Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
76734
Mexico’s Social Protection System in Health and the Financial
Protection of Citizens without Social Security
June 2012
Human Development Department
Latin America and the Caribbean Regional Office
Document of the World Bank
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
ABBREVIATIONS AND ACRONYMS
ADL Activity of Daily Living
CNPSS National Commision for Social Protection in Health (Comisión Nacional de Protección
Social en Salud)
ENIGH National Survey of Household Income and Expenditures (Encuesta Nacional de Ingresos
y Gastos de los Hogares)
FGC Federal Government Contribution (Contribución del Gobierno Federal)
FPGC Fund for Catastrophic Expenditures (Fondo de Protección contra Gastos Catastróficos)
GHL General Health Law (Ley General de Salud)
IMSS Mexican Institute for Social Insurance (Instituto Mexicano para Seguro Social)
ISSSTE Institute of Social Security and Insurance for Civil Service (Instituto de Seguridad y
Servicios Sociales de los Trabajadores del Estado)
NHCS National health system (Sistema Nacional de Salud)
OOP Out�?of�?pocket expenditures
SMNG Health Insurance for a New Generation (Seguro Médico de una Nueva Generación)
SP Social Insurance (Seguro Popular)
SPSS System of Social Protection in Health (Sistema de Protección Social en Salud)
SSF Family Health Insurance (Seguro de Salud para la Familia)
SSL Social Security Law
Vice President: Hasan Tuluy
Country Director: Gloria Grandolini
Sector Director: Keith Hansen
Sector Manager: Joana Godinho
Country Sector Leader: Wendy Cunningham
Task Team Leaders: Christoph Kurowski
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
TABLE OF CONTENTS
II
A. INTRODUCTION ................................................................................................................ 1
B. BACKGROUND .................................................................................................................. 2
C. STUDY APPROACH ............................................................................................................ 3
D. KEY FINDINGS ................................................................................................................... 4
..................................................................................................... 4
Health status and utilization of care
Table 1: Incidence of illness and utilization of care by income decile ................................................. 5
Table 2. Prevalence of illness – SPSS, uninsured and social security households ................................ 6
Table 3. Utilization of health services when ill – SPSS, uninsured and social security households ...... 6
Table 4: Determinants of the prevalence of illness 1 – All households ............................................... 7
Out�?of�?pocket expenditures ................................................................................................................. 7
Table 5: Out�?of�?pocket expenditures, disposable income and out�?of�?pocket expenditures as a
percentage of disposable income by income deciles [Mexican Pesos, 2008] ...................................... 7
Table 6: Household characteristics – SPSS, uninsured and social security households ...................... 9
Table 7. Annual out�?of�?pocket expenditures – SPSS, uninsured and social security households ...... 10
Table 8. Effects of selected determinants of the out�?of�?pocket expenditure .................................... 10
Table 9. Annual out�?of�?pocket expenditure for Matched Pairs�? SPSS, uninsured and Social Security
............................................................................................................................................................ 10
Table 10. Annual out�?of�?pocket expenditures on medicines– SPSS, Table x. uninsured and social
security households ............................................................................................................................ 11
Table 11. Effects of selected determinants of the out�?of�?pocket expenditure on medicines
(logarithmic) ........................................................................................................................................ 11
Table 12. Annual out�?of�?pocket expenditure on medicines for Matched Pairs�? SPSS, uninsured and
Social Security ..................................................................................................................................... 11
Table 13. Annual out�?of�?pocket expenditures on outpatient�?care – SPSS, uninsured and social
security households ............................................................................................................................ 12
Table 14. Effects of selected determinants of the out�?of�?pocket expenditure on outpatient�?care
(logarithmic) ........................................................................................................................................ 12
Table 15. Annual out�?of�?pocket expenditure on outpatient�?care for Matched Pairs�? SPSS, uninsured
and Social Security .............................................................................................................................. 12
Table 16. Annual out�?of�?pocket expenditures on inpatient�?care – SPSS, uninsured and social security
households .......................................................................................................................................... 13
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Table 17. Effects of selected determinants of the out�?of�?pocket expenditure on inpatient�?care (logarithmic) 13
.....
Table 18. Annual out�?of�?pocket expenditure on inpatient�?care for Matched Pairs�? SPSS, uninsured and Social
Security 13
....................................................................................................................................................................
Catastrophic health expenditures ....................................................................................................... 14
Table 19: Incidence of catastrophic expenditures by income decile ..................................................................... 14
Table 20. Incidence of catastrophic expenditure –SPSS, uninsured and social security households...................... 15
Table 21. . Effects of selected determinants of the incidence of catastrophic expenditure ................................... 15
Table 22. Incidence of catastrophic expenditure for Matched Pairs�? SPSS, uninsured and social security
households .............................................................................................................................................................. 17
Figure 1. Out�?of�?pocket expenditures, disposable income and catastrophic expenditures ................................... 18
Figure 2. Composition of out�?of�?pocket expenditures for households with catastrophic expenditures ................ 19
Figure 3. Composition of out�?of�?pocket expenditures for SPSS households with catastrophic expenditures. ....... 20
Figure 4. Composition of out�?of�?pocket expenditures for uninsured households with catastrophic expenditures.
20
.................................................................................................................................................................................
Figure 5. Composition of out�?of�?pocket expenditures for social security households with catastrophic
expenditures. .......................................................................................................................................................... 21
E. DISCUSSION .................................................................................................................... 22
...................................................................... 26
Annex 1. Determinants of out�?of�?pocket expenditures
Annex 2. Determinants of Catastrophic Expenditures ....................................................................... 28
Annex 3. Determinants of affiliation to the SPSS excluding social security households .................... 30
F. REFERENCES .................................................................................................................... 31
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
A. Introduction
1. As in many low�? and middle�?income countries, Mexico’s health system is fragmented into
different sub�?systems with access linked to labor market status. Social security schemes provide health
care for formal sector workers and their dependents, while Mexico’s System for Social Protection in
Health (SPSS), better known as its pilot and main pillar Seguro Popular (SP), offers health care financial
protection to the rest of the population.
2. The SPSS was introduced in 2003 to reduce the substantial inequalities in health and financial
protection between Mexicans who have and do not have social security. It complemented the financing
arrangements and strengthened the country’s national care health system (NHCS), increasing the
availability of public funding, guaranteeing access to explicitly�?defined services and making them free at
the point of use.
3. The present study aimed to shed further light on the on the SPSS’ impact on coverage and
financial protection. Since its inception, the SPSS and in particular the SP had been subject to several
evaluations. This study complemented the body of evidence in two important ways. First, it researched
the impact of the SPSS on financial protection controlling comprehensively for the many household
characteristics that are associated with SPSS affiliation, including health status. Second, and building on
its approach to control for household characteristics, it endeavored to compare not only SPSS with
uninsured but for the first time also SPSS with social security households.
4. The study has been carried out in collaboration with the Mexico’s National Commission on
Social Protection in Health and the Federal Ministry of Health. It is part of a series of World Bank
research pieces that intends to provide new insights into the many successes of Mexico’s 2003 health
sector reform, but also the remaining challenges facing the health system serving Mexicans without
social security.
5. This paper is structured as follows. After this introduction, the paper provides additional
background information on Mexico’s health system and lays out the study approach. It follows a
presentation of key results. The paper closes with a discussion of key findings and conclusions.
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
B. Background
6. The Mexican Health System is fragmented and its sub�?systems can be categorized into two
major groups depending on their principle source of financing. First, there are contributory
subsystems, financed primarily from employer and earnings�?based contributions and second, there are
non�?contributory subsystems, financed primarily from general revenues.
