The First Line of Defense for Public HealthcareSat, 09/05/2015 - 13:36
Q: As the National Commissioner for Seguro Popular, what can you tell us about its creation and purpose?
A: As an ophthalmologist and a transplant surgeon, I was the first physician to become National Commissioner. Before accepting this position, I was Secretary of Health for the State of Mexico. This state has the largest health system in the country, covering 16 million inhabitants, so I had real experience dealing with the public health sector on a large scale. When I took this position, I was already familiar with the particulars of the public health system, its programs, budget, priorities, strengths, weaknesses, and areas of opportunity. The Social System for Health Protection (SPSS), also known as Seguro Popular, was created as a social alternative for health protection for Mexicans who were not affiliated to any other public health institution, such as IMSS or ISSSTE. One of the main reasons for its creation was to reduce the out-of-pocket costs that Mexicans paid for medication and medical services. The introduction of Seguro Popular has reduced these costs from 56.2% in 2003 to 45.2% in 2012, according to the OECD.
Q: What is the extent of treatments covered by Seguro Popular?
A: Seguro Popular covers 100% of primary healthcare, which comprises medical consultations with general physicians, vaccinations, mammograms, and other preventive studies. It also covers 85% of secondary care, which is comprised of four basic specialties: gynecology, pediatrics, general surgery, and internal medicine. Finally, it covers 100% of tertiary level care through the Fund for Catastrophic Expenses, incorporating 59 expensive procedures using reserves amounting to US$903 million. To reduce this sum, the Mexican government should make prevention a priority. It is believed that 80% of the diseases that Mexicans contract in their lifetimes can be solved at the first level of care, if diagnosed in time. Currently, there are 64 million Mexicans with diabetes who are not in control of their blood glucose levels and in 15 years, these patients will need highly advanced and expensive procedures such as dialysis, amputations, or laser photocoagulation to treat diabetic retinopathy. Through the Universal Catalog of Health Services (CAUSES), Seguro Popular offers several procedures for the detection and prevention of preventable diseases, including breast cancer, uterine cancer, prostate cancer, diabetes, HIV, cardiovascular diseases, and cornea and bone marrow transplants.
Q: Mexico’s public health expenditure is below the OECD average. How can Seguro Popular help the Mexican government improve its healthcare investments?
A: While there may never be enough investment in healthcare, it is possible to improve results by prioritizing needs and ensuring that budgets are used appropriately. The public health sector should focus on a range of factors, such as preventive measures to control chronic diseases, consolidated acquisitions to ensure a steady supply of drugs, and more efficient control of the resources transferred from Seguro Popular to the states. Seguro Popular used to have no control over how the states utilized the budget granted to them by the central government, which led to problems as money was allocated to unrelated areas. To resolve this, President Enrique Peña Nieto urged the central health sector to increase control by modifying the General Health Law. These changes were implemented in June 2014 and now this ensures a higher supply of medicines, more adequate equipment for state hospitals, and more doctors and nurses. Seguro Popular has also implemented other measures to improve healthcare, including Programa 32x32, which encourages an exchange of services among all 32 states in Mexico. Finally, our current administration has financed 227 projects to construct, renovate, and equip hospitals in 22 states, with a total investment of US$300 million.
Q: What were the main changes made to the General Health Law?
A: The recent changes to the law strengthened transparency in the use of resources. We also increased penalties from four to seven years in prison and fines from 1,000 to 500,000 days of minimum wage to whoever misuses Seguro Popular resources. The improvements to the law also allow patients to receive medical attention at public hospitals in any state in the country while empowering them to request reimbursement from the patient’s state of residence. This was not possible before and states simply had to absorb those costs. This convergence will also allow refunds between different institutions. Other changes include the consolidated purchasing of medications. The collaboration between ISSSTE, IMSS, and the National Institutes of Health of 17 states, gave IMSS a stronger position to negotiate lower costs. In 2014, more than US$206 million were saved by consolidating the purchases of five states. In 2015, the scope was broadened to 17 states and US$519 million were saved. Since Mexican states are autonomous, the acquisition of medicines cannot be managed at the federal level, meaning that even though they receive their budget from federal reserves, they ultimately decide how to spend it, which is why it is necessary for states to agree and consolidate their purchases.
