November, 18th.

1. MACROECONOMICS AND HEALTH:INVESTING IN HEALTH FOR ECONOMIC DEVELOPMENTREPORT BY THE MEXICAN COMMISSION ON MACROECONOMICS AND HEALTH (MCMH) VERSION FOR CONSULTATION AND COMMENTS November, 18th.

2. Table of contents • Overview of the MCMH´s objectives, organization and main findings • Nora Lustig • The Human Development Trap in Mexico • David Mayer • Inequality in Health and Health Care: Mexico in comparative perspective • John Scott • Social Protection in Health • Carlos Noriega • The Importance of Public Goods in the Health Sector: A Case Study of Mexico • Luis de la Calle • 6. Main Recommendations

3. Overview of the MCMH´s objectives, organization and main findings Nora Lustig

4. In the case of middle-income countries, the International Commission of Macroeconomics and Health (CMH) stated the following: “In most middle-income countries, average health spending per person is already adequate to ensure universal coverage for essential interventions. Yet such coverage does not reach many of the poor. In view of the adverse consequences of ill health on overall economic development and poverty reduction, we strongly urge the middle-income countries to undertake fiscal and organizational reforms to ensure universal coverage for priority health interventions.” Additionally, the CMH suggested the creation of similar commissions on a national level. I. Introduction

5. The Mexican Commission on Macroeconomics and Health was created on July 29th, 2002 by the initiative of the Minister of Health of Mexico, Julio Frenk. The Commission includes experts from academic institutions, the government, civil society and the private sector. Based on their professional experience, these experts have been able to analyze and reflect upon the link between health and economic development. I. Introduction

6. The Commission’s mandate consists of: analyzing the relationship between investing in health and the economic development of Mexico; evaluating the extent to which advances have been made in health indicators in our country Mexico’s investment in health including public goods the existing system of social protection against adverse health shocks. proposing health-related actions and initiatives, specifically in the realm of public policy, in order to reap benefits for economic development and poverty reduction. I. Introduction

7. A study on the direct relation between health and growth in Mexico (1970-1995) using life expectancy and the mortality rate for different age groups as health indicators, suggests that health is responsible for approximately one third of long-term economic growth I. Introduction

8. Due to its direct and indirect impact, health is one of the important determinants of the incidence of poverty as well as its persistence over time, known as “poverty traps”. For a poverty trap to exist, several elements must be combined. The principal ones are: increasing returns on education (remuneration progressively increases for those who have higher education levels) and a population that can clearly (and statistically) be divided in two groups, one with low human capital and another with high human capital. In Mexico there is evidence of a poverty trap. II. Health and poverty traps

9. It is important not only to create incentives and implement policies to invest in health, but also to avoid or minimize its deterioration in adverse situations Adverse situations III. Systemic and Idiosyncratic Shocks and Social Protection • Idiosyncratic • (illness, death, unemployment, or a bad harvest) • Social Insurance • b. Systemic • (epidemics, economic crises and natural disasters) • Safety Nets

10. Health levels in Mexico are below those for countries with equivalent per capita income levels The expected infant mortality rate, controlling for Mexico’s level of development, is 22% below the actual observed rates Mexico reported twenty thousand infant deaths above the norm IV. Health levels in Mexico

11. Millennium Development Goals Goal 1: Halve the proportion of people who suffer from hunger If we use the relationship in height according to age as an indicator of malnutrition, we will find that the decrease between 1988 and 1999 was about 22% less that what was required to fulfill the Millennium Development Goal, assuming a linear trend. Between 1992 and 2002, “food poverty” fell by only 10%, much less than the required 44%.

12. Millennium Development Goals Goal 4: Evolution of child and infant mortality indicators In terms of Millennium Development Goals, Mexico has shown a progress rate of 55.4%, which is greater than that observed in four of the developed countries and satisfactory in terms of the Goals because it surpasses 44%. Likewise, in the last decade Mexico has had a significant improvement in vaccination rates, especially against measles. In 1990 only 75.3% of infants under 12 months had been vaccinated against this disease and in 2002 the number was at 96%.

