Dissonant health transition in the states of Mexico, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND: Child and maternal health outcomes have notably improved in Mexico since 1990, whereas rising adult mortality rates defy traditional epidemiological transition models in which decreased death rates occur across all ages. These trends suggest Mexico is experiencing a more complex, dissonant health transition than historically observed. Enduring inequalities between states further emphasise the need for more detailed health assessments over time. The Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013) provides the comprehensive, comparable framework through which such national and subnational analyses can occur. This study offers a state-level quantification of disease burden and risk factor attribution in Mexico for the first time. METHODS: We extracted data from GBD 2013 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) in Mexico and its 32 states, along with eight comparator countries in the Americas. States were grouped by Marginalisation Index scores to compare subnational burden along a socioeconomic dimension. We split extracted data by state and applied GBD methods to generate estimates of burden, and attributable burden due to behavioural, metabolic, and environmental or occupational risks. We present results for 306 causes, 2337 sequelae, and 79 risk factors. FINDINGS: From 1990 to 2013, life expectancy from birth in Mexico increased by 3·4 years (95% uncertainty interval 3·1-3·8), from 72·1 years (71·8-72·3) to 75·5 years (75·3-75·7), and these gains were more pronounced in states with high marginalisation. Nationally, age-standardised death rates fell 13·3% (11·9-14·6%) since 1990, but state-level reductions for all-cause mortality varied and gaps between life expectancy and years lived in full health, as measured by HALE, widened in several states. Progress in women's life expectancy exceeded that of men, in whom negligible improvements were observed since 2000. For many states, this trend corresponded with rising YLL rates from interpersonal violence and chronic kidney disease. Nationally, age-standardised YLL rates for diarrhoeal diseases and protein-energy malnutrition markedly decreased, ranking Mexico well above comparator countries. However, amid Mexico's progress against communicable diseases, chronic kidney disease burden rapidly climbed, with age-standardised YLL and DALY rates increasing more than 130% by 2013. For women, DALY rates from breast cancer also increased since 1990, rising 12·1% (4·6-23·1%). In 2013, the leading five causes of DALYs were diabetes, ischaemic heart disease, chronic kidney disease, low back and neck pain, and depressive disorders; the latter three were not among the leading five causes in 1990, further underscoring Mexico's rapid epidemiological transition. Leading risk factors for disease burden in 1990, such as undernutrition, were replaced by high fasting plasma glucose and high body-mass index by 2013. Attributable burden due to dietary risks also increased, accounting for more than 10% of DALYs in 2013. INTERPRETATION: Mexico achieved sizeable reductions in burden due to several causes, such as diarrhoeal diseases, and risks factors, such as undernutrition and poor sanitation, which were mainly associated with maternal and child health interventions. Yet rising adult mortality rates from chronic kidney disease, diabetes, cirrhosis, and, since 2000, interpersonal violence drove deteriorating health outcomes, particularly in men. Although state inequalities from communicable diseases narrowed over time, non-communicable diseases and injury burdens varied markedly at local levels. The dissonance with which Mexico and its 32 states are experiencing epidemiological transitions might strain health-system responsiveness and performance, which stresses the importance of timely, evidence-informed health policies and programmes linked to the health needs of each state. FUNDING: Bill & Melinda Gates Foundation, Instituto Nacional de Salud Pública.

Getting ready for reduced donor dependency: the co-financing of family planning commodities.

