Broadening universal health coverage for children in Mexico
Authors: Thomas Hone, Octavio Gómez-Dantés
Journal: The Lancet Global Health (2019)

Universal health coverage remains high on the international political agenda with Sustainable Development Goal Target 3.8, the G20 declaration recommitment to universal health coverage in June, 2019,1The LancetG20 Osaka: when will global health commitments be realised?.Lancet. 2019; 394: 1Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar and the upcoming high-level meeting at the UN General Assembly in September, 2019. However, many countries are still grappling with the practicalities and complexities of advancing universal health coverage. These issues include defining universal, delivering meaningful coverage not just access, and deciding on the range of health-care services offered, in addition to building the necessary political consensus and administrative capacity.2O'Connell T Rasanathan K Chopra M What does universal health coverage mean?.Lancet. 2014; 383: 277-279Summary Full Text Full Text PDF PubMed Scopus (91) Google Scholar Progress is slow—in 2017 around half of the world's population did not have full coverage of essential services3WHOThe World BankTracking universal health coverage: 2017 Global Monitoring Report. World Health Organization, Geneva2017Google Scholar—and little is known about whether the quality of these services is sufficient to deliver health gains.4Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (606) Google Scholar Thoughtful, robust, and usable evidence is crucial for advancing universal health coverage. Where countries have made major progress towards universal health coverage, not enough systematic and reliable assessments are being done, often due to a scarcity of local evaluation traditions and data and analytical challenges. Furthermore, the quality of interventions, their long-term effects, and effects on inequalities are often not explored. In their research article, Celhay and colleagues5Celhay P Martinez S Muñoz M Perez M Perez-Cuevas R Long-term effects of public health insurance on the health of children in Mexico: a retrospective study.Lancet Glob Health. 2019; (published online Aug 9.)http://dx.doi.org/10.1016/S2214-109X(19)30326-2Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar directly address this evidence gap by examining the effects of expanding universal health coverage to children in Mexico and exploiting its phased implementation to deliver a robust evaluation. There has been global attention on Mexico's efforts to expand universal health coverage. The Lancet's 2006 Series on Mexico's health system reform highlighted Mexico's progress towards universal health coverage as an example for other countries and laid out key lessons.6Frenk J González-Pier E Gómez-Dantés O Lezana MA Knaul FM Comprehensive reform to improve health system performance in Mexico.Lancet. 2006; 368: 1524-1534Summary Full Text Full Text PDF PubMed Scopus (239) Google Scholar These lessons included promoting health as a social right and an aspiration across the political spectrum, investment in institutions and human resource development, and expanding coverage to those without health insurance. The key component of Mexico's reforms is the world-renowned Seguro Popular (Popular Health Insurance), which provides health-care coverage to individuals without access to other social insurance schemes through a universal benefits package of services and a fund for high-cost treatments. Evidence shows that Seguro Popular has led to improvements in health coverage, health conditions and financial impoverishment, especially for the poor.7Knaul FM González-Pier E Gómez-Dantés O et al.The quest for universal health coverage: achieving social protection for all in Mexico.Lancet. 2012; 380: 1259-1279Summary Full Text Full Text PDF PubMed Scopus (296) Google Scholar, 8Gakidou E Lozano R González-Pier E et al.Assessing the effect of the 2001–06 Mexican health reform: an interim report card.Lancet. 2006; 368: 1920-1935Summary Full Text Full Text PDF PubMed Scopus (139) Google Scholar However, universal health coverage is a pathway requiring continued attention and progress as health priorities change and resourcing, benefits packages, and financing systems adapt. In Mexico in the mid-2000s, there was recognition that further strengthening of Seguro Popular was needed to reduce, among other things, child mortality, address health inequalities, and tackle impoverishing health-care costs for children. In 2006, Seguro Médico Siglo XXI (SMSXXI; 21st Century Medical Insurance) was introduced, expanding the coverage of services for children younger than 5 years and growing Mexico's commitment to universal health coverage. The SMSXXI is an innovation in advancing universal