Setbacks in the quest for universal health coverage in Mexico: polarised politics, policy upheaval, and pandemic disruption.

2023 marks the 20-year anniversary of the creation of Mexico's System of Social Protection for Health and the Seguro Popular, a model for the global quest to achieve universal health coverage through health system reform. We analyse the success and challenges after 2012, the consequences of reform ageing, and the unique coincidence of systemic reorganisation during the COVID-19 pandemic to identify strategies for health system disaster preparedness. We document that population health and financial protection improved as the Seguro Popular aged, despite erosion of the budget and absent needed reforms. The Seguro Popular closed in January, 2020, and Mexico embarked on a complex, extensive health system reorganisation. We posit that dismantling the Seguro Popular while trying to establish a new programme in 2020-21 made the Mexican health system more vulnerable in the worst pandemic period and shows the precariousness of evidence-based policy making to political polarisation and populism. Reforms should be designed to be flexible yet insulated from political volatility and constructed and managed to be structurally permeable and adaptable to new evidence to face changing health needs. Simultaneously, health systems should be grounded to withstand systemic shocks of politics and natural disasters.

The Need for Culturally Tailored CKD Education in Older Latino Patients and Their Families.

Older Latino adults (aged 65+years) comprise the fastest growing minoritized group among the older population in the United States and experience a disproportionate burden of kidney failure as well as disparities in kidney care compared with non-Hispanic White individuals. Despite significant need and barriers uniquely faced by this population, few educational resources or decision aids are available to meet the language and cultural needs of Latino patients. Decision aids are designed to improve knowledge and empower individuals to engage in shared decision making and have been shown to improve decisional quality and goal-concordant care among older patients with chronic kidney disease (CKD). In this commentary, we examine the barriers faced by older Latino people with CKD who must make dialysis initiation decisions. We conclude that there is a need for culturally concordant decision aids tailored for older Latino patients with CKD to overcome barriers in access to care and improve patient-centered care for older Latino CKD patients.

Shared Decision Making Among Older Adults With Advanced CKD.

RATIONALE & OBJECTIVE: Older adults with advanced chronic kidney disease (CKD) face difficult decisions about dialysis initiation. Although shared decision making (SDM) can help align patient preferences and values with treatment options, the extent to which older patients with CKD experience SDM remains unknown. STUDY DESIGN: A cross-sectional analysis of patient surveys examining decisional readiness, treatment options education, care partner support, and SDM. SETTING & PARTICIPANTS: Adults aged 70 years or older from Boston, Chicago, San Diego, or Portland (Maine) with nondialysis advanced CKD. PREDICTORS: Decisional readiness factors, treatment options education, and care partner support. OUTCOMES: Primary: SDM measured by the 9-item Shared Decision Making Questionnaire (SDM-Q-9) instrument, with higher scores reflecting greater SDM. Exploratory: Factors associated with SDM. ANALYTICAL APPROACH: We used multivariable linear regression models to examine the associations between SDM and predictors, controlling for demographic and health factors. RESULTS: Among 350 participants, mean age was 78 ± 6 years, 58% were male, 13% identified as Black, and 48% had diabetes. Mean SDM-Q-9 score was 52 ± 28. SDM item agreement ranged from 41% of participants agreeing that "my doctor and I selected a treatment option together" to 73% agreeing that "my doctor told me that there are different options for treating my medical condition." In multivariable analysis adjusted for demographic characteristics, lower estimated glomerular filtration rate, and diabetes, being "well informed" and "very well informed" about kidney treatment options, having higher decisional certainty, and attendance at a kidney treatment options class were independently associated with higher SDM-Q-9 scores. LIMITATIONS: The cross-sectional study design limits the ability to make temporal associations between SDM and the predictors. CONCLUSIONS: Many older patients with CKD do not experience SDM when making dialysis decisions, emphasizing the need for greater access to and delivery of education for individuals with advanced CKD.