7. The group of contributory systems comprised five social security institutions; the two major
ones are the Mexican Institute for Social Insurance (Instituto Mexicano para Seguro Social or IMSS)
and the Institute of Social Security and Insurance for Civil Service (Instituto de Seguridad y Servicios
Sociales de los Trabajadores del Estado or ISSSTE). Affiliation is mandatory for salaried (IMSS) and
public workers (ISSSTE) with dependents having the option to enroll. Together, IMSS and ISSSTE cover
57% percent of the population (Presidencia de la República, 2011). Benefits include a comprehensive
package of medical care that is in general free at the time of use. In addition, benefits include old�?age
and accident insurance, sick and maternal leave and day care.
8. The main non�?contributory subsystems are the Sistema de Protección Social en Salud (Social
Protection System in Health or SPSS) and the National Health Care System (NHCS). The SPSS is in
general open to all Mexicans without social security and entails four schemes for different population
groups and/or with different benefits. First, Seguro Popular offers defined in the Catálogo Universal de
Servicios de Salud (CAUSES) comprehensive primary care and approximately 90% of standard secondary
care interventions. The Fondo de Protección de Gastos Catastróficos (Fund for the Protection of
Catastrophic Expenditures or FPGC) finances selected high�?cost, tertiary care interventions, including,
for example, the treatment of childhood cancers and cardio�? and neuro�?vascular diseases. Third, the
Seguro Médico para una Nueva Generación (Health Insurance for a New Generation or SMNG) is open to
children born since December 1st 2006. Its benefits complement those of the FPGC, including tertiary
care for all childhood illnesses. Finally, the Embarazo Saludable strategy is open to all pregnant women
offering antenatal care, hospital�?based, skilled birth attendance, and postpartum care. The NHCS is
open to all Mexicans. Entitlements are not explicit and access to care depends on the availability of
resources and services in public facilities.
9. As it goes to scale, the SPSS gradually replaces the financing system and strengthens the
NHCS. First it replaces budgets with per capita allocations to increase public financing and thus
ensure the availability or resources to finance the SPSS entitlements and to reduce fiscal imbalances
(across federal entities). Prior to the introduction of the SPSS, the Federal Government set the federal
budget envelope for the financing of the national health care system based on expenditures in the
previous year, adjusted for inflation. It determined allocations to federal entities for the provision of
services based on the payroll and infrastructure of each state health system, with minor adjustments for
mortality rates. In contrast, the SPSS is financed with an actuarially�?set per�?capita quota. The quota is
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
financed by the governments of the federation and federal entities. The specific arrangements mimic
the tripartite funding model of the contributory social security schemes. The Federal government makes
two contributions: the social contribution (cuota social) and the federal solidarity contribution
(aportación solidaria federal); �? the latter being adjusted for transfer under other health programs.
Federal entities make a single contribution called the state solidarity contribution (aportación solidaria
estatal). From the per�?capita quota, 89% are transferred to federal entities to finance the benefits of the
Seguro Popular, and 8% are transferred to the Comisión Nacional de Protección Social en Salud (National
Commission for Social Protection in Health or CNPSS) to finance the benefits of the FGC. The remainder
of funds is allocated to a trust fund for infrastructure or earmarked to build up reserves. In addition to
the per�?capita quota, the federal government transfers funds to federal entities for the delivery of the
benefits included in the SMNG and the Embarazo Saludable program.
10. Second, the SPSS replaces user fees with beneficiary contributions to improve the financial
protection of the poor. As part of the NHCS financing architecture, providers charge fees for the use of
services. Under the SPSS, services are free at the time of use. In turn, however, the financing
architecture of the SPSS includes a beneficiary contribution set according to a household’s ability to pay.
The latter is assessed through a self�?administered proxy�?means test. The beneficiary contribution,
however, has by and large not been enforced.
C. Study Approach
11. The study drew primarily on the Encuesta Nacional de Ingresos y Gastos de los Hogares (the
National Survey of Household Income and Expenditures or ENIGH). The National Survey of Household
Income and Expenditures is representative at the national level and for urban and rural areas. Data are
collected every two years. On the expenditure side, it differentiates between more than 70 different
categories. It captures information from approximately 30,000 households and 120,000 individuals in
three different months during February to October of a given year.
12. The National Survey of Household Income and Expenditures of 2008 has two major
advantages over previous waves. First, a new survey design allowed for more robust and in�?depth
analyses of health and health insurance questions. For the first time, the survey captured information
about the prevalence of illness (see below). In addition, it captured information about the health
insurance status of individuals. In the past, information about the latter had been limited to workers.
Second, the 2008 wave was collected at a time where the SPSS had covered approximately half of its
target population, which allowed for a powerful comparison of SPSS, uninsured and social security
households.
13. The study classified households into three mutually exclusive groups. SPSS households had at
least one member enrolled with the SPSS, but no member enrolled with the social security systems.
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Social security households had at least one member enrolled with IMSS or ISSSTE, but no member
enrolled with the SPSS. Uninsured households had no member enrolled with neither SPSS nor the social
security systems. It is important to note that enrollment is on a family basis. Therefore, the study
excluded approximately 1,300 households with members enrolled with both SPSS and the social security
systems.
14. Given the ENIGH design, the study defined key health and health financing concepts as
follows:
Illness: Households with at least one member with a condition preventing her from activities of daily
living during the previous 12 months.
Coverage: Household with at least one member with a condition preventing her from activities of daily
living during the previous 12 months that sought health care for the treatment of such condition.
Out�?of�?pocket health expenditures1: Expenditures on inpatient and outpatient�?care, medicines,
alternative medicines, medical devices and dental care during the previous 30 days. For purposes of
comparison with other studies, data were annualized.
Catastrophic health expenditures2: Households with out�?of�?pocket expenditures during 3 months
exceeding 30 percent of disposable household income over the same period of time. In addition, the
study assessed catastrophic expenditures as out�?of�?pocket expenditures of 20 percent and 10 percent of
disposable income.
The study employed the following methodologies: Chi�?2 and T�?tests to compare means for statistical
significance; logarithmic regressions to identify determinants of key outcomes; and propensity scores to
match households and thus control for differences among population groups.
D. Key findings
Health status and utilization of care
15. Mexican households faced illnesses at a prevalence of more than 50 percent with more than
95 percent of affected households seeking health care (table 1). The prevalence of illness varied
somewhat randomly across income deciles from a low of 55.8 percent in income decile 1 to a high of
60.0 percent in income decile 5. In contrast, the ratio of households seeking care when facing an illness
1
In the remainder of this document, we refer to out�?of�?pocket health expenditures as out�?of�?pocket expenditures
or OOP expenditures.
2
In the remainder of this document, we refer to catastrophic health expenditures as catastrophic expenditures.
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
increased rather steadily across income deciles from a low of 91.8 percent in income decile 1 to 97.6
percent in income decile 10.
Table 1: Incidence of illness and utilization of care by income decile
Income Incidence of Coverage 2/
decile illness 1/
1 55.8% 91.8%
2 57.4% 92.2%
3 56.3% 94.2%
4 55.4% 95.7%
5 60.0% 95.8%
6 55.7% 95.8%
7 56.9% 97.1%
8 58.0% 96.6%
9 59.5% 96.7%
10 56.4% 97.6%
Average 57.1% 95.4%
1/ Illness: Households with at least one member having a condition that prevented her from carrying out
activities of daily living (ADL).
2/Coverage: Households with at least one member having conditions that prevented her from carrying
out ADL and seeking care among households with at least one member having a condition that
prevented her from carrying out ADL.
