Private health expenditures

Role of private sector in the quest for
Health Universal Coverage
The case of three Latin American countries
Felicia Knaul, Gustavo Nigenda,
Rocio Sáenz, Ursula Geidón, Héctor Arreola
Prince Mahidol Conference
Bangkok, January 26, 2012
Coverage
Financing
Health reform
Country characteristics
Costa Rica1
Mexico2
Colombia3
1943
Social Security Fund (CCSS)
1983-1996
Decentralization of health services from
MoH to State MoHs.
1991
National Social Health Insurance
Insurance schemes:
1) contributory
2) subsidized
1998
Reorganization of health services
Cooperatives as Health Care Providers
2003
System of Social Protection in Health
Seguro Popular de Salud for uninsured
population.
CCSS
• Government
• Employers
• Employees
Social Insurance
• Government (federal)
• Employers
• Employees
Cooperatives
• CCSS
Seguro Popular
• Government (federal and state)
• Households
Social insurance
• 86.8% Social Security Fund (CCSS)
– 75% workers, retirees and
dependent
– 11.8% homeless by the State
Social Insurance (2009):
• 39% IMSS
• 9% ISSSTE
• 25% SPSS
• 2% Others
•
15.8% Cooperatives
2003
Ministry of Social Protection
Social Insurance
Contributory regime
• Government
• Employees and Self employees
Subsidized regime
• Government
• Solidarity fund
• Local tax revenues
• Benefits funds
Social insurance (2006)
• 34% Contributory
• 39% Subsidized
SSPH (2009):
• 25% SPS
Private (2010): 1.78%
Sources: (1) (2) (3) The World Bank. Lessons from reforms in low– and middle–income countries. Good Practice in Health Financing. Eds Pablo Gottret, George J.
Schieber, and Hugh R. Waters. Washington 2008
(1) PAHO. La salud de las Américas. Washington 2007
(1) CEPAL. La Reforma de salud de Costa Rica. Nueva York 2005.
(2) Secretaría de Salud. Boletín de Información Estadistica. Tomo III Servicios otorgados y programas sustantivos. México: SSA; 2009.
(2) Instituto Nacional de Estadística y Geografía (INEGI) [internet] Censo de Población y Vivienda 2010. Consulta interactiva de datos.
Available in:
http://www.inegi.org.mx/lib/olap/consulta/general_ver4/MDXQueryDatos.asp?#Regreso&c=27770
Role of private sector in the quest for Health Universal Coverage
THE CASE OF COSTA RICA
Costa Rica: Health Indicators, 1990–2004
Indicator
1990–91 1995–96 2003–04 1990–2004
Gross birth rate
26.4
22.7
17.3Decrease
Infant mortality rate (per 1,000 live births)
14.3
12.5
9.7Decrease
Life expectancy at birth
76.7
76.5
78.6Increase
Men
74.7
74.3
76.4Increase
Women
78.9
78.8
80.9Increase
Maternal mortality rate (per 100,000 live births)
19.8
22
25.3Increase
Children with low birth weight (%)
6.3
7
6.5Increase
Dengue per 100,000 inhabitants
9.5a
109.7
347Increase
Measles per 100,000 inhabitants
103.2
1.4
AIDS per 100,000 inhabitants
2.9
4.7
3.7Increase
Vaccination SRP-measles (% 1 year)
91
88
89Decrease
Vaccination VOP3-poliomyelitis (% 1 year)
92
86
89Decrease
Total population served by water system
n.a.
95.80%
0Decrease
99.00%Increase
Source: Gottret P, Schieber GJ, Waters HR (coed.) Lessons from reforms in low– and middle–income countries. Good practices in health financing.
Washington: The World Bank; 2008.
Note: n.a. = not available.
a. This rate corresponds to 1992–93.
Costa Rica: Health Expenditure
Indicators 1998, 2000, and 2003
Sector
1998
Total health expenditures (US$ millions)
2000
2005
859.85
1,004.62
1,415.00
Health expenditures (% of GDP)
6.1
6.3
7.1
Private health expenditures (% of GDP)
1.3
1.3
1.7
Public health expenditures (% of GDP)
Per capita health expenditures (current
US$)
Public health expenditures (% of total
health expenditure)
Public health expenditure (% of total
government expenditure)
4.8
5
5.4
230
258
327
77.9
79
76
21
21.7
21
25
28
24
51.1
49.6
51.6 a
Private health expenditures (% of
total health expenditure)
Participation of hospitals in public
health expenditures (%)
Source: Gottret P, Schieber GJ, Waters HR (coed.) Lessons from reforms in low– and middle–income countries. Good practices in health
financing. Washington: The World Bank; 2008.
a. This figure is for 2003.
Health Care Reform in Costa Rica
Ministry of Health (MOH)
–
Stewardship role of the system
Social Security Fund (CCSS in Spanish)
Started in 1943/ Reorganization 1998
–
Financer and provider of health services in the country.
–
With capacity to use its own services network or buy services.
–
Launching of a new PHC model based on management
agreements.
–
Policy to strengthen Integral Health Basic Care Team (EBAIS in
Spanish), the CCSS hired general practitioners and primary care
technicians.
Costa Rica Cooperatives as
Health Care Providers
Started in 1988

Introduction of the first health care cooperatives.