Family planning (FP) programmes in low and lower-middle income countries are confronting the dual impact of reduced external donor commitments and stagnant or reduced domestic financing, worsened by economic consequences of the COVID-19 pandemic. Co-financing-a donor-government agreement to jointly fund aspects of a programme, with transition towards the government assuming increasing responsibility for total cost-can be a powerful tool to help build national ownership, fiscal sustainability and programme visibility. Using Gavi's successful co-financing model as reference, the current paper draws out a set of key considerations for developing policies on co-financing of FP commodities in resource-poor settings. Macroeconomic and contextual sensitivities must be incorporated while classifying countries and determining co-financing obligations-using the actual GNI per capita on a scale or sovereign credit ratings, in conjunction with programmatic indicators, may be preferred. It is also important for policies to allow sufficiently long time for countries to transition-dependent on the country context, may be up to 10 years as allowed under the US Agency for International Development FP graduation policy and flexibility to revisit the terms following externalities that can influence the fiscal space for health. Incentivizing new domestic financing to pay for co-financing dues is critical, so as not to displace government funding from related health or social sector programs. Pragmatic ways to ensure country compliance can include engaging both the ministries of health and finance as co-signatories to identify and address known administrative and fiscal challenges; establishing dedicated co-financing account with the finance ministry; and instituting a mutual monitoring mechanism. Lastly, the overall process of policymaking can benefit from an alignment of goals and interests of the key development partners.

The 30-Billion-Dollar Distribution Markups and Taxes of Pharmaceuticals in Latin American Countries: Impact, Options, and Trade-Offs.

OBJECTIVES: The World Health Organization provides 10 specific guidelines for managing the prices of pharmaceutical products. Many of those are widely known and used such as reference pricing, value-based pricing, price transparency, and tendering. Less attention and knowledge is concentrated in markup regulation across the pharmaceutical supply chain and distribution and in tax exemptions or reductions. This article quantifies the impact of these price components in the Latin American (LatAm) region and places the findings in the context of economic theory and international policy experiences. METHODS: 2020 retail pharmaceutical sales data from 8 major LatAm markets covered in the IQVIA database were decomposed into ex-factory, distributor markups, and taxes using price build up information and the Price Decipher Methodology developed by the Novartis Global Pricing Governance and Negotiation team. The findings were reviewed by an international panel representing academia, health policy, health economics, patient, and industry. RESULTS: The ex-factory market value of the analyzed markets was $49 billion. Distribution markups added $20 billion and taxes a further $10.5 billion. This represented a 63% increase over ex-factory prices, considered high if compared with 24% for an international benchmark of 35 ex-LatAm countries. Reducing markups for these LatAm countries to 24% would represent up to $19 billion in savings for payers and patients. CONCLUSIONS: There is potential for significant cost reductions associated with tax and distribution markup refinements in the LatAm retail pharmaceutical market. National policies should be informed by additional context-specific research for effective implementation.

The quest for universal health coverage: achieving social protection for all in Mexico.

Mexico is reaching universal health coverage in 2012. A national health insurance programme called Seguro Popular, introduced in 2003, is providing access to a package of comprehensive health services with financial protection for more than 50 million Mexicans previously excluded from insurance. Universal coverage in Mexico is synonymous with social protection of health. This report analyses the road to universal coverage along three dimensions of protection: against health risks, for patients through quality assurance of health care, and against the financial consequences of disease and injury. We present a conceptual discussion of the transition from labour-based social security to social protection of health, which implies access to effective health care as a universal right based on citizenship, the ethical basis of the Mexican reform. We discuss the conditions that prompted the reform, as well as its design and inception, and we describe the 9-year, evidence-driven implementation process, including updates and improvements to the original programme. The core of the report concentrates on the effects and impacts of the reform, based on analysis of all published and publically available scientific literature and new data. Evidence indicates that Seguro Popular is improving access to health services and reducing the prevalence of catastrophic and impoverishing health expenditures, especially for the poor. Recent studies also show improvement in effective coverage. This research then addresses persistent challenges, including the need to translate financial resources into more effective, equitable and responsive health services. A next generation of reforms will be required and these include systemic measures to complete the reorganisation of the health system by functions. The paper concludes with a discussion of the implications of the Mexican quest to achieve universal health coverage and its relevance for other low-income and middle-income countries.

Collectively achieving primary health care and educational goals through school-based platforms: financing solutions for intersectoral collaboration.