16. SPSS households were more likely to face an illness than uninsured and social security
households (table 2). More than 65 percent of SPSS households reported having at least one household
member suffering from a health condition that prevented her from carrying out activities of daily living
(ADL) over the past 12 months. The prevalence among SPSS households was 12.7 percentage points
higher than among uninsured households (p=0.00) and 9.0 percentage points higher than among social
security households (p=0.00). Compared to SPSS households, the probability of uninsured households
to have a member suffering from a health condition that prevented her from carrying out ADL’s was
0.68 (p<0.01) and of social security households 0.80 (p<0.01). Factors other than insurance status that
explained the likelihood of episodes of illnesses in households related to the age�?structure of
households and their income. The likelihood was higher among households with more members, with
elderly members and was lower among households with less income and, somewhat strikingly, with
households with children.
17. When facing illnesses, SPSS households seemed more likely to seek health care than
uninsured households, but were less likely to do so than social security households (table 3 and 4). In
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
94.5 percent of all health episodes that prevented members of SPSS households from carrying out ADL’s,
they used health services. The coverage of SPSS households was 1.8 percentage points higher than of
uninsured households (p<0.1) but 2.9 percentage points lower than of social security households
(p=0.00). Similarly, compared to SPSS households, the probability of uninsured households to seek
health care when a member suffered from illness was 0.74 (p<0.01) but of social security households
1.61 (p<0.01). Factors other than insurance status that explained the likelihood of seeking care when
facing illness related to the age�?structure of households and their income. The likelihood was higher
among households with children, with elderly members, and with higher incomes.
Table 2. Prevalence of illness – SPSS, uninsured and social security households
SPSS �? SPSS &
SPSS Uninsured
Uninsured Uninsured
*** 12.7
Illness (%) 1/ 65.5 52.8 57.8
(p=0.000)
SPSS �? SPSS &
Social
SPSS Social Social
Security
Security Security
*** 9.0
Illness (%) 1/ 65.5 56.5 59.0
(p=0.000)
*p<0.1, ** p<0.05, ***p<0.01
Table 3. Utilization of health services when ill – SPSS, uninsured and social security households
SPSS �? SPSS &
SPSS Uninsured
Uninsured Uninsured
* 1.8
Coverage (%) 2/ 94.3 92.5 93.3
(p=0.058)
SPSS �? SPSS &
Social
SPSS Social Social
Security
Security Security
*** �?2.9
Coverage (%) 2/ 94.3 97.1 96.3
(p=0.000)
*p<0.1, ** p<0.05, ***p<0.01
1/ Illness: Households with at least one member having a condition that prevented her from carrying out
activities of daily living (ADL).
2/Coverage: Households with at least one member having conditions that prevented her from carrying
out ADL and seeking care among households with at least one member having a condition that
prevented her from carrying out ADL.
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Table 4: Determinants of the prevalence of illness 1 – All households
Determinants of illness Odds Determinants of Odds Ratio
Ratio coverage
SPSS Reference SPSS reference
Social Security ***0.796 Social Security ***1.608
(p=0.000) (p=0.003)
No insurance ***0.682 No insurance *0.741
(p=0.000) (p=0.054)
Children aged 0�?14 ***0.72 Children aged 0�?14 **1.125
(p=0.002) (p=0.005)
Members of 65 or more ***1.917 Members of 65 or ***1.657
years (p=0.000) more years (p=0.000)
Size of the household ***1.248
(p=0.000)
Logarithm of current ***0.98 Logarithm of current ***1.438
income per capita (p=0.000 income per capita (p=0.000)
*p<0.1, ** p<0.05, ***p<0.01
Out�?of�?pocket expenditures
18. In average, households faced out�?of�?pocket expenditures of approximately MX$ 2,560 per
year constituting approximately 2.1 percent of their disposable income. Out�?of�?pocket expenditures
increased steadily across income deciles from a low of MX$674 in income decile 1 to a high of MX$
8,930 in income decile 10. In turn, out�?of�?pocket expenditures as a percentage of disposable household
income decreased steadily from a high of 5.7 percent in income decile 1 to a low of 1.8 percent in
income decile 10.
Table 5: Out�?of�?pocket expenditures, disposable income and out�?of�?pocket expenditures as a
percentage of disposable income by income deciles [Mexican Pesos, 2008]
Income OOP health Disposable OOP as a % of
decile expenditures income disposable
income
1 674 11,793 5.7%
2 1,093 26,942 4.1%
3 1,200 39,834 3.0%
4 1,367 52,145 2.6%
5 1,554 65,842 2.4%
6 1,827 83,981 2.2%
7 2,321 109,491 2.1%
8 2,763 144,665 1.9%
9 3,927 206,816 1.9%
10 8,930 500,653 1.8%
Average 2,560 123,794 2.1%
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
19. SPSS households had significantly lower out�?of�?pocket expenditures than uninsured and social
security households. On average, SPSS households incurred out�?of�?pocket health expenditures of MX$
1,517 per year. This was MX$ 934 or 38.1 percent lower than the out�?of�?pocket expenditures of
uninsured households (p=0.00) and MX$ 1,501 or 49.7 percent lower than those of social security
households (p=0.00).
20. For the population as a whole, however, household characteristics other than the insurance
status mattered more as determinants of out�?of�?pocket expenditures (Table 8 and annex 1). When
compared to affiliation with SPSS, neither lack of insurance (p=0.30) nor affiliation with social security
(p=0.76) had a significant effect on out�?of�?pocket expenditures. However, households characteristics
such as larger household size, the presence of an infant, the presence of an elderly, a member suffering
recently from illness, a higher number of household members with a bad or very bad health status, a
higher educational degree of the household head, a higher income and the location in a more developed
(less deprived) community were associated with significantly higher out�?of�?pocket expenditures.
21. Moreover, the frequency of these household characteristics varied substantially across
population groups with different insurance status (table 9). SPSS households had a larger size and
included more frequently infants and their members faced more frequently episodes of illnesses and
were more frequently in a bad or very bad health status compared to both uninsured and social security
households, all of which made SPSS households more likely to have higher out�?of�?pocket expenditures.
In contrast, the heads of SPSS households were less educated and the households less frequently
located in more developed (or less deprived) communities, again, compared to both uninsured and
social security households, all of which made SPSS households less likely to have higher out�?of�?pocket
expenditures.