Q: How do you ensure the provision of quality services?
A: Many believe that Seguro Popular is a public institution comprising hospitals, doctors, and medicines, but in reality Seguro Popular is a large insurance organization that works as a financial instrument. We seek to guarantee that our affiliates can provide high-quality healthcare, a process to which we contribute in several ways. The quality of a hospital is generally evaluated according to its equipment, personnel, infrastructure, and the availability of medication. To ensure this quality, we have created the State Regime of Social Health Protection (REPSS) that organizes visits to hospitals and clinics to monitor the quality of the services provided and ensure that patients receive efficient and timely treatment and medication. REPSS also ensures that patients are not being overcharged for these services. Finally, we also created guidelines with the Treasury to delineate Seguro Popular’s expenditures. The guidelines stipulate that 30% of the funds sent to the states must be spent on medication and deposited in the Federation Treasury (TESOFE), where the central government can monitor usage. This is intended to eliminate the shortage of medication.
Q: The public health sector receives a large amount of patients but has a limited amount of hospitals and a budget deficit. How can it still meet its obligations in terms of adequate care?
A: The budget for Seguro Popular for 2015 is approximately US$5.2 billion. Of this budget, 40% is spent on salaries, 30% on medication, 20% on preventive measures, 6% on REPSS, and 4% for building new hospitals, rehabilitating old ones, and the acquisition of new equipment. Around US$187 million is used every year to improve infrastructure. President Peña Nieto has made 26 healthcare commitments, mainly to renovate hospitals and replace obsolete equipment, which will largely be funded by Seguro Popular and the Ministry of Health. However, while our number of affiliates has greatly increased, the number of public hospitals has remained static. In cases where the needs of the patients exceed the capacities of the public health sector, we have agreements with 35 private hospitals, from which Seguro Popular can solicit services.
Q: The upcoming reform of the General Health Law is expected to integrate the public health sector, including IMSS, ISSSTE, and Seguro Popular. How will this precisely affect Seguro Popular?
A: This process will focus on portability and convergence for it will not be possible to merge all these institutions into a single body, as each has its own collective contract, payment scales, and union that will prevent a complete merger. Our first goal in this process is to unify the payment scales, which is far from straightforward. We have had 15 different meetings about this subject over the last two years but no consensus has been reached. Still, we have already unified delivery services and emergency attention. We recently signed a general agreement between IMSS, ISSSTE, the Ministry of Health, and Secretariats of Health in different states to provide pregnant women with access to 463 specialized clinics in Mexico.
Q: How much do the complications stemming from chronic diseases cost Seguro Popular?
A: The budget for the prevention of chronic diseases stands at US$1 billion. Years ago, Mexican lives were mostly threatened by infectious diseases but now we are dying of conditions such as diabetes, strokes, and cancer, which are extremely expensive for the public health system. Our priority is to improve the quality of health services and to increase preventive measures to limit chronic diseases. These measures take the form of prevention campaigns, one of which is currently seeking to promote the preventive detection of breast cancer by bringing mammograms to rural communities. There are also campaigns for preventing smoking, detecting prostate cancer, and providing prenatal care to pregnant women. In my opinion, the budget for preventive measures should be raised by 50% in order to reduce future costs.
Q: Is there any campaign focused exclusively on rural areas to address healthcare issues?
A: Yes, but they should ideally be rolled out nationwide. We provide health services for The Ministry of Social Development’s Prospera program, the goal of which is to help the poorest in the country. It involves an initiative to fight hunger in rural communities and provides educative materials in more than 20 indigenous languages on several topics, such as preventing unplanned pregnancies. Prospera has a budget of about US$313 million to address these issues.