Associations among political voting preference, high-risk health status, and preventative behaviors for COVID-19.

BACKGROUND: We investigate the relationships among political preferences, risk for COVID-19 complications, and complying with preventative behaviors, such as social distancing, quarantine, and vaccination, as they remain incompletely understood. Since those with underlying health conditions have the highest mortality risk, prevention strategies targeting them and their caretakers effectively can save lives. Understanding caretakers' adherence is also crucial as their behavior affects the probability of transmission and quality of care, but is understudied. Examining the degree to which adherence to prevention measures within these populations is affected by their health status vs. voting preference, a key predictor of preventative behavior in the U. S, is imperative to improve targeted public health messaging. Knowledge of these associations could inform targeted COVID-19 campaigns to improve adherence for those at risk for severe consequences. METHODS: We conducted a nationally-representative online survey of U.S. adults between May-June 2020 assessing: 1) attempts to socially-distance; 2) willingness/ability to self-quarantine; and 3) intention of COVID-19 vaccination. We estimated the relationships between 1) political preferences 2) underlying health status, and 3) being a caretaker to someone with high-risk conditions and each dependent variable. Sensitivity analyses examined the associations between political preference and dependent variables among participants with high-risk conditions and/or obesity. RESULTS: Among 908 participants, 75.2% engaged in social-distancing, 94.4% were willing/able to self-quarantine, and 60.1% intended to get vaccinated. Compared to participants intending to vote for Biden, participants who intended to vote for Trump were significantly less likely to have tried to socially-distance, self-quarantine, or intend to be vaccinated. We observed the same trends in analyses restricted to participants with underlying health conditions and their caretakers Underlying health status was independently associated with social distancing among individuals with obesity and another high-risk condition, but not other outcomes. CONCLUSION: Engagement in preventative behavior is associated with political voting preference and not individual risk of severe COVID-19 or being a caretaker of a high-risk individual. Community based strategies and public health messaging should be tailored to individuals based on political preferences especially for those with obesity and other high-risk conditions. Efforts must be accompanied by broader public policy.

Development of a Youth Civic Engagement Program: Process and Pilot Testing with a Youth-Partnered Research Team.

Although research suggests neighborhood-level factors influence youth well-being, few studies include youth when creating interventions to address these factors. We describe our three-step process of collaborating with youth in low-income communities to develop an intervention focused on civic engagement as a means to address neighborhood-level problems impacting their well-being. In the first step, we analyzed qualitative interviews from a project in which youth shared perceptions about their neighborhoods (e.g., interpersonal relations with neighbors and institutions). Three major themes were identified: pride in youth's communities, desire for change, and perceptions of power and responsibility. Based on these themes, we completed the second step: developing a civic engagement and leadership program, called LEAP, aimed at helping youth take an active role in addressing neighborhood problems. In the third step, we collaborated with youth who completed a pilot version of the civic program and provided feedback to finalize it for large-scale testing. While discussing our process, we highlight the importance of including youth voices when developing programs that affect them. Furthermore, we note the need for more research exploring whether civic engagement serves as a mechanism for encouraging youth involvement in addressing neighborhood-level health disparities and identifying potential psychological costs of such involvement.

Patient Education for Kidney Failure Treatment: A Mixed-Methods Study.