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Table 6: Household characteristics – SPSS, uninsured and social security households
Characteristic SPSS Uninsured Social Average
security
Size of the
4.5 3.7 3.8 4.0
household (mean)
Infants in the
0.11 0.06 0.05 0.06
household (mean)
Members with bad
or very bad health 0.33 0.22 0.18 0.23
status (mean)
HoH high school
6 17 32 22
completed (%)
Households in the
first 2 income 42 31 7 20
deciles (%)
Households in the
first 5 income 79 66 31 50
deciles (%)
Households living
in localities with
9 6 0 4
very high
deprivation (n)
Households living
in localities with
23 13 5 11
medium
deprivation (n)
22. When controlling for household characteristics associated with SPSS affiliation (annex 3) SPSS
households had significantly lower out�?of�?pocket expenditures than uninsured households – though
with a smaller margin �? but similar to those of social security households (table 9). Matching SPSS with
uninsured households, SPSS household expenditures amounted to MX$ 1,493 per year compared to
MX$ 2,043 per year for uninsured households (p<0.05). Matching SPSS with social security households,
SPSS household expenditures amounted to MX$1,485 per year compared to MX$1,654 per year for
social security households (p=0.73)
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Table 7. Annual out�?of�?pocket expenditures – SPSS, uninsured Table 8. Effects of selected
and social security households [Mexican Pesos, 2008] determinants of the out�?of�?pocket
SPSS �? SPSS & expenditure
SPSS Uninsured
Uninsured Uninsured SPSS Reference
***�?934 2,082 No insurance 0.082
1,517 2,450
p=0.00 (p=0.303)
SPSS & Social Security 0.026
Social SPSS �? Social Social (p=0.759)
SPSS
Security Security Security More than 4 �?0.223
members (p=0.000)
***�?1501 2,606 With infants 0.447
1,517 3,018 (p=0.000)
p=0.00
*p<0.1, ** p<0.05, ***p<0.01 With members of 65 0.255
or more years (p=0.000)
Illness 0.394
Table 9. Annual out�?of�?pocket expenditure for Matched Pairs�? (p=0.000)
SPSS, uninsured and Social Security [Mexican Pesos, 2008] With member in bad 0.177
SPSS �? health status (p=0.000)
SPSS Uninsured HoH primary school Reference
Uninsured
**�?550 not finished
1,493 2,043
p=0.03
SPSS – HoH – high school 0.328
Social finished (p=0.000)
SPSS Social
Security Income decile 1 Reference
Security
�?168 Income decile 5 0.702
1485 1654 (p=0.000)
p=0.73
*p<0.1, ** p<0.05, ***p<0.01 Community – Very Reference
high deprivation
Community – 0.465
Medium deprivation (p=0.000)
23. The pattern for medicine�?specific out�?of�?pocket expenditures was very similar to the one for
total out�?of�?pocket expenditures. SPSS households incurred medicine�?specific out�?of�?pocket
expenditures of MX$ 612 per year. This was MX$ 237 or 27.9 percent lower than the medicine�?specific
out�?of�?pocket expenditures of uninsured households (p=0.00) and MX$ 125 or 22.5 percent lower than
those of social security households (p=0.01). The same household characteristics that mattered most
for total out�?of�?pocket expenditures also mattered most for medicine�?specific out�?of�?pocket
expenditures with the exception of a significant effect of social security affiliation, but none for the
presence of an infant and income below income decile 3. When matching SPSS with uninsured
households, SPSS household medicine�?specific out�?of�?pocket expenditures amounted to MX$ 432 per
year compared to MX$ 557 per year for uninsured households (p<0.01). Matching SPSS with social
security households, SPSS household’s medicine�?specific out�?of�?pocket expenditures amounted to MX$
430 per year compared to MX$ 484 per year for social security households (p=0.70).
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Table 10. Annual out�?of�?pocket expenditures on medicines– Table 11. Effects of selected
SPSS, Table x. uninsured and social security households determinants of the out�?of�?pocket
[Mexican Pesos, 2008] expenditure on medicines
SPSS �? SPSS & (logarithmic)
SPSS Uninsured
Uninsured Uninsured SPSS Reference
***�?237 756 No insurance �?0.016
612 849
p=0.00 (p=0.851)
SPSS & Social Security �?0.148
Social SPSS �? Social Social (p=0.067)
SPSS
Security Security Security More than 4 �?0.155
members (p=0.000)
***�?329 851 With infants 0.089
612 941 (p=0.120)
p=0.00
*p<0.1, ** p<0.05, ***p<0.01 With members of 0.267
65 or more years (p=0.000)
Illness 0.184
Table 12. Annual out�?of�?pocket expenditure on medicines (p=0.011)
for Matched Pairs�? SPSS, uninsured and Social Security With member in 0.171
[Mexican Pesos, 2008] bad health status (p=0.000)
SPSS �? HoH primary school Reference
SPSS Uninsured not finished
Uninsured
***�?125
432 557 HoH – high school 0.177
p=0.00
SPSS – finished (p=0.002)
Social Income decile 1 Reference
SPSS Social
Security
Security Income decile 5 0.578
�?54 (p=0.000)
430 484
p=0.70 Community – Very Reference
*p<0.1, ** p<0.05, ***p<0.01 high deprivation
Community – 0.317
Medium (p=0.002)
deprivation
24. The pattern for outpatient�?care specific out�?of�?pocket expenditures was also very similar to
the one for total out�?of�?pocket expenditures. SPSS households incurred outpatient�?care specific out�?
of�?pocket expenditures of MX$ 476 per year. This was MX$ 232 or 32.8 percent lower than the
outpatient�?care specific out�?of�?pocket expenditures of uninsured households (p=0.00) and MX$ 163 or
22.3 percent lower than those of social security households (p=0.01). The same household
characteristics that mattered most for total out�?of�?pocket expenditures also mattered most for
outpatient�?care�?specific out�?of�?pocket expenditures with the exception that community development
had no significant effect above the threshold of medium deprivation. When matching SPSS with
uninsured households, SPSS household’s outpatient�?care specific out�?of�?pocket expenditures amounted
to MX$ 567 per year compared to MX$ 730 per year for uninsured households (p<0.01). Matching SPSS
with social security households, SPSS household’s outpatient�?care specific out�?of�?pocket expenditures
amounted to MX$ 564 per year compared to MX$ 536 per year for social security households (p=0.81)
11
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Table 13. Annual out�?of�?pocket expenditures on Table 14. Effects of selected
outpatient�?care – SPSS, uninsured and social security determinants of the out�?of�?pocket
households [Mexican Pesos, 2008] expenditure on outpatient�?care
SPSS �? SPSS & (logarithmic)
SPSS Uninsured
Uninsured Uninsured SPSS Reference
***�?232 617 No insurance 0.033
476 708
p=0.00 (p=0.720)
SPSS & Social Security �?0.032
Social SPSS �? Social Social (p=0.748)
SPSS
Security Security Security More than 4 �?0.273
members (p=0.000)
***�?386 756 With infants 0.208
476 862 (p=0.001)
p=0.00
*p<0.1, ** p<0.05, ***p<0.01 With members of 65 0.115
or more years (p=0.043)
Illness 0.229
Table 15. Annual out�?of�?pocket expenditure on outpatient�? (p=0.012)
care for Matched Pairs�? SPSS, uninsured and Social Security With member in bad 0.123
[Mexican Pesos, 2008] health status (p=0.000)
SPSS �? HoH primary school Reference
SPSS Uninsured
Uninsured not finished
***�?163
567 730
p=0.00 HoH – high school 0.315
SPSS – finished (p=0.000)
Social
SPSS Social Income decile 1 Reference
Security
Security Income decile 5 0.532
28 (p=0.000)
564 536
p=0.81 Community – Very Reference
*p<0.1, ** p<0.05, ***p<0.01 high deprivation
Community – 0.277
Medium deprivation (p=0.030)
25. However, the pattern for inpatient�?care specific out�?of�?pocket expenditures was substantially
different from the one for total out�?of�?pocket expenditures; most importantly, when controlling for
key determinants, SPSS household had similar inpatient�?care specific out�?of�?pocket expenditures to
uninsured households. SPSS households incurred inpatient�?care specific out�?of�?pocket expenditures of
MX$ 299 per year. This was MX$ 165 or 35.5 percent lower than the inpatient�?care specific out�?of�?
pocket expenditures of uninsured households (p<0.05) and MX$ 270 or 47.5 percent lower than those of
social security households (p<0.01). Household characteristics that mattered most for inpatient�?care
specific out�?of�?pocket expenditures differed substantially from those that mattered most for total out�?
of�?pocket expenditures. First, compared with SPSS affiliation, both lack of insurance and affiliation with
social security was associated with significantly higher inpatient�?care specific out�?of�?pocket
expenditures. Second, among household characteristics that mattered most for total out�?of�?pocket
expenditures, only the presence of an infant, a member suffering from illness, a higher educational
12
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
degree of the household head, and income from decile 6 upwards were associated with significantly
higher inpatient care�?specific out�?of�?pocket expenditures. When matching SPSS with uninsured
households for characteristics other than insurance status, SPSS household’s inpatient�?care specific out�?
