The role of public health insurance in protecting against the costs of ill health: Evidence from Mexico

In the absence of health insurance, households have to self-insure against the risk of ill health, which may involve the use of mechanisms that have long-term consequences. This study analyses whether Mexican households are able to smooth consumption after severe health shocks, as well as the contribution of public health insurance in the form of social security and, more recently, the Seguro Popular programme. Using data from the Mexican Family Life Survey, a nationally representative longitudinal survey, the results indicate that unexpected health events such as accidents and deterioration in physical capacity are associated with large declines in non-medical consumption. Social security seems to provide protection against both types of shocks, but the endogeneity-corrected estimates indicate that the Seguro Popular programme only protects consumption against accidents. This suggests that income losses associated with disability shocks, for which the programme does not offer protection, are likely larger than medical care expenditures, and poses the question of whether other social security benefits, such as disability insurance, should also be extended to non-beneficiaries

The expansion of public health insurance in Mexico: health, financial and distributional effects

During the past decade, the Mexican government launched an ambitious expansion of public health insurance through the Seguro Popular programme (SP). As a result, health care access was legislated as citizens’ entitlement, a generous benefit package was offered, and public health expenditure was significantly increased. In 2011, the programme had reached 52 million affiliates. However, there is limited evidence on its effects on a number of outcomes and their distribution. This thesis analyses three aspects that are key to evaluate health system performance. Specifically, using quasi-experimental methods and recent distributional measures of pure health, it examines the effect of universal insurance coverage on infant mortality, non-medical consumption, and health inequalities. Drawing on municipality-level data, the first article finds that the programme led to a 3.9 per cent decrease in infant and neonatal mortality. These reductions were concentrated in more populated, urban, and less marginalised municipalities, however, probably because this type of municipalities have been traditionally better equipped and are thus better prepared to offer all the interventions from the benefit package. Based on data from the Mexican Family Life Survey (MxFLS), the second article shows that unexpected health events such as accidents and deterioration in physical capacity are associated with large declines in non-medical consumption. Social security seems to provide protection against both types of shocks, but endogeneity-corrected estimates show that the SP only protects consumption against accidents. This suggests that income losses associated with disability shocks for which the programme does not offer protection, are likely larger than medical care expenditures, and poses the question of whether other social security benefits, such as disability insurance, should also be extended. Finally, the third article analyses the distribution of health in the context of the SP implementation. Unlike traditional studies, pure health inequality and mobility are analysed using a recently developed class of indices appropriate for categorical data. If a downward-looking definition of status is employed, the distribution of health appears stable, but if an upward-looking definition is adopted, a significant increase in inequality is observed. Evidence of strong persistence in health was also found. This lack of improvement in the health distribution suggests that factors other than health insurance coverage, such as institutional performance, are more important determinants of health inequalities. Overall, this thesis finds important health effects from extending health insurance coverage but limited effects on economic welfare and the distribution of health status across the entire population

From Transit Hub to Major Supplier of Illicit Cigarettes to Argentina and Brazil: The Changing Role of Domestic Production and Transnational Tobacco Companies in Paraguay Between 1960 and 2003

Background  Paraguay has reportedly been a major transit hub for illicit tobacco products since the 1960s, initially to supply markets in Argentina and Brazil and, more recently, other regional markets and beyond. However, to date there has been no systematic analysis, notably independent of the tobacco industry, of this trade including the roles of domestic production and transnational tobacco companies (TTCs). This article fills that gap by detailing the history of Paraguay’s illicit cigarette trade to Brazil and Argentina of TTC products and Paraguayan production between 1960 and 2003. The effective control of illicit cigarette flows, under Article 15 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) and the Protocol to Eliminate the Illicit Trade in Tobacco Products, requires fuller understanding of the changing nature of the illicit trade. Methods  We systematically searched internal industry documents to understand the activities and strategies of leading TTCs in Paraguay and subregion over time. We also mapped illicit trade volume and patterns using US government and UN data on the cigarette trade involving Paraguay. We then estimated Paraguay’s cigarette production from 1989 to 2003 using tobacco leaf flows from the United Nations Commodity Trade Statistics Database (UN Comtrade). Results  We identify four phases in the illicit tobacco trade involving Paraguay: 1) Paraguay as a transit hub to smuggle BAT and PMI cigarettes from the U.S. into Argentina and Brazil (from the 1960s to the mid-1970s); 2) BAT and PMI competing in north-east Argentina (1989–1994); 3) BAT and PMI competing in southern and southern-east Brazil (mid to late 1990s); and 4) the growth in the illicit trade of Paraguayan manufactured cigarettes (from the mid- 1990s onwards). These phases suggest the illicit trade was seeded by TTCs, and that the system of supply and demand on lower priced brands they developed in the 1990s created a business opportunity for manufacturing in Paraguay. Brazil’s efforts to fight this trade, with a 150% tax on exports to Latin American countries in 1999, further prompted supply of the illicit trade to shift from TTCs to Paraguayan manufacturers. Conclusion  This paper extends evidence of the longstanding complicity of TTCs in the illicit trade to this region and the consequent growth of Paraguayan production in the 1990s. Our findings confirm the need to better understand the factors influencing how the illicit tobacco trade has changed over time, in specific regional contexts, and amid tobacco industry globalization. In Paraguay, the changing roles of TTC and domestic production have been central to shifting patterns of illicit supply and distribution since the 1960s. Important questions are raised, in turn, about TTCs efforts to participate as legitimate partners in global efforts to combat the problem, including a leading role in data gathering and analysis