13. Millennium Development Goals Goal 5: Maternal health The progress on maternal mortality rate is 32.7%, lower than required. The number of births attended by trained medical personnel should be 100%, but in Mexico it is only at 86%.

14. Millennium Development Goals Goal 6: Combat HIV/AIDS, malaria and other serious diseases In terms of Goal 6, which consists of reducing the spread of HIV/AIDS and the incidence of malaria and other serious diseases, important progress has been made. The rate of HIV/AIDS among the adult population in Mexico is one of the lowest in Latin America and the Caribbean in proportion to its population, but it has the second highest number of people living with the disease. Regarding malaria, the situation in Mexico is substantially better than that of the rest of Latin America and Caribbean countries. In 2000, only eight cases occurred for every 100,000 inhabitants. In Latin America and the Caribbean, there were eight deaths caused by tuberculosis (TB) for every 100,000 inhabitants in 2002. In Mexico during that same year, only five deaths occurred for every 100,000 inhabitants.

15. Millennium Development Goals Goal 7: Sustainable access to safe drinking water In terms of environmental conditions and sanitation, measured through access to drinking water, on average Mexico is very close to achieving the target suggested by the Millennium Development Goals. Nevertheless, compared to other Latin American countries, access levels are still lower than those observed in countries like Chile and Colombia.

16. In Mexico, there is enormous disparity in health levels across states and municipalities: Infant mortality: A. In some areas in the state of Chiapas, infant mortality (at 66.2 per thousand live births) is similar to that of countries much poorer than Mexico like Sudan. B. In contrast, the Benito Juarez district in Mexico City, with a rate of 17.2, has levels similar to Western Europe and Israel. Beyond the Millennium Development Goals

17. Closing the gaps. Infant mortality rate by municipalities, 2000 Beyond the Millennium Development Goals Infant Mortality rate Ranked by marginality index Source: Based on CONAPO (2001).

18. C. There is also great differences in childbirth coverage under medical supervision i. Half of the states have more than 90% coverage, but there are states with less than 60% coverage. ii. At municipalities level, the percentage of childbirths attended in the 386 highly-marginalized municipalities is slightly higher than 36%. In contrast, in the 247 least-marginalized municipalities, coverage in clinics is almost 94%. Also, in some indigenous communities the percentage of births attended by medical personal is under 10%. Beyond the Millennium Development Goals

19. Health-related goals for Mexico should include confronting new challenges such as the increase of cardiovascular diseases and diabetes mellitus. Chronic illnesses of this nature are associated with changing income levels as well as demographic changes. The incidence of diabetes has increased greatly in recent years; at the end of the 70’s it was the fourth cause of death in our country and now it is considered the first, causing 12% of all deaths in Mexico. New Challenges

20. In 2003, Mexico’s total investment in health care was 6.1% of the GDP, lower than: 1) The Latin American average (6.3%). 2) Other countries with similar income levels, such as, Chile (7.0%), Costa Rica (7.2%), Brazil (7.6%), and Uruguay (10.9%). 3) OCDE countries, such as, Canada, (9.9%), United States (14.6%). In 2001 public investment represented 44% of the total investment in health, while in Latin American countries with similar or even lower income to that of Mexico had a higher percentage of public investment, such as, Argentina (48.5%) and Nicaragua (53.4%) . V. Are we Investing well in Health?

21. A comparative international study by the World Health Organization in 2000 indicated that the most critical problem presented by Mexico at the end of the millennium, being ranked 144th among 189 countries, was that of “equity in contributions” for the following reasons: 1) A high proportion of persons (over 50%) does not have any kind of insurance. 2) Out-of-pocket payments represent more than half of total health expenditures. V. Are we Investing well in Health?

