Persistent inequities in maternal mortality in Latin America and the Caribbean, 1990-2019

BACKGROUND

Despite the resources and personnel mobilized in Latin America and the Caribbean to reduce the maternal mortality ratio (MMR, maternal deaths per 100 000 live births) in women aged 10-54 years by 75% between 2000 and 2015, the region failed to meet the Millenium Development Goals (MDGs) due to persistent barriers to access quality reproductive, maternal, and neonatal health services.

METHODS

Using 1990-2019 data from the Global Burden of Disease project, we carried out a two-stepwise analysis to (a) identify the differences in the MMR temporal patterns and (b) assess its relationship with selected indicators: government health expenditure (GHE), the GHE as percentage of gross domestic product (GDP), the availability of human resources for health (HRH), the coverage of effective interventions to reduce maternal mortality, and the level of economic development of each country.

FINDINGS

In the descriptive analysis, we observed a heterogeneous overall reduction of MMR in the region between 1990 and 2019 and heterogeneous overall increases in the GHE, GHE/GDP, and HRH availability. The correlation analysis showed a close, negative, and dependent association of the economic development level between the MMR and GHE per capita, the percentage of GHE to GDP, the availability of HRH, and the coverage of SBA. We observed the lowest MMRs when GHE as a percentage of GDP was close to 3% or about US$400 GHE per capita, HRH availability of 6 doctors, nurses, and midwives per 1,000 inhabitants, and skilled birth attendance levels above 90%.

CONCLUSIONS

Within the framework of the Sustainable Development Goals (SDGs) agenda, health policies aimed at the effective reduction of maternal mortality should consider allocating more resources as a necessary but not sufficient condition to achieve the goals and should prioritize the implementation of new forms of care with a gender and rights approach, as well as strengthening actions focused on vulnerable groups.

Human resources for health and maternal mortality in Latin America and the Caribbean over the last three decades: a systemic-perspective reflections

BACKGROUND

The role of human resources for health in the operation of health systems is crucial. However, training and incorporating them into institutions is a complex process due to the continuous misalignment between the supply and demand of health personnel. Taking the case of the Latin American and Caribbean region countries, this comment discusses the relationship between the availability of human resources for health and the maternal mortality ratio for the period 1990-2021. It proposes the need to resume planning exercises from a systemic perspective that involves all areas of government and the private sector linked to the training and employment of health workers.

MAIN TEXT

We used secondary data from a global source to show patterns in the relationship between these two aspects and identify gaps in the Latin American and Caribbean regions. The results show enormous heterogeneity in the response of regional health systems to the challenge of maternal mortality in the region. Although most countries articulated specific programs to achieve the reduction committed by all countries through the Millennium Development Goals, not all had the same capacity to reduce it, and practically none met the target. In addition, in the English Caribbean countries, we found significant increases in the number of health personnel that do not explain the increases in the maternal mortality rate during the period.

CONCLUSIONS

The great lesson from the data shown is that some countries could articulate responses to the problem using available resources through effective strategies, considering the specific needs of their populations. Although variations in maternal mortality rate cannot be explained solely through the provision of health personnel, it is important to consider that it is critical to find new modalities on how human resources for health could integrate and create synergies with other resources to increase systems capacity to deliver care according to conditions in each country.

A Gender-Based and Quasi-Experimental Study of the Catastrophic and Impoverishing Health-Care Expenditures in Mexican Households with Elderly Members, 2000-2020

Latin America has experienced a rise in noncommunicable diseases (NCDs) which is having repercussions on the structuring of healthcare delivery and social protection for vulnerable populations. We examined catastrophic (CHE) and excessive (EHE, impoverishing and/or catastrophic) health care expenditures in Mexican households with and without elderly members (≥65 years), by gender of head of the households, during 2000-2020. We analyzed pooled cross-sectional data for 380,509 households from eleven rounds of the National Household Income and Expenditure Survey. Male- and female-headed households (MHHs and FHHs) were matched using propensity scores to control for gender bias in systematic differences regarding care-seeking (demand for healthcare) preferences. Adjusted probabilities of positive health expenditures, CHE and EHE were estimated using probit and two-stage probit models, respectively. Quintiles of EHE by state among FHHs with elderly members were also mapped. CHE and EHE were greater among FHHs than among MHHs (4.7% vs 3.9% and 5.5% vs 4.6%), and greater in FHHs with elderly members (5.8% vs 4.9% and 6.9% vs 5.8%). EHE in FHHs with elderly members varied geographically from 3.9% to 9.1%, being greater in less developed eastern, north-central and southeastern states. Compared with MHHs, FHHs face greater risks of CHE and EHE. This vulnerability is exacerbated in FHHs with elderly members, because of gender intersectional vulnerability. The present context, marked by a growing burden of NCDs and inequities amplified by COVID-19, makes key interlinkages across multiple Sustainable Development Goals (SDGs) apparent, and calls for urgent measures that strengthen social protection in health.

[Exploring facilitators and barriers to implementing expanded nursing roles in MexicoEstudo de facilitadores e barreiras para a implementação de funções ampliadas de enfermagem no México]

Objective

To explore the perceptions of nursing professionals regarding facilitators and barriers to the implementation of expanded nursing functions in a state in central Mexico.

Methods

Qualitative descriptive phenomenological study. During 2022, 18 semi-structured interviews were conducted with three types of informants: a) head nurses at state-level facilities; b) head nurses at local-level facilities; and c) heads of health units and operational nursing staff who have direct contact with patients.

Results

The following facilitators were identified: willingness to adopt the strategy (seen as favorable by managers and acceptable by nursing staff); reorganization of functions (simplification of processes and analysis of the situation of health units); access to training; and characteristics of nursing staff (professionalization, work experience, and favorable attitude). Barriers included: conditions at the first level of care (personnel shortages, too many administrative activities, lack of physical space, materials, supplies, and consumables), resistance to change (professional jealousy of other disciplines and duplication of tasks), staff salaries, lack of training, not trusted with expanded duties, and attitude of patients (resistance to nursing care).

Conclusions

By understanding the perceptions of nursing professionals, we can identify key elements for the successful expansion of nursing functions through expansion of the competencies of operational staff. Reorganization and proper management at different levels of decision-making will be necessary.

Recruitment of nursing students in the context of the COVID-19 pandemic in Mexico. A rapid response to the health emergency

The Mexican government implemented a strategy to increase nursing staff in response to COVID-19, including the early graduation of university students, to incorporate them into the care frontline. This exploratory qualitative study aimed to analyze nursing students' experiences recruited by health institutions to care for COVID patients. It included 12 participants who received and accepted job proposals in health institutions for patient care during their internship. Data were collected through semi-structured interviews with prior informed consent. The experiences of the participants were integrated into three themes: the students took advantage of the modified social service regulations to be recruited by an institution and integrate into COVID-19 care; the recruitment and remuneration conditions were plagued with anomalies and important informalities in the process; and the preparation for care was very incipient, so learning occurred in the very care process. The pandemic allowed the participants to enter the nursing labor market in extraordinary and substandard conditions.

Burden of non-communicable diseases and behavioural risk factors in Mexico: Trends and gender observational analysis

Background

There is scarce gender-disaggregated evidence on the burden of disease (BD) worldwide and this is particularly prominent in low- and middle-income countries. The objective of this study is to compare the BD caused by non-communicable diseases (NCDs) and related risk factors by gender in Mexican adults.

Methods

We retrieved disability-adjusted life years (DALYs) estimates for diabetes, cancers and neoplasms, chronic cardiovascular diseases (CVDs), chronic respiratory diseases (CRDs), and chronic kidney disease (CKD) from the Global Burden of Disease (GBD) Study from 1990-2019. Age-standardized death rates were calculated using official mortality microdata from 2000 to 2020. Then, we analysed national health surveys to depict tobacco and alcohol use and physical inactivity from 2000-2018. Women-to-men DALYs and mortality rates and prevalence ratios (WMR) were calculated as a measure of gender gap.