The health and economic burden of smoking in 12 Latin American countries and the potential effect of increasing tobacco taxes: an economic modelling study

Background: Worldwide, smoking tobacco causes 7 million deaths annually, and this toll is expected to increase, especially in low-income and middle-income countries. In Latin America, smoking is a leading risk factor for death and disability, contributes to poverty, and imposes an economic burden on health systems. Despite being one of the most effective measures to reduce smoking, tobacco taxation is underused and cigarettes are more affordable in Latin America than in other regions. Our aim was to estimate the tobacco-attributable burden on mortality, disease incidence, quality of life lost, and medical costs in 12 Latin American countries, and the expected health and economic effects of increasing tobacco taxes. Methods: In this modelling study, we developed a Markov probabilistic microsimulation economic model of the natural history, medical costs, and quality-of-life losses associated with the most common tobacco-related diseases in 12 countries in Latin America. Data inputs were obtained through a literature review, vital statistics, and hospital databases from each country: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Honduras, Mexico, Paraguay, Peru, and Uruguay. The main outcomes of the model are life-years, quality-adjusted life-years, disease events, hospitalisations, disease incidence, disease cost, and healthy years of life lost. We estimated direct medical costs for each tobacco-related disease included in the model using a common costing methodology for each country. The disease burden was estimated as the difference in disease events, deaths, and associated costs between the results predicted by the model for current smoking prevalence and a hypothetical cohort of people in each country who had never smoked. The model estimates the health and financial effects of a price increase of cigarettes through taxes, in terms of disease and health-care costs averted, and increased tax revenues. Findings: In the 12 Latin American countries analysed, we estimated that smoking is responsible for approximately 345 000 (12%) of the total 2 860 921 adult deaths, 2·21 million disease events, 8·77 million healthy years of life lost, and $26·9 billion in direct medical costs annually. Health-care costs attributable to smoking were estimated to represent 6·9$26·7 billion in health-care costs in the next 10 years, with a total economic benefit of $43·7 billion. Interpretation: Smoking represents a substantial health and economic burden in these 12 countries of Latin America. Tobacco tax increases could successfully avert deaths and disability, reduce health-care spending, and increase tax revenues, resulting in large net economic benefits.Fil: Pichón-riviere, Andres. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Alcaraz, Andrea. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Palacios, Alfredo. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Rodríguez, Belén. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Reynales Shigematsu, Luz Myriam. Instituto Nacional de Salud Pública; MéxicoFil: Pinto, Márcia. Fundación Oswaldo Cruz; BrasilFil: Castillo Riquelme, Marianela. Ministerio de Salud; ChileFil: Peña Torres, Esperanza. Instituto de Evaluación Tecnológica En Salud; ColombiaFil: Osorio, Diana Isabel. Instituto de Evaluación Tecnológica en Salud; ColombiaFil: Huayanay, Leandro. Universidad Peruana Cayetano Heredia; PerúFil: Loza Munarriz, Cesar. Universidad Peruana Cayetano Heredia; PerúFil: Sáenz de Miera-Juárez, Belén. Universidad Autónoma de Baja California Sur; MéxicoFil: Gallegos Rivero, Verónica. Centro Nacional de Excelencia Tecnológica en Salud; MéxicoFil: De La Puente, Catherine. Universidad de La Frontera; ChileFil: Navia Bueno, María del Pilar. Universidad Mayor de San Andrés; BoliviaFil: Caporale, Joaquín. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Roberti, Javier Eugenio. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Virgilio, Sacha Alexis. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentin

Working Times and Overweight: Tight Schedules, Weaker Fitness?

