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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 Héctor Arreola Ornelas and Oscar Méndez,Mexican Health Foundation

Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

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Page 1: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

A Diagonal Approach to

analyzing UHC: Cancer and the

Mexico Seguro Popular

Felicia Marie Knaul,Director, Harvard Global

Equity Initiativeand Mexican Health

FoundationAnd

Héctor Arreola Ornelas and Oscar Méndez,Mexican Health

Foundation

Page 2: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711
Page 3: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

NEW CHALLENGE DISEASES

(NCD)Chronicity

+ Polarized and protacted epidemiological transtion

Page 4: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

#2 cause of death in wealthy countries #3 in upper middle-income#4 in lower middle-income and # 8 in low-income countries

For children & adolescents 5-14cancer is

Page 5: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

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).

Page 6: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

Adults

BreastCervix Prostate

Testis

HL

N HL

Leukaemia

All cancers

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

Children

LOW INCOME

HIGH INCOME

Survival inequality gap

LOW INCOME

HIGH INCOME

100%

The opportunity to survive (M/I)should not be defined by income.

Yet it is.

Page 7: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

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.

Page 8: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

Health system functions and diagonal integration

Diagonal, synergistic:

verticaland

horizontal integration

Disease Specific: vertical

integration, horizontal

segmentation

Generalized: vertical

segmentation, horizontalintegration

Atomized:vertical

and horizontal

segmentation

Stewardship

Financing Revenue collection Fund Pooling Purchasing

Provision

Revenue generation

FUC

TIO

NS

Adapted from Murray and Frenk; WHO Bulletin 2000

Disease 1Disease 2Disease 3

Page 9: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

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 that include horizontal and vertical coverage

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

5. Developing effective health services research and indicators

Diagonal strategies for NCD

Page 10: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

A Diagonal Approach toFinancial Protection

Vert

ical

Cov

erag

e: N

umbe

r of

Dis

ease

s an

d In

terv

entio

ns

The Diagonal Approach

:

Financing (a

nd delivery)

Horizontal Coverage: Number of Beneficiaries

Prevents impoverishm

ent and catastrophic expenditures:Pre-paid, subsidized, public

Page 11: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

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

Page 12: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

MEXICO: SEGURO POPULAR

Page 13: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

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

0

40

1979 2008

1-4 5-14

Malignant tumors

40

5%16%

Respiratory infectionsInfectious and parasitic diseases

%

1979 20080

Page 14: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

Source: Lozano, Knaul, Gómez-Dantés, Arreola-Ornelas y Méndez, 2008, Tendencias en la mortalidad por cáncer de mama en México, 1979-2007. FUNSALUD, Documento de trabajo. Observatorio de la Salud, con base en datos de la OMS y la Secretaría de Salud de México.

Mortality from breast and cervical cancer in Mexico1955-2008: less death from cervical

#2 cause of death, women 30-54

Rate for100,000 women adjusted for age

0

4

8

12

16

1955

1965

1975

1985

1995

2005

CérvixMama

1979

0

4

8

12

16

1980 1985 1990 1995 2000 2005

Distrito FederalMR x 100,000 women

2008

0

Oaxaca

5

10

15

20

25 MR x 100,000 women

19791980 1985 1990 1995 2000 2005

2008

Page 15: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

Key Financing Elementsof 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 cost-effectiveness and burden of disease – expands over time

4. Fund for Catastrophic Illness covering specific interventions for specific diseases – expands over time

Page 16: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

# of covered services: personal

Source: Comisión Nacional de Protección Social en Salud, 2010

104 113146

249262 266

XX??

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

Households affiliated to Seguro Popular

2006

2004

~100%

2012

2005

~17.

2 m

illon

es d

e fa

mili

as

3%

9%

30%

20%

42%

1.5 3.5

mill

ones

5.1

mill

ones

7.3

mill

ones

53%

0.6

9.1

mill

ones

2007

2008

2003

61%10

.5 m

illon

es20

09

85%

14.7

mill

ones

2010

2006

2004

2012

2005

2007

2008

2003

2009

2010

275

+

2011

282

Page 17: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

Incorporation of Diseases in the Catastrophic Fund

Disease Category Initiation of CoverageCervical Cancer 2004

HIV-AIDS 2005

Intensive neonatal care 2005

Cataracts 2006

Childhood cancers 2006 – LLA 2008 - All cancer

Bone marrow transplants 2006

Transplants for congenital and acquired defects (Health Insurance for a New Generation)

All children born after December 2006

Breast Cancer 2007

Acute myocardial infarction, non-Hodgkin’s lymphona, lysosomal diseases, bone marrow transplant, corneal transplant and testicular tumor

2011

Page 18: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

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, 30-month survival has increased from approximately 30% to almost 70% and adherence to treatment from 70% to 95%. (Pérez-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)

Page 19: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

Beneficiaries: Population covered

Ben

efits

: cov

ered

inte

rven

tions

Horizontal and vertical financial protection strategies: Seguro Popular in Mexico

Catastrophic IllnessACCELERATED VERTICAL COVERAGE: Ex: breast cancer,

AIDS

Package of essential personal

services

Community Health Services

Poor Rich

Health insurance for a new generation

Page 20: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

Barrier: Lack of financialprotection for early detection.

Source: Groot et al, 2006. The Breast Journal

• 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.

Page 21: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

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.

Page 22: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

Juanita

Page 23: Coverage and Financial Protecction of Cancer in Mexico: Seguro Popular 130711

A Diagonal Approach to

analyzing UHC: Cancer and the

Mexico Seguro Popular

Felicia Marie Knaul,Director, Harvard Global

Equity Initiativeand Mexican Health

FoundationAnd

Héctor Arreola Ornelas and Oscar Méndez,Mexican Health

Foundation