Findings

Regarding DALYs, WMR was >1 for diabetes, cancers, and CKD in 1990, indicating a higher burden in women. WMR decreased over time in all NCDs, except for CRDs, which increased to 0.78. However, WMR was <1 for all in 2019. The mortality-WMR was >1 for diabetes and cardiovascular diseases in 2000 and <1 for the rest of the conditions. The WMR decreased in all cases, except for CRDs, which was <1 in 2020. The WMR for tobacco and alcohol use remained under 1. For physical inactivity, it was >1 and increasing.

Conclusions

The gender gap has changed for selected NCDs in favour of women, except for CRDs. Women face a lower BD and are less affected by tobacco and alcohol use but face a higher risk of physical inactivity. Policymakers should consider a gendered approach for designing effective policies to reduce the burden of NCDs and health inequities.

Nursing practice environment and missed care at highly specialised hospitals in Mexico: A cross-sectional observational study

BACKGROUND

The influence of the work environment on missed care and service quality has been well documented. However, available evidence concerning this relationship comes mostly from developed countries. Few studies have been conducted in low- or middle-income countries. We assessed the relationship between the work environment and missed nursing care in highly specialised hospitals in Mexico.

METHODS

We conducted an observational cross-sectional study with data collected from January 2019 to February 2020 in 11 highly specialised hospitals (n = 510 nurses). We estimated missed nursing care utilising the MISSCARE questionnaire and used the Practice Environment Scale-Nursing Work Index instrument to assess the work environment. After describing the main attributes of the study sample according to the type of work environment, we constructed five adjusted fractional regression models, the first concerning the overall index of missed care, and the others pertaining to its various dimensions.

RESULTS

The sample analysed was balanced as regards adjustment variables according to the type of work environment. The adjusted estimates confirmed an inverse relationship between the missed care index and enjoying an enhanced, or favourable, work environment. Overall, the difference was 9 percentage points (pp); however, by dimension of missed care, the major differences between enhanced and attenuated, or unfavourable, work environments were registered for basic care, followed by patient education and discharge planning (4pp) and individual needs (8pp).

CONCLUSIONS

The work environment determines the frequency of missed nursing care, both overall and by dimension. Nursing managers need to create short- and mid-term strategies favouring positive work environments in order to improve working conditions for nursing professionals.

The experience of obstetric nursing students in an innovative maternal care programme in Chiapas, Mexico: a qualitative study

In Mexico, over the last decade, more non-physician medical professionals have been participating in birth care according to recent federal regulations. So far, very few sites have been able to implement birth care models where midwives and obstetric nurses participate. We describe the experience of a group of intern obstetric nurses participating in a model that provides respectful birth care to rural populations, managed by an international NGO in partnership with the Ministry of Health of Chiapas, Mexico. We conducted a case study including individual interviews and focus group discussions with obstetric nurse interns participating in the Compañeros En Salud programme over four years from 2016 to 2019. We applied targeted content analysis to the qualitative data. There were 28 participants from 4 groups of interns. Informants expressed their opinions in four areas: (a) training as a LEO, (b) training experience at CES, (c) LEO role in health care delivery; and (d) LEOs' perspectives about respectful maternity care. Interns identified gaps in their training including a higher load of theoretical content vs practical experience, as well as little supervision of clinical care in public hospitals. Their adaptation to the health services model has increased over time, and recent classes acknowledge the difficulties that earlier ones had to confront, including the challenging interactions with hospital staff. Interns have incorporated the value of respectful birth care and their role to protect this right in rural populations. Findings could be useful to call for the expansion of the model in public birth centres.

Missed nursing care in highly specialized hospitals: A Mexican case study

OBJECTIVE

To assess the status of missed nursing care and the reasons for its occurrence in a highly specialised public hospital in Mexico.

MATERIALS AND METHODS

An observational cross-sectional analysis with data collected from January to June 2019 at the National Institute of Rehabilitation Luis Guillermo Ibarra Ibarra in Mexico City. We assessed missed care and its causes by conducting the MISSCARE survey among 116 nursing professionals selected from a population of 162 nurses. This work presents the estimated rates of missed care-overall and broken down into its four dimensions-as well as the reasons for its occurrence, namely limited labour resources, inadequate material resources and communication problems among work teams.

RESULTS

The overall score for missed care was 16% (95% CI: 11.84%-20.15%), with the following rates by dimension: 19.48% for basic care, 14.66% for individual needs, 6.47% for patient education and discharge planning, and 4.31% for continuous patient assessment. The main reason cited for missed care was inadequate material resources, followed by limited labour resources and communication problems among work teams.

CONCLUSION

Basic care and individual needs interventions were the most frequently omitted services, primarily because of inadequate material resources, limited labour resources and communication problems among work teams. An increase in the frequency of missed care can be expected in light of the high demand for health services, particularly as regards labour and material resources, imposed by the SARS-CoV-2 pandemic.

Advanced Practice Nursing Roles: A Comparison Between Mexico and the United Kingdom

The COVID-19 pandemic has placed nursing at the forefront of public attention across the globe and has highlighted the critical role of nursing in healthcare service provision. Advanced practice nursing has been recognized for more than 50 years, but the rate of its growth and development varies significantly across the world. One of the key aims of the Better Health Programme Mexico, which commenced in 2019, was to develop advanced practice nursing in Mexico. The Programme was based on the United Kingdom model, where advanced practice nursing has been in place—though not subject to statutory regulation—for more than 40 years. The aim of this article is to compare the frameworks that underpin advanced practice nursing in the United Kingdom and in Mexico. In the present article, current practice in both countries was researched, and the structure, systems, and processes relating to nursing regulation and the frameworks to support advanced practice nursing were examined. A gap analysis report undertaken as part of the Better Health Programme identified challenges in developing advanced practice nursing in Mexico and the United Kingdom and highlighted the need for stakeholders to agree on an approach toward a rigorous regulatory framework in both settings. In summary, this article highlights the issues facing nurses and regulators in both countries in terms of advanced practice nursing and identifies strategies that can be used to strengthen the advanced practice nurse role.

Performance of the Mexican nursing labor market: a repeated cross-sectional study, 2005-2019

BACKGROUND

The close link between human resources for health and the performance of health systems calls for a comprehensive study of the labor market. This paper proposes a performance metric for the nursing labor market, measures its magnitude and analyzes its predictors over the last 15 years.

DESIGN AND METHODS

A repeated cross-sectional analysis using data from the quarterly population-based National Survey of Occupation and Employment 2005-2019 (ENOE in Spanish). An aggregate total of 19,311 Mexican nurses (population N = 4,816,930) was analyzed. Nursing labor market performance was defined as the level of non-precarious employment of nurses in the health sector. After describing the sociodemographic, labor and contextual characteristics of the nurses surveyed, we identified the key correlates of market performance using repeated cross-sectional multiple logistic regression analysis. We then estimated the adjusted prevalence of market performance according to the survey period and socioeconomic region of residence.

RESULTS

The exogenous indicators analyzed shed light on various aspects of the market structure. Unemployment remained stable at 5% during the period examined, but underemployment rose by 26% and precarious employment, our endogenous indicator, also grew significantly. On the whole, our indicators revealed a notable deterioration in the structure of the nursing labor market; they varied by age and sex as well as between public and private institutions. Although the steepest deterioration occurred in the private sector, we observed an increase in precarious jobs among public institutions formerly protective of employment conditions.