health coverage. It combines financial incentives to promote uptake and health-care quality and expansion of the comprehensiveness of services offered to children. State governments in Mexico received funds for enrolment of eligible children (with the objective of expanding primary care provision), and hospital providers were incentivised to provide high-cost services to enrolled children through per case reimbursement. Furthermore, providers were reimbursed at a higher rate if they met the necessary quality requirements to receive government accreditation. In their Article, Celhay and colleagues5Celhay P Martinez S Muñoz M Perez M Perez-Cuevas R Long-term effects of public health insurance on the health of children in Mexico: a retrospective study.Lancet Glob Health. 2019; (published online Aug 9.)http://dx.doi.org/10.1016/S2214-109X(19)30326-2Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar analyse multiple data sources and use quasi-experimental methods to assess the effect of the SMSXXI on household finances, health-care use and quality, and health outcomes. It is the first comprehensive evaluation of the SMSXXI and adds to existing quasi-experimental evaluations in Mexico of the Progresa-Oportunidades-Prospera programme (a conditional cash transfer programme), and Seguro Popular—both related to the SMSXXI.9King G Gakidou E Imai K et al.Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme.Lancet. 2009; 373: 1447-1454Summary Full Text Full Text PDF PubMed Scopus (176) Google Scholar, 10Frenk J Gómez-Dantés O Quasi-experimental study designs series—paper 3: systematic generation of evidence through public policy evaluation.J Clin Epidemiol. 2017; 89: 17-20Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar Celhay and colleagues5Celhay P Martinez S Muñoz M Perez M Perez-Cuevas R Long-term effects of public health insurance on the health of children in Mexico: a retrospective study.Lancet Glob Health. 2019; (published online Aug 9.)http://dx.doi.org/10.1016/S2214-109X(19)30326-2Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar show that roll-out of the SMSXXI was associated with a 7% (95% CI 2–12) reduction in late neonatal mortality, better self-rated health, and reductions in reported episodes of flu and episodes. In the long-term, they find higher height-for-age scores, and notably report that these benefits are concentrated in more vulnerable populations. They also find that SMSXXI is associated with a 14·6% reduction in catastrophic household expenditures on health care. Within the health system, providers responded to the expansion of SMSXXI with increased investments in resources and staff. These investments included increases in hospital beds, a 14% (95% CI 8–21) increase in the provision of incubators and cots, a 8% (3–13) increase in medical specialists, and 7% (1–13) increase in staff members. The findings from this study show that incremental expansions of universal health coverage can deliver important health and financial protection improvements, especially for the vulnerable. Furthermore, innovative financial mechanisms can help drive health-care quality improvement and expansion which is essential for achieving Sustainable Development Goals beyond universal health coverage.11Hone T Macinko J Millett C Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals?.Lancet. 2018; 392: 1461-1472Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar However, key questions for future research remain. Although the concepts of equity and health-care quality were mentioned in the study, more detailed evaluations of effects are needed. This includes the need to relate these findings to results from similar studies of other health and social programmes implemented in Mexico, better understand how to address the uneven progress toward universal health coverage between social strata, whether novel policies can drive sustainable quality improvements to guarantee effective coverage, and how we can translate these policies to other settings effectively. We declare no competing interests. Long-term effects of public health insurance on the health of children in Mexico: a retrospective studySMSXXI promoted access to covered interventions and encouraged better primary care. The programme also promoted increased supply and quality of care by improving human and physical resources sensitive to unmet needs. Increased resource availability and improved supply of health care, rather than increased use, contributed to reduce infant mortality and improved long-term health as proxied by self-reported morbidity and child height. Consistent with the programme's focus on uninsured and low-income populations, the effects on mortality, long-term health status, and OOPHE were concentrated in vulnerable groups. Full-Text PDF Open Access