Getting to universal health coverage

Big 3 Julio Frenk

December 11, 2014 — Julio Frenk is Dean of the Faculty at the Harvard School of Public Health and T & G Angelopoulos Professor of Public Health and International Development, a joint appointment with the Harvard Kennedy School of Government.

What does it take to develop a successful universal health coverage program in a state or a country?

When I became Mexico’s Minister of Health in 2000, my single most important goal—the thing I quickly became most passionate about—was expanding health insurance coverage to all of our citizens. At that point, half of the country’s 100 million inhabitants were uninsured. Of course, I knew this was ambitious—very ambitious—but it never occurred to me that it was impossible. I just got to work.

And then, through the indiscretion of someone, an email from a very high ranking person in the Ministry of Health wound up in my hands. It said, in essence, “The Minister has lost his marbles. How does he think it is possible to insure 50 million people?”

This was a competent civil servant, and I didn’t want to fire him—even if I he did think I was losing my mind. Instead, I called him to my office and I said: “Look, it’s come to my attention that you’ve been questioning my sanity, so let me tell you why I’m not crazy.”

I’m proud to say that the universal coverage program we instituted, known as Seguro Popular, is firmly ensconced in Mexico—and it does indeed now cover 58 million previously uninsured people, my colleague’s doubts notwithstanding.

To achieve that success, I believe — as my colleague Michael Reich has written — that one needs an ethical pillar, a political pillar, and a technical pillar.

Every health system reflects a series of ethical assumptions, so every attempt to reform the health system should begin by asking “what values should our health system promote?”

In Mexico, the technical pillar of the reform was built by using sound evidence, much of it derived from national data and from comparative analyses of other health systems facing similar challenges. Evidence empowers policymakers with convincing means to challenge the status quo and promote change. It also helps to build the political and ethical pillars of the reform.

What was the most important information you discovered from the data-gathering effort?

We uncovered two very important issues.

First, we learned that the health system had not kept up with the pressures resulting from a protracted and polarizing epidemiologic transition in Mexico. While poorer people were still dying at early ages from malnutrition, common infections and reproductive health problems, at the same time a growing proportion of the population was living longer. Ironically we were victims of our own success. As the numbers of people dying from infectious diseases was falling, chronic non-communicable diseases such as obesity, diabetes, heart disease and cancer were becoming dominant.   At the time I became Minister, we were only spending 5.3% of our GDP on health care – the U.S. spends 18%. As a result, our health system was not adequately equipped or financed to handle the prevention and treatment of a growing population with chronic diseases.

The second issue revealed was that half of Mexico’s people were uninsured. Similar to the U.S., in Mexico health insurance was mostly an employment benefit rather than a universal entitlement. But until we did the research, we in the government didn’t really understand how large catastrophic, out-of-pocket health care payments were.

About 50% of Mexico’s citizens were self-employed or employed, and therefore lacked health insurance. As a result, Mexico was facing an unacceptable paradox: While health is a key factor in the fight against poverty, a large number of families were becoming impoverished because they had to pay for their own health care and prescription medications. A single major illness could bankrupt an entire family.

How did you ultimately move from having data and proof that reform was needed to getting actual reform to occur?

Health care had already been formally recognized as a social right by the Mexican Constitution 20 years earlier. A portion of the political pillar was therefore already in place. But its implementation was only benefiting some people, while excluding others.

In the context of a young democracy, we deliberated as a government and as a people on the moral implications of the existing health care system. The Mexican reform ultimately was formulated and promoted on the basis of a guiding concept and a set of explicit values. At the basis of that ethical framework was that health care is not a commodity or a privilege, but it is a social right. The guiding concept underlying reform in Mexico was the “democratization of health.”

As part of our reform, we identified 260 essential interventions for health conditions of high incidence and relatively low cost which account for more than 95% of the demand for services. These included services for such things as family planning, ante-natal care; delivery and newborn care; detection and treatment of diseases such as diabetes, hypertension and tuberculosis. We also identified an initial package of 60 high-cost interventions that cover diseases that can generate catastrophic expenditures – including the treatment for HIV/AIDS, cancer in children, and cervical and breast cancer among others. These 320 services became the heart of our health reform, based not only on their cost-effectiveness, but also on the social acceptability and social preferences – our nation’s collective ethical and political sense of what was right for people to have access to.

The package of interventions then provided the blueprint to estimate the resources required to strengthen the health system. To fund these services ultimately meant that we needed to increase by a full percentage point of GDP the amount we invest in health care – a large sum of fresh money that was allocated to health over an 8-year period. This was no mean feat politically. But in part by emphasizing data that shows how health increases wealth, and by including in deliberations other ministries in the government focused on growing Mexico’s economy, we were able to convince people that bringing health services to over 50 million more Mexicans was not only the right thing to do ethically, it was also the smart thing to do economically.

– Julie Rafferty

photo: Kent Dayton