One of the best courses I ever took, was a course on empirical methods taught by Gary King in the Government Department at Harvard. That is why I think it is so great that he now does Global Health research.

Mexico has been credited as one of the countries that has done the most to expand access to health services in a “developing” country context. Starting in 2003, the government launched a series of reforms to introduce universal health insurance, which is subsidized for the poor. The program, known as Seguro Popular, aimed to provide coverage to 50 million uninsured Mexican.

Gary King and co-authors launched a randomized clustered evaluation of the program on a large sample of households. The treatment was encouragement to join insurance as well as additional funds to upgrade the facilities in the areas. They used a random phase-in of the program, which is pretty cool and something I wish more countries used, to study the program effects.

After 10 months, the authors did find evidence that the program had been successful in reducing overall catastrophic and out-of-pocket expenditures for inpatient and outpatient medical procedures, and that the findings were strongest for the poorest individuals. However, the program had no effect on medication spending, health outcomes, or utilization. This finding was not consistent with previous observational studies.

There are a lot of potential reasons for these results, which the authors discuss in depth in their article, but it seems these findings were disappointing for all those that had hoped for so much to come of the program. Some have questioned if 10 months is too soon to evaluate the program. I am not sure what I would have expected, but I think the findings of this study should be used as a careful warning to other countries that are significantly expanding access to health insurance.

While these programs will probably do more in the long-run, short term gains might be hard to achieve – or at least demonstrate. I suspect this might be the case in Ghana, which has recently implemented national health insurance, and China which as promised a doubling of health spending in the coming years.

Health reform can be long and painful process, causing lots of headaches, costing lots of money, and may not even show immediate results on health. It is a wonder that anyone is doing it these days, but I am happy that they are….even here in the U.S…because these programs wil likely pay off in the long-run.

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1 Response » to “More pesos but not more health…China and Ghana beware”

  1. April says:

    Thanks Karen for posting.
    It’s hard to understand the description of the control group they created, but if I understand correctly – they compared SP to doing nothing (e.g. no other form of support).

    I think it is somewhat damning that there is no increase in utilization – as the folks targeted by the program are generally not using enough health services to begin with (and remember, they are comparing this to a control group who got nothing….as opposed to comparing SP to other interventions using the same amount of funding).
    So, I find the results in Mexico rather discouraging.

    But, don’t be mislead by the reference to Seguro Popular as a reform that gave poor people insurance. Seguro Popular is not really an insurance intervention. While there is a package described which enrollees are “entitled” to – they don’t really end up with an enforceable agreement between themselves and the “insurer” which is really just the closest clinic run by the Secretariat of Health. They can’t get “insured” by anyone else – if not happy with their coverage. Nor can they use their “insurance” anywhere else, if services are not available or satisfying to them. The most they can do if unhappy is dis-enroll – which gains them nothing – though it would deprive the public clinic of the additional public funding linked to their enrollment.

    The Colombians on the other hand did implement an insurance intervention to reduce out-of-pocket spending AND increase use of services by the poor – and it worked.
    Pls see this paper by Ursula Giedion and others in Health Affairs

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