Guillermo Soberón, Manuel Ruiz de Chavez, Felicia Knaul, Julio Frenk

1. The role of FUNSALUD in generating and catalyzing Evidence and information for policy making ….examples from health economics and quantitative analysis Guillermo Soberón, Manuel Ruiz de Chavez, Felicia Knaul, Julio Frenk

2. FUNSALUD and the creation of evidence for policy making • Health and the economy • Fairness in financing • Human resources • Recent themes • Relevance for other sectors, countries and institutions Outline …1993-1999 ….2000….

3. Founded in 1985 by business and community leaders from the public and academic sectors Private, non-profit Think-tank Funding: Private sector associates National research organizations International research organizations Public sector Private foundations Bilateral and multilateral organizations Catalizer of ideas, strategies and national and international research and frameworks into the national policy arena FUNSALUD

4. Translating the topic from the international to the national level and introducing it into the national debate Innovation and application of the analysis Involving Mexican institutions from the public and private sectors National and international debate Promoting and disseminating the analysis: Publications Students and teaching Re-Institucionalization of the analysis at the policy implementation stage Key ingredients

5. FUNSALUD and the creation of evidence for policy making • Health and the economy • Health and economic development • Health financing and National Health Accounts • Burden of disease • Cost effectiveness analysis • Political mapping • Fairness in financing • Human resources • Recent themes: • Health and competitiveness • Human Genome: • INMEGEN y Consorio Promotor • Technology for health: Research Unit • Relevance for other sectors, countries and institutions Outline …1993-1999 ….2000….

6. Research begins on health and the economy, 1993 Novel international techniques are applied to Mexico Economía y salud: Propuestas para el avance del sistema de salud, 1994 Center on Health and the Economy, 1995 Masters in Health Economics, 1997 Observatorio de la salud, 1997 Program on health and the economy, 1999 World Health Report, 2000 Participation in the transition team of the Presidente Elect Fox, 2000 Health: investment for development opportunities Hacia un México más saludable: una visión del sector privado, 2001 Centre for Social and Economic Analysis, 2001 Caleidoscopio de la salud. De la investigación a las políticas y de las políticas a la acción, 2003 Competitividad y salud: hacia un sistema de salud más eficaz y eficiente FUNSALUD: Health and the Ecomony 1993 2000 2003

8. Health and economic development: the virtuos circle Higher costs Inequitable, inefficient, poor quality services Desigualdad de oportunidades Less human capital Less economic development More poverty Fewer resources Less productivity and competitiveess More health Equitable, quality, efficient health services More human capital Economic development Less poverty Productivity and competitiveness CONCEPT: Health is a motor for economic development, and vice versa Institutions: Academics, World Bank, IDB, WHO (CMH) Institutional development: Masters in health economics

9. 55% 42% Public Spending Prepayment Out-of-Pocket Spending 3% 52% 48% Health Financing and National Health Accounts FINDING, 1994: More than 50% of health spending is private, out of pocket. Institutions: Harvard U., World Bank, OECD, PAHO, INEGI Institutional development: now undertaken at MOH and at state level (15..) for resource allocation, reform design and setting levels of family contributions (fair finance) 2002, SSa (MOH) 1994, FUNSALUD Estimación Baja 43% 57% 43% 57% Estimación Alta SSA. Sistema de Cuentas Nacionales y Estatales de Salud. México. D.F. 2003

10. Burden of disease National Health Program, 2001-6 “Economía y Salud”, FUNSALUD,1994 AVISAS Perdidos por grupo de causas y genero Principales causas de pérdida de años saludables (AVISAS) Causas % Causas % 15.7 Lesiones accidentales Afecciones Perinatales 7.7 10.5 Diabetes Mellitus 5.8 Enf. cardiovasculares 9.7 Homicidios y Violencia 4.8 Afecciones perinatales 7.3 Cardiopatía isquémica 4.5 Enf. del aparato digestivo 5.9 Accidentes de vehículos de motor 4 Enf. neuropsiquiatricas 5.9 Infecciones respiratorias bajas 3 Lesiones intencionales Enf. diarreicas 5.6 Enfermedad cerebrovascular 2.9 Infecciones respiratorias 5.4 Cirrosis hepática 2.9 Neoplasias malignas 5.4 Atropellamiento 2.3 Anomalias congènitas 4.9 Desnutrición proteico-calórico 1.9 Enf. De la nutrición 4.4 Enfermedades diarreicas 1.8 Enf. Respiratorias crónicas 2.4 Demencias 1.7 2.1 Consumo de alcohol 1.6 Enf. del aparato genitourinario