RATIONALE & OBJECTIVE: Education programs are needed for people with advanced chronic kidney disease to understand kidney failure treatment options and participate in shared decision-making (SDM). Little is known about the content and accessibility of current education programs or whether they support SDM. STUDY DESIGN: Stakeholder-engaged, mixed-methods design incorporating qualitative observations and interviews, and a quantitative content analysis of slide presentations. SETTING & PARTICIPANTS: Four sites located in Boston, Chicago, Portland (Maine), and San Diego. ANALYTICAL APPROACH: Thematic analysis based on the Ottawa Framework (observations and interviews) and descriptive statistical analysis (slide presentations). RESULTS: Data were collected from observations of 9 education sessions, 5 semistructured interviews with educators, and 133 educational slide presentations. Sites offered group classes or one-on-one sessions. Development, quality, and accuracy of educational materials varied widely. Educators emphasized dialysis (often in-center hemodialysis), with little mention of conservative management. Educators reported patients were often referred too late to education sessions and that some patients become overwhelmed if they learn of the implications of kidney failure in a group setting. Commonly, sessions were general and did not provide opportunities for tailored information most supportive of SDM. Few nephrologists were involved in education sessions or aware of the educational content. Content gaps included prognosis, decision support, mental health and cognition, advance care planning, cost, and diet. Slide presentations used did not consistently reflect best practices related to health literacy. LIMITATIONS: Findings may not be broadly generalizable. CONCLUSIONS: Education sessions focused on kidney failure treatment options do not consistently follow best practices related to health literacy or for supporting SDM. To facilitate SDM, the establishment of expectations for kidney failure treatment options should be clearly defined and integrated into the clinical workflow. Addressing content gaps, health literacy, and communication with nephrologists is necessary to improve patient education in the setting of advanced chronic kidney disease.

US clinicians' perspectives on advance care planning for persons with dementia: A qualitative study.

BACKGROUND: Although advance care planning (ACP) for persons with dementia (PWD) can promote patient-centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians. METHODS: Qualitative study using semi-structured interviews (August 2018-December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision-making was approached, and how decision-making capacity was assessed. RESULTS: Of 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as possible with PWD. Three themes emerged: value of early ACP preserves PWD's autonomy in cases of differing PWD carepartner values, acute medical crises, and clinician paternalism; barriers to ACP with PWD including the dynamic and subjective assessment of patient decision-making capacity, inconsistent awareness of cognitive impairment by clinicians, and the need to balance patient and family carepartner involvement; and strategies to support ACP include clarifying clinicians' roles in ACP, standardizing clinicians' approach to PWD and their carepartners, and making time for ACP and decision-making assessments that allow PWD and carepartner involvement regardless of the patients' capacity. CONCLUSIONS: Clinicians found early ACP for PWD valuable in promoting patient-centered care among an at-risk population. In sharing their perspectives on conducting ACP for PWD, clinicians described challenges that are amenable to changes in training, workflow, and material support for clinician time. Clinical practices need sustainable scheduling and financial support models.

Non-pharmaceutical interventions to combat COVID-19 in the Americas described through daily sub-national data.

This dataset covers national and subnational non-pharmaceutical interventions (NPI) to combat the COVID-19 pandemic in the Americas. Prior to the development of a vaccine, NPI were governments' primary tools to mitigate the spread of COVID-19. Variation in subnational responses to COVID-19 is high and is salient for health outcomes. This dataset captures governments' dynamic, varied NPI to combat COVID-19 for 80% of Latin America's population from each country's first case through December 2021. These daily data encompass all national and subnational units in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru. The dataset includes individual and aggregate indices of nine NPI: school closures, work suspensions, public event cancellations, public transport suspensions, information campaigns, local travel restrictions, international travel controls, stay-at-home orders, and restrictions on the size of gatherings. We also collected data on mask mandates as a separate indicator. Local country-teams drew from multiple data sources, resulting in high-quality, reliable data. The dataset thus allows for consistent, meaningful comparisons of NPI within and across countries during the pandemic.

Clinician's experiences with involuntary commitment for substance use disorder: A qualitative study of moral distress.