of�?pocket expenditures amounted to MX$ 347 per year compared to MX$ 535 per year for uninsured
households (p=0.37). Matching SPSS with social security households, SPSS household’s inpatient�?care
specific out�?of�?pocket expenditures amounted to MX$ 350 per year compared to MX$ 266 per year for
social security households (p=0.37)
Table 16. Annual out�?of�?pocket expenditures on Table 17. Effects of selected determinants
inpatient�?care – SPSS, uninsured and social security of the out�?of�?pocket expenditure on
households [Mexican Pesos, 2008] inpatient�?care (logarithmic)
SPSS �? SPSS & SPSS Reference
SPSS Uninsured No insurance 1.497
Uninsured Uninsured
**�?165 399 (p=0.001)
299 464 Social Security 0.953
p=0.01
(p=0.051)
SPSS &
SPSS �? More than 4 0.001
Social Social members (p=0.994)
SPSS Social
Security Security With infants 0.745
Security
(p=0.000)
***�?270 495 With 0.095
299 569 members of (p=0.686)
p=0.00
*p<0.1, ** p<0.05, ***p<0.01 65 or more
years
Table 18. Annual out�?of�?pocket expenditure on Illness 1.247
inpatient�?care for Matched Pairs�? SPSS, uninsured and (p=0.004)
Social Security [Mexican Pesos, 2008] With member �?0.008
in bad health (p=0.961)
SPSS �?
SPSS Uninsured status
Uninsured
HoH primary Reference
�?187.83 school not
347 535
p=0.37 finished
Social SPSS – Social HoH – high 0.805
SPSS
Security Security school (p=0.005)
84 finished
350 266 Income decile Reference
p=0.80
*p<0.1, ** p<0.05, ***p<0.01 1
Income decile �?0.052
5 (p=0.886)
Community – Reference
Very high
deprivation
Community – 0.150
Medium (p=0.735)
deprivation
13
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Catastrophic health expenditures3
26. Mexican households faced catastrophic expenditures of 30 percent of disposable income at an
incidence of 2.5 percent, of 20 percent of disposable income at an incidence of 3.9 percent and of 10
percent of disposable income at an incidence of 7.8 percent. Independent of the threshold, the
incidence of catastrophic expenditures declined more or less steadily across income deciles, from a high
of 10.5 percent in income decile 1 to a low of 0.6 percent in income decile 10 for a threshold of 30
percent of disposable income; from a high of 13.6 percent in income decile 1 to a low of 1.3 percent in
income decile 8 for a threshold of 20 percent of disposable income; and from a high of 20.9 percent in
income decile 1 to a low of 4.6 percent in income decile 10 for a threshold of 30 percent of disposable
income.
Table 19: Incidence of catastrophic expenditures by income decile
CAT 30 CAT 20 CAT 10
Income decile 1/ 2/ 3/
1 10.5% 13.6% 20.9%
2 4.8% 7.0% 12.3%
3 2.4% 3.9% 8.6%
4 2.0% 3.3% 7.7%
5 0.9% 2.4% 5.5%
6 1.1% 1.8% 5.2%
7 0.9% 2.1% 5.2%
8 0.6% 1.3% 3.9%
9 0.8% 1.4% 3.8%
10 0.6% 1.7% 4.6%
Average 2.5% 3.9% 7.8%
1/ Households with catastrophic expenditure higher than 30% of disposable income
2/ Households with catastrophic expenditure higher than 20% of disposable income
3/ Households with catastrophic expenditure higher than 10% of disposable income
27. Independent of the ratio of out�?of�?pocket expenditure to disposable income, SPSS households
experienced catastrophic expenditures with a frequency similar to uninsured households (Table 20).
SPSS households faced out�?of�?pocket expenditures of more than 30 percent of disposable income with
an incidence of 4.3 percent and uninsured households with an incidence of 3.8 percent (p=0.96). SPSS
households faced out�?of�?pocket expenditures of more than 20 percent of disposable income with an
incidence of 6.1 percent and uninsured with an incidence of 5.7 percent (p=0.58). And SPSS households
faced out�?of�?pocket expenditures of more than 10 percent of disposable income with an incidence of
11.1 percent and uninsured with an incidence of 11.2 percent (p=0.26).
3
In the remainder of the paper, we will refer to catastrophic health expenditures as catastrophic expenditures.
14
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Table 20. Incidence of catastrophic expenditure –SPSS, uninsured and social security households
SPSS �? SPSS &
SPSS Uninsured
Uninsured Uninsured
0.5 4.0
CAT 30 (%) 1/ 4.3 3.8
p=0.96
0.4 5.9
CAT 20 (%) 2/ 6.1 5.7
p=0.58
�?0.1 11.2
CAT 10 (%) 3/ 11.1 11.2
p=0.26
SPSS �? SPSS &
Social
SPSS Social Social
Security
Security Security
***3.18% 2.0
CAT 30 (%) 1/ 4.3 1.1
p=0.00
***4.13% 3.1
CAT 20 (%) 2/ 6.1 2.0
p=0.00
***6.53% 6.4
CAT 10 (%) 3/ 11.1 4.6
p=0.00
1/ Households with catastrophic expenditure higher than 30% of disposable income
2/ Households with catastrophic expenditure higher than 20% of disposable income
3/ Households with catastrophic expenditure higher than 10% of disposable income
*p<0.1, ** p<0.05, ***p<0.01
28. In contrast and again independent of the ratio of out�?of�?pocket expenditure to disposable
income, SPSS households experienced catastrophic expenditures with a significantly higher frequency
than social security households (table 20). For the 30 percent threshold, the difference was 3.2
percentage points (p=0), for the 20 percent threshold 4.1 percent (p=0) and for the 10 percent threshold
6.5 percent (p=0).
29. As in the case for out�?of�?pocket expenditures, for the population as a whole, household
characteristics other than the insurance status mattered most as determinants of catastrophic
expenditures (table 21 and annex 2). Independent of the ratio of out�?of�?pocket expenditures to
disposable household income, when compared to neither affiliation with SPSS, neither lack of insurance
nor affiliation with social security had any significant effect on the incidence of catastrophic
expenditures. The household characteristics that mattered most as determinants of catastrophic
expenditures were identical to those that determined out�?of�?pocket expenditures with the only
exception that community development had no significant effect at the level of very low deprivation.
Table 21. . Effects of selected determinants of the incidence of catastrophic expenditure
CAT 30 CAT 20 CAT 10
SPSS Reference
15
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
No insurance 1.482 1.347 1.286
(p=0.155) (p=0.209) (p=0.110)
Social Security 0.741 0.925 0.873
(p=0.362) (p=0.751) (p=0.433)
More than 4 0.994 0.974 0.859
members (p=0.965) (p=0.811) (p=0.054)
With infants 2.245 2.155 1.987
(p=0.000) (p=0.000) (p=0.000)
With members of 65 1.448 1.206 1.200
or more years (p=0.006) (p=0.094) (p=0.047)
Illness 3.216 2.890 2.203
(p=0.000) (p=0.000) (p=0.000)
With member in bad 1.214 1.302 1.265
health status (p=0.003) (p=0.000) (p=0.000)
HoH primary school Reference
not finished
HoH – high school 1.985 1.784 1.748
finished (p=0.001) (p=0.000) (p=0.000)
Income decile 1 Reference
Income decile 5 0.053 0.099 0.170
(p=0.000) (p=0.000) (p=0.000)
Community – Very Reference
high deprivation
Community – 1.668 1.918 2.099
Medium deprivation (p=0.019) (p=0.000) (p=0.000)
30. When controlling for household characteristics associated with SPSS affiliation, SPSS
households showed a significant lower incidence of catastrophic expenditures than uninsured
households; moreover, the stark differences between SPSS and social security households vanished
almost completely (table 22). Matching SPSS with uninsured households, SPSS household faced out�?of�?
