2 ESW Financial Protection final - World Bank

Mexico’s Social Protection System in Health and the Financial Protection of Citizens without Social Security

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June 2012

Human Development Department Latin America and the Caribbean Regional Office

Document of the World Bank

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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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TABLE OF CONTENTS

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A. INTRODUCTION ................................................................................................................ 1

B. BACKGROUND .................................................................................................................. 2

C. STUDY APPROACH ............................................................................................................ 3

D. KEY FINDINGS ................................................................................................................... 4

Health status and utilization of care ..................................................................................................... 4

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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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

Annex 1. Determinants of out‐of‐pocket expenditures ...................................................................... 26

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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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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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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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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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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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 decile

Incidence of illness 1/

Coverage 2/

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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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 UninsuredSPSS ‐

Uninsured SPSS &

Uninsured

Illness (%) 1/ 65.5 52.8*** 12.7(p=0.000)

57.8

SPSS Social Security

SPSS ‐ Social Security

SPSS & Social Security

Illness (%) 1/ 65.5 56.5*** 9.0

(p=0.000)59.0

*p<0.1, ** p<0.05, ***p<0.01

Table 3. Utilization of health services when ill – SPSS, uninsured and social security households


Uninsured SPSS &

Uninsured

Coverage (%) 2/ 94.3 92.5* 1.8

(p=0.058)93.3



SPSS & Social Security

Coverage (%) 2/ 94.3 97.1*** ‐2.9

(p=0.000)96.3

*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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Table 4: Determinants of the prevalence of illness 1 – All households

Determinants of illness Odds Ratio

Determinants of coverage

Odds Ratio

SPSS Reference SPSS reference

Social Security ***0.796(p=0.000)

Social Security ***1.608 (p=0.003)

No insurance ***0.682(p=0.000)

No insurance *0.741 (p=0.054)

Children aged 0‐14 ***0.72(p=0.002)

Children aged 0‐14 **1.125 (p=0.005)

Members of 65 or more years

***1.917(p=0.000)

Members of 65 or more years

***1.657 (p=0.000)

Size of the household ***1.248(p=0.000)

Logarithm of current income per capita

***0.98(p=0.000


***1.438 (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 decile

OOP health expenditures

Disposable income

OOP as a % of 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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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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Table 6: Household characteristics – SPSS, uninsured and social security households

Characteristic SPSS Uninsured Social security

Average

Size of the household (mean)

4.5 3.7 3.8 4.0

Infants in the household (mean)

0.11 0.06 0.05 0.06

Members with bad or very bad health status (mean)

0.33 0.22 0.18 0.23

HoH high school completed (%)

6 17 32 22

Households in the first 2 income deciles (%)

42 31 7 20

Households in the first 5 income deciles (%)

79 66 31 50

Households living in localities with very high deprivation (n)

9 6 0 4

Households living in localities with medium deprivation (n)

23 13 5 11

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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Table 7. Annual out‐of‐pocket expenditures – SPSS, uninsured and social security households [Mexican Pesos, 2008]

SPSS Uninsured SPSS ‐

Uninsured SPSS &

Uninsured

1,517 2,450 ***‐934p=0.00

2,082



SPSS &

Social

Security

1,517 3,018 ***‐1501

p=0.002,606

Table 8. Effects of selected determinants of the out‐of‐pocket

expenditure

SPSS Reference

No insurance 0.082(p=0.303)

Social Security 0.026(p=0.759)

More than 4 members

‐0.223(p=0.000)

With infants 0.447(p=0.000)

With members of 65 or more years

0.255(p=0.000)

Illness 0.394(p=0.000)

With member in bad health status

0.177(p=0.000)

HoH primary school not finished

Reference

HoH – high school finished

0.328(p=0.000)

Income decile 1 Reference

Income decile 5 0.702(p=0.000)

Community – Very high deprivation

Reference

Community – Medium deprivation

0.465(p=0.000)

*p<0.1, ** p<0.05, ***p<0.01

Table 9. Annual out‐of‐pocket expenditure for Matched Pairs‐ SPSS, uninsured and Social Security [Mexican Pesos, 2008]


Uninsured

1,493 2,043 **‐550p=0.03


SPSS – Social Security

1485 1654 ‐168

p=0.73

*p<0.1, ** p<0.05, ***p<0.01

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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Table 10. Annual out‐of‐pocket expenditures on medicines– SPSS, Table x. uninsured and social security households

[Mexican Pesos, 2008]


Uninsured SPSS &

Uninsured

612 849 ***‐237p=0.00

756



SPSS &

Social

Security

612 941 ***‐329p=0.00

851

Table 11. Effects of selected determinants of the out‐of‐pocket

expenditure on medicines (logarithmic)