Founded by the employees of primary health care clinics

Autonomous, legal entities that assumed responsibility for managing
the facility.

Cooperative assumed full responsibility for maintaining the
transferred equipment and buying new equipment.

Gauri, Cercone and Briceño (2004) showed an average of 9.7 to
33.8 percent more general visits, 27.9 to 56.6 percent more dental
visits, and 28.9 to 100 percent fewer specialist visits than CCSS
clinics
Costa Rica: Primary Health Care Program
Coverage, 1990–2003
Source: Gottret P, Schieber GJ, Waters HR (coed.) Lessons from reforms in low– and middle–income countries. Good practices in health
financing. Washington: The World Bank; 2008.
Costa Rica: Outpatient Consultations per
Inhabitant, by Income Decile, 1998 and 2001
1998
2001
Source: Gottret P, Schieber GJ, Waters HR (coed.) Lessons from reforms in low– and middle–income countries. Good practices in health
financing. Washington: The World Bank; 2008.
Note: Income deciles (Ds) are defined using the 1998 and 2001 Household Surveys.
Costa Rica
Sustainability
Transparency
Participation
Complementation
and modernization
of ethical
framework for
social security
Social
Security
Solidarity
Universality
Equity
Renovation and
strengthening of
the general
principles for
social security
Reconstitution of the social pact with Costa Rican social security
Costa Rica
Equity
Solidarity
FUNDING MODEL
INSURED
POPULATION
Participation
Transparency
Universality
HEALTH CARE
MODEL
Transparency
MANAGEMENT
MODEL
Sustainability
Source: Saenz MR, Acosta M, Muiser J, Bermúdez JL. Sistema de salud de Costa Rica. Salud Pública Méx 2011; 53(2):156-167
Role of private sector in the quest for Health Universal Coverage
THE CASE OF MEXICO
Mexican Health System
Public sector
Insured population
ISSSTE
IMSS
Uninsured population
PEMEX
SEDENA
Structure
SEMAR
STC Metro
SPS
University hospitals
IMSS-Op
MoH
75%
Population
15%
Population
Private sector
Population
with capacity to pay
Hospitals
Alternative
health
care
Private
consultation
10%
Population
NGOs
IMSS. Mexican Social Security Institute. ISSSTE. State’s Employees´ Social Security and Social Services Institute. PEMEX. Mexican Petroleum. SEDENA. Ministry of National Defense.
SEMAR. Ministry of Navy. SCT Metro. Public Transport System. IMSS Oportunidades. Program of the Federal Government, managed by IMSS. MoH. Ministry of Health. NGOs. Non
Governmental Organizations.
Mexican Health System
Public sector
Employe
r
Employee
Federal
Government
State
Government
Households
Financing
SPS
IMSS
SEDENA
SEMAR
PEMEX
STC Metro
University Hosp.
IMSS Op
MoH & SMoH
ISSSTE
Private sector
Employe
r
Households
Private hospitals
NGOs
Alternative Medicine
Private consultation
IMSS. Mexican Social Security Institute. ISSSTE. State’s Employees´ Social Security and Social Services Institute. PEMEX. Mexican Petroleum. SEDENA. Ministry of National Defense. SEMAR. Ministry of Navy. SCT Metro.
Public Transport System. IMSS Oportunidades. Program of the Federal Government, managed by IMSS. MoH. Ministry of Health. NGOs. Non Governmental Organizations. SMoH. State Ministries of Health
Mexico indicators
Key issues

Financing (2009)1:










%
%
US$
%
%
%
%
%
Public domain in the service
Private health facilities (% of total) (2010)
11.23
%
Insurance (2009) 2:





Source:
47.8
92.3
514.8
3.3
48.3
11.9
3.1
6.5
Provision:


Out-of-pocket health expenditure (% of total expenditure on health)
Out-of-pocket health expenditure (% of private expenditure on health)
Health expenditure per capita (current US$)
Private health expenditure (% of GDP)
Public health expenditure (% of total health expenditure)
Public health expenditure (% of government expenditure)
Public health expenditure(% of GDP)
Total health expenditure (% of GDP)
Private institutions3
IMSS
ISSSTE
SPSS
Pemex, Sedena, State services
1.78%
39%
9%
25%
2%
1. The World Bank [Internet] Data Indicators. Available in: http://data.worldbank.org/country/mexico Consulted Jan 2012
2. Secretaría de Salud. Boletín de Información Estadistica. Tomo III Servicios otorgados y programas sustantivos. México: SSA; 2009.
3. Instituto Nacional de Estadística y Geografía (INEGI) [internet] Censo de Población y Vivienda 2010. Consulta interactiva de datos.
Available in:
http://www.inegi.org.mx/lib/olap/consulta/general_ver4/MDXQueryDatos.asp?#Regreso&c=27770
Expenditure in reproductive health and gender
equity by financing agent. Mexico, 2009
Non-profit institutions serving
households (NGOs) 0.2%
Direct payments by households
27.0%
Private insurance companies
6.0%
ISSSTE 3.5%
Financing agent
IMSS-Op
IMSS-Op
6.4%
6.4%
System of Social Protection
in Health 7.7%
MoH and State MoH
14.2%
%
MoH and State MoH
6 255 737
14.2
System of Social Protection in
Health
3 387 607
7.7
IMSS-Op
2 832 751
6.4
15 404 300
35
ISSSTE
1 525 981
3.5
Empresas de seguros privadas
2 661 463
6
Pagos directos de los hogares
11 861 375
27
83 282
0.2
IMSS
IMSS
35.0%
Expenditure
(thousands
Mexican pesos)
Non-profit institutions serving
households (NGOs)
Total expenditure on reproductive
health
44 012 495
* The total health expenditure in 2009 ascended to 762 335 201.6 thousand pesos.
Public expenditure was 276.7 367 898 and private 394 436 924.9 thousand pesos.
‡ Gross domestic product in 2009 ascended to 11,888,054,013 thousand pesos at
current prices.
Source: Ávila-Burgos L, Montañez-Hernández JC, Cahuana-Hurtado L, Aracena-Genao Belkis. Cuentas en salud reproductiva y equidad de género.
Estimación 2009 y comparativo 2003-2009. México: Instituto Nacional de Salud Pública; 2011.
Mexico: Healthcare infrastructure and
resources 2007
Personnel
Facilities
Public 1
Facilities
Outpatients
care centers 3
Hospitals
Beds
Consultancy
rooms
20 664
19 495
3 140
NA
1 169
3 140
80 066
42 744
57 338
Public 1
Private 2
13 130
Physicians 4
SSA
Private 2
152 566
68 535
Outpatients care
centers
NA
28 886
NA
Hospitals
NA
39 649
NA
208 612
95 343
Outpatients care
centers
NA
29 170
NA
Hospitals
NA
66 173
NA
Nurses 5
64 754
39 212
1/ Includes information from the following institutions: Ministry of Health, State-owned, IMSS-Oportunidades, University hospitals, IMSS, ISSSTE, PEMEX, SEDENA and SEMAR.
2/ Includes only hospitals
3/ Includes facilities and mobile teams.
4/ Includes physicians in contact with patient (general practitioners, specialists, dentists, interns, residents and interns).
5/ Includes nurses, specialists, interns, assistants and administrative activities.
NA Not available
Source: National Health Information (SINAIS - MoH) [Internet] Numeralia de recursos humanos de los sectores público y privado, 2000-2007. Available in:
http://www.sinais.salud.gob.mx/recursoshumanos/index.html
Numeralia de recursos físicos de los sectores público y privado, 2000-2007. Available in: http://www.sinais.salud.gob.mx/infraestructura/index.html
Public Financing – private provision with primary
health units and basic team
Jalisco
OPD Jalisco Health Services
Public
Financing
Objective:
TO EXPAND COVERAGE
Through contracting Decentralized
Public Entity (OPD-Ministry of Health)
has set up a network of primary
(independent basic team and health
centers) and secondary (hospitals)
care services in geographical areas
(urban and rural) where no MOH units
are available.
Contracting. Basic salary plus productivity
payments
Health care units
Basic Team
Private
service
H. I Ievel of
care
H. II level of care
Package of ambulatory and
hospital services
Doctor
Nurse
Health Promoter
provision
Medical consultation, health promotion
and disease prevention activities
Users
Source: Nigenda, González, et. al. (2006): Interacción público privada en la prestación de servicios de salud, México: INSP/Conacyt.
Demand
System of Social Protection in Health and
Public – Private participation
Federal
Ministry of
Health
• Baja California
• Baja California
Sur
• Campeche
• Chiapas
• Coahuila
• Guerrero
• Hidalgo
• Oaxaca