pocket expenditures of more than 30 percent of disposable income with an incidence of 4.1 percent
compared to 4.8 percent for uninsured households (p<0.05), out�?of�?pocket expenditures of more than
20 percent of disposable income with an incidence of 6.0 percent compared to 7.0 percent (p<0.05) and
out�?of�?pocket expenditures of more than 10 percent of disposable income with an incidence of 10.6
percent compared to 12.8 percent (p=0.00). In contrast, matching SPSS with social security households,
SPSS household faced out�?of�?pocket expenditures of more than 30 percent of disposable income with an
incidence of 4.1 percent compared to 3.8 percent for social security households (p=0.52), out�?of�?pocket
expenditures of more than 20 percent of disposable income with an incidence of 6.0 percent compared
to 6.2 percent (p=0.76) and out�?of�?pocket expenditures of more than 10 percent of disposable income
with an incidence of 10.6 percent compared to 9.1 percent (p<0.1)
16
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Table 22. Incidence of catastrophic expenditure for Matched Pairs�? SPSS, uninsured and social security
households
SPSS �?
SPSS Uninsured
Uninsured
**�?0.7
CAT 30 (%) 1/ 4.1 4.8
P<0.05
**�?1.0
CAT 20 (%) 2/ 6.0 7.0
p=0.02
***�?2.1
CAT 10 (%) 3/ 10.6 12.8
p=0.00
SPSS –
Social
SPSS Social
Security
Security
0.3
CAT 30 (%) 1/ 4.1 3.8
p=0.52
�?0.2
CAT 20 (%) 2/ 6.0 6.2
p=0.76
*1.6
CAT 10 (%) 3/ 10.6 9.1
p=0.08
1/ Households with catastrophic expenditure higher than 30% of disposable income
2/ Households with catastrophic expenditure higher than 20% of disposable income
3/ Households with catastrophic expenditure higher than 10% of disposable income
*p<0.1, ** p<0.05, ***p<0.01
17
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Out�?of�?pocket expenditures, disposable household income and catastrophic expenditures
31. For SPSS and uninsured households facing catastrophic expenditures, the depth of the shock
was primarily dependent of disposable income; in contrast, for social security households, the depth
of the shock was dependent on both level of out�?of�?pocket expenditures and disposable income.
Across levels of the depth (10 to 50 percent of disposable income), out�?of�?pocket expenditures of SPSS
households hovered around MX$9,500 while their disposable income declined by 75% percent from
MX$28,970 to MX$ 7,260. Similarly, out�?of�?pocket expenditures of uninsured households hovered
around MX$14,000 while their disposable income declined by 82% percent from MX$ 63,550 to
MX$11,670. In contrast, out�?of�?pocket expenditures of Social Security households increased by 65%
percent from MX$ 28,500 to MX$ 81,060 while their disposable income declined only by 25.6 percent
from MX$ 141,410 to MX$ 104,140.
Figure 1. Out�?of�?pocket expenditures, disposable income and catastrophic expenditures
[Mexican Pesos, 2008]
$160,000.00
Annual out of pocket expenditure and
$140,000.00
$120,000.00
income by household
$100,000.00
$80,000.00
$60,000.00
$40,000.00
$20,000.00
$-
>10% >20% >30% >40% >50%
32. In contrast, independent of the insurance status, household expenditures on inpatient care
constituted the largest share of out�?of�?pocket expenditures. Moreover, the share of inpatient
expenditures grew with the depth of the shock. For SPSS households, the share increased from 32
percent to 65 percent, for uninsured households from 31 percent to 62 percent, and, for social security
households, from 38 percent to 67 percent.
18
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Figure 2. Composition of out�?of�?pocket expenditures for households with catastrophic expenditures
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
>10% >20% >30% > 40% >50%
Outpatient Medicines Inpatient Others
19
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Figure 3. Composition of out�?of�?pocket expenditures for SPSS households with catastrophic
expenditures.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
>10% >20% >30% > 40% >50%
Outpatient Medicines Inpatient Others
Figure 4. Composition of out�?of�?pocket expenditures for uninsured households with catastrophic
expenditures.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
>10% >20% >30% > 40% >50%
Outpatient Medicines Inpatient Others
20
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Figure 5. Composition of out�?of�?pocket expenditures for social security households with catastrophic
expenditures.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
>10% >20% >30% > 40% >50%
Outpatient Medicines Inpatient Others
21
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
E. Discussion
33. After a short period of time �? approximately 5 years after its inception – the SPSS covered
almost half of its target population and targeted households with low incomes and members suffering
from health conditions. In the early years, enrollment into the SPSS had focused on the poor, with
specific affiliation targets for low income deciles and highly marginalized, small municipalities; in
addition, the law foresaw a member contribution – that was hardly enforced though �? with exemptions
for households in the lowest income deciles. As a result, in 2008, roughly 68 percent of SPSS households
fell under the assets poverty line compared to 51 percent of the uninsured population and 23 percent of
social security households. Enrollment into the SPSS had also focused on the sick and vulnerable using a
multi�?pronged approach. Independent of the income status, enrollment had been open to individuals
suffering from severe disease when seeking care at public facilities. Moreover, the Seguro Médico para
una Nueva Generación and the Embarazo Saludable strategy had targeted children and pregnant
women. As a result, approximately 66 percent of SPSS households reported the recent illness of a
member compared to 53 of the uninsured households and 57 percent of social security households.
34. However, the SPSS suffered from an error of inclusion as it covered more than one million
households benefitting from social security coverage. At the time of the 2008 National Survey of
Household Income and Expenditures, the only eligibility criterion for SPSS affiliation was lack of social
security coverage, which is however difficult to enforce, in particular, as re�?affiliation with the SPSS is
required only every three years. The analysis of the survey data suggested that 5 percent of the
population enjoyed both SPSS and social security coverage. As the federal government subsidized all
insurance schemes with the social quota of close to US$65 per person per year, the observed multiple
affiliation constituted an avoidable cost of approximately US$350 million.
35. Out�?of�?pocket spending was the main source of health financing, correlating strongly with
income, but affecting disproportionately poor households with the majority seeking health care when
needed. Despite significant increases in government spending over the past decade, out�?of�?pocket
expenditures had continued to rise and constituted more than 50 percent of total health spending in
2009, placing Mexico among the upper middle�?income countries with the highest shares of out�?of�?
pocket financing of health (World Bank, 2010). The largest share of out�?of�?pocket expenditures fell on
medicines (34.7 percent) followed by outpatient�?care (28.9 percent), inpatient�?care (18.9 percent) and
others (17.5 percent). Out�?of�?pocket spending correlated closely with health indicators, risk factors for
health conditions (e.g. the age composition of households) and income; as a share of disposable income,
however, out�?of�?pocket expenditures had a greater impact on poorer households. For example, out�?of�?
pocket expenditures constituted close to 6 percent of disposable income of households in the first
income decile. This was good news only as a sign that even the poorest households did not lack access
but sought health care; in fact, more than 90 percent of the poorest households used health services
when facing illness. However, if recurrent at these levels, out�?of�?pocket expenditures that are not
catastrophic in the first place can drive households into or deeper into poverty. In this context it is
22
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
important to note that the data presented in this study reflected expenditures and income in three
separate months, but were annualized to compare findings with other studies.
