Public private interactions in health: Three Mexican examples INSP CISS. Gustavo Nigenda López, PhD Luz Maria Gonzalez Michael Reich Jose Arturo Ruiz

Transcription

1 Public private interactions in health: Three Mexican examples Gustavo Nigenda López, PhD Luz Maria Gonzalez Michael Reich Jose Arturo Ruiz August, 2006.

2 Objective Describe the structure and operation of three cases/models of public private interaction in health in Mexico; present main research results; and discuss implications for the Mexican health care system.

3 Mexican health care system structure MEXICAN HEALTH CARE SYSTEM STRUCTURE Sub-system Social Security Public Assistance Private Financing Federal government (General Taxation) Employer (Payroll taxes) Employee (Payroll taxes) Federal government General taxes State governme nts and recovery fees Employer Premium/ Direct payment Individu al Fee for Service Organization Provision Others ISSSTE PEMEX IMSS Public Hospitals/Social Security Public Clinic; Doctors under salary IMSS Solidaridad Ministry of Health Public Hospitals Public clinics Salaried doctors Private Insuran ce Pre-paid care Private Hospitals Private clinics Doctors paid by fee for service Users Formal sector Families of the insured Retired Poor populations Informal sector Rural communities Selfemployed General population High/Low income Source: PHR Plus, USAID, ABC (2004)

4 Private care in Mexico 55% of health expenditure in Mexico is private 52% is out-of-pocket expenditure 3% is through private insurance Private expenditure is estimated through household income-expenditure surveys Public expenditure is estimated through institutional budgeting and expenditure.

5 Resources in the private sub-system Clinics/Hospitals: 1-10 beds: 1974 (2001) beds: 779 (2001) 50 & more: 69 (2001) Total beds: 31,000 (2001) 136,428 (Pu) Doctors: 62,951 (1999) - 82,362 (Pu) Nurses: 29,365 (1999) - 99,752 (Pu) Surgery rooms: 2,520 (2001) 2,805 (Pu) Private insurance companies: 38 (2006) Source: Ministry of Health of Mexico. Asociación Mexicana de Instituciones de Seguros

6 Public-private interactions In the literature on public-private interactions, various terms are used, including mix, collaboration, society, and partnership, all of which suggest a normative position. Given that these studies are just beginning in Mexico, we have decided to use the term interaction, which is conceptually broad and normatively limited.

7 Description of cases and objectives Case 1. Ministry of Health of Jalisco contracting a network of private providers. The Ministry of Health through the Decentralized Public Organism (OPD) has contracted a network of primary care services (basic health teams) and secondary care units (general hospitals) in geographical areas (rural y urban) where no public network units are available. The objective is to expand the coverage of health services. Case 2. Opening of a private beds ward in a public hospital in Veracruz. This is a tertiary care public hospital that sells hospital services to private users. Users gain access by means of an institutional agreement between the hospital and a social security institution or private insurance company. They can also be referred by the public area of the hospital. The objective is to create an alternative source of funds to strengthen the finances of the public area. Case 3. Public hospital (General Hospital of Mexico) that sells ambulatory services to private users. In this case the hospital sells diagnostic services and specialized ambulatory treatment (e.g., chemiotherapy) to private users. Users gain access through institutional agreements between the hospital and social security institutions, private insurers, or other public hospitals. The objective is to create an alternative source of funding to strengthen the provision of services in the public area.

8 Basic characteristics (2005) 183 people under contract 60 Health basic teams 7 hospitals 1.2 million USD Coverage: 30,000 families

9 Case 1: Public financing private provision of services in primary and secondary units Public financing DPE State Ministry of Health Contract: basic salary plus extra payment according to Contracting productivity Basic teams Private provision of services Doctor Nurse Health promotor Demand Medical consultation, health promotion and prevention activities Low-income users

10 Case 1: Public financing private provision of services in primary and secondary units Public financing DPE of the State Ministry of Health Contract: payment by intervention Health care units Private provision of services General Hospitals Specialty hospitals Demand Hospital and ambulatory package of services Low-income Users

11 Basic Health Teams Personnel 1. Personnel profile Category Doctors 34.4% Nurses 31.3% Others 34.3% Sex Male 30% Female 70% Other remunerated activities Yes 53% No 47%

12 Length of time contracting with OPD Servicios de Salud Jalisco 56.96% 36.56% Un año o menos trabajando con la OPD 6.45% 2 a 4 años No respondió

13 Most frequently confronted problems in the provision of health services % % % 50.54% 59.14% % % 40.86% Yes No Lack of drugs Lack of equipment Inadequate infrastructure Excessive demand

14 Opinions on the consequences of public-private interaction % % 80.65% 59.14% 50 Yes No Both working for the benefit of the community 19.35% Reduces costs to the population 40.86% Constitutes a positive network of services 94.62% 5.38% First step towards privatization 90.32% 9.68% Opening door For abuse and corruption