• Querétaro
• Sinaloa
• Zacatecas
3%
National
Commission for
Social
Protection in
Health
State System of
Social Protection
in Health
60%
Purchase
of Services
State Ministry
of Health
34%
Management
Agreement
Without management agreements
Public
Without
Management
Agreement
• Michoacán
Source: Instituto Nacional de Salud Pública. Evaluación de procesos administrativos 2007. México: SPSS-SSA; 2008.
Private/Public
• Aguascalientes • Nuevo León
• Chihuahua
• Quintana Roo
• Colima
• Puebla
• Distrito Federal • San Luis
Potosí
• Durango
• Estado de
• Sonora
México
• Tamaulipas
• Guanajuato
• Tlaxcala
• Jalisco
• Tabasco
• Morelos
• Yucatán
• Nayarit
• Veracruz
Role of private sector in the quest for Health Universal Coverage
THE CASE OF COLOMBIA
The Colombian Social Insurance Regime
Government
funds
$
$
Pays on behalf
of the poor
Payroll tax & solidarity
contribution, based on
capacity to pay
National Insurance
Fund
Population with
ability to pay
Poor
population
Insurer provides
preestablished
benefits package,
irrespective of
payment
$
Risk based
premiums
Identified
by proxy
means test
$
Contracts health
services
Health insurers
Chooses
health insurer
(public & private)
Providers
(public &
private)
Chooses
providers within
insurer’s
network
Source:
Giedion, 2008
Colombia: Health Economic indicators 2005
Source: Gottret P, Schieber GJ, Waters HR (coed.) Lessons from reforms in low– and middle–income countries. Good practices in health
financing. Washington: The World Bank; 2008.
Colombia: Insurance Coverage, by
Income Quintile, 1992–2003
Source: Gottret P, Schieber GJ, Waters HR (coed.) Lessons from reforms in low– and middle–income countries. Good practices in health
financing. Washington: The World Bank; 2008.
10%
44%
Prepaid
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
OOP
Composition of health expenditure,
Colombia, 1993-2003
8%
8%
45%
26%
Other private
Colombia has radically
OOP
changed
its health financing
Payroll taxes
sources
Taxes
40%
23%
1993
2003
Source: Giedion, 2008 based on Colombian National Health Accounts, Barón, 2006.
Impact on barriers of access
Subsidized Regime
Access barriers, Propensity Score Matching
Estimates
50%
Demand barriers
40%
Supply barriers
HI
reduces
barriers
of access
30%
36%
20%
7%
10%
18%
0%
6%
Not insured
affiliated
Not
Subsidized Regime
HI
changes
the types
of access
problems
Impact of insurance on utilization
Subsidized Regime
PSM
estimates
Use of ambulatory
health services in last
12 months
Subsidized
insurance for
the poor
increases
utilization
+41%
Child taken to a health
care facility when
coughing
+17%
Child taken to a health
care facility when
suffering from
diarrhea
+23%
Child being
immunized complete
schedule
+8%
Important because diarrhea
and acute respiratory
infection are still among the
first 5 mortality causes in
children
Interesting because
immunization is
free for all irrespective of
HI status
Note: Only statistically significant results are reported on this slide. PSM, Kernel Epanechnikov , bandwidth 0.001
Impact of insurance on financial protection
Subsidized Regime
PSM
estimates
OOP represent 10%
or more of nonsubsistence income
Subsidized
insurance for
the poor
mitigates the
impact of
catastrophic
expenditure
OOP represents 20%
or more of nonsubsistence income
OOP represents 30%
or more of nonsubsistence income
OOP represents 40%
or more of nonsubsistence income
-36%
-39%
-44%
This is important as
5% /30%
of all Colombians/health
service users have
monthly OOP above 30%
of their monthly
subsistence income
-27%
Note: Only statistically significant results are reported on this slide. PSM, Kernel Epanechnikov , bandwidth 0.001
Discussion

Three different health system models with three different ways of
integrating private participation.

Colombia integrates at the level of management of funds and
provision of services with high regulation. Private sector participates in
Insurance coverage and health services coverage.

Costa Rica integrates the private sector at the level of primary care provision
with specific regulation. Restrics private participation to health services
coverage.

Mexico allows the contracting of private services but without specific
regulation. Opens the possibility of private participation in health services
provision but does not encourages it.
Role of private sector in the quest for
Health Universal Coverage
The case of Latin America
Felicia Knaul, Gustavo Nigenda,
Rocio Sáenz, Ursula Geidón, Héctor Arreola
Prince Mahidol Conference
Bangkok, January 26, 2012