CONCLUSIONS

The deterioration of the labor market jeopardizes the ability of nursing professionals to participate in the market as well as to obtain secure jobs once they do enter. The Mexican Health System suffers from a chronic dearth of nurses, reducing its capacity to achieve its core objectives including enhanced coverage and increased effectiveness. Nursing workforce planning requires a context where the conditions in which the market currently operates, and its potential deterioration are considered.

Sociodemographic and work environment correlates of missed nursing care at highly specialized hospitals in Mexico: A cross-sectional study

BACKGROUND

Despite its direct relevance to quality of care, little is known about missed nursing care or its sociodemographic and work environment correlates at highly specialized hospitals in low- and middle-income countries.

OBJECTIVE

To analyze the frequency of missed nursing care among Mexican nursing professionals, and to assess its associated sociodemographic and labor-related predictors.

DESIGN AND METHODS

A cross-sectional, observational study based on data collected from 315 nursing professionals in 11 highly specialized public hospitals in Mexico. We assessed missed nursing care both as a total figure and according to the four dimensions of the MISSCARE inventory. We estimated its sociodemographic and work-related predictors using fractional logistic analysis.

RESULTS

The global score for missed nursing care was 15.21%: 7.94% concerned individual needs, 9.37% discharge planning and patient education, 18.10% basic care, and 1.59% care under continuous assessment. The odds of engaging in missed nursing care increased with age and were higher among women and night-shift workers. In contrast, they decreased among nursing professionals who were satisfied with their jobs, and among those working in suitable environments.

CONCLUSIONS

Missed nursing care in highly specialized public hospitals is associated with the sociodemographic characteristics and labor-related conditions -including the work environments- of the nurses. Given its impact on both health-care users and institutions, further research on the subject is urgently needed. It is essential to improve the design, implementation and evaluation of comprehensive strategies aimed at reducing the frequency of missed nursing care and achieving universal health coverage.

Public health insurance and ethnic disparities in maternal health care: the case of vulnerable Mexican women over the last 25 years

This article examines the coverage in the continuum of antenatal-postnatal care for vulnerable women in Mexico according to indigenous status and assesses the influence of public health insurance strategies on the evolution of coverage over the last 25 years. We studied a total of 19 613 567 Mexican women, aged 12-54 years at last birth, based on a pooled cross-sectional analysis of data from the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics. After describing sociodemographic characteristics and maternal-health coverage by indigenous status, we constructed a pooled fixed-effects and interaction multivariable regression model to assess the influence of the Seguro Popular programme on continuum of care. We estimated adjusted continuum of care coverage between 1994 and 2018 according to Seguro Popular affiliation and indigenous status. Prior to the Seguro Popular programme, crude coverage in the continuum of care for non-indigenous women stood at 14.5% [95% confidence interval (CI): 13.2-15.8%] or 11 percentage points higher than for indigenous women. During the last period of the programme, it rose to 46.5% [95% CI: 45.6-47.5%] and 34.1% [95% CI: 30.7-37.4%], respectively. Our regression analysis corroborated findings that, on average, indigenous women faced lower odds of benefiting from continuum of care [adjusted odds ratio (aOR) = 0.48, 95% CI: 0.40-0.57] than did their non-indigenous counterparts. It also revealed that coverage for indigenous women without Seguro Popular affiliation was 26.7% [95% CI: 23.3-30.1%] or 12 percentage points lower than for those with Seguro Popular affiliation (38.6%, 95% CI: 35.7-41.4%). Our regression results confirmed that the latter benefited from higher odds of continuum of care (aOR = 1.67, 95% CI: 1.36-2.26). Gaps between those of indigenous and non-indigenous status have persisted, but the Seguro Popular clearly contributed to reducing the coverage gaps between these two groups of women. Strategies yielding better outcomes are required to improve the structural conditions of indigenous populations.

Measuring and analysing social efficiency in the production of maternal health services in Mexico, 2008-15

'Social efficiency' (SE) denotes the capacity of health systems to ensure equitable access to quality health services at no financial risk to users. Mexico and other low- and middle-income countries have rarely studied the performance of their health systems from an SE perspective. We propose a metric for assessing SE in the production of maternal health services in the public sector among populations without social security, analysing contextual correlates of the demand for these services. Analysis was based on administrative data collected from the 243 health jurisdictions (HJs) in Mexico for the period 2008-15. We defined production inputs as the availability of physical and human resources and social product as the unweighted sum of social sub-products, including an equitable distribution of maternal health resources, the provision of quality maternal health care and financial protection for users. We described the SE scores, the main contextual characteristics as well as those related to the demand for maternal health services. We then performed a variance decomposition analysis of the SE score by component and estimated the SE territorial concentration patterns. Finally, we identified the structural characteristics modelling SE by means of a spatial autoregressive panel data model with fixed effects by year. The SE score rose from 57.7% in 2008 to 71.9% in 2015 (P < 0.01), with its quality component accounting for the largest proportion of variance (30%). SE peaked in HJs with low social marginalization and rurality, and with service demand characterized by low parity and older populations. Different SE levels demonstrated territorial concentration patterns. Analysing SE as a metric for health system performance offers elements that contribute to the achievement of UHC as well as to the design and implementation of effective maternal health interventions intended particularly for the most socially vulnerable sectors of the population.

Progress and challenges for advanced practice nursing in Mexico and the United Kingdom

AIM

The aim of this study is to compare the advanced practice nursing development in Mexico with the United Kingdom.

BACKGROUND

In spite of the involvement of global and local bodies to establish and develop advanced practice nursing worldwide, progress remains variable due to the lack of homogeneity in health care systems and policies.

EVALUATION

Using thematic analysis from interviews of 29 health care professionals in Mexico, we identified four major issues that impact on the development of advanced practice nursing: (a) workforce, (b) organizational and institutional, (c) regulatory and legal and (d) academic and educational.

KEY ISSUES

Learning from the UK experience in relation to overcoming some of these issues has been insightful in terms of how advanced practice nursing skills in Mexican nurses can be developed.

CONCLUSIONS

Mexico is still in early stages of the development of APN. Based on the UK experience, the government may have to move forward to support higher level training, create labour market positions, establish new nursing functions, promote task-shifting and particularly implement solid regulation.

IMPLICATIONS FOR NURSING MANAGEMENT

The development of advanced practice nursing represents important challenges for training and practice of nursing in Mexico and the United Kingdom; therefore, interested actors will have to reach key agreements that could work as the foundations of an assertive planning process.

The Sustainable Development Goals and Technological Capacity

In order to achieve the Sustainable Development and Health Goals, it is essential to increase the technological capacity of the most disadvantaged populations. In the 21st century, the necessary technologies for this exist. The gap in technological capacity reflects the existence of a technological gradient between large- and small-scale production, due to an absence of incentives for innovation and a lack of technological dissemination in small businesses and communities. Technological change is central to development, but it is a public good that the market economy does not provide efficiently. Providing it requires the implementation of public policies aimed at technological innovation and dissemination. Reducing the technological gradient is therefore a major part of the United Nations 2030 Agenda for Sustainable Development and the Pan American Health Organization's 2018-2030 Sustainable Health Agenda for the Americas. This also applies to the development of health systems, which function as a redistribution mechanism to break poverty traps. In addition, experiences in these systems are relevant to the implementation of policies that increase technological capacities aimed at reducing poverty, improving social determinants of health, and thereby reducing the scale of the human development trap.

Predictors of nursing students' academic performance in the National Autonomous University of Mexico, 2010-2019: A retrospective study

BACKGROUND

The available literature suggests that diverse factors, including sociodemographic, academic, psychological, and occupational, can have impacts on nursing students' academic performance. Therefore, it follows that the institutional environment can mediate on these influences.

