A randomised assessment of Seguro Popular — Mexico's recently-introduced pilot universal health insurance system — has shown that household-crippling* expenditure has been reduced for both poor families and the general population. The findings are discussed in an Article published Online First and in an upcoming edition of The Lancet, written by Professor Gary King, Harvard University, Cambridge, MA, USA, and colleagues.
The aim of Seguro Popular is to reduce catastrophic* health expenditures by providing social protection in health. The project consists of health policies and priorities, including entitlements for affiliated families, well-defined benefits packages including coverage for 266 unique health interventions, 312 medicines, increased funds to state health ministries proportional to the number of Seguro Popular-affiliated families, federal funds for personal and non-personal health services, and creation of special federal funds for catastrophic medical expenditures associated with certain diseases.
In the largest randomised health policy experiment ever conducted, the authors randomly assigned treatment within 74 matched pairs of communities, representing 118 569 households in seven Mexican states, and measured outcomes in a baseline survey (Aug-Sept 2005) and a follow-up survey 10 months later (July-Aug 2006) in 50 of these pairs. Oportunidades** anti-poverty programme particpants were enrolled in Seguro Popular automatically by the state; therefore, for this group the campaign informed them of their new rights under Seguro Popular. The treatment consisted of encouragement to enrol in a health-insurance programme that was free to the poor, and upgraded medical facilities and services. Participant states also received funds to improve health facilities and to provide medications for services in treated communities. Control communities received nothing extra.
Across all survey responders, Seguro Popular reduced the proportion of households experiencing catastrophic expenditures by 23%; among compliers***, this reduction was 55%. This meant a reduction in health spending across all responders of 426 pesos (US$ 31); among compliers, the average reduction in health spending was 915 pesos (US$ 66). Contrary to expectations and previous observation research, no effects were found on medication spending, health outcomes, or utilisation of health care.
The Article introduces new research designs and statistical methods that made it possible to evaluate this large public policy program far less expensively than had previously been possible. As the authors explain, using standard procedures "would have increased our standard errors by as much as 600%" and so would have required the randomisation of many more communities to produce results with the same margin of error. Since randomised public policy assessments tend to fail due to political and other interventions, the article introduces fail-safe procedures "designed to survive these types of interventions." This result opens up the possibility of subjecting other public policies in Mexico and elsewhere to scientific evaluation and evidence-based standards.
The authors conclude: "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."
In an accompanying Comment, 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: "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."
Professor Gary King, Harvard University, Cambridge, MA, USA T) +1 617-495-2027 E) king@harvard.edu
Professor Cesar G Victora, Universidade Federal de Pelotas, Brazil and Johns Hopkins University, Baltimore, MD, USA T) +55 53 9982 6676 E) cvictora@terra.com.br
For full Article and Comment, see: http://press.thelancet.com/mexicofinal.pdf
Notes to editors:
*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.
Journal
The Lancet