Challenges and dilemmas on universal coverage for non-communicable diseases in middle-income countries: evidence and lessons from Mexico

Abstract

BackgroundDespite more than 20 years of reform projects in health systems, the universal coverage strategy has not reached the expected results in most middle-income countries (MICs). Using evidence from the Mexican case on diabetes and hypertension as tracers of non-communicable diseases, the effective coverage rate barely surpasses half of the expected goals necessary to meet the challenges that these two diseases represent at the population level. Prevalence and incidence rates do not diminish either; they even grow. In terms of the economic burden, this means that lack of financial protection and catastrophic expense rates have increased, contrary to what could have been expected.DiscussionAs any complex system, health systems present challenges and dilemmas that are difficult to solve. In terms of universal coverage, when contrasting normative coverage versus effective coverage, the epidemiological, cultural, organizational and economic challenges and barriers become evident. Such challenges have not allowed a greater effectiveness of the contributions of state of the art medicine in the resolution of health problems, particularly in relation to diabetes and hypertension.ConclusionsDespite of the existence of many universal coverage projects, strategies and programs implemented in MICs, challenges remain and, far from disappearing, unresolved problems are still present, even with increasing trends. The model of care based on a curative biomedical approach was enough to respond to the health needs of the last century, but is no longer adapted to the needs of the present century. The dilemmas of continuity vs. rupture require to review and discuss the background and structure of health systems and their underlying models of care. These two elements have not allowed the different coverage schemes to guarantee greater effectiveness in the application of state of the art medicine, nor a greater health care financial protection for patients and their families. We thus can either accept the fragmented health systems and bio-medical-curative models of care approach or, instead, we can move towards integrated health systems that would be based on a socio-medical-preventive approach to health care.

Recent trends for the management of hypertension in older adults in Latin America in the context of universal coverage: Evidence from Mexico

“…Both the cost of case management findings and the epidemiological trends in the number of cases of hypertension are similar to other findings published for Mexico and other countries in Latin America and other countries 22 23 Indeed, the results of the epidemiological and economic burden, as well as the out‐of‐pocket expenses of users are also similar to the latest OECD reports and other studies, 24‐27 where the high economic burden represented by out‐of‐pocket expenses for health reasons is also highlighted in countries such as Mexico, Chile and Brazil.…”

Trends and age-period-cohort effects on hypertension mortality rates from 1998 to 2018 in Mexico

“…If all of the hypertension cases had been treated, the cost at the national level would have doubled, from 3.2 billion dollars to 7.4 billion dollars. An increase in the out-of-pocket expenses due to hypertension treatment was observed in the time period from 2005 to 2015 25 . This highlights the importance of health promotion related to preventable diseases such as hypertension.…”

“…In Mexico, universal coverage is still a work in progress. The proportion of patients that effectively received care after seeking services from the health system to control the disease does not go above 50% of the service users 25 . If all of the hypertension cases had been treated, the cost at the national level would have doubled, from 3.2 billion dollars to 7.4 billion dollars.…”

Análisis y reflexiones sobre la iniciativa de reforma a la Ley General de Salud de México 2019

“…Como estrategia de reducción del gasto de bolsillo de los hogares, el Insabi podría tener un impacto enorme en el bienestar de los hogares, sobre todo en aquéllos con personas que sufren padecimientos crónicos como diabetes e hipertensión y que a través de su gasto de bolsillo cubren poco más de la mitad del gasto total de la atención de estas enfermedades. [20][21][22][23] La factibilidad financiera del Insabi estará determinada, por un lado, por la cartera y la estructura de los servicios que requiere la población sin seguridad social y que serán ofrecidos por dicho Instituto; por otro lado, los fondos, fuentes y flujos de financiamiento y los criterios que se utilizarán para transferir los recursos a los estados -como pagos capitados o pagos según intervenciones prestadas -son aspectos clave que afectarán la viabilidad de la propuesta.…”