OBJECTIVE

Based on a 10-years student performance follow-up information reservoir, to analyze the relationships between student performance and a set of sociodemographic and academic characteristics of students enrolled in the programs of Bachelor of Nursing (LE), and Bachelor of Nursing and Obstetrics (LEO), in the National School of Nursing and Obstetrics (ENEO) of the National Autonomous University of Mexico (UNAM).

METHODOLOGY

The registers (n = 3984) from the Academic Control Integral System of the ENEO-UNAM were used. The students' main sociodemographic and academic characteristics were described, and multiple-regression models were estimated in order to identify predictors of school performance.

RESULTS

Sustained increments in the enrolment of LE and LEO students during the study period. Changes were noticed regarding the sex distribution and the enrolment age. More students chose the LE program during this period. School performance was higher among female students, among students in their last semesters, and among students who had been granted a scholarship. In contrast, students who had previously failed a subject performed lower.

CONCLUSION

The identified school performance predictors suggest the need to strengthen institutional policies aimed at promoting the achievement of academic excellence so that graduate students become better prepared to enter the labor markets and address the nursing demands of society.

Economic evaluation of a novel community-based diabetes care model in rural Mexico: a cost and cost-effectiveness study

OBJECTIVES

Diabetes is the leading cause of disability-adjusted life years in Mexico, and cost-effective care models are needed to address the epidemic. We sought to evaluate the cost and cost-effectiveness of a novel community-based model of diabetes care in rural Mexico, compared with usual care.

DESIGN

We performed time-driven activity-based costing to estimate annualised costs associated with typical diabetes care in Chiapas, Mexico, as well as a novel diabetes care model known as Compañeros En Salud Programa de Enfermedades Crónicas (CESPEC). We conducted Markov chain analysis to estimate the cost-effectiveness of CESPEC compared with usual care from a societal perspective. We used patient outcomes from CESPEC in 2016, as well as secondary data from existing literature.

SETTING

Rural primary care clinics in Chiapas, Mexico.

PARTICIPANTS

Adults with diabetes.

INTERVENTIONS

CESPEC is a novel, comprehensive, diabetes care model that integrates community health workers, provider education, supply chain management and active case finding.

OUTCOME MEASURE

The primary outcome was the incremental cost-effectiveness of CESPEC compared with care as usual, per quality-adjusted life year (QALY) gained, expressed in 2016 US dollars.

RESULTS

The economic cost of the CESPEC diabetes model was US$144 per patient per year, compared with US$125 for diabetes care as usual. However, CESPEC care was associated with 0.13 additional years of health-adjusted life expectancy compared with usual care and 0.02 additional years in the first 5 years of treatment. This translated to an incremental cost-effectiveness ratio (ICER) of US$2981 per QALY gained over a patient's lifetime and an ICER of US$10 444 over the first 5 years. Findings were robust to multiple sensitivity analyses.

CONCLUSIONS

CESPEC is a cost-effective, community-based model of diabetes care for patients in rural Mexico. Given the high prevalence and significant morbidity associated with diabetes in Mexico and other countries in Central America, this model should be considered for broader scale up and evaluation.

Assessing the continuum of care for maternal health in Mexico, 1994-2018

OBJECTIVE

To describe the temporal and geographical patterns of the continuum of maternal health care in Mexico, as well as the sociodemographic characteristics that affect the likelihood of receiving this care.

METHODS

We conducted a pooled cross-sectional analysis using the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics, collating sociodemographic and obstetric characteristics of 93 745 women aged 12-54 years at last delivery. We defined eight variables along the antenatal-postnatal continuum, both independently and conditionally. We used a pooled fixed-effects multivariable logistic model to determine the likelihood of receiving the continuum of care for various properties. We also mapped the quintiles of adjusted state-level absolute change in continuum of care coverage during 1994-2018.

FINDINGS

We observed large absolute increases in the proportion of women receiving timely antenatal and postnatal care (from 48.9% to 88.2% and from 39.1% to 68.7%, respectively). In our conditional analysis, we found that the proportion of women receiving adequate antenatal care doubled over this period. We showed that having social security and a higher level of education is positively associated with receiving the continuum of care. We observed the largest relative increases in continuum of care coverage in Chiapas (181.5%) and Durango (160.6%), assigned human development index categories of low and medium, respectively.

CONCLUSION

Despite significant progress in coverage of the continuum of maternal health care, disparities remain. While ensuring progress towards achievement of the health-related sustainable development goal, government intervention must also target underserved populations.

Prevalence of Depression and Generalized Anxiety Disorder Among Mexican Indigenous Adolescents and Young Adults: Challenges for Healthcare

Providing evidence on mental disorders in indigenous adolescents is critical to achieving universal health coverage (UHC). The prevalence of symptoms of depression and generalized anxiety disorder symptoms were estimated for 2082 adolescents aged 14-20 years in Chiapas, Mexico. Mental disorders were assessed using the 9-item Patient-Health Questionnaire and the 7-item Generalized Anxiety Disorder Scale. Among the adolescents evaluated, 35.8% suffered from depression or generalized anxiety disorder. Of those, 6.1% reported a previous diagnosis. 32.1% of adolescents with both mental disorders reported having attempted suicide. Gender, substance use, adverse living experiences and living conditions were correlated to the presence of depression and/or generalized anxiety disorder. It is mandatory for Mexican health authorities to develop effective instruments aiming to screen and diagnose mental health conditions in adolescents, as well as to provide timely treatment in primary health-care units.

Los Objetivos de Desarrollo Sostenible y las capacidades tecnológicas

Para lograr los objetivos de desarrollo y salud sostenibles, es esencial incrementar las capacidades tecnológicas de las poblaciones más desfavorecidas. Entrado el siglo XXI, existen las tecnologías necesarias para ello. El déficit en capacidades tecnológicas se debe a la existencia de un gradiente tecnológico entre la producción de gran y de pequeña escalas, debido a la falta de incentivos para la innovación y la difusión en empresas y comunidades pequeñas. En estos ámbitos el cambio tecnológico, punto medular del desarrollo, es un bien público que la economía de mercado no provee eficientemente. Su provisión requiere la aplicación de políticas públicas de innovación y difusión tecnológicas. La reducción del gradiente tecnológico constituye, pues, parte medular de la Agenda 2030 para el Desarrollo Sostenible, de las Naciones Unidas, y la Agenda de Salud Sostenible para las Américas 2018-2030, de la Organización Panamericana de la Salud. Esto es aplicable, así mismo, al desarrollo de los sistemas de salud, que funcionan también como mecanismos de redistribución para romper las trampas de pobreza. Asimismo, las experiencias en esos sistemas tienen relevancia para aplicar políticas de incremento de capacidades tecnológicas que disminuyan la pobreza, mejoren los determinantes sociales de la salud y, con ello, reduzcan la magnitud de la trampa de desarrollo humano.

[Implementation research of primary health care in Paraguay in three periods of government: political, technical and social dimensions at the subnational level.]

OBJECTIVE

The study hopes to contribute to the analysis of political, technical and social dimensions and sub-dimensions that affect the processes of adjustments to the health system model based on the renewed PHC (Primary Health Care) strategy, at the regional (meso) and local levels. (micro), levels where problems and obstacles are externalized and institutional capacity gaps are verified, in contexts of changes in political leadership, which put their sustainability at risk. The observation included three government periods (2008-2012, 2012- 2013 and 2013-2018), in two departments of Paraguay (Misiones -rural- and Central -urban-).

METHODS

Qualitative research on the implementation of public health policy in Paraguay, aimed at promoting improvements in health services in specific contexts, through case studies, complemented with a documentary review. It explores macro, meso, and micro health processes, disaggregated in their political, social, and technical dimensions, to trace the PHC management profile over time. Directors, managers, and professionals in the field of health with experience, commitment, adherence, and prior knowledge were interviewed, using a priori analysis categories. The data and selection of discursive fragments were processed with the Atlas Ti software and auxiliary matrices in Excel.