BACKGROUND: Petitions for involuntary commitment of people living with a substance use disorder (SUD) have almost doubled since 2011 in Massachusetts through the policy Section 35. However, the efficacy of this controversial policy remains unclear, and clinicians differ on whether it ought to be used. This study examines how clinicians decide whether to use Section 35 and their experiences of moral distress, the negative feeling that occurs when a clinician is required to pursue a treatment option against their moral judgement due to institutional constraints, associated with its use. METHODS: Qualitative semi-structured interviews with clinicians in Massachusetts were conducted between December 2019 and February 2020 and continued until thematic saturation. Thematic and narrative analysis was conducted with recorded and transcribed interviews. RESULTS: Among 21 clinicians, most (77%) experienced some or high moral distress when utilizing Section 35 for involuntary commitment, with clinicians working in emergency departments experiencing less distress than those working in SUD clinics. Clinicians with low moral distress referenced successful patient anecdotes and held an abstinence-based view of SUD, while clinicians with high moral distress were concerned by systemic treatment failures and understood SUD through a nuanced and harm reduction-oriented view. Clinicians across professional settings were concerned by the involvement of law enforcement and criminal justice settings in the Section 35 process. Clinicians employed a variety of strategies to cope with moral distress, including team-based decision-making and viewing the petition as a last resort. Barriers to utilizing Section 35 included restrictive court hours and lack of post-section aftercare services. CONCLUSION: Widespread distress associated with use of involuntary commitment and inconsistent approaches to its use highlight the need for better care coordination and guidance on best practices for utilization of this policy.

Immigrants and the Affordable Care Act: Changes in Coverage and Access to Care by Documentation Status.

Little is known about the effects of the ACA's coverage expansion among immigrant groups of differing immigration status. Using data from the California Health Interview Survey (2003-2016), we compare changes in health coverage and access to care among immigrants in California before and after implementation of the ACA. We find that the ACA has led to major gains in coverage for lawful permanent residents in California, similar in scope to changes among citizens. However, unauthorized immigrants have experienced only modest increases in coverage, with the result disparity in uninsured rates for this group relative to citizens and permanent residents widening considerably since 2014. Findings indicate a significant increase in having a usual source of care across all groups, but without a significant change in disparities for this outcome. Our results have important implications for the intersection of health policy, immigration, and health equity.

Intention to obtain a COVID-19 vaccine among Brazilian immigrant women in the U.S.

BACKGROUND: COVID-19 has disproportionately impacted low-income immigrant communities. There is concern that the current uptake of COVID-19 vaccines is suboptimal and that this may be contributing to COVID-19 inequities. However, little is known about the acceptability of COVID-19 vaccines among immigrants in the U.S. Our goal was to gauge COVID-19 vaccine intentions among Brazilian immigrant women living in the U.S. METHODS: We conducted an online survey between July and August 2020 offered in Portuguese and English languages among a convenience sample of Brazilian immigrant women ages 18 years and older. Women were recruited through online advertisements by community-based organizations and social media groups to complete a survey that assessed intention to get a COVID-19 vaccine, attitudes toward vaccines, and perceptions about the pandemic. RESULTS: Of the total sample (N = 353), most (70.8%) indicated they intended to get a COVID-19 vaccine. In bivariate analyses, vaccine intentions were significantly associated with perceptions about the severity of the pandemic, trusted sources of health information, and the number of years lived in the U.S. Multinomial logistic regression models revealed that those who did not intend to be vaccinated had lived a longer time in the U.S. (OR: -0.12 95% CI: -0.19, -0.05), perceived the pandemic to be a minor issue (OR: 1.52, 95% CI: 0.62, 2.42), and trusted information from social networks (OR: -1.94, 95% CI: -3.25, -0.63) or private news sources (OR: -1.71, 95% CI: -2.78, -0.63). CONCLUSIONS: While most women reported they would get a COVID-19 vaccine, efforts to reach those who may be hesitant should target those who have lived in the U.S. for longer periods of time and do not perceive the pandemic to be a major crisis. Healthcare providers may be particularly suited to deliver this information given high levels of trust.

Does Shared Decision-Making for Prostate Cancer Screening Among African American Men Happen? It Depends on Who You Ask.