15 Description of cases and objectives Case 1. Ministry of Health of Jalisco contracting a network of private providers. The Ministry of Health through the Decentralized Public Organism (OPD) has contracted a network of primary care services (basic health teams) and secondary care units (general hospitals) in geographical areas (rural y urban) where no public network units are available. The objective is to expand the coverage of health services. Case 2. Opening of a private beds ward in a public hospital in Veracruz. This is a tertiary care public hospital that sells hospital services to private users. Users gain access by means of an institutional agreement between the hospital and a social security institution or private insurance company. They can also be referred by a private physician. The objective is to create an alternative source of funds to strengthen the finances of the public area. Case 3. Public hospital (General Hospital of Mexico) that sells ambulatory services to private users. In this case the hospital sells diagnostic services and specialized ambulatory treatment (e.g., chemiotherapy) to private users. Users gain access through institutional agreements between the hospital and social security institutions, private insurers, or other public hospitals. The objective is to create an alternative source of funding to strengthen the provision of services in the public area.

16 Case 2: Public provision to private clients- Structure and sources of financing Contracts: PEMEX, ISSSTE, UV, private insurers Payroll paid by state budget Private Financing Public Users payment Hotel services Private payment Laboratory, cat scan, etc. Recovery fees

17 Case 2: Organizational arrangement for the provision of services PUBLIC AREA Provision of Services PRIVATE AREA Public area Private area Hospital doctor Hospital nurse Hospital doctor/ Private doctor Private doctor Users Public/ public Users Public/ private Users Private/ private

18 Study Results Lack of transparency in the use of resources Lack of technical definitions regarding pricing and allocation of resources Unfair distribution of benefits for actors involved (doctors most-benefited actor) Public and private patients with relative benefits Subsidies may be moving from public to private

19 Description of cases and objectives Case 1. Ministry of Health of Jalisco contracting a network of private providers. The Ministry of Health through the Decentralized Public Organism (OPD) has contracted a network of primary care services (basic health teams) and secondary care units (general hospitals) in geographical areas (rural y urban) where no public network units are available. The objective is to expand the coverage of health services. Case 2. Opening of a private beds ward in a public hospital in Veracruz. This is a tertiary care public hospital that sells hospital services to private users. Users gain access by means of an institutional agreement between the hospital and a social security institution or private insurance company. They can also be referred by the public area of the hospital. The objective is to create an alternative source of funds to strengthen the finances of the public area. Case 3. Public hospital (General Hospital of Mexico) that sells ambulatory services to private users. In this case the hospital sells diagnostic services and specialized ambulatory treatment (e.g., chemiotherapy) to private users. Users gain access through institutional agreements between the hospital and social security institutions, private insurers, or other public hospitals. The objective is to create an alternative source of funding to strengthen the provision of services in the public area.

20 Case 3: Public provision of ambulatory services to private clients. Financing Federal budget Financing Own resources Recovery fees (public area) Donations (public & private) Contracts: PEMEX, ISSSTE, private hospitals etc. Payment by private patients without contract

21 Case 3: Provision of services Provision of services Noninsured population with or without referral Public Private Private users under contract agreement or not All services including hospital services X-ray, cat scan, mastography, audiology Doctors, nurses and technicians

22 Costs cobalt 60 treatment Cost per session Treatment cost Concepts Paliative Curative First time Subsequent Average number of sessions by type of treatment Personnel , , Current , , Capital , , Total direct costs , , Total indirect Costs , Grand total , , USD = 11 Mexican pesos Maximum price charged by HGM to private patients for a first-time session = 650 pesos.

23 Benefits and risks Case Benefits Risks Case 1. Coverage increase High levels of users satisfaction in both areas Dissatisfaction of private providers because of fees and the delay in the payment of services Lack of evaluation of the model s performance Case 2. Increase in access to services for poor populations There is no costing system Additional payment for doctors but no extra payment for other categories of personnel that provide services in the private area Lack of accreditation of private doctors who send their patients to the hospital Differences in the quality of care Case 3. More resources for the public area Efficient utilization of technological capacities There is no costing system Differences in quality of care between public and private area (waiting times) No strategic evaluation of the model

24 Challenges To carry out new studies that provide empirical evidence about these types of PPI in such a way that contributes to the understanding of the phenomenon, the identification of its achievements and obstacles, and its capacity to improve access to health services, particularly to poor populations. To systematize various PPI experiences in order to provide evidence to decision-makers that could lead to the development of regulatory frameworks used to strengthen the performance of the country s health care system. To revise regulatory mechanisms, both at federal and state levels, in order to guarantee the achievement of the objective of mutual benefit (between public and private agencies) and to make PPI a viable option for the financing and provision of health services. To learn from lessons provided by specific experiences of PPI and evaluate the benefits that the participation of the private sector could generate within the Mexican health care system.

25 Final considerations It is possible to establish public private interactions yielding positive consequences Public private interaction requires a solid technical foundation to be in place in order to achieve proposed objectives. Costing systems should be used to estimate the value of services and establish the prices that should be used by public institutions to sell services; otherwise subsides could move in unintended directions. Increase in patient access and satisfaction levels are important but not definitive in considering that a PPI model is producing benefits. Regulatory frameworks should be developed and applied by state and federal Ministries of Health to guarantee that the model is appropriate both technically and financially.

26 Many thanks