RESULTS

Social changes and health outcomes are perceived in the study regions, despite financial restrictions and no flexibility of public spending on health attributed to the leadership and individual performance of health workers, which establish differences in terms of empowerment, cohesion and commitment in the development of the strategies outlined by the technical teams and decision-makers responsible for the implementation of policy lines in primary health care.

CONCLUSIONS

There are technological limitations, asymmetries of the information subsystems that translate into management weaknesses, as well as little community participation in the design and evaluation of health plans. Coordination weaknesses and improvement plans were detected in operating units of the regional networks, as well as. different training modalities. The availability of specialists in family medicine is low.

Incorporating genomic medicine into primary-level health care for chronic non-communicable diseases in Mexico: A qualitative study

OBJECTIVE

To analyze the viability of incorporating genomic medicine technology into the process of detecting and diagnosing chronic non-communicable diseases (CNCDs) at primary-care facilities in Mexico, and to discuss its implications for health systems in other countries with similar characteristics.

MATERIAL AND METHODS

We conducted 29 semi-structured interviews with health authorities as well as providers and users of health services in the state of Morelos. We investigated knowledge of genomic technology among interviewees; the accessibility, management, and organization of health services; and CNCDs prevention, control, and care practices.

RESULTS

The incorporation of genomic medicine technology into the CNCDs primary-care process is viable. However, the following challenges were identified: a lack of knowledge and limited information among interviewees regarding the effectiveness and benefits of genomic medicine technology, coupled with the need to mobilize and reassign trained human resources for drawing, registering, safeguarding, transporting, and controlling the quality of the genetic samples, as well as for the outsourcing of private laboratory services.

CONCLUSION

Using genetic information to detect CNCDs at an early stage offers an enormous potential for upgrading CNCDs prevention and control efforts. This, in turn, could translate into more efficient and financially sustainable health systems in Mexico and other low- and middle-income countries.

The COVID-19 pandemic presents an opportunity to develop more sustainable health workforces

This commentary addresses the critically important role of health workers in their countries' more immediate responses to COVID-19 outbreaks and provides policy recommendations for more sustainable health workforces. Paradoxically, pandemic response plans in country after country, often fail to explicitly address health workforce requirements and considerations. We recommend that policy and decision-makers at the facility, regional and country-levels need to: integrate explicit health workforce requirements in pandemic response plans, appropriate to its differentiated levels of care, for the short, medium and longer term; ensure safe working conditions with personal protective equipment (PPE) for all deployed health workers including sufficient training to ensure high hygienic and safety standards; recognise the importance of protecting and promoting the psychological health and safety of all health professionals, with a special focus on workers at the point of care; take an explicit gender and social equity lens, when addressing physical and psychological health and safety, recognising that the health workforce is largely made up of women, and that limited resources lead to priority setting and unequitable access to protection; take a whole of the health workforce approach-using the full skill sets of all health workers-across public health and clinical care roles-including those along the training and retirement pipeline-and ensure adequate supervisory structures and operating procedures are in place to ensure inclusive care of high quality; react with solidarity to support regions and countries requiring more surge capacity, especially those with weak health systems and more severe HRH shortages; and acknowledge the need for transparent, flexible and situational leadership styles building on a different set of management skills.

Cancer survivorship needs in Brazil: Patient and family perspective

Introduction

Cancer Survivorship is a growing public health challenge. Effective responses from health care and social services depend on appropriate identification of survivors and their families´ specific needs. There are few studies on survivorship in low and middle-income countries, therefore, more evidence-based studies are necessary to develop a comprehensive approach to cancer survivorship.

Objectives

Identify the needs of cancer survivors and their relatives, specifically those of individuals with breast, cervical or prostate cancer, and with acute lymphocytic leukemia (ALL).

Methods

A qualitative, exploratory study conducted in two referral institutions in Brazil, located in Rio de Janeiro (Southeast region) and Fortaleza (Northeast region). The study included 47 patients of public and private health services and 12 family members. We used script-based semi-structured interviews. The discursive material obtained was categorized and analyzed using the Thematic Analysis approach.

Results

The analysis identified three central themes: 1) consequences of cancer treatment; 2) Changes in daily life associated with cancer survivorship; and 3) Unmet structural needs in cancer survivorship.

Conclusion

Social and cancer control policies in Brazil should provide resources, specific care standards and clinical, psychological and social support. Cancer survivors should also receive rehabilitation and work reintegration guidelines. This matter requires broader access to qualified cancer information, development of an integrated patient-centered care and care model, and more research resources for the country's post-treatment cancer period.

Tackling maternal mortality by improving technical efficiency in the production of primary health services: longitudinal evidence from the Mexican case

Ensuring regular and timely access to efficient and quality health services reduces the risk of maternal mortality. Specifically, improving technical efficiency (TE) can result in improved health outcomes. To date, no studies in Mexico have explored the connection of TE with either the production of maternal health services at the primary-care level or the maternal-mortality ratio (MMR) in populations without social security coverage. The present study combined data envelopment analysis (DEA), longitudinal data and selection bias correction methods with the purpose of obtaining original evidence on the impact of TE on the MMR during the period 2008-2015. The results revealed that MMR fell 0.36% (P < 0.01) for every percentage point increase in TE at the jurisdictional level or elasticity TE-MMR. This effect proved lower in highly marginalized jurisdictions and disappeared entirely in those with low- or medium-marginalization levels. Our findings also highlighted the relevance of certain social and economic aspects in the attainment of TE by jurisdictions. This clearly demonstrates the need for comprehensive, cross-cutting policies capable of modifying the structural conditions that generate vulnerability in specific population groups. In other words, achieving an effective and sustainable reduction in the MMR requires, inter alia, that the Mexican government review and update two essential elements: the criteria behind resource allocation and distribution, and the control mechanisms currently in place for executing and ensuring accountability in these two functions.

The correlates of precarious working conditions in the Mexican nursing labour market from 2005 to 2018: A repeated cross-sectional study

AIM

To analyse sociodemographic and labour correlates of labour precariousness among Mexican nurses from 2005 to 2018.

BACKGROUND

The progressive loss of labour rights has led to a situation characterized by precarious working conditions among health workers globally.

METHODS

A repeated cross-sectional and population-based study was carried out (N = 3,699,282). A generalized ordinal logistic regression model was estimated to assess correlates of precariousness. Precariousness was defined as a non-weighted score of the sum of five dichotomous variables: (a) non-written contract; (b) income lower than two times the minimum wage; (c) with a partial or an extended workday; (d) without social benefits; and (e) without social security.

RESULTS

The labour precariousness level increased during the studied period, particularly among the younger and the older, the single ones and among those located in suburban and rural areas. Nurses with lower levels of training were more exposed to precarious conditions, as well as those with jobs in private health institutions or working outside the health sector.

CONCLUSIONS

Precarious work is considered a combination of global and local labour factors, including the lack of protective labour policies in health institutions, which calls for the development of a public policy to protect jobs in the health sector.

IMPLICATIONS FOR NURSING MANAGEMENT

Given that precarious work is considered a combination of global and local labour factors, including the lack of protective labour policies in health institutions, public health institutions should avoid nursing outsourcing employment as much as possible, and full-time contracts should respect the fundamental international and country-specific labour rights.

Improving the effective maternal-child health care coverage through synergies between supply and demand-side interventions: evidence from Mexico

Background

Over the last two decades, the Mexican government has released several efforts to achieve universal health coverage (UHC), based on the principles of fairness and social protection, to reduce the inequities in utilization, access, and quality of care existing in the health system. Two of the most important social public policies that have targeted the population without access to social security include the 1997 conditional cash transfers (CCT) program known as Prospera (formerly Oportunidades or Progresa) and the Seguro Popular de Salud (SPS by its Spanish initials), launched in 2003. These two programs, so far, have survived changes in the federal administrations being the most longstanding social programs targeting poor (or unprotected) populations ever in the history of modern Mexico. We tested the existence of positive synergies between demand-side (or CCT-Prospera) and supply-side (or Seguro Popular de Salud, SPS) social programs in the achievement of effective coverage (EC) of maternal-child health interventions in Mexico.

