Tecnologico de Monterrey, School of Social Science and Government, Monterrey, N.L., México.
Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico.
J Glob Health. 2023 Nov 24;13:04134. doi: 10.7189/jogh.13.04134.
The fragmentation of health systems in low- and middle-income countries (LMICs) deepens health inequities and shifts the economic burden of health care to families via out-of-pocket spending (OOPHE). This problem has been addressed by introducing public health insurance programs for poor people; however, there is a lack of knowledge about how equitable these programs are. We aimed to analyse the long-term effects of the Seguro Popular (SP) voluntary health insurance program, recently phased out and replaced by the Health Institute for Welfare (Instituto de Salud para el Bienestar (INSABI)), on OOPHE equity in the poor Mexican population.
We conducted a pooled cross-sectional analysis using eleven waves of the National Household Income and Expenditure Survey (2002-2020). We identified the effect of SP by selecting households without social security (with SP or without health insurance (n = 169 766)) and matched them by propensity score to reduce bias in the decision to enrol in SP. We estimated horizontal and vertical equity metrics and assessed their evolution across subpopulations.
The program's entry years (2003-2010) show a positive redistributive effect associated with a focalised stage of the program, while oversaturation could have diluted these effects during 2010-2014, with adverse results in terms of vertical equity and re-ranking among insured families. SP is more horizontally inequitable than for those uninsured. Within SP, the redistributive effect could improve up to 13% if all families with similar expenditures were spending equal OOPHE and horizontal equity was eliminated. Regarding vertical equity, SP outperforms the insured population with middle-range coverage some years after the implementation, but this progress disappears.
To achieve universal health coverage, health authorities need to create and execute financial protection mechanisms that effectively address structural inequalities. This involves implementing a more comprehensive risk-pooling mechanism that makes social insurance sustainable in the long-run by increasing the social-economic influx of resources. It is essential to monitor oversaturation and financial sustainability to achieve optimal results. The replacement of the SP with INSABI highlights the complexity of maintaining a social insurance program where the ideology of different governments can influence the program structure, regulation, financing, and even its existence.
中低收入国家（LMICs）的卫生系统碎片化加深了卫生不平等现象，并通过自费支出（OOPHE）将医疗保健的经济负担转嫁给家庭。为了解决这个问题，已经为贫困人口引入了公共医疗保险计划；然而，对于这些计划的公平性知之甚少。我们旨在分析最近逐步淘汰并由福利健康研究所（Instituto de Salud para el Bienestar (INSABI)）取代的大众健康保险计划（Seguro Popular (SP)）对墨西哥贫困人口自费支出公平性的长期影响。
我们使用十一轮全国家庭收入和支出调查（2002-2020 年）进行了一项基于群组的横截面分析。我们通过选择没有社会保障的家庭（有 SP 或没有健康保险（n=169766））并通过倾向得分匹配来选择他们，以减少参加 SP 的决定中的偏差。我们估计了水平和垂直公平性指标，并评估了它们在各子群体中的演变情况。
该计划的参与年份（2003-2010 年）显示出与计划聚焦阶段相关的积极再分配效应，而 2010-2014 年期间的过度饱和可能削弱了这些效应，导致垂直公平性和参保家庭的重新排名出现不利结果。SP 比未参保的家庭更不公平。在 SP 内部，如果所有支出相似的家庭都支出相等的自费支出，并且消除了水平公平性，那么再分配效应最多可以提高 13%。关于垂直公平性，SP 在实施后的几年内优于中等覆盖范围的参保人群，但这种进步会消失。
为了实现全民健康覆盖，卫生当局需要创建和执行有效的财政保护机制，以解决结构性不平等问题。这涉及到创建一个更全面的风险池机制，通过增加社会经济资源的流入，使社会保险在长期内具有可持续性。监测过度饱和和财务可持续性对于实现最佳效果至关重要。SP 被 INSABI 取代突显了维持社会保险计划的复杂性，不同政府的意识形态会影响计划结构、监管、融资，甚至计划的存在。
