摘要：Objectives. We examined whether remittances sent from the United States to Mexico were used to access health care in Mexico. Methods. Data were from a 2006 survey of 2 localities in the municipal city of Tepoztlán, Morelos, Mexico. We used logistic regression to determine whether household remittance expenditure on health care was associated with type of health insurance coverage. Results. Individuals who lacked insurance coverage or who were covered by the Seguro Popular program were significantly more likely to reside in households that spend remittances on health care than were individuals covered by an employer-based insurance program. Conclusions. Improving the coverage and quality of care within Mexico's health care system will help ensure that remittances serve as a complement, and not a substitute, to formal access to care. Every year, Mexican migrants living in the United States send home billions of US dollars in the form of remittances, also known as “migradollars.” Since the 1980s, the flow of remittances has increased annually so that in 2006, Mexicans in the United States remitted 10 times the amount that was remitted in 1990, with an average annual growth rate of 15%. 1 According to the Central Bank of Mexico, remittances to Mexico during 2006 totaled $23.1 billion. 2 In 2007, the sum of remittances appears to have leveled off: a survey conducted for the Inter-American Development Bank estimated total remittances for 2007 to be $23.4 billion. 3 Existing evidence suggests that remittances are used largely to purchase basic necessities. 4 – 7 In this context, US remittances provide migrants and their families in Mexico access to goods and services that they could not otherwise afford, including food, housing, and consumer goods. Another possibility that has received less attention in the literature is that remittances are used to access health care. Mexico is marked by large inequities in health care access and consumption. 8 The provision of health care is governed by a hybrid combination of employment-based formal insurance for salaried workers, publicly provided services for those excluded from formal insurance programs, and a much smaller percentage (2%) with private insurance coverage. 9 According to the 2005 Mexican Conteo de Población y Vivienda (Count of Population and Housing), approximately 40% of the Mexican population had access to a formal insurance program. 10 The rest of the population falls outside of the purview of formal social insurance programs and includes those who are self-employed, nonsalaried, unemployed, and informal workers; the majority of which are poor and are served by the Secretaría de Salud (SSA; Mexican Ministry of Health). 9 The uninsured largely access health care through out-of-pocket payments paid either to public clinics or to a large, mostly unregulated private sector that provides fee-for-service care. 11 Out-of-pocket payments represent the highest proportion of health care expenditure in Mexico. 12 In an effort to reduce out-of-pocket spending and promote more equitable resource distribution, a new program called Seguro Popular (Popular Health Insurance Program) was introduced in 2004 and continues to expanded across the country. 8 The program's aim is to increase financial protection of individuals outside the formal insurance programs by providing coverage for essential interventions (249 as of 2006) and selected catastrophic treatments. 11 The package of covered services will be expanded and updated annually. Currently, the program includes ambulatory care and hospitalization for basic specialties (e.g., internal medicine, general surgery, obstetrics and gynecology, pediatrics, geriatrics). 8 As of September 2006, roughly 4 million families were enrolled in the program. 11 Migrants living in the United States (i.e., international migrants) and their families in Mexico may be more reliant on out-of-pocket spending on health care, which may be funded by remittances. Because they are less likely to have salaried jobs within the formal economy in Mexico, they are less likely to have access to an employer-based formal health insurance program in Mexico. 13 There is some existing evidence that remittances are used to purchase health services in Mexico, although estimates vary widely. One study based on a community survey in Oaxaca estimates that as little as 1% of remittances are spent on health care. 14 Estimates from a national-based survey of migrant households put the number closer to 50%. 15 Such variability in estimates is likely caused by differences in sampling frames and survey methodology (e.g., whether respondents were allowed to list multiple uses for remittances or only 1). One of the few existing studies that looks explicitly at the relationship between remittances and household expenditure on health care used data from the Encuesta Nacional de Ingresos y Gastos de los Hogares (ENIGH; National Household Income and Expenditure Survey). 16 The study found that households receiving remittances spend more money on primary care expenses than do those that do not receive remittances. 16 Another study using the ENIGH data also found a similar effect and reported that households receiving remittances exhibit a 44% rise in the share of the household budget spent on health care. 17 Data from the Encuesta Nacional a Hogares Rurales de Mexico (ENHRUM; Mexico National Rural Household Survey) found that rural households with international migrants spend more income on health than do either internal migrant households or households with no migrants. 18 The pattern between remittance receipt and health expenditure coupled with Mexico's large uninsured population (estimated at over 50%) raises the possibility that remittances may be used as a compensatory mechanism to address gaps in health care provision among Mexican migrant families. 8 , 19 If remittances serve as a method for redressing gaps in health care coverage, we would expect to find differences in how remittances are used by health insurance status. We examined whether remittances sent from Mexican immigrants in the United States to relatives in Mexico are used to pay for health care in Mexico. We tested this possibility by examining patterns of household remittance expenditure by individual health insurance status. For all analyses we used data from a household census completed in the municipal city of Tepoztlán, Morelos, Mexico. The survey included an extensive module on US migration experience and remittance expenditure as well as health and health care, which allowed us to examine the associations between remittances, health insurance status, and health status at a level of detail that previously had not been possible.