Methods

We performed a retrospective-cohort analysis to 6413 women aged 12-49 years who participated in a probabilistic survey conducted in 2012. We calculated EC as the product of three indexes: need, utilization and quality of health care. Correlates of EC were identified estimating a logistic regression model. We also presented adjusted EC by specific women groups.

Results

EC among beneficiaries of both programs was similar to estimates in Social Security affiliates (54%). For those not affiliated to any of the programs or those who received benefits for only one of them, the EC was 47.6% and 45.5% respectively. Adjusted estimates of EC suggest that overall, having both programs (Prospera + SPS) has a positive effect on maternal and child care coverage, which makes the observed differences in EC not statistically significant between those affiliated to both programs in comparison with the observed in the population with social security.

Conclusions

Results support positive synergies between Prospera and SPS in the reduction of the gaps in EC. The most vulnerable population groups need to be reached by the combination of these programs so that public health efforts translate into greater EC of maternal health services and better maternal-child outcomes.

Regulation of nursing in Mexico: actors, processes and outcomes

This paper aims to analyze the regulatory structure of nursing in Mexico through its legislation and perspectives of participant stakeholders. A case study was undertaken using qualitative and quantitative data sources, as well as from the review of official documents. The analysis included data from the sources according to the four realms proposed by the Moran & Wood (1993) model. The more advanced realm was the market entry since the state regulates entry through a license of practice. The regulation of competition is weak, showing very reduced areas of autonomous practice. The labor market is offering a wide variety of entry options with clear signs of deterioration. The dominant payment mechanism is salary, showing a structure that incorporates a component that does not impact on pensions at the end of the labor cycle. The regulation of nursing is a component of its professionalization, and as such, it is understood as a multidimensional consolidating process, particularly realms related to the regulation of competition, market structure, and payment mechanisms, in which nursing representatives should play a more active role in the future.

The precarization of the Mexican nursing labor market: a repeated cross-sectional analysis for the period 2005-2018

BACKGROUND

Precarization of labor conditions has been expanding over the last three decades as a consequence of global economic transformations. The health workforce labor market is exposed to these transformations as well. In Mexico, analyses of the nursing labor market have documented high levels of unemployment and underemployment; however, precarization has been not considered as a relevant indicator in these analyses. In this study, precarization is analyzed using a quantitative approach to show its prevalence and geographic distribution between 2005 and 2018.

METHODS

A repeated cross-sectional study was carried out with data from the population-based National Occupation and Employment Survey (ENOE in Spanish) which is administered quarterly to people 15 years or older in over 120 000 households. All individuals who reported having nursing training (technical or university level) were selected for this study. Our main variable was labor precariousness, which included three dimensions: (i) economic, (ii) regulatory, and (iii) occupational safety. We show the evolution of the relative weight of nursing activity between the years 2005 and 2018, the main socio-demographic characteristics of nurses as well as their main labor conditions, and the geographic distribution of precariousness for the 32 federal states in México.

RESULTS

Four of the five indicators of labor precariousness increased among the group of nurses analyzed: (a) the percentage of people with no written contract, (b) the percentage of people with incomes lower than two times the minimum wage, (c) the percentage of nurses without social security, and (d) the percentage of nurses without social benefits. The percentage of nurses that work under some condition of work precariousness increased from 46% in 2005-2006 to 54% in 2018. Finally, the number of states with high precariousness level increased from seven in 2005-2006 to 17 in 2018.

CONCLUSIONS

Throughout Mexico, nursing precariousness has expanded reaching 53% by 2018. The advancement of precarization of nursing jobs implies a reduction in the capacity of the Mexican health system to reach its coverage and care goals as nurses represent 52% of all available workers that provide direct services to the population.

[Barriers for indigenous women to access obstetric services within the framework of integrated health services networks]

OBJECTIVE

To analyze the barriers that indigenous women face in access to the network of obstetric services in the context of the implementation of integrated healthcare networks (IHN).

METHOD

We designed a cross-sectional descriptive study including quantitative and qualitative methods. Sampling was intentional, no probabilistic. Data collection was carried out in Oaxaca, Mexico, during 2017-2018. A total of 149 indigenous women who used obstetrical services were surveyed and sociodemographic characteristics were obtained. Later were selected 30 cases that had complications during pregnancy and childbirth for a semi-structured interview. Non-participant observation was conducted.

RESULTS

The network of obstetric services comprises four institutions with different models of care and therefore different types of facilities and human resources to assist indigenous women. Nearly 20% of women did not start prenatal care in the first trimester of pregnancy and 27.2% had complications during the gestational period. The main barriers were availability (hours of operation, geographical aspects), accessibility (lack of financial resources), acceptability (ancestral practices vs. medical recommendations), and continuity of service (difficulties for admit patients in hospitals referred from first line of care).

CONCLUSIONS

The networks model allows access to obstetric services but does not guarantee care. For this it is necessary to improve both: the infrastructure of the obstetric service providers, and the care processes. It is necessary to broaden the vision of the IHN management model considering the perspective of human rights and equity in health.

Interprofessional training for the delivery of community health services in Mexico: the experience of Partners in Health

Interprofessional training in health is scarce in Mexico. Partners in Health (CES in Spanish), is the branch of an international civil society organization that provides health services to poor and rural populations. CES runs a set of ten health centers in Chiapas, Mexico, in partnership with the local Ministry of Health. A key component of the provision strategy is to train healthcare providers, mainly medical and nursing students in their final year of training, to create healthcare teams that work together while fostering their individual capacities. CES offers a diploma on Global Health and Social Medicine, where medical and nursing students -also called pasantes- interact to discuss jointly the effects of global and social determinants of health in local communities, as well as specific clinical topics. A qualitative study including interviews and nonparticipant observations was undertaken to identify initial achievements and challenges of the experience. CES has achieved important benefits related to teamwork as well as clinical capacities of individuals as healthcare providers. However, challenges have emerged: differences in social origin, personal development expectations, professional identity and institutional roles hinder team cohesion. Consequently, CES has introduced adjustments to reduce the negative impact of these differences. Although the training model needs further development, the possibility of transferring some of its good practices to non-CES scenarios should be seriously considered by health authorities.

Government expenditure on health and maternal mortality in México: A spatial-econometric analysis

OBJECTIVE

To assess the relationship between government expenditure on maternal health (GE) and maternal mortality (MM) in Mexican poor population between 2000 and 2015 in the 2457 Mexican municipalities.

METHODS

Using administrative data, we performed the analysis in three stages: First, we tested the presence of selection bias in MM. Next, we assessed the presence of spatial dependence in the incidence and severity of MM. Finally, we estimated a spatial error model considering the correction of estimates for the spatial dependence and selection bias assessed before.

RESULTS

MM and GE were not randomly distributed throughout the Mexican territory; the most socially vulnerable municipalities exhibited the highest levels of MM severity but the lowest levels of GE and available human and physical resources for maternal health; the incidence of MM was independent of GE; elasticity of GE-severity in MM was -4% (P < 0.01).

CONCLUSIONS

Resource allocation for maternal health must move towards a more comprehensive vision, and efforts to achieve an effective delivery of universal health services must improve, particularly regarding the most vulnerable municipalities.