36. Catastrophic expenditures affected disproportionately households generating little income
and lacking social security. Given that out�?of�?pocket spending was the main source of health financing
and higher than in many other upper middle income countries, it did not surprise that households also
incurred catastrophic health expenditures at a rate (2.5 percent) that was higher than in many
comparator countries (Perticara, 2008) (Van Doorslaer, 2007) (Xu, 2007) (Saadi Yardima, 2010)). As for
out�?of�?pocket expenditures, the incidence of catastrophic expenditures correlated directly with health
indicators and risk factors for health conditions, but indirectly with income, thus disproportionately
affecting the poor. For example, the incidence of catastrophic expenditures was 10.5 percent in the
lowest income decile compared to 0.6 percent in the highest income quintile. Furthermore, the
incidence was approximately 4 percent among Mexicans without social security compared to 1 percent
of Mexicans with social security.
37. A main objective of the SPSS is to overcome these inequalities in financial protection;
however, the evidence�?base for such an effect has been limited. Evidence stem primarily from
research using a data�?set of an experimental study and a demographic health survey carried out during
the early stages of the SPSS implementation (2005/2006) (King, 2009). Various studies using one of the
datasets had shown significant reductions in catastrophic expenditures associated with SPSS coverage
(municipalities or health clusters) or affiliation (households). Findings regarding out�?of�?pocket
expenditures were less clear cut, showing significant effects only for the probability of having out�?of�?
pocket expenditures, among low asset households or at low levels of statistical significance.
38. This study broke new ground by combining common and new approaches to assess the SPSS
impact on financial protection controlling comprehensively for differences in household
characteristics that were associated with SPSS affiliation, including �? for the first time – differences in
health status. The benefits of this approach were multiple. Results promised to be exceptionally robust;
moreover, the propensity score matching of households allowed for a meaningful comparison between
SPSS and social security households. This latter type of comparisons will become increasingly important
to gauge the impact of the SPSS, as it has been rapidly scaled�?up over the past two years and it is
expected to comprehensively offer health insurance to all Mexicans without social security by 2012. The
strengths of the approach had also some disadvantages. Most importantly, the National Survey of
Household Income and Expenditures of 2008 provided for the first time data on the health and health
insurance status of household members; this, however, did not allow combining ENIGH 2008 data with
information from previous waves, which limited the number of observations and prevented the analysis
of rare events. While this limitation did not have consequences for the analysis of out�?of�?pocket and
catastrophic health expenditures, it did not allow for an assessment of impoverishing effects. To avoid
this problem in the future, it will be important that subsequent waves of the National Survey of
Household Income and Expenditures will include comparable health modules.
23
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
39. This is the first study to show reductions in both out�?of�?pocket and catastrophic expenditures
using the National Survey of Household Income and Expenditures data from a period of higher levels
of SPSS coverage. Matching households based on propensity scores, it demonstrated a reduction of
out�?of�?pocket expenditures of slightly more than 25 percent and a reduction in the incidence of
catastrophic expenditures of slightly more than 15 percent at high levels of statistical significance. The
observed differences were slightly lower than those of studies using the experimental data set or the
demographic health survey. Previous studies using difference�?in�?difference methods on individual or
various waves of data from the National Survey of Household Expenditures and Income had shown no
significant effect for the population of SPSS households (Barros, 2008)
40. In addition, the study confirmed what has been known about the impact of the SPSS on
various types of out�?of�?pocket expenditures. It demonstrated significant effects on out�?of�?pocket
spending on outpatient care and medicines, but not on inpatient care. The latter however requires
cautious interpretation, as the number of observations was low. As such, the study results were
consistent with the literature. Previous studies had consistently demonstrated a significant effect on
out�?of�?pocket spending for outpatient care (Galarraga, 2010) (Barros, 2008) (Grogger, 2011) . Only
studies using demographic and health and the National Survey of Household Income and Expenditures
had shown effects on out�?of�?pocket spending for medicines; in contrast studies using data from the
demographic and health survey and the experimental study demonstrated effects on spending for
inpatient care (Galarraga, 2010).
41. The study findings suggested that improvements in the financial protection of Mexican’s
without social security are commensurate to the spending on the SPSS. Most importantly, when
controlling for other determinants through propensity score matching, there was no significant
difference in the amount of out�?of�?pocket expenditures and the incidence of catastrophic expenditures
between SPSS and social security households. At the same time, however, the per�?capita expenditure
for SPSS and uninsured households was MX$ $2,827.34 or 32% percent lower than for social security
households.
42. Despite the significant impact of the SPSS on the financial protection of Mexican lacking social
security, it seems too early to declare victory as the effective financial protection of the poor remains
an unfinished agenda. The study’s comparison of out�?of�?pocket expenditures, disposable income, and
depth of shock demonstrated an instructive pattern. For social security households, out�?of�?pocket
expenditures increased and disposable income fell with the depth of shock. In contrast, in the case of
SPSS and uninsured households, out�?of�?pocket expenditures remained stable while disposable income
fell. In other words, for SPSS and uninsured households, the depth of a shock was primarily dependent
from the level of disposable household income only. Moreover, independent of the insurance status,
the share of inpatient out�?of�?pocket spending grew with the depth of shock, constituting at least 50
percent of out�?of�?pocket among households with shocks of at least 30 percent of disposable income.
This seemed consistent with earlier findings that the SPSS had a protective effect among low asset
households and rural households with access to larger health facilities (that is more than a doctor and
24
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
an examination room. The latter pointed to an access challenge; other research had also hinted to lack
of demand for SPSS services (Cárdenas, 2011)
25
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Annex 1. Determinants of out�?of�?pocket expenditures
Out�?of�? OOP �? OOP – OOP –
pocket Medicines Outpatien Inpatient�?