Despite abundant evidence demonstrating that improvements to health and education are positively correlated, and the importance of school-based platforms to achieve shared impacts, collaboration between ministries of health and education remains limited across low- and middle-income countries. Enhancing this collaboration is essential to realize mutually beneficial results, especially following the COVID-19 pandemic, which severely impacted health and education outcomes globally and highlighted the importance of resilient, domestically funded systems for delivering key social services including primary health care and education. We argue that the lack of an effective joint financing mechanism has hindered adoption of collaborative multisectoral approaches such as the WHO/UNESCO's Health Promoting Schools (HPS) model. HPS is well-positioned to organize, finance, and deliver primary health care and education services through a school-based platform and strategy. Case studies from several low- and middle-income countries highlight the need to expand limited inter-ministerial collaborations to achieve cross-sectoral benefits and ensure sustainability of HPS beyond the lifecycle of external partners' support. It is important to identify ways to widen the resource envelope for sector-specific activities and create efficiencies through mutually beneficial outcomes. This paper offers two pragmatic solutions: an inter-ministerial joint financing mechanism that starts with alignment of budgets but matures into a formal system for pooling funds, or a fixed-term co-financing mechanism that uses donor contributions to catalyze inter-ministerial collaborations. Achieving sustainability in these initiatives would require engaging the ministries of health, education, and finance; developing a common administrative, financial, and monitoring mechanism; and securing long-term commitment from all concerned stakeholders.

Policymakers' perspective on the importance of procedural fairness to implement and sustain health financing reforms.

Fair process is instrumental to implementing and sustaining health financing reforms. Ensuring a fair process during the design and adoption phases can garner political capital and secure a sense of citizens' ownership. This will prove useful when reforms are contested before benefits are yet to be fully materialized. Since many well devised health financing reforms are vulnerable to being dismantled after a few years of being launched, fair process should play a more strategic role in the implementation and evaluation phases when policies get challenged and reformulated to reflect the changing political and socioeconomic landscapes and to better manage early evidence on performance.

[Economics of health system transformation]. / Economía de la transformación del sistema de salud.

Health conditions in Mexico have evolved along with socioeconomic conditions. As a result, today's health system faces several problems characterized by four overlapping transitions: demand, expectations, funding and health resources. These transitions engender significant pressures on the system itself. Additionally, fragmentation of the health system creates disparities in access to services and generates problems in terms of efficiency and use of available resources. To address these complications and to improve equity in access and efficiency, thorough analysis is required in how the right to access health care should be established at a constitutional level without differentiating across population groups. This should be followed by careful discussion about what rules of health care financing should exist, which set of interventions ought to be covered and how services must be organized to meet the health needs of the population.

Prevalence of hepatitis C in the adult Mexican population: National Survey of Health and Nutrition 2018.

Background: Hepatitis C is a preventable and treatable disease that has been declared a public health problem. In 2012, the prevalence of HCV serum anti-bodies in the Mexican adult population aged 20 to 49 years was 0·30%. Methods: We randomly selected a probabilistic sub-sample of 12,389 adults (20+ years) from adults participating in the National Health and Nutrition Survey (ENSANUT) 2018 who provided a venous blood sample. Anti-HCV antibodies and HCV RNA were determined for this sub-sample. We estimated the national prevalence of anti-HCV antibodies and the proportion with viral RNA detection and evaluated their association with sociodemographic characteristics for all adults and with sexual behaviours in those aged 20 to 49 years using logistic regression. Findings: The national prevalence of anti-HCV antibodies in serum was 0·38% (95%CI 0·24, 0·59) in the population aged 20 years and older; 14·9% of them had viral RNA. In the population aged 20 to 49 years antibody prevalence was 0·23% (95%CI 0·11, 0·48), being higher for males and people living in urban areas. In the population aged 50 years and older, the prevalence was 0·59% (95%CI 0·34, 1·06). Interpretation: The prevalence of antibodies anti-HCV in people aged 20 to 49 years was similar in 2018 than in 2012, suggesting that the prevalence of HCV has remained stable. ENSANUT is a household study and could underestimate the prevalence of HCV. Further efforts must be made to identify cases in non-household populations. Funding: National Institute of Statistics and Geography and National Institute of Public Health of Mexico [CIEE/1807].

Cost-effectiveness of a self-management and comprehensive training intervention in patients with type 2 diabetes up to 5 years of diagnosis in a specialized hospital in Mexico City.