11. Cost effectiveness: benefit packages Catalogue of benefits (CABEME-2002 y CASES-2003), SSa, 2002 Economía y Salud, 1994 A B C Familiar Integral Universal 69 $98 83 $132 101 $149 78 $302 105 $403 120 nd Number of interventions COST: Incremental annual* EFFECTIVENESS:Reduction in burden of disease Number of interventions COST: Annual per person* EFFECTIVENESS: Burden of disease, fair financing 18% 24% 25% *Pesos de 1994

12. FUNSALUD and the creation of evidence for policy making • Health and the economy • Fairness in financing • Human resources • Recent themes: • Health and competitiveness • Human Genome: • INMEGEN y Consorio Promotor • Technology for health: Research Unit • Relevance for other sectors, countries and institutions Outline …1993-1999 ….2000….

13. Research begins on health and the economy, 1993 Economía y salud: Propuestas para el avance del sistema de salud, 1994 Center on Health and the Economy, 1995 Masters in Health Economics, 1997 Observatorio de la salud, 1997 Program on health and the economy, 1999 World Health Report, 2000 Framework on Health System Performance Participation in the transition team of the Presidente Elect Fox (2000)and inputs for the National Health Program, 2001 Hacia un México más saludable: una visión del sector privado, 2001 Center for Social and Economic Analysis, 2001 Caleidoscopio de la salud. De la investigación a las políticas y de las políticas a la acción, 2003 Competitividad y salud: hacia un sistema de salud más eficaz y eficiente FUNSALUD: Health and the Ecomony 1993 2000 2003

15. Health System Objectives Level Distribution Health Responsiveness Efficiency Fair financing and financial protection Equity Quality

16. Challenges to the health system: PNS 2001-2006 Equity Quality Financial Protection Popular Health Insurance, 2001…. System for Social Protection in Health, 1st January 2004 Priority

17. Performance of the Mexican Health System World Rank Level of health Inequality in health Responsiveness Fairness of Finance 55 65 53 144 Overall performance 61 of 191

18. Encuesta Nacional de Ingresos y Gastos de los Hogares, INEGI, 1992, 4, 6, 8, 00, 02 Encuesta Nacional de Evaluación del Desempeño, 2002. SSa. Encuesta Nacional de Aseguramiento y Gasto en Salud, 2001. SSa-INSP-Funsalud Encuesta Mundial sobre Estados de Salud, 2001. OMS Data

19. Families with catastrophic and impoverishing health expenditure 2 million: Catastrophic spending (>= 30% of family disposible income) .5 million 1.7 million 1.5 million 2.3 million: Absolute impoverishment(crossing the poverty line or deepening absoute poverty)

20. The study undertakes simulation analysis of the impact of a universal system of social protection in health with the characteristics of the SPSS-SPS and a projected reduction in out of pocket health spending: Reducing the overall level of spending in a fixed proportion The uninsured behave in a similar way to the insured By size of the population in each municipality By type of health spending: medications, ambulatory, hospitalization, maternity Metodology

21. Impact of universal insurance on impoverishment and fair finance Simulation of health spending Initial value 60% decrease in oop Uninsured spend as the insured Index of Fairness in Financial Contributions 0.915 0.954 0.986 Position relative to other countries (OMS, 2000) 127 24 76 Families with castastrophic spending (relative) 0.6% 3.4 % 2.6% Familes with catastrophic and/or impoverishing expenditures 2.9% 6.4 % 5.3% The greatest benefits, in fair financing and catastrophic and impoverishing health spending, are in the rural areas (poorest) and from covering nominally small expenditures (medicines, ambulatory).

22. Application of the WHO framework by the Transition Team of President Elect Fox, 2000 Evidence for priority-setting Aplication and extension of the Framework to the Mexican case to formulate proposals for universal social insurance in health and measure potential impact, 2000 Evidence for policy design Incorporation of the Popular Insurance Program as a strategy in the National Health Program 2001-6, 2001 Evidence for policy design Large-scale piloting of the Popular Health Insurance, 2002-2003 Incorporation into an evaluation scheme The reform of the General Health Law is passed to create the System for Social Protection in Health, 2003 Evidence for advocacy and concensus-building The reform goes into effect, January 1st 2004 Evidence for policy design-specifics and evaluation Analysis of financial protection as evidence for policy making, 2000-2004

23. FUNSALUD and the creation of evidence for policy making • Health and the economy • Fairness in financing • Human resources • Recent themes: • Health and competitiveness • Human Genome: • INMEGEN y Consorio Promotor • Technology for health: Research Unit • Relevance for other sectors, countries and institutions Outline …1993-1999 ….2000….