SPSS Reference

No insurance ‐0.016(p=0.851)

Social Security ‐0.148(p=0.067)

More than 4 members

‐0.155(p=0.000)



0.267(p=0.000)

Illness 0.184(p=0.011)


0.171(p=0.000)


Reference


0.177(p=0.002)




Reference


0.317(p=0.002)

*p<0.1, ** p<0.05, ***p<0.01

Table 12. Annual out‐of‐pocket expenditure on medicines for Matched Pairs‐ SPSS, uninsured and Social Security



Uninsured

432 557 ***‐125 p=0.00



430 484 ‐54

p=0.70

*p<0.1, ** p<0.05, ***p<0.01

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)


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Table 13. Annual out‐of‐pocket expenditures on outpatient‐care – SPSS, uninsured and social security

households [Mexican Pesos, 2008]


Uninsured SPSS &

Uninsured

476 708 ***‐232 p=0.00

617



SPSS &

Social

Security

476 862 ***‐386 p=0.00

756

Table 14. Effects of selected determinants of the out‐of‐pocket expenditure on outpatient‐care

(logarithmic)

SPSS Reference


Social Security ‐0.032(p=0.748)

More than 4 members

‐0.273(p=0.000)



0.115(p=0.043)

Illness 0.229(p=0.012)


0.123(p=0.000)


Reference


0.315(p=0.000)




Reference


0.277(p=0.030)

*p<0.1, ** p<0.05, ***p<0.01

Table 15. Annual out‐of‐pocket expenditure on outpatient‐care for Matched Pairs‐ SPSS, uninsured and Social Security



Uninsured

567 730 ***‐163 p=0.00



564 536 28

p=0.81

*p<0.1, ** p<0.05, ***p<0.01

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


13

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 inpatient‐care – SPSS, uninsured and social security

households [Mexican Pesos, 2008]


Uninsured SPSS &

Uninsured

299 464 **‐165 p=0.01

399



SPSS &

Social

Security

299 569 ***‐270 p=0.00

495

Table 17. Effects of selected determinants of the out‐of‐pocket expenditure on

inpatient‐care (logarithmic) SPSS Reference



More than 4 members

0.001(p=0.994)



0.095(p=0.686)

Illness 1.247(p=0.004)

With member in bad health

status

‐0.008(p=0.961)


Reference


0.805(p=0.005)

Income decile 1

Reference

Income decile5

‐0.052(p=0.886)

Community –Very high deprivation

Reference

Community –Medium

deprivation

0.150(p=0.735)

*p<0.1, ** p<0.05, ***p<0.01

Table 18. Annual out‐of‐pocket expenditure on inpatient‐care for Matched Pairs‐ SPSS, uninsured and

Social Security [Mexican Pesos, 2008]


Uninsured

347 535 ‐187.83 p=0.37



350 266 84

p=0.80

*p<0.1, ** p<0.05, ***p<0.01


14

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

Income decile CAT 30 1/

CAT 20 2/

CAT 10 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



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.


15

Table 20. Incidence of catastrophic expenditure –SPSS, uninsured and social security households


Uninsured SPSS &

Uninsured

CAT 30 (%) 1/ 4.3 3.80.5

p=0.96 4.0

CAT 20 (%) 2/ 6.1 5.70.4

p=0.58 5.9

CAT 10 (%) 3/ 11.1 11.2‐0.1

p=0.26 11.2

SPSSSocial

Security


SPSS & Social

Security

CAT 30 (%) 1/ 4.3 1.1 ***3.18% p=0.00

2.0

CAT 20 (%) 2/ 6.1 2.0***4.13% p=0.00

3.1

CAT 10 (%) 3/ 11.1 4.6 ***6.53% p=0.00

6.4




*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


16


1.347(p=0.209)

1.286 (p=0.110)


0.925(p=0.751)

0.873 (p=0.433)

More than 4 members

0.994(p=0.965)

0.974(p=0.811)

0.859 (p=0.054)


2.155(p=0.000)

1.987 (p=0.000)


1.448(p=0.006)

1.206(p=0.094)

1.200 (p=0.047)

Illness 3.216(p=0.000)

2.890(p=0.000)

2.203 (p=0.000)


1.214(p=0.003)

1.302(p=0.000)

1.265 (p=0.000)


Reference


1.985(p=0.001)

1.784(p=0.000)

1.748 (p=0.000)



0.099(p=0.000)

0.170 (p=0.000)


Reference


1.668(p=0.019)

1.918(p=0.000)

2.099 (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)


17

Table 22. Incidence of catastrophic expenditure for Matched Pairs‐ SPSS, uninsured and social security households


Uninsured

CAT 30 (%) 1/ 4.1 4.8**‐0.7 P<0.05

CAT 20 (%) 2/ 6.0 7.0**‐1.0 p=0.02

CAT 10 (%) 3/ 10.6 12.8***‐2.1 p=0.00

SPSSSocial

Security


CAT 30 (%) 1/ 4.1 3.80.3

p=0.52

CAT 20 (%) 2/ 6.0 6.2‐0.2

p=0.76

CAT 10 (%) 3/ 10.6 9.1*1.6

p=0.08




*p<0.1, ** p<0.05, ***p<0.01


18

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


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.

