Colorectal cancer in Mexico: should a middle income country invest in screening or in treatment?

Emma Verastegui 0 1 Alejandro Mohar 0 1 0 A. Mohar Instituto Nacional de Cancerologia , Av. San Fernando 22, 14080 Mexico City, Mexico 1 E. Verastegui (&) Unidad de Etica Clinica, Instituto Nacional de Cancerologia , Av. San Fernando 22, 14080 Mexico City, Mexico Mexico, like many other middle-income countries, is experiencing a demographic and epidemiological transition resulting in an older population suffering from chronic diseases. At the present time, cancer is the second cause of death in the country. Until recently, cervical carcinoma was the most frequent type of cancer in the country, however, the incidence of breast, prostate and colon cancers is growing. The demand for health care and health expenditure represented by cancer treatment challenges the limited resources the country has, particularly as patients seek treatment in advanced stages of the disease. Interestingly enough, these types of cancers could be detected in the early stages with rather simple screening procedures. The purpose of this paper is to describe the Mexican health system, and the impact of its fragmentation on access to medicines. Focusing on colorectal cancer (CRC), we describe its epidemiology, screening procedures and the inequities in health care access for these patients. JEL Classification I11 I12 I18 The Mexican health-care system is, organisationally, different from other OECD countries. The fragmented health system is characterised by the presence of several public purchasers that are vertically integrated with providers, and serve different parts of the population with little interconnection. In addition, there is a very large, and mostly unregulated, private sector [1]. The country's health expenditure is one of the lowest among the OECD countries (6.6% GDP 2006). Mexico does not have a single, national scheme providing health care coverage as a whole. Access to health care, insurance coverage and health outcomes vary across regions, and are characterised by a relatively low level of public spending with a high burden of out-of-pocket expenditure [2]. - The Mexican health-care system Approximately half the population enjoys social insurance coverage for health care, including pharmaceuticals. The other half of the population relies on federal and statefunded services, with the exception of a minority which has private health insurance. Social insurance is compulsory for all salaried workers in the formal labour market. The socially insured population receives health care at the Instituto Mexicano del Seguro Social (IMSS, Mexican Institute of Social Services) and at the Instituto de Seguridad y Servicios Sociales de los Trabajadores Del Estado (ISSSTE, Institute of Security and Social Services for Government Workers). The IMSS and ISSSTE beneficiaries and their dependents are covered for most health-care services, including most prescription pharmaceuticals included in their respective formularies, and receive health care at no out-of-pocket cost, as long as using providers employed by the IMSS or ISSSTE. The uninsured population obtain health-care services through the Ministry of Health (MoH) or state health services facilities1, subject to an evaluation of socio-economic status; however, patients must pay out-of-pocket for any drugs. Recent reforms have established a public health insurance scheme, the Seguro Popular de Salud, or Popular Health Insurance, covering drug costs for patients enrolled in the programme based on a catalogue of 249 essential interventions and 17 interventions (mostly high-specialty) relating to catastrophic expenditures [3]. Private insurance in Mexico is very limited. At present, only 3% of the population, mostly high-income individuals, has private insurance with employer-subsidised group plans accounting for half of private health insurance coverage. The public sector, whether state (MoH) or social security (IMSS, ISSSTE), provides health services at all levels of care in their own facilities (23,269 medical facilities). The private hospital sector provides around one-third of all hospital beds in the country (4,103 hospitals with 3,082 private) [4, 5]. Nearly half of the private hospital facilities are concentrated in Mexico City, while richer states have a greater availability of private sector facilities than poorer states [1, 5]. Private sector hospitals in Mexico are quite diverse: small physician-owned clinics with fewer than five beds account for 27% of private hospital beds [6]. Over half of private hospitals do not have X-ray units; about onethird do not have a full-time doctor [1]. Only 3% of private hospital beds are in hospitals with more than 50 beds. These hospitals provide high-tech and highly specialised care. The country is undergoing demographic and epidemiological transition,2 with mortality and morbidity patterns in most states having increasing chronic and lifestyle-related illnesses,3 ultimately placing greater pressure on health care systems.4 Furthermore, the social security sector is facing pressures from within as a result of increasing pension payments for its own workers. 1 Mexicos health system is decentralised, each state has its own secretariat of health and provides only for their region. This paper will use generically the MoH, but this will also cover state services. 2 Mexicos current population is approximately 109 million people, and by 2025, almost 10% of the Mexican population is estimated to be over 65; this percentage is expected to double by 2050. 3 However, in states with lower levels of socio-economic develop ment and in rural areas, a considerable epidemiological backlog remains. 4 The burden of chronic diseases has increased, and cancer is the second cause of mortality after cardiovascular diseases. Pharmaceutical expenditure Mexico has witnessed growth rates in health expenditure surpassing general rates of inflation, primarily due to pharmaceutical costs. Although the country has the lowest per capita income among most OECD countries, pharmaceutical expenditure is much higher than total health spending, with one of the highest percentages of GDP [5]. However, yearly PPP average expenditure is only $138.00 USD ( 95) compared to $792.00 USD ( 535) in the US [7]. Drug prices in Mexico are about 80% of American prices; nevertheless, when prices are adjusted for income, differences in pharmaceutical prices are more than five times the income-adjusted level [5]. Furthermore, about 90% of the pharmaceutical expenditure comes from private agents [8]. A large proportion of individuals without access to social security (IMSS, ISSSTE) protection belong to the poorest segments of the population, and a high share of households in lower-income quintiles face catastrophic and poverty-creating health-care expenditures. Expenditure and resource allocation A consequence of half the population without health insurance coverage is a large discrepancy in total disposable income devoted to health care (...truncated)