BACKGROUND: Shared decision-making (SDM) is recommended for prostate cancer screening, but little is known about how this process is perceived by patients and providers. SDM is especially important for African American men, who are at high risk for the disease. OBJECTIVE: To evaluate agreement in SDM ratings among patients, providers, and objective observers. METHOD: African American men ages 45-70 were recruited from primary care practices to participate in a study evaluating a decision aid (DA). Immediately after using the DA, patients proceeded to primary care appointments. Afterwards, patients and physicians completed surveys assessing perceptions about SDM. Clinical visits were also audio-recorded and coded to assess SDM. RESULTS: Mean scores on SDM measures among patients were 73.2 (SD = 27.5, 95% CI 55.71-90.62), 83.1 among physicians (SD = 7.8 95% CI 78.14-88.06), and 67.1 among objective raters (SD = 36.8 95% CI 43.72-90.45). Among patient-provider dyads, mean agreement was 49.9%. CONCLUSION: Patients, physicians, and objective observers perceived SDM differently. Understanding discordant experiences of SDM is vital for improving clinical guidance about SDM especially among African Americans who have historically faced healthcare discrimination and mistrust. DAs, particularly for African American men, should incorporate strategies to empower patients to advocate for their communication needs and preferences. TRIAL REGISTRATION: Clinical trials identifier number: NCT02787434.

Understanding The Use Of Medicare Procedure Codes For Advance Care Planning: A National Qualitative Study.

In 2016 Medicare introduced advance care planning Current Procedural Terminology (CPT) codes to reimburse clinicians for time spent providing the service. Despite recent increases, use of these codes remains low for reasons incompletely captured by quantitative research. To further identify barriers and facilitators to code use for Medicare fee-for-service enrollees, we conducted case studies at eleven health systems, including 272 interviews with clinicians, administrators, and key leadership. Five themes related to use of the new codes emerged: code-based constraints to billing, burdening patients with unexpected charges, ethical concerns with billing for discussion of advance care plans, incentives to signal the importance of their use in billing, and increasing both workflow burden and the need for institutional supports and training. Respondents also observed that use was facilitated by health systems' investment in clinician training and in processes to audit the codes' use. Our findings suggest that increased reimbursement, strong institutional commitment and support, and streamlined workflow could improve the use of the new CPT codes to document receipt of and ensure access to Medicare advance care planning.

Treatment Decision Making for Older Kidney Patients during COVID-19.

BACKGROUND AND OBJECTIVES: Coronavirus disease 2019 (COVID-19) disrupted medical care across health care settings for older patients with advanced CKD. Understanding how shared decision making for kidney treatment decisions was influenced by the uncertainty of an evolving pandemic can provide insights for supporting shared decision making through the current and future public health crises. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We performed thematic and narrative analyses of semistructured interviews with patients (CKD stages 4 and 5, age 70+), care partners, and clinicians from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020. RESULTS: We interviewed 76 participants (39 patients, 17 care partners, and 20 clinicians). Among patient participants, 13 (33%) patients identified as Black, and seven (18%) had initiated dialysis. Four themes with corresponding subthemes emerged related to treatment decision making and the COVID-19 pandemic: (1) adapting to changed educational and patient engagement practices (patient barriers to care and new opportunities for telemedicine); (2) reconceptualizing vulnerability (clinician awareness of illness severity increased and limited discussions of patient COVID-19 vulnerability); (3) embracing home-based dialysis but not conservative management (openness to home-based modalities and limited discussion of conservative management and advanced care planning); and (4) satisfaction and safety with treatment decisions despite conditions of uncertainty. CONCLUSIONS: Although clinicians perceived greater vulnerability among older patients CKD and more readily encouraged home-based modalities during the COVID-19 pandemic, their discussions of vulnerability, advance care planning, and conservative management remained limited, suggesting areas for improvement. Clinicians reported burnout caused by the pandemic, increased time demands, and workforce limitations, whereas patients remained satisfied with their treatment choices despite uncertainty. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: Decision Aid for Renal Therapy (DART), NCT03522740.

