Catastrophic and impoverishing health expenditures in fragmented public health systems: lessons from Mexico, 2000–2022
File(s)
Published version
Author(s)
Cerecero-García, Diego
Gómez-Dantés, Octavio
Hone, Thomas
Pineda-Antúnez, Carlos
Mohar-Betancourt, Alejandro
Type
Journal Article
Abstract
Background
Universal Health Coverage (UHC) requires that all individuals access comprehensive health services without facing financial hardship. Fragmented health systems, characterised by multiple uncoordinated financing schemes, can weaken financial risk protection and disproportionately expose vulnerable populations to out-of-pocket expenditures (OOP). Evidence on how fragmentation affects financial protection in Latin America is limited. This study examines the long-term trends in catastrophic, impoverishing, and excessive health expenditures in Mexico’s fragmented public health system.
Methods
We analysed 470,104 households from the Mexican National Household Income and Expenditure Survey (ENIGH, 2000–2022), corresponding to an estimated 341.3 million household-wave observations nationally. Financial hardship was measured using standard indicators: catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and excessive health expenditure (EHE). Descriptive results used a more granular insurance breakdown, whereas the main analyses grouped households into four main public insurance categories: uninsured, Seguro Popular/INSABI, social security, and mixed public coverage. Heckprobit models estimated adjusted probabilities of financial hardship, accounting for selection among households with positive health expenditure. Analyses incorporated the complex survey design and expansion factors, and sensitivity analyses used alternative thresholds for CHE and EHE.
Findings
Financial protection improved for most households between 2000 and 2014, particularly among Seguro Popular affiliates. After 2020, following the replacement of this public insurance scheme with INSABI, protection deteriorated, with CHE and EHE reaching their highest levels among mixed insurance households by 2022. Social security households consistently experienced the lowest financial burden, while uninsured and INSABI-affiliated households faced substantially higher risk. Increased use of private healthcare, especially for medicines, contributed to rising OOP. Sensitivity analyses confirmed these trends.
Conclusion
Fragmentation in Mexico’s public health system has intensified inequalities in financial protection. The coexistence of multiple uncoordinated insurance schemes has failed to protect households from economic hardship, particularly those in the informal sector. Achieving meaningful UHC will require integrated financing reforms that standardise benefits, reduce administrative complexity, and address persistent gaps in service provision.
Universal Health Coverage (UHC) requires that all individuals access comprehensive health services without facing financial hardship. Fragmented health systems, characterised by multiple uncoordinated financing schemes, can weaken financial risk protection and disproportionately expose vulnerable populations to out-of-pocket expenditures (OOP). Evidence on how fragmentation affects financial protection in Latin America is limited. This study examines the long-term trends in catastrophic, impoverishing, and excessive health expenditures in Mexico’s fragmented public health system.
Methods
We analysed 470,104 households from the Mexican National Household Income and Expenditure Survey (ENIGH, 2000–2022), corresponding to an estimated 341.3 million household-wave observations nationally. Financial hardship was measured using standard indicators: catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and excessive health expenditure (EHE). Descriptive results used a more granular insurance breakdown, whereas the main analyses grouped households into four main public insurance categories: uninsured, Seguro Popular/INSABI, social security, and mixed public coverage. Heckprobit models estimated adjusted probabilities of financial hardship, accounting for selection among households with positive health expenditure. Analyses incorporated the complex survey design and expansion factors, and sensitivity analyses used alternative thresholds for CHE and EHE.
Findings
Financial protection improved for most households between 2000 and 2014, particularly among Seguro Popular affiliates. After 2020, following the replacement of this public insurance scheme with INSABI, protection deteriorated, with CHE and EHE reaching their highest levels among mixed insurance households by 2022. Social security households consistently experienced the lowest financial burden, while uninsured and INSABI-affiliated households faced substantially higher risk. Increased use of private healthcare, especially for medicines, contributed to rising OOP. Sensitivity analyses confirmed these trends.
Conclusion
Fragmentation in Mexico’s public health system has intensified inequalities in financial protection. The coexistence of multiple uncoordinated insurance schemes has failed to protect households from economic hardship, particularly those in the informal sector. Achieving meaningful UHC will require integrated financing reforms that standardise benefits, reduce administrative complexity, and address persistent gaps in service provision.
Date Issued
2026-02-20
Date Acceptance
2026-01-05
Citation
Health Economics Review, 2026, 16
ISSN
2191-1991
Publisher
BMC
Journal / Book Title
Health Economics Review
Volume
16
Copyright Statement
© The Author(s) 2026. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Identifier
https://www.ncbi.nlm.nih.gov/pubmed/41553638
PII: 10.1186/s13561-026-00717-z
Subjects
Catastrophic health expenditures
Financial protection in health
Fragmentation
Impoverishing health expenditures
Mexico
Universal health coverage
Publication Status
Published
Coverage Spatial
Germany
Article Number
22
Date Publish Online
2026-01-19