INTRODUCTION: To assess the cost-effectiveness of a multidisciplinary and comprehensive innovative diabetes care program (CAIPaDi) versus usual treatment in public health institutions. RESEARCH DESIGN AND METHODS: Using a cost-effectiveness analysis, we compared the CAIPaDi program versus usual treatment given in Mexican public health institutions. The analysis was based on the IQVIA Core Diabetes Model, a validated simulation model used to estimate long-term clinical outcomes. Data were prospectively obtained from the CAIPaDi program and from public databases and published papers. Health outcomes were expressed in terms of life-years gained and quality-adjusted life years (QALYs). Health and economic outcomes were estimated from a public perspective and discounted at 5% per year over a 20-year horizon. Costs are reported in US dollars (US$) of 2019. A probabilistic sensitivity analysis was performed using life-years gained and QALYs. RESULTS: The CAIPaDi costs on average US$559 (95% CI: -$879 to -$239) less than the usual treatment (95% CI: -$879 to -$239) and produced a difference in mean life-years gained (0.48, 95% CI: 0.45 to 0.52) and mean QALYs (1.43, 95% CI: 1.40 to 1.46). The cost-effectiveness ratio resulted in a saving per life-year gained of -US$1155 (95% CI: -$1962 to -$460). Mean differences in QALYs resulted in a saving per QALY of -US$735 (95% CI: -$1193 to -$305). Probabilistic sensitivity analysis proved the results are robust on both life-years gained and QALYs. CONCLUSIONS: CAIPaDi has a better cost-effectiveness ratio than the usual therapy in Mexican public health institutions.

Clinical benefits, costs, and cost-effectiveness of neonatal intensive care in Mexico.

BACKGROUND: Neonatal intensive care improves survival, but is associated with high costs and disability amongst survivors. Recent health reform in Mexico launched a new subsidized insurance program, necessitating informed choices on the different interventions that might be covered by the program, including neonatal intensive care. The purpose of this study was to estimate the clinical outcomes, costs, and cost-effectiveness of neonatal intensive care in Mexico. METHODS AND FINDINGS: A cost-effectiveness analysis was conducted using a decision analytic model of health and economic outcomes following preterm birth. Model parameters governing health outcomes were estimated from Mexican vital registration and hospital discharge databases, supplemented with meta-analyses and systematic reviews from the published literature. Costs were estimated on the basis of data provided by the Ministry of Health in Mexico and World Health Organization price lists, supplemented with published studies from other countries as needed. The model estimated changes in clinical outcomes, life expectancy, disability-free life expectancy, lifetime costs, disability-adjusted life years (DALYs), and incremental cost-effectiveness ratios (ICERs) for neonatal intensive care compared to no intensive care. Uncertainty around the results was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. In the base-case analysis, neonatal intensive care for infants born at 24-26, 27-29, and 30-33 weeks gestational age prolonged life expectancy by 28, 43, and 34 years and averted 9, 15, and 12 DALYs, at incremental costs per infant of US$11,400, US$9,500, and US$3,000, respectively, compared to an alternative of no intensive care. The ICERs of neonatal intensive care at 24-26, 27-29, and 30-33 weeks were US$1,200, US$650, and US$240, per DALY averted, respectively. The findings were robust to variation in parameter values over wide ranges in sensitivity analyses. CONCLUSIONS: Incremental cost-effectiveness ratios for neonatal intensive care imply very high value for money on the basis of conventional benchmarks for cost-effectiveness analysis. Please see later in the article for the Editors' Summary.

[Healthy pharmaceutical policy]. / Política farmacéutica saludable.

Today, the pharmaceutical industry is experiencing a profound transition. Globalization and technological advancement represent the principal pressures for change in the market, where it is increasingly more difficult for this type of industry to efficiently recoup the growing cost of innovation. Mexico needs to analyze the policy implications of these change factors and promote, in the pharmaceutical market, policies that maximize health gains on invested resources. Pharmaceutical policy offers a rare example for a complementary approach between a sound health policy and an efficient economic policy; that is, a "healthy pharmaceutical policy."