$-

$20,000.00

$40,000.00

$60,000.00

$80,000.00

$100,000.00

$120,000.00

$140,000.00

$160,000.00

>10% >20% >30% >40% >50%

An

nu

al o

ut

of p

ock

et e

xpen

dit

ure

an

d

inco

me

by

hou

seh

old


19

Figure 2. Composition of out‐of‐pocket expenditures for households with catastrophic expenditures

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>10% >20% >30% > 40% >50%

Outpatient Medicines Inpatient Others


20

Figure 3. Composition of out‐of‐pocket expenditures for SPSS households with catastrophic expenditures.

Figure 4. Composition of out‐of‐pocket expenditures for uninsured households with catastrophic expenditures.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>10% >20% >30% > 40% >50%


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>10% >20% >30% > 40% >50%



21

Figure 5. Composition of out‐of‐pocket expenditures for social security households with catastrophic expenditures.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>10% >20% >30% > 40% >50%



22

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


23

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.


24

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


25

an examination room. The latter pointed to an access challenge; other research had also hinted to lack

of demand for SPSS services (Cárdenas, 2011)


26

Annex 1. Determinants of out‐of‐pocket expenditures

Out‐of‐pocket

OOP ‐ Medicines

OOP – Outpatient‐care

OOP – Inpatient‐

care

SPSS Reference


‐0.016(p=0.851)

0.033(p=0.720)

1.497 (p=0.001)


‐0.148(p=0.067)

‐0.032(p=0.748)

0.953 (p=0.051)

Illness 0.394(p=0.000)

0.184(p=0.011)

0.229(p=0.012)

1.247 (p=0.004)

Ilness x No insurance 0.187(p=0.048)

0.264(p=0.004)

‐0.014(p=0.895)

‐1.141 (p=0.019)

Illness x Social Security ‐0.104(p=0.235)

0.073(p=0.382)

‐0.086(p=0.420)

‐1.074 (p=0.040)

HoH of 65 or more years

0.043(p=0.625)

0.011(p=0.890)

0.151(p=0.105)

0.964 (p=0.018)


Reference

HoH primary school finished

0.074(p=0.126)

‐0.011(p=0.827)

‐0.062(p=0.253)

0.161 0.490)

HoH secondary school finished

0.107(p=0.035)

‐0.004(p=0.933)

‐0.037(p=0.529)

0.391 0.121)

HoH high school finished

0.328(p=0.000)

0.177(p=0.002)

0.315(p=0.000)

0.805 (p=0.005)

More than 4 members ‐0.223(p=0.000)

‐0.155(p=0.000)

‐0.273(p=0.000)

0.001 (p=0.994)


0.089(p=0.120)

0.208(p=0.001)

0.745 (p=0.000)

With members of 65 and older

0.255(p=0.000)

0.267(p=0.000)

0.115(p=0.043)

0.095 (p=0.686)



0.072(p=0.331)

0.195(p=0.071)

‐0.117 (p=0.740)


0.296(p=0.000)

0.286(p=0.002)

0.395 (p=0.288)


0.396(p=0.000)

0.436(p=0.000)

0.178 (p=0.653)


0.578(p=0.000)

0.532(p=0.000)

‐0.052 (p=0.886)


0.549(p=0.000)

0.588(p=0.000)

0.642 (p=0.097)


0.757(p=0.000)

0.812(p=0.000)

0.703 (p=0.062)


0.876(p=0.000)

1.016(p=0.000)

0.160 (p=0.684)

Income decile 9 1.428 1.058 1.339 0.766


27

(p=0.000) (p=0.000) (p=0.000) (p=0.057)


1.453(p=0.000)

1.876(p=0.000)

1.068 (p=0.004)

With member in bad halth status

0.177(p=0.000)

0.171(p=0.000)

0.123(p=0.000)

‐0.008 (p=0.961)


Reference

Community – High deprivation

0.413(p=0.001)

0.395(p=0.000)

0.259(p=0.054)

0.003 (p=0.995)