Although the rise in obesity and overweight is related to time constraints influencing health investments (e.g., exercise, shopping and cooking time, etc.), there is limited causal evidence to substantiate such claims. This paper estimates the causal effect of a change in working times on overweight and obesity drawing from evidence from a national policy (the Aubrey reform) implemented in the beginning of the past decade in France that reduced the work week from 39 to 35 hours, or 184 hours per year. This policy came into effect in 2001 but one region, Alsace-Mosselle, blunted its impact by counting two existing public holidays towards the 184-hour reduction. In this region, hours of work per year only fell by 168. However, in 2003, Alsace-Mosselle was forced to fully comply with national policy. We use longitudinal data from GAZEL (INSERM) 1997-2006 that contains detailed information about health indicators, including measures of height and weight. Drawing from a difference-in-differences strategy, we estimate the effect of a differential reduction in working times on body weight. Our results show evidence of 8 percential points increase in the probability of overweight among blue collar workers when the exposure to the reform, and a non-significant overweight reduction when the reform ‘turned off’. In contrast, we find no effect among white collar workers. The effects are robust to different specifications and placebo tests

El consumo de tabaco en los hogares mexicanos, 1994-2005

Objetivo. Caracterizar la evolución del consumo de tabaco en los hogares mexicanos entre 1994 y 2005. Material y métodos. Se estimaron indicadores relevantes (proporciones y medias) a partir de la Encuesta Nacional de Ingresos y Gastos de los Hogares (1994 a 2005). Se presentan intervalos de confianza de los parámetros estimados. Resultados. La prevalencia del consumo de tabaco en hogares se redujo de 11.2% (IC 95%: 10.4-12.1) en 1994 a 7.8% (IC 95%: 7.3-8.3) en 2005. El consumo promedio de tabaco se mantuvo estable entre 1994 y 2004. La prevalencia e intensidad del consumo de tabaco entre los hogares de menor ingreso ¿4.2% (IC 95%: 3.4-5.1) y 4.9 cajetillas por mes (IC 95%: 4.1-5.7) respectivamente¿ resultaron menores que en los de mayor ingreso ¿11.2% (IC 95%: 10.0-12.4) y 7.6 cajetillas por mes (IC 95%: 6.8-8.4)¿ respectivamente. Por el contrario, el gasto en tabaco como porcentaje del gasto total entre los hogares de menor ingreso ¿5.5% (IC 95%: 4.2-6.9)¿ resultó mayor que entre los de mayor ingreso ¿2.5% (IC 95%: 2.1-2.8)¿. La participación promedio del gasto en cigarros en el gasto total de los hogares fumadores de menor ingreso no presentó diferencias signifi- cativas con respecto a la participación del gasto en educación y esparcimiento ¿8.1% (IC 95%: 5.7-10.5)¿, vestido y calzado ¿4.5% (IC 95%: 3.4-5.6)¿ o cuidados de la salud ¿4.5% (IC 95%: 2.6-6.3)¿. Conclusiones. A pesar de que la prevalencia del consumo de tabaco en hogares es menor a la de hace una década, el gasto en tabaco ocupa una parte importante del gasto total de los hogares fumadores, en particular, de los que tienen menores ingresos. Dada la escasez de recursos en estos últimos, el gasto en tabaco compite con la obtención de satisfactores básicos como alimentos y educación, por lo que representa una carga para ellos

El consumo de tabaco en los hogares mexicanos, 1994-2005 Household tobacco consumption in Mexico, 1994-2005