A longitudinal assessment of technical efficiency in the outpatient production of maternal health services in México

We assess technical efficiency (TE) level for Mexican Ministry of Health (MoH) primary care units. Assessment was focused on the production of adequate maternal health services defined as the coverage level of women who received timely and frequent antenatal care, and institutional and medical care during childbirth. We conducted a longitudinal analysis of administrative and socio-demographic information concerning 233 health jurisdictions for the period 2008-15. Crude TE was calculated using window data envelopment analysis (Windows-DEA). Empirical analysis included the description of several factors affecting the production of maternal health services, including the heterogeneity and trends assessment of TE among health jurisdictions. We estimated a pooled regression model with robust standard errors to identify correlates of TE and estimated adjusted performance scores. Results indicate that while the production of adequate maternal-health services and TE in health jurisdictions proved insufficient, they rose by 22% (from 40.9% to 49.8%) and 14% (from 54.3% to 62%), respectively, over time. Furthermore, variance in efficiency among production units diminished and persistent regularities were observed. Performance was highest in the Northern as opposed to the Southern and Southeastern health jurisdictions, but lowest in the most marginalized zones of the country marked by economic inequality and the presence of indigenous populations. The Mexican Health System has reached a paradoxical situation: the steady escalation of financial resources in the public health subsystem over the past 15 years has yielded sub-optimal results as regards coverage for essential maternal health interventions among the poorest. Mexican government must put in place a set of measures to guarantee efficiency in the system's performance without affecting equity gains. This necessarily involves reconsidering, and where necessary replacing, the criteria behind the allocation and distribution of resources, as well as the mechanisms for controlling how resources are used and accountability is fulfilled.

Un Estudio Piloto del Clima Laboral de las Enfermeras Mexicanas: A Pilot Study of Mexican Nurses’ Work Environments

Introducción:

Llevar a cabo un estudio piloto para examinar el clima laboral de las enfermeras en México utilizando un instrumento comparable internacionalmente.

Métodos:

La versión en español de la Escala de Práctica Ambiental del Índice de Trabajo de las Enfermeras fue el instrumento usado en este investigación. Un estudio piloto transversal de 453 enfermeras mexicanas de seis sitios utilizando técnicas de recolección de datos en papel y en línea. El estudio se realizó entre 2011 y 2013. El análisis de componentes principales analizó la fiabilidad y validez del instrumento traducido.

Resultados:

El instrumento traducido produjo cinco factores, pero las cargas de los ítems difirieron. Sin embargo, el instrumento fue capaz de identificar áreas problemáticas y no problemáticas del ambiente de trabajo de las enfermeras mexicanas.

Conclusiones:

La versión en español mexicano del instrumento puede evaluar de manera confiable el ambiente de trabajo hospitalario en México.

Stewardship and governance: structuring dimensions for Implementation Primary Health Care Policies in Paraguay, 2008-2017

This study analyzes the conduction patterns of implementing Primary Health Care (PHC) in Paraguay in three government periods (2008-2012, 2012-2013 and 2013-2017) and three management levels (national, regional and local). This is a qualitative study based on grounded theory. A priori categories on PHC stewardship and governance in Paraguay were analyzed. An open-ended questionnaire was applied to a sample of social, political and technical stakeholders: ministers, coordinators, managers, consultants, and international organizations' experts. Data were processed combining the use of Atlas Ti software and sorting findings in a structured Excel matrix. Gaps in leadership, regulatory mechanisms, technical capacities for health planning and management and financial implementation methods have affected PHC continuous expansion and strengthening process. The findings show limitations and possibilities for the implementation of this health policy in Paraguay, evidencing the need for greater qualification of management and political stability in its conduction.

Welfare effects of health insurance in Mexico: The case of Seguro Popular de Salud

This study contributes with original empirical evidence on the distributional and welfare effects of one of the most important health policies implemented by the Mexican government in the last decade, the Seguro Popular de Salud (SPS). We analyze the effect of SPS on households' welfare using a decomposable index that considers insured and uninsured households' response to out-of-pocket (OOP) payments using both social welfare weights and inequality aversion. The disaggregation of the welfare index allows us to explore the heterogeneity of the SPS impact on households' welfare. We applied propensity score matching to reduce the self-selection bias of being SPS insured. Overall results suggest non-conclusive results of the impact of SPS on households' welfare. When we disaggregated the welfare index by different sub-population groups, our results suggest that households' beneficiaries of SPS with older adults or living in larger cities are better protected against OOP health care payments than their uninsured counterparts. However, no effect was found among SPS-insured households living in rural and smaller cities, which is a result that could be attributed to limited access to health resources in these regions. Scaling up health insurance coverage is a necessary but not sufficient condition to ensure the protection of SPS coverage against financial risks among the poor.

Implementation and clinical effectiveness of a community-based non-communicable disease treatment programme in rural Mexico: a difference-in-differences analysis

Non-communicable diseases (NCDs) account for the five largest contributors to burden of disease in Mexico, with diabetes representing the greatest contributor. However, evidence supporting chronic disease programmes in Mexico is limited, especially in rural communities. Compañeros En Salud (CES) partnered with the Secretariat of Health of Chiapas, Mexico to implement a novel community-based NCD treatment programme. We describe the implementation of this programme and conducted a population-based, retrospective analysis, using a difference-in-differences regression approach to estimate the impact of the programme. Specifically, we examined changes in diabetes and hypertension control rates between 2014 and 2016, comparing CES intervention clinics (n = 9) to care-as-usual at non-CES clinics (n = 806), adjusting for differences in facility-level characteristics. In 2014, the percent of diabetes patients with this condition under control was 36.9% at non-CES facilities, compared with 41.3% at CES facilities (P > 0.05). For hypertension patients, these figures were 45.2% at non-CES facilities compared with 56.2% at CES facilities (P = 0.02). From 2014 to 2016, the percent of patients with diabetes under control declined by 9.2% at non-CES facilities, while improving by 11.3% at non-CES facilities where the Compañeros En Salud Programa de Enfermedades Crónicas intervention was implemented (P < 0.001). Among hypertension patients, those with the condition under control increased by 21.5% at non-CES facilities between 2014 and 2016, compared with 16.2% at CES facilities (P > 0.05). Introduction of the CES model of NCD care was associated with significantly greater improvements in diabetes management between 2014 and 2016, compared with care-as-usual. Hypertension control measures were already greater at CES facilities in 2014, a difference that was maintained through 2016. These findings highlight the successful implementation of a framework for providing NCD care in rural Mexico, where a rapidly increasing NCD disease burden exists.

Use of performance metrics for the measurement of universal coverage for maternal care in Mexico

This study provides evidence for those working in the maternal health metrics and health system performance fields, as well as those interested in achieving universal and effective health care coverage. Based on the perspective of continuity of health care and applying quasi-experimental methods to analyse the cross-sectional 2009 National Demographic Dynamics Survey (n = 14 414 women), we estimated the middle-term effects of Mexico's new public health insurance scheme, Seguro Popular de Salud (SPS) (vs women without health insurance) on seven indicators related to maternal health care (according to official guidelines): (a) access to skilled antenatal care (ANC); (b) timely ANC; (c) frequent ANC; (d) adequate content of ANC; (e) institutional delivery; (f) postnatal consultation and (g) access to standardized comprehensive antenatal and postnatal care (or the intersection of the seven process indicators). Our results show that 94% of all pregnancies were attended by trained health personnel. However, comprehensive access to ANC declines steeply in both groups as we move along the maternal healthcare continuum. The percentage of institutional deliveries providing timely, frequent and adequate content of ANC reached 70% among SPS women (vs 64.7% in the uninsured), and only 57.4% of SPS-affiliated women received standardized comprehensive care (vs 53.7% in the uninsured group). In Mexico, access to comprehensive antenatal and postnatal care as defined by Mexican guidelines (in accordance to WHO recommendations) is far from optimal. Even though a positive influence of SPS on maternal care was documented, important challenges still remain. Our results identified key bottlenecks of the maternal healthcare continuum that should be addressed by policy makers through a combination of supply side interventions and interventions directed to social determinants of access to health care.