22. Out-of-pocket payments tend to be greater, as a percentage of total family income, in the poorest homes. The Mexican population in the lowest income decile spends, in direct payments, approximately 6.3% of its income on health attention, while homes in the highest-income decile spend 2.6% of theirs. V. Are we Investing well in Health?

23. The government program, most important in terms of resources and coverage that provide health benefits is the Human Development ProgramOportunidades. Oportunidades is associated with… V. Are we Investing well in Health? in maternal mortality (11%) stronger very highly in infant mortality (2%) marginalized municipalities average food consumption (11%)

24. Investment in health has important returns: according to World Bank estimates (2004), for countries with an institutional quality index that is equal to the mean, a 10% increase in public expenditures in health as a proportion of the GNP is associated with: 1) 7% reduction in maternal mortality rates, 2) 0.69% reduction in mortality rates for children under the age of five, and 3) 4.14% decrease in the number of underweight children under five. V. Are we Investing well in Health?

25. The Human Development Trap in Mexico David Mayer

26. Nobel Prize studies: Nutrition and health explain between a third and half of the economic growth in England over the last two centuries (Fogel). Similar results are found using diverse health variables, countries and regions, including Mexico and Latin America. Nutrition and Health Promote Long-Term Economic Growth

27. Human Economic Growth Development Production Human and Capital Intergenerational Technological Investment Feedback Change Pro - Market Reforms in: Characterized by Trade, Investment, Legal Market Failures and Financial Institutions… Human Development and Economic Growth

28. Education Family Wealth: Income, Income, Early Child Education, Education, Development Health Health Health Next Generation Evidence for a Poverty Trap in Mexico

29. Unrealized Increasing Returns to Education  Underinvestment in Education  Underinvestment in ECD Unrealized Returns to ECD  Slow Transition or Poverty Trap Twin-Peaked Distribution of Educational Achievement  Poverty Trap Early Child Development (ECD) and the Intergenerational Accumulation of Human Capital

30. Twin-Peaked Distribution of Education in Mexico Fuente: ENIGH 1984, 1989, 1992, 1994, 1996, 1998, 2000

31. Nutrition and health, in particular ECD, can be instrumental in debilitating the hold of poverty traps in human capital accumulation Conclusions

32. Inequality in Health and Health Care: Mexico in comparative perspective John Scott

33. Inequalities in health and access to health care in Mexico are high by international standards The capacity to reduce these inequalities through public action is constrained by: Low fiscal capacity Low health priority in public spending allocation Fractioned public health care system with deep contrasts in financing, benefits, and coverage Health and Health Care Inequalities

34. Distribution of a dult he ight (20 - 64) : 2000 Distribution of IMR : 2000 70 162 Ordenados por TMI 66.9 161 60 160 159 50 158 157 40 156 30 155 154 20 153 17.2 152 10 1 2 3 4 5 6 7 8 9 10

35. 90% Poorest 20% 80% Richest 50% 70% 60% 50% 40% 30% 20% 10% 0% SSA IMSS Tortilla ISSSTE LICONSA Nacionales Desayunos Solidaridad Institutos IMSS- (DIF) Oportunidades IVA Gasto Fiscal medicinas Share of public spending on heath and nutrition benefiting poor and non-poor

36. ISSSTE IVA medicinas (gasto fiscal) Institutos Nacionales Pemex Total Hospitalaria IMSS Total Materna Total Primaria LICONSA SS DIF (Desayunos) IMSS-Oportunidades Oportunidades (transferencias) -0.800 -0.600 -0.400 -0.200 0.000 0.200 0.400 0.600 Fuente: Estimación del autor utilizando ENIGH 2002, ENSA 2000 (IMSS-Opotunidades, Institutos Nacionales) Concentration Coefficients of Public Spending on Health and Nutrition: 2000-2002

