foundation

NEW CHALLENGE DISEASES (NCD)

Chronicity + Polarized and protacted epidemiological transtion

For children & adolescents 5-14 cancer is #2 cause of death in wealthy countries #3 in upper middle-income #4 in lower middle-income and # 8 in low-income countries

In developing regions, breast cancer

Most common cancer in developed and developing regions Most frequent cause of cancer-related death in developing and developed regions A leading cause if death especially for young women 268,000 of the 458,000 deaths per year are in LIMCs: 58% 4.4 million women alive (diagnosed): how many in developing regions?
(Globocan, 2010; Boyle y Levin, 2008; Beaulieu, Bloom, y Bloom, 2009).

The opportunity to survive (M/I) should not be defined by income. Yet it is.
Children Adults

100%

Survival inequality gap

Leukaemia
Cervix Prostate HL N HL

All cancers

Breast Testis

LOW INCOME

HIGH INCOME

LOW INCOME

HIGH INCOME

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

Why a Diagonal Approach to Health System Strengthening and UHC

Rather than focusing on disease-specific vertical programs or only horizontally on system constraints, harness synergies that provide opportunity to tackle disease-specific priorities while addressing systemic gaps. Optimize available resources so that the whole is more than the sum of the parts Bridge the divides as patients suffer diseases over a lifetime, most of it chronic
Sepulveda et al., 2006.

Health system functions and diagonal integration

Diagonal, synergistic: vertical and horizontal integration Disease Specific: vertical integration, horizontal segmentation Generalized: vertical segmentation, horizontal integration Atomized: vertical and horizontal segmentation

Stewardship

FUCTIONS

Financing
Revenue collection Fund Pooling Purchasing

Provision Revenue generation

Disease 1 Disease 2

Adapted from Murray and Frenk; WHO Bulletin 2000

Disease 3

Diagonal strategies for NCD

1. Harness platforms: Integrate disease prevention, screening and survivorship into MCH, SRH, HIV/AIDs, social welfare/anti-poverty programs 2. Delivery: Catalyze, employ and deploy community health workers and expert patients 3. Financing: social protection strategies include horizontal and vertical coverage that

4. Stewardship: Improve regulatory frameworks to remove non-price barriers to pain control

5. Developing effective health services research and indicators

A Diagonal Approach to Financial Protection

Prevents impoverishment and catastrophic expenditures: Pre-paid, subsidized, public

Horizontal Coverage: Number of Beneficiaries

UHC: intersection between coverage and financial protection in the face of chronicity

Stages lifecycle of interventions for a chronic illness

Primary prevention Secondary prevention (early detection) Diagnosis Treatment Survivorship care Palliative care

Depth of the package = effective coverage + effective financial protection

MEXICO: SEGURO POPULAR

Distribution of mortality, 1-15 years Mexico, 1979-2008

40

1-4

40

5-14
16%

1979

2008

5% 0

1979

2008

Malignant tumors Infectious and parasitic diseases Respiratory infections

Mortality from breast and cervical cancer in Mexico1955-2008: less death from cervical
16
Rate for100,000 women adjusted for age
25 MR x 100,000 women 20 15 10

Oaxaca

12

5
1979

Crvix Mama
1955 1965 1975 1985 1995 2005

16

MR x 100,000 women

Distrito Federal

12
8 4 0

#2 cause of death, women 30-54

Source: Lozano, Knaul, Gmez-Dants, Arreola-Ornelas y Mndez, 2008, Tendencias en la mortalidad por cncer de mama en Mxico, 1979-2007.
FUNSALUD, Documento de trabajo. Observatorio de la Salud, con base en datos de la OMS y la Secretara de Salud de Mxico.

1979

2008

1980

1985

1990

1995

2000

2005

2008

1980

1985

1990

1995

2000

2005

Key Financing Elements of the 2003 Mexico Reform:

1. Access to publicly-funded, heavily subsidized,
progressive health insurance Seguro Popular- for all families excluded from Social Security

2. Separate budgeting and funds for public health

goods with universal coverage

3. Package of personal health services based on costeffectiveness and burden of disease expands over time

4. Fund for Catastrophic Illness covering specific

interventions for specific diseases expands over time

Increase in population coverage + expansion of package of services w/ increased MOH budget dedicated to SPS
XX??

Households affiliated to Seguro Popular

85% 61%

~100 %

# of covered services: personal

266 282 275

~17.2 millones de familias

53%

249

262

42%
10.5 millones 14.7 millones

30%
7.3 millones

9.1 millones

+
104

146 113

20%
3.5 millones

9% 2004 1.5 3% 2003 0.6

2006 5.1 millones

2005

2007

2008

2009

2010

2012

2003

2004

2005

2006

2007

2008

2009

Source: Comisin Nacional de Proteccin Social en Salud, 2010

2012

2010

2011

Incorporation of Diseases in the Catastrophic Fund

Disease Category
Cervical Cancer HIV-AIDS

Initiation of Coverage
2004 2005

Intensive neonatal care

Cataracts Childhood cancers Bone marrow transplants Transplants for congenital and acquired defects (Health Insurance for a New Generation)

2005
2006 2006 LLA 2008 - All cancer 2006 All children born after December 2006

Breast Cancer
Acute myocardial infarction, non-Hodgkins lymphona, lysosomal diseases, bone marrow transplant, corneal transplant and testicular tumor

2007

2011

Rigorous evaluation
Rigorous evaluation processes have been underway since the SPS was established and the results are encouraging.

The incidence of catastrophic spending has decreased by more than 20% among those who have taken on Seguro Popular, as has overall out of pocket spending especially among the poorest households. (King , Gakidou , Imai et al, 2009) Since the incorporation of childhood cancers into the program in 2006, 30month survival has increased from approximately 30% to almost 70% and adherence to treatment from 70% to 95%. (Prez-Cuevas etal 2010)
Another study of breast cancer begun in 2007, reported an 80% survival rate of 30-months after initiating treatment and an increase in adherence to treatment from 79% to 98%. (Lara Medina et al, 2010) A separate study showed that hypertensive adults insured through Seguro Popular had a significantly higher probability of accessing effective treatment and that this was associated with a greater supply of health professionals (Bleich et al., 2010)

Horizontal and vertical financial protection strategies: Seguro Popular in Mexico

Benefits: covered interventions
Catastrophic Illness ACCELERATED VERTICAL COVERAGE: Ex: breast cancer, AIDS

Package of essential personal services

Health insurance for a new generation
Community Health Services

Poor

Rich

Beneficiaries: Population covered

Barrier: Lack of financial protection for early detection.

Since February 2007, every Mexican woman has the right to full financial protection for the treatment of breast cancer. Yet, early detection is only covered for those already insured, difficult to access and there is a threat of reducing the entitlement and early detection is unaffordable mammography, biopsy and pathology - at the most subsidized level in a public hospital costs more than one month of subsistence income.
Source: Groot et al, 2006. The Breast Journal

Effective financial coverage: breast cancer in Mexico

Primary prevention Secondary prevention (early detection) Diagnosis Treatment Survivorship care Palliative care

Large and exemplary investment in treatment for women and the health system yet a low survival rate. By applying a

diagonal approach, this can and is be remedied.

Juanita

A Diagonal Approach to analyzing UHC: Cancer and the Mexico

Seguro Popular
Felicia Marie Knaul, Director, Harvard Global Equity Initiative and Mexican Health Foundation
And

Hctor Arreola Ornelas and Oscar Mndez,Mexican Health Foundation