The gap in human resources to deliver the guaranteed package of prevention and health promotion services at urban and rural primary care facilities in Mexico

BACKGROUND

The purpose of this study was to estimate the gap between the available and the ideal supply of human resources (physicians, nurses, and health promoters) to deliver the guaranteed package of prevention and health promotion services at urban and rural primary care facilities in Mexico.

METHODS

We conducted a cross-sectional observational study using a convenience sample. We selected 20 primary health facilities in urban and rural areas in 10 states of Mexico. We calculated the available and the ideal supply of human resources in these facilities using estimates of time available, used, and required to deliver health prevention and promotion services. We performed descriptive statistics and bivariate hypothesis testing using Wilcoxon and Friedman tests. Finally, we conducted a sensitivity analysis to test whether the non-normal distribution of our time variables biased estimation of available and ideal supply of human resources.

RESULTS

The comparison between available and ideal supply for urban and rural primary health care facilities reveals a low supply of physicians. On average, primary health care facilities are lacking five physicians when they were estimated with time used and nine if they were estimated with time required (P < 0.05). No difference was observed between available and ideal supply of nurses in either urban or rural primary health care facilities. There is a shortage of health promoters in urban primary health facilities (P < 0.05).

CONCLUSION

The available supply of physicians and health promoters is lower than the ideal supply to deliver the guaranteed package of prevention and health promotion services. Policies must address the level and distribution of human resources in primary health facilities.

[Working conditions in outpatient clinics adjacent to private pharmacies in Mexico City: perspective of physicians]

OBJECTIVE

To analyse the working conditions of physicians in outpatient clinics adjacent to pharmacies (CAFs) and their organizational elements from their own perspective.

METHODS

We carried out an exploratory qualitative study. Semi-structured interviews were conducted with 32 CAF physicians in Mexico City. A directed content analysis technique was used based on previously built and emerging codes which were related to the experience of the subjects in their work.

RESULTS

Respondents perceive that work in CAFs does not meet professional expectations due to low pay, informality in the recruitment process and the absence of minimum labour guarantees. This prevents them from enjoying the benefits associated with formal employment, and sustains their desire to work in CAF only temporarily. They believe that economic incentives related to number of consultations, procedures and sales attained by the pharmacy allow them to increase their income without influencing their prescriptive behaviour. They express that the monitoring systems and pressure exerted on CAFs seek to affect their autonomy, pushing them to enhance the sales of medicines in the pharmacy.

CONCLUSIONS

Physicians working in CAFs face a difficult employment situation. The managerial elements used to induce prescription and enhance pharmacy sales create a work environment that generates challenges for regulation and underlines the need to monitor the services provided at these clinics and the possible risk for users.

[Efficiency of human resources for health: an approach to its analysis in Mexico]

Objective:

To analyze efficiency indicators of human resources working at Mexico's Ministry of Health.

Materials and methods:

Three dimensions of efficiency were explored: a) labor wastage, b) distribution of human resources (HR) across levels of care, and c) productivity.

Results:

Health workers present significant levels of unemployment and underemployment; distribution does not meet international recommendations, and heterogeneous levels of productivity were found among states.

Conclusions:

Health and educational authorities should develop and implement a HR plan that takes into consideration the needs and demands of the covered population, and includes a clearly defined set of measures to regulate the future production of HR as well as their distribution among and within state health systems, and that allocates incentives to improve performance.

Breast cancer policy in Latin America: account of achievements and challenges in five countries

BACKGROUND

The recent increase of breast cancer mortality has put on alert to most countries in the region. However it has taken some time before breast cancer could be considered as a relevant problem. Only in recent years breast cancer has been considered a priority in some Latin American countries and resources have been mobilized to confront the problem at the institutional level. The article analyzes the efforts made in five Latin American countries (Argentina, Brazil, Colombia, Mexico and Venezuela) in the last 15 years to design and implement policies to address the growing incidence of breast cancer.

METHODS

Data was collected between July and December 2010 from both primary and secondary sources. Semi-structured interviews were conducted with key informants from governmental and non-governmental organizations. Secondary data was obtained from publications in journals, government reports and official statistics in each country. Analysis combines information from both types of sources.

RESULTS

Countries have followed different paths and are in different stages of policy implementation. In all cases early detection is a key strategy. Through the design of programs and guidelines, the allocation of financial resources to treat patients, as well as a formally structured information system, Brazil and Mexico have been able to set up comprehensive national policies. Argentina, Colombia and Venezuela have made important advancements but not yet capable of coordinating comprehensive national policies.

CONCLUSION

Breast cancer is being considered a priority in all five countries but there are different stages in the rolling out of comprehensive national policies due to differences in their capacity to allocate resources, implement operational strategies and encourage the participation of relevant stakeholders.

Understanding the dynamics of the Seguro Popular de Salud policy implementation in Mexico from a complex adaptive systems perspective

BACKGROUND

In 2003, Mexico's Seguro Popular de Salud (SPS), was launched as an innovative financial mechanism implemented to channel new funds to provide health insurance to 50 million Mexicans and to reduce systemic financial inequities. The objective of this article is to understand the complexity and dynamics that contributed to the adaptation of the policy in the implementation stage, how these changes occurred, and why, from a complex and adaptive systems perspective.

METHODS

A complex adaptive systems (CAS) framework was used to carry out a secondary analysis of data obtained from four SPS's implementation evaluations. We first identified key actors, their roles, incentives and power, and their responses to the policy and guidelines. We then developed a causal loop diagram to disentangle the feedback dynamics associated with the modifications of the policy implementation which we then analyzed using a CAS perspective.

RESULTS

Implementation variations were identified in seven core design features during the first 10 years of implementation period, and in each case, the SPS's central coordination introduced modifications in response to the reactions of the different actors. We identified several CAS phenomena associated with these changes including phase transitions, network emergence, resistance to change, history dependence, and feedback loops.

CONCLUSIONS

Our findings generate valuable lessons to policy implementation processes, especially those involving a monetary component, where the emergence of coping mechanisms and other CAS phenomena inevitably lead to modifications of policies and their interpretation by those who implement them. These include the difficulty of implementing strategies that aim to pool funds through solidarity among beneficiaries where the rich support the poor when there are no incentives for the rich to do so. Also, how resistance to change and history dependence can pose significant challenges to implementing changes, where the local actors use their significant power to oppose or modify these changes.

A Performance Analysis of Public Expenditure on Maternal Health in Mexico

We explore the relationship between public expenditure, coverage of adequate ANC (including timing, frequent and content), and the maternal mortality ratio--adjusted by coverage of adequate ANC--observed in Mexico in 2012 at the State level. Additionally, we examine the inequalities and concentration of public expenditure between populations with and without Social Security. Results suggest that in the 2003-2011 period, the public expenditure gap between women with and without Social Security decreased 74%, however, the distribution is less equitable among women without Social Security, across the States. Despite high levels of coverage on each dimension of ANC explored, coverage of adequate ANC was lower among Social Security than non-Social Security women. This variability results in differences up to 1.5 times in State-adjusted maternal mortality rate at the same level of expense and maternal mortality rate, respectively. The increase in the economic resources is only a necessary condition for achieving improved health outcomes. Providing adequate health services and achieving efficient, effective and transparent use of resources in health, are critical elements for health systems performance. The attainment of universal effective coverage of maternal health and reducing maternal mortality in Mexico, requires the adjustment of policy innovations including the rules of allocation and execution of health resources. Health policies should be designed on a more holistic view promoting a balance between accessibility, effective implementation and rigorous stewardship.