37. Social Protection in Health Carlos Noriega

38. Health shocks: Greater incidence and more frequently amongst the poor Health expenditures:Catastrophic expenditures lead to extreme poverty Relevance of poverty trap for Mexico: Total health expenditures: 52% in the form of OOPE Coverage: more than 40% of population is not covered Poverty Trap

39. Most efficient way to confront health risks Most efficient way to confront equity issues · De-link financing from access: Equal treatment for equal needs independently of income level · Target state subsidies to the poor: demand subsidies · Eliminate financial uncertainty for the poorest · Reduce health gaps between the better-off and the poorest Advantages of universal coverage

40. Towards a National Health System ·A consistent and well integrated legal, financial and operational framework. ·Separation of financing from provision of health services Revenue collection ·Public funding: more progressive ·Co-financing: federal-local governments Pooling ·Single risk-pool through a singe financing pool ·Public insurance covers basic health services ·Private insurance covers complementary services Allocation ·Defined basket of services provided ·Decentralization contracting services Characteristics of a National Health System

41. Elements ·Coverage aimed at poor/rural population ·Portable and with a standardized coverage (cost-effective interventions) ·Co-financed by federal-local governments plus user-fees ·Separates financing from provision of health services Advantages ·Affordable pre-paid health care ·Public funding with progressive subsidies Challenges ·Segmentation of health institutions ·Coordination with social security institutions Seguro Popular de Salud

42. The Importance of Public Goods in the Health Sector: A Case Study of Mexico Luis de la Calle

43. Non-exclusive, non-rival Sub-optimal investment Provision strategies: Best shot Weakest link Summation Public goods

44. Public health: Elimination of diseases, micronutrient distribution mechanisms, measures to control disease transmission. Knowledge and information: Information campaigns, knowledge dissemination (e.g., new treatments), standardization of information/data bases, intellectual property rights protection. Protection against sanitary risks: Immunization campaigns, accident prevention, health and safety in the work place. Inventory of Public Goods

45. Increase in labor productivity Savings on health expenditures Increase in the attractiveness of investing in human capital; increases life expectancy and the rate of depreciation for human capital investments Improves investment environment in general Promotes technological development Advances market expansion Incorporates human assets previously left inactive (infrastructure for the handicapped) Development impact

46. Public goods contribute to the economic development process. Quality and quantity of public goods is a barometer of a country’s level of development. PGs make an important contribution to improving social inequalities; non-exclusivity means universality of coverage. PGs provide the means to attend to systemic health risks. It is important to consider the appropriate means used to generate the PG: Best shot, weakest link, summation. A consideration of PGs should be incorporated into the design of public health policies. Conclusions

47. Regarding goals that Mexico must take on, it is important to go beyond the Millennium Development Goals in several dimensions: Moving up the time frame for specific targets Establishing targets at the sub-national level to reduce the large existing gaps Including the fight against illnesses and diseases not considered in the Millennium Development Goals (such as hypertension and diabetes mellitus) Main Recommendations

48. 2. To generate a process to define health targets at the national and state level, and, when possible, at municipal levels. These goals… Should be defined in areas which make them socially and politically legitimate as well as financially and institutionally feasible. Should Include general health aspects such as food consumption, sanitation, housing and the environment Main Recommendations

49. 3. To revise and overhaul current investment programs in public health at all government levels in order to make them coherent with agreed-upon goals. In particular, it would be desirable… To increase total expenditures Reassign funds towards preventive medicine and programs with a specific focus Redistribute funds among regions and socioeconomic groups in order to make the system more progressive Complementary public investments should meet current needs Main Recommendations

50. 4. To eradicate malnutrition and poor nutrition among children. To revise and develop policies that guarantee good nutrition in Mexico in terms of supporting and rationalizing production and distribution of foods, promoting good dietary habits, and assuring a sufficient supply of micronutrients 5. To guarantee timely access to appropriate medical attention in cases of pregnancy, childbirth and postpartum care in marginalized rural and urban areas in order to reduce maternal and perinatal mortality and morbidity Main Recommendations