Community ‐ Medium deprivation

0.465(p=0.000)

0.317(p=0.002)

0.277(p=0.030)

0.150 (p=0.735)

Community ‐ Low deprivation

0.434(p=0.000)

0.338(p=0.001)

0.107(p=0.430)

0.153 (p=0.747)

Community – Very low deprivation

0.324(p=0.002)

0.281(p=0.008)

‐0.099(p=0.452)

0.199 (p=0.669)

Community ‐ Rural Reference

Community ‐ Semirural ‐0.031(p=0.692)

‐0.017(p=0.804)

‐0.037(p=0.649)

‐0.500 (p=0.058)

Community ‐ Semiurban ‐0.113(p=0.115)

‐0.107(p=0.158)

‐0.146(p=0.066)

‐0.569 (p=0.059)

Community ‐ Urban ‐0.103(p=0.137)

‐0.062(p=0.366)

‐0.165(p=0.037)

‐0.333 (p=0.242)

Constant 3.012(p=0.000)

2.960(p=0.000

3.385(p=0.000

3.952 (p=0.000


28

Annex 2. Determinants of Catastrophic Expenditures

Dependent variable Catastrophic Expenditure

(10%)

Catastrophic Expenditure

(20%)

Catastrophic Expenditure

(30%)

SPSS Reference


1.347(p=0.209)

1.482 (p=0.155)


0.925(p=0.751)

0.741 (p=0.362)

Illness 2.203(p=0.000)

2.890(p=0.000)

3.216 (p=0.000)

Illness x No insurance 1.212(p=0.293)

1.088(p=0.754)

0.922 (p=0.795)

Illness x Social Security 0.997(p=0.988)

1.012(p=0.966)

1.353 (p=0.400)

HoH of 65 or more years

1.175(p=0.277)

1.120(p=0.563)

0.874 (p=0.572)


Reference

HoH primary school finished

1.152(p=0.162)

1.130(p=0.325)

1.099 (p=0.514)

HoH secondary school finished

1.254(p=0.040)

1.163(p=0.323)

1.279 (p=0.193)

HoH high school finished

1.748(p=0.000)

1.784(p=0.000)

1.985 (p=0.001)

More than 4 members 0.859(p=0.054)

0.974(p=0.811)

0.994 (p=0.965)


2.155(p=0.000)

2.245 (p=0.000)

With members of 65 and older

1.200(p=0.047)

1.206(p=0.094)

1.448 (p=0.006)



0.242(p=0.000)

0.196 (p=0.000)


0.159(p=0.000)

0.098 (p=0.000)


0.095(p=0.000)

0.067 (p=0.000)


0.099(p=0.000)

0.053 (p=0.000)


0.090(p=0.000)

0.061 (p=0.000)


0.093(p=0.000)

0.038 (p=0.000)


0.082(p=0.000)

0.048 (p=0.000)

Income decile 9 0.112 0.063 0.049


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(p=0.000) (p=0.000) (p=0.000)


0.073(p=0.000)

0.026 (p=0.000)


1.265(p=0.000)

1.302(p=0.000)

1.214 (p=0.003)


Reference

Community – High deprivation

1.784(p=0.000)

1.611(p=0.027)

1.636 (p=0.039)

Community ‐ Medium deprivation

2.099(p=0.000)

1.918(p=0.000)

1.668 (p=0.019)

Community ‐ Low deprivation

1.793(p=0.000)

1.560(p=0.031)

1.599 (p=0.033)

Community – Very low deprivation

1.265(p=0.174)

1.098(p=0.670)

1.262 (p=0.368

Community ‐ Rural Reference

Community ‐ Semirural 0.947(p=0.653)

1.046(p=0.758)

0.845 (p=0.357

Community ‐ Semiurban 0.912(p=0.468)

0.968(p=0.846)

0.923 (p=0.676

Community ‐ Urban 1.011(p=0.932

1.189(p=0.296

0.976 (p=0.909


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Annex 3. Determinants of affiliation to the SPSS excluding social security households

SPSS Reference

Illness 0.348(p=0.000)

With children of 14 and less

0.364(p=0.000)


‐0.253(p=0.000)

Community – Rural Reference

Community – Semirural

‐0.191(p=0.000)

Community – Semiurban

‐0.371(p=0.000)

Community – Urban ‐0.712(p=0.000)

Constant 1.797(p=0.000)

SPSS Reference

With bad health status

0.229(p=0.000)

Years of contribution to Social Security

‐0.057(p=0.000)


‐0.725(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)


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F. References Barros, R. (2008). Wealthier but not much healthier: Effects of a Health Insurance Program for the Poor 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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