24. Inefficiencies in human resource utilization Paradox of human resource waste: Doctors and nurses without employment; Mexicans without health care. 43% 27% 160,000 60,000 Physicians Nurses Employed in health Unemployed or inactive Fuente: INEGI, Encuesta Nacional de Empleo Urbano, 2o Trimestre, 1999.

25. Medical employment pattern Hombre 9% 10% 2% 79% Employed in the medical sector Partially employed in the health sector Employed outside of the health sector 10% 32% 51% Unemployed, inactive, or outside of the labora market 7% Mujer Fuente: INEGI, Encuesta Nacional de Empleo Urbano, 2o Trimestre, 2000.

26. Growth in labor market participation by gender in Latinamerica 300 250 MEN WOMEN 200 150 % 100 50 0 Brasil México Cuba Perú Bolivia Chile Colombia Ecuador Paraguay América Latina Nicaragua Honduras Panamá Uruguay Argentina Venezuela Guatemala El Salvador Costa Rica R.Dominicana Fuente: FLACSO, “Mujeres Latinoamericanas en Cifras”, 1995.

27. National Health Program 2001-2006 Programa de Acción Mujer y Salud The Democratization of Health in MexicoTowards a Universal Health System

28. FUNSALUD and the application of evidence for policy making …1993-1999 • Health and the economy …..2000… • Fairness in financing • Human resources • Recent themes: • Health and competitiveness • Human Genome: • INMEGEN y Consorio Promotor • Technology for health: Unidad de analisis • Relevance for other sectors, countries and institutions Outline

29. Investing in health is investing in competitiveness • Differences in health explain approximately 17% of the variation in worker productivity among countries – differences similar to education and physical capital. (Weil, 2001; Bloom, Canning y Sevilla, 2002) • An increase of one year in life expectancy can result in an increase of 4% in total product of a country. (Bloom, Canning y Sevilla, 2001) Yet, health and the health sector have not been incorporated into the analysis of competitiveness at the national or international levels.

30. Interactions between health and the economy POBREZA Y SALUD Health Conditions System 5 5 1 1 4 4 2 2 Conditions 7 7 Economy ENTRE POBREZA Y INTERACCIONES SALUD 3 3 System 6 6 8 8 Fuente: Knaul, Frenk y Aguilar, 2001

31. High proportion of out-of-pocket spending in Mexico is inefficient Reino Unido 3 Alemania 11 EEUU 17 Greater economic development, more insurance coverage and less out of pocket spending Canadá 17 Noruega 18 Finlandia 19 Japón 20 Suecia 22 Costa Rica 22 Colombia 26 Ecuador 39 Chile 49 Ghana Bangladesh 54 58 México, 2002 Haití 63 Etiopía 64 Nepal 74 Sudán 79 India 85 Sierra Leona 90

32. FUNSALUD and the application of evidence for policy making …1993-1999 • Health and the economy …..2000… • Fairness in financing • Human resources • Other recent themes: • Health and competitiveness • Human Genome: • INMEGEN y Consorio Promotor • Technology for health: Unidad de analisis • Relevance for other sectors, countries and institutions Outline

33. Art of selecting and defining the most relevant topics for applied policy analysis Methodology for inserting analysis, frameworks and topics into the policy arena Re-institutionalising Institutional and intellectual space for debating topics that may not be appropriate in terms of timing or maturity for the national policy arena Financial base combined with intellectual independence is unusual among NGOs; Participation of the private sector in an analytic space in the social sectors Frameworks for health systems can be adapted to other systems especially in the social sectors Relevance for other sectors, countries and institutions

34. Conferencia organizada en memoria del Dr. Juan Luis Londoño, figura central en la innovación y mejoramiento de los sistemas de salud y líder en los debates internacionales en los campos de equidad y abatimiento de la pobreza.

35. 45 35 25 15 5 0 1973 1975 1977 1979 1981 1983 1985 1987 1989 España Finlandia Alemania Suiza Japón Portugal Reino Unido Suecia Estados Unidos Mujeres como Proporción del Total de Médicos Países Industrializados, 1973-1989