[Generalized cost-effectiveness of preventive interventions against cervical cancer in Mexican women: results of a Markov model from the public sector perspective]. / Relación costo-efectividad de las intervenciones preventivas contra el cáncer cervical en mujeres mexicanas.

OBJECTIVE: To develop a generalized cost-effectiveness analysis (GCEA) of the HPV vaccine, hybrid capture screening (HC) and Papanicolaou screening (Pap) in the Mexican context. MATERIALS AND METHODS: From April to August 2007, in Mexico, a GCEA of the interventions was developed for 10 possible scenarios using a Markov model from the public sector perspective as payer. RESULTS: Scenarios considering 80% coverage show an ACER per DALY averted of $16678 pesos for Pap of women between ages 25 and 64, $17277 pesos for HC of women between ages 30 and 64, and $84008 pesos for vaccination of 12-year-old girls. Annual financing of $621, $741 and $2255 million pesos, respectively, is needed for these scenarios. CONCLUSIONS: A selective, combined introduction of Pap-HC screening that considers the comparative advantages of application in different populations and geographical areas is suggested. Additionally, it is suggested to introduce the vaccine once a threshold price of $181 pesos per dose -when the vaccine becomes equal in terms of cost-effectiveness to HC- has been achieved.

End-Stage Renal Disease Models in the Americas: Optimizing Resources to Achieve Better Health Outcomes.

End-stage renal disease, the last and most severe stage of chronic kidney disease, represents a major and rising concern for countries in Latin America, driven in large part by aging populations and the near-epidemic rises in diabetes, obesity, and hypertension. This places a great clinical, economic, and social burden on the region's health systems. During the ISPOR 6th Latin America Conference held in Sao Paulo, Brazil, in September 2017, an educational forum debated on value-based decision making in the treatment of end-stage renal disease in Latin America. We summarize the current state and how to build strategies and implement actions to move to a more patient-centered, outcomes-based approach for renal care in the region, taken from the discussions in the conference and also from a literature review. Models of renal care used in Ontario (Canada), Colombia, and a Chilean hospital stress the importance of empowering and supporting patients and their families, allowing for a better coordination between primary care providers and specialists, providing financial incentives to health units, and establishing an entity that holds insurers and providers accountable for health outcomes and costs of treatment. The study uses the framework of value-based health care for the evaluation of different dialysis options-peritoneal dialysis, hemodialysis, home dialysis, and so forth-and calls for the countries to adopt an integrated care model. We emphasize that countries in Latin America need to recognize the chronic kidney disease challenge and develop health systems and efficient renal care models to be able to reduce the burden of the disease.

Comprehensive reform to improve health system performance in Mexico.

Despite having achieved an average life expectancy of 75 years, much the same as that of more developed countries, Mexico entered the 21st century with a health system marred by its failure to offer financial protection in health to more than half of its citizens; this was both a result and a cause of the social inequalities that have marked the development process in Mexico. Several structural limitations have hampered performance and limited the progress of the health system. Conscious that the lack of financial protection was the major bottleneck, Mexico has embarked on a structural reform to improve health system performance by establishing the System of Social Protection in Health (SSPH), which has introduced new financial rules and incentives. The main innovation of the reform has been the Seguro Popular (Popular Health Insurance), the insurance-based component of the SSPH, aimed at funding health care for all those families, most of them poor, who had been previously excluded from social health insurance. The reform has allowed for a substantial increase in public investment in health while realigning incentives towards better technical and interpersonal quality. This paper describes the main features and initial results of the Mexican reform effort, and derives lessons for other countries considering health-system transformations under similarly challenging circumstances.

Assessing the effect of the 2001-06 Mexican health reform: an interim report card.