t�?care care
SPSS Reference
No insurance 0.082 �?0.016 0.033 1.497
(p=0.303) (p=0.851) (p=0.720) (p=0.001)
Social Security 0.026 �?0.148 �?0.032 0.953
(p=0.759) (p=0.067) (p=0.748) (p=0.051)
Illness 0.394 0.184 0.229 1.247
(p=0.000) (p=0.011) (p=0.012) (p=0.004)
Ilness x No insurance 0.187 0.264 �?0.014 �?1.141
(p=0.048) (p=0.004) (p=0.895) (p=0.019)
Illness x Social Security �?0.104 0.073 �?0.086 �?1.074
(p=0.235) (p=0.382) (p=0.420) (p=0.040)
HoH of 65 or more 0.043 0.011 0.151 0.964
years (p=0.625) (p=0.890) (p=0.105) (p=0.018)
HoH primary school not Reference
finished
HoH primary school 0.074 �?0.011 �?0.062 0.161
finished (p=0.126) (p=0.827) (p=0.253) 0.490)
HoH secondary school 0.107 �?0.004 �?0.037 0.391
finished (p=0.035) (p=0.933) (p=0.529) 0.121)
HoH high school 0.328 0.177 0.315 0.805
finished (p=0.000) (p=0.002) (p=0.000) (p=0.005)
More than 4 members �?0.223 �?0.155 �?0.273 0.001
(p=0.000) (p=0.000) (p=0.000) (p=0.994)
With infants 0.447 0.089 0.208 0.745
(p=0.000) (p=0.120) (p=0.001) (p=0.000)
With members of 65 0.255 0.267 0.115 0.095
and older (p=0.000) (p=0.000) (p=0.043) (p=0.686)
Income decile 1 Reference
Income decile 2 0.204 0.072 0.195 �?0.117
(p=0.005) (p=0.331) (p=0.071) (p=0.740)
Income decile 3 0.382 0.296 0.286 0.395
(p=0.000) (p=0.000) (p=0.002) (p=0.288)
Income decile 4 0.534 0.396 0.436 0.178
(p=0.000) (p=0.000) (p=0.000) (p=0.653)
Income decile 5 0.702 0.578 0.532 �?0.052
(p=0.000) (p=0.000) (p=0.000) (p=0.886)
Income decile 6 0.770 0.549 0.588 0.642
(p=0.000) (p=0.000) (p=0.000) (p=0.097)
Income decile 7 1.036 0.757 0.812 0.703
(p=0.000) (p=0.000) (p=0.000) (p=0.062)
Income decile 8 1.204 0.876 1.016 0.160
(p=0.000) (p=0.000) (p=0.000) (p=0.684)
Income decile 9 1.428 1.058 1.339 0.766
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
(p=0.000) (p=0.000) (p=0.000) (p=0.057)
Income decile 10 1.975 1.453 1.876 1.068
(p=0.000) (p=0.000) (p=0.000) (p=0.004)
With member in bad 0.177 0.171 0.123 �?0.008
halth status (p=0.000) (p=0.000) (p=0.000) (p=0.961)
Community – Very high Reference
deprivation
Community – High 0.413 0.395 0.259 0.003
deprivation (p=0.001) (p=0.000) (p=0.054) (p=0.995)
Community �? Medium 0.465 0.317 0.277 0.150
deprivation (p=0.000) (p=0.002) (p=0.030) (p=0.735)
Community �? Low 0.434 0.338 0.107 0.153
deprivation (p=0.000) (p=0.001) (p=0.430) (p=0.747)
Community – Very low 0.324 0.281 �?0.099 0.199
deprivation (p=0.002) (p=0.008) (p=0.452) (p=0.669)
Community �? Rural Reference
Community �? Semirural �?0.031 �?0.017 �?0.037 �?0.500
(p=0.692) (p=0.804) (p=0.649) (p=0.058)
Community �? Semiurban �?0.113 �?0.107 �?0.146 �?0.569
(p=0.115) (p=0.158) (p=0.066) (p=0.059)
Community �? Urban �?0.103 �?0.062 �?0.165 �?0.333
(p=0.137) (p=0.366) (p=0.037) (p=0.242)
Constant 3.012 2.960 3.385 3.952
(p=0.000) (p=0.000 (p=0.000 (p=0.000
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Annex 2. Determinants of Catastrophic Expenditures
Dependent variable Catastrophic Catastrophic Catastrophic
Expenditure Expenditure Expenditure
(10%) (20%) (30%)
SPSS Reference
No insurance 1.286 1.347 1.482
(p=0.110) (p=0.209) (p=0.155)
Social Security 0.873 0.925 0.741
(p=0.433) (p=0.751) (p=0.362)
Illness 2.203 2.890 3.216
(p=0.000) (p=0.000) (p=0.000)
Illness x No insurance 1.212 1.088 0.922
(p=0.293) (p=0.754) (p=0.795)
Illness x Social Security 0.997 1.012 1.353
(p=0.988) (p=0.966) (p=0.400)
HoH of 65 or more 1.175 1.120 0.874
years (p=0.277) (p=0.563) (p=0.572)
HoH primary school not Reference
finished
HoH primary school 1.152 1.130 1.099
finished (p=0.162) (p=0.325) (p=0.514)
HoH secondary school 1.254 1.163 1.279
finished (p=0.040) (p=0.323) (p=0.193)
HoH high school 1.748 1.784 1.985
finished (p=0.000) (p=0.000) (p=0.001)
More than 4 members 0.859 0.974 0.994
(p=0.054) (p=0.811) (p=0.965)
With infants 1.987 2.155 2.245
(p=0.000) (p=0.000) (p=0.000)
With members of 65 1.200 1.206 1.448
and older (p=0.047) (p=0.094) (p=0.006)
Income decile 1 Reference
Income decile 2 0.373 0.242 0.196
(p=0.000) (p=0.000) (p=0.000)
Income decile 3 0.218 0.159 0.098
(p=0.000) (p=0.000) (p=0.000)
Income decile 4 0.182 0.095 0.067
(p=0.000) (p=0.000) (p=0.000)
Income decile 5 0.170 0.099 0.053
(p=0.000) (p=0.000) (p=0.000)
Income decile 6 0.149 0.090 0.061
(p=0.000) (p=0.000) (p=0.000)
Income decile 7 0.184 0.093 0.038
(p=0.000) (p=0.000) (p=0.000)
Income decile 8 0.142 0.082 0.048
(p=0.000) (p=0.000) (p=0.000)
Income decile 9 0.112 0.063 0.049
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
(p=0.000) (p=0.000) (p=0.000)
Income decile 10 0.142 0.073 0.026
(p=0.000) (p=0.000) (p=0.000)
With member in bad 1.265 1.302 1.214
health status (p=0.000) (p=0.000) (p=0.003)
Community – Very high Reference
deprivation
Community – High 1.784 1.611 1.636
deprivation (p=0.000) (p=0.027) (p=0.039)
Community �? Medium 2.099 1.918 1.668
deprivation (p=0.000) (p=0.000) (p=0.019)
Community �? Low 1.793 1.560 1.599
deprivation (p=0.000) (p=0.031) (p=0.033)
Community – Very low 1.265 1.098 1.262
deprivation (p=0.174) (p=0.670) (p=0.368
Community �? Rural Reference
Community �? Semirural 0.947 1.046 0.845
(p=0.653) (p=0.758) (p=0.357
Community �? Semiurban 0.912 0.968 0.923
(p=0.468) (p=0.846) (p=0.676
Community �? Urban 1.011 1.189 0.976
(p=0.932 (p=0.296 (p=0.909
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Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
Annex 3. Determinants of affiliation to the SPSS excluding social security households
SPSS Reference
Illness 0.348
(p=0.000)
With children of 14 0.364
and less (p=0.000)
Logarithm of current �?0.253
income per capita (p=0.000)
Community – Rural Reference
Community – �?0.191
Semirural (p=0.000)
Community – �?0.371
Semiurban (p=0.000)
Community – Urban �?0.712
(p=0.000)
Constant 1.797
(p=0.000)
SPSS Reference
With bad health 0.229
status (p=0.000)
Years of �?0.057
contribution to (p=0.000)
Social Security
Logarithm of current �?0.725
income per capita (p=0.000)
Self employed Reference
Firm �? Micro �?0.124
(p=0.000)
Firm �? Small �?0.484
(p=0.000)
Firm �? Medium �?0.849
(p=0.000)
Firm �? Large 0.554
(p=0.000)
Constant 6.067
(p=0.000)
30
Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security
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in Mexico.
Cárdenas, S. (2011). Perfil de los afiliados del Seguro Popular.
Galarraga, O. (2010). Health insurance for the poor: impact on catastrophic and out�?of�?pocket health
expenditures in Mexico.
Grogger, J. (2011). The Effect of Seguro Popular on Health Expenditures:.
King, G. (2009). Public Policy for the poor? A randomised assessment of the Mexican universal health
insurance program.
Perticara, M. (2008). Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos.
Presidencia de la República. (2011). Quinto Informe.
Saadi Yardima, M. (2010). Catastrophic health expenditure and impoverishment in Turkey.
Van Doorslaer, E. (2007). Catastrophic payments for care in Asia.
World Bank. (Forthcoming). Missing in Action? –Part Two of Mexico’s 2003 Health Sector Reform.
World Bank. (2010). Trends in government and health financing in Mexico.
Xu, K. (2007). Protecting Households from Catastrophic Health spending.
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