OBJETIVO: Caracterizar la evolución del consumo de tabaco en los hogares mexicanos entre 1994 y 2005. MATERIAL Y MÉTODOS: Se estimaron indicadores relevantes (proporciones y medias) a partir de la Encuesta Nacional de Ingresos y Gastos de los Hogares (1994 a 2005). Se presentan intervalos de confianza de los parámetros estimados. RESULTADOS: La prevalencia del consumo de tabaco en hogares se redujo de 11.2% (IC 95%: 10.4-12.1) en 1994 a 7.8% (IC 95%: 7.3-8.3) en 2005. El consumo promedio de tabaco se mantuvo estable entre 1994 y 2004. La prevalencia e intensidad del consumo de tabaco entre los hogares de menor ingreso -4.2% (IC 95%: 3.4-5.1) y 4.9 cajetillas por mes (IC 95%: 4.1-5.7) respectivamente- resultaron menores que en los de mayor ingreso -11.2% (IC 95%: 10.0-12.4) y 7.6 cajetillas por mes (IC 95%: 6.8-8.4)- respectivamente. Por el contrario, el gasto en tabaco como porcentaje del gasto total entre los hogares de menor ingreso -5.5% (IC 95%: 4.2-6.9)- resultó mayor que entre los de mayor ingreso -2.5% (IC 95%: 2.1-2.8)-. La participación promedio del gasto en cigarros en el gasto total de los hogares fumadores de menor ingreso no presentó diferencias significativas con respecto a la participación del gasto en educación y esparcimiento -8.1% (IC 95%: 5.7-10.5)-, vestido y calzado -4.5% (IC 95%: 3.4-5.6)- o cuidados de la salud -4.5% (IC 95%: 2.6-6.3)-. CONCLUSIONES: A pesar de que la prevalencia del consumo de tabaco en hogares es menor a la de hace una década, el gasto en tabaco ocupa una parte importante del gasto total de los hogares fumadores, en particular, de los que tienen menores ingresos. Dada la escasez de recursos en estos últimos, el gasto en tabaco compite con la obtención de satisfactores básicos como alimentos y educación, por lo que representa una carga para ellos.OBJECTIVE: To analyze household tobacco consumption and expenditure in Mexico from 1994 to 2005. MATERIAL AND METHODS: The National Surveys on Household Income and Expenditures conducted in Mexico from 1994 to 2005 were used to estimate relevant statistics (proportions and means). Confidence intervals of the estimated parameters are presented. RESULTS: Smoking household prevalence decreased from 11.2% (IC95%: 10.4-12.1) in 1994 to 7.8% (IC95%: 7.3-8.3) in 2005. This percentage was lowest in low-income households -4.2% (IC95%: 3.4-5.1)- and highest in high-income households -11.2% (IC95%: 10.0-12.4). On the contrary, expenditure on tobacco as a percentage of total household expenditures was highest in low-income households -5.5% (IC95%: 4.2-6.9)- and lowest in high-income households -2.5% (IC95%: 2.1-2.8). CONCLUSIONS: Household smoking prevalence is lower than a decade before; however, expenditure on tobacco represents a high share of households’ total expenditures, particularly, among low-income smoker households. Consequently, tobacco is a burden for low-income smoker households where resources to buy essential goods and services are scarce

El efecto del precio del tabaco sobre el consumo: un análisis de datos agregados para México The effect of tobacco prices on consumption: a time series data analysis for Mexico

Objetivo. Estimar la elasticidad precio de la demanda de cigarros en México con base en fuentes de información y metodología distintas a las utilizadas en estudios previos sobre el tema. Material y métodos. Se utilizaron series trimestrales de consumo, ingreso y precio para el periodo de 1994 a 2005. Se estimó un modelo de demanda de largo plazo mediante mínimos cuadrados ordinarios (MCO) y se investigó la existencia de una relación de cointegración. Además, se estimó un modelo mediante mínimos cuadrados ordinarios dinámicos (MCOD) para corregir posibles problemas de endogeneidad de las variables independientes y autocorrelación de los residuales. Resultados. Las estimaciones mediante MCOD mostraron que un incremento del precio de los cigarros de 10% podría reducir el consumo en 2.5% (p<0.05) y aumentar la recaudación fiscal en 16.11%. Conclusiones. Los resultados confirmaron la efectividad de los impuestos como herramienta para el control del tabaco en México. El incremento de los impuestos puede utilizarse para aumentar el precio de los cigarros, y por consiguiente, para reducir el consumo y aumentar la recaudación fiscal.<br>Objective. To estimate the price elasticity of the demand for cigarettes in Mexico based on data sources and a methodology different from the ones used in previous studies on the topic. Material and Methods. Quarterly time series of consumption, income and price for the time period 1994 to 2005 were used. A long-run demand model was estimated using Ordinary Least Squares (OLS) and the existence of a cointegration relationship was investigated. Also, a model using Dinamic Ordinary Least Squares (DOLS) was estimated to correct for potential endogeneity of independent variables and autocorrelation of the residuals. Results. DOLS estimates showed that a 10% increase in cigarette prices could reduce consumption in 2.5% (p<0.05) and increase government revenue in 16.11%. Conclusions. The results confirmed the effectiveness of taxes as an instrument for tobacco control in Mexico. An increase in taxes can be used to increase cigarette prices and therefore to reduce consumption and increase government revenue