Since 2001, Mexico has been designing, legislating, and implementing a major health-system reform. A key component was the creation of Seguro Popular, which is intended to expand insurance coverage over 7 years to uninsured people, nearly half the total population at the start of 2001. The reform included five actions: legislation of entitlement per family affiliated which, with full implementation, will increase public spending on health by 0.8-1.0% of gross domestic product; creation of explicit benefits packages; allocation of monies to decentralised state ministries of health in proportion to number of families affiliated; division of federal resources flowing to states into separate funds for personal and non-personal health services; and creation of a fund to protect families against catastrophic health expenditures. Using the WHO health-systems framework, we used a wide range of datasets to assess the effect of this reform on different dimensions of the health system. Key findings include: affiliation is preferentially reaching the poor and the marginalised communities; federal non-social security expenditure in real per-head terms increased by 38% from 2000 to 2005; equity of public-health expenditure across states improved; Seguro Popular affiliates used more inpatient and outpatient services than uninsured people; effective coverage of 11 interventions has improved between 2000 and 2005-06; inequalities in effective coverage across states and wealth deciles has decreased over this period; catastrophic expenditures for Seguro Popular affiliates are lower than for uninsured people even though use of services has increased. We present some lessons for Mexico based on this interim evaluation and explore implications for other countries considering health reforms.

Priority setting for health interventions in Mexico's System of Social Protection in Health.

Explicit priority setting presents Mexico with the opportunity to match the pressure and complexity of an advancing epidemiological transition with evidence-based policies driven by a fundamental concern for how to make the best use of scarce resources to improve population health. The Mexican priority-setting experience describes how standardised analytical approaches to decision making, mainly burden of disease and cost-effectiveness analyses, combine with other criteria--eg, being responsive to the legitimate non-health expectations of patients and ensuring fair financing across households--to design and implement a set of three differentiated health intervention packages. This process is a key element of a wider set of reform components aimed at extending health insurance, especially to the poor. The most relevant policy implications include lessons on the use of available and proven analytical tools to set national health priorities, the usefulness of priority-setting results to guide long-term capacity development, the importance of favouring an institutionalised approach to cost-effectiveness analysis, and the need for local technical capacity strengthening as an essential step to balance health-maximising arguments and other non-health criteria in a transparent and systematic process.

Mexico's path towards the Sustainable Development Goal for health: an assessment of the feasibility of reducing premature mortality by 40% by 2030.

BACKGROUND: The United Nations Sustainable Development Goal for health (SDG3) poses complex challenges for signatory countries that will require clear roadmaps to set priorities over the next 15 years. Building upon the work of the Commission on Investing in Health and published estimates of feasible global mortality SDG3 targets, we analysed Mexico's mortality to assess the feasibility of reducing premature (0-69 years) mortality and propose a path to meet SDG3. METHODS: We developed a baseline scenario applying 2010 age-specific and cause-specific mortality rates from the Mexican National Institute of Statistics and Geography (INEGI) to the 2030 UN Population Division (UNPD) population projections. In a second scenario, INEGI age-specific and cause-specific trends in death rates from 2000 to 2014 were projected to 2030 and adjusted to match the UNPD 2030 mortality projections. A third scenario assumed a 40% reduction in premature deaths across all ages and causes. By comparing these scenarios we quantified shortfalls in mortality reductions by age group and cause, and forecasted life expectancy pathways for Mexico to converge to better performing countries. FINDINGS: UNPD-projected death rates yield a 25·9% reduction of premature mortality for Mexico. Accelerated reductions in adult mortality are necessary to reach a 40% reduction by 2030. Mortality declines aggregated across all age groups mask uneven gains across health disorders. Injuries, particularly road traffic accidents and homicides, are the main health challenge for young adults (aged 20-49 years) whereas unabated diabetes mortality is the single most important health concern for older adults (aged 50-69 years). INTERPRETATION: Urgent action is now required to control non-communicable diseases and reduce fatal injuries in Mexico, making a 40% reduction in premature mortality by 2030 feasible and putting Mexico back on a track of substantial life expectancy convergence with better performing countries. Our study provides a roadmap for setting national health priorities. Further analysis of the equity implications of following the suggested pathway remains a subject of future research. FUNDING: Mexico's Ministry of Health, University of California, San Francisco, and Bill & Melinda Gates Foundation.