Strengthening Health Systems To Face Pandemics: Subnational Policy Responses To COVID-19 In Latin America.

Nonpharmaceutical interventions such as stay-at-home orders continue to be the main policy response to the COVID-19 pandemic in countries with limited or slow vaccine rollout. Often, nonpharmaceutical interventions are managed or implemented at the subnational level, yet little information exists on within-country variation in nonpharmaceutical intervention policies. We focused on Latin America, a COVID-19 epicenter, and collected and analyzed daily subnational data on public health measures in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru to compare within- and across-country nonpharmaceutical interventions. We showed high heterogeneity in the adoption of these interventions at the subnational level in Brazil and Mexico; consistent national guidelines with subnational heterogeneity in Argentina and Colombia; and homogeneous policies guided by centralized national policies in Bolivia, Chile, and Peru. Our results point to the role of subnational policies and governments in responding to health crises. We found that subnational responses cannot replace coordinated national policy. Our findings imply that governments should focus on evidence-based national policies while coordinating with subnational governments to tailor local responses to changing local conditions.

Nephrologists' Attitudes Toward Native Kidney Biopsy: A Qualitative Study.

RATIONALE & OBJECTIVE: Although kidney biopsy is a useful tool, nephrologists' approach toward biopsies is inconsistent for reasons incompletely understood, including lack of established clinical guidelines. We examined contemporary clinical decision-making patterns among nephrologists to perform native kidney biopsy. STUDY DESIGN: Qualitative study using semistructured interviews. SETTING & PARTICIPANTS: Purposive sampling was used to select nephrologists from different regions in the United States. Semistructured interviews were continued until thematic saturation. ANALYTICAL APPROACH: A modified grounded theory was used to identify dominant themes reflecting the nephrologists' decision-making styles about kidney biopsy. RESULTS: Twenty nephrologists were interviewed: 16 (80%) were from academic centers, 3 (15%) performed their own biopsies, and 7 (35%) had been in practice for less than 10 years. The median time of practice was 14 years. We found substantial variability among the nephrologists in their attitude toward using kidney biopsy, which reflected individual differences in weighing the risks and benefits of the procedure for an individual patient. Five overarching themes were identified: operator comfort with biopsy and availability of interventional radiologist, exposure to biopsy during training and years of experience, concerns about the invasiveness of biopsy and inflicting harm, perception of evidence base and limited treatment options, and patient characteristics and preference. LIMITATIONS: Generalizability was limited because the nephrologists sampled may not have been broadly representative. CONCLUSIONS: Multiple factors influence nephrologists' decision to pursue kidney biopsy, with substantial variability among nephrologists that can have meaningful clinical implications. This suggests the need to establish consensus guidelines to make biopsy practice more standardized.

Why are some people reluctant to be vaccinated for COVID-19? A cross-sectional survey among U.S. Adults in May-June 2020.

Understanding reasons for COVID-19 vaccine hesitancy is necessary to ensure maximum uptake, needed for herd immunity. We conducted a cross-sectional online survey between May 29-June 20, 2020 among a national sample of U.S. adults ages 18 years and over to assess cognitive, attitudinal and normative beliefs associated with not intending to get a COVID-19 vaccine. Of 1219 respondents, 17.7% said that they would not get a vaccine and 24.2% were unsure. In multivariable analyses controlled for gender, age, income, education, religious affiliation, health insurance coverage, and political party affiliation, those who reported that they were unwilling be vaccinated (versus those who were willing) were less likely to agree that vaccines are safe/effective (Relative Risk Ratio (RRR): 0.45, 95% confidence interval (CI): 0.31, 0.66), that everyone has a responsibility to be vaccinated (RRR: 0.39, 95% CI: 0.30, 0.52), that public authorities should be able to mandate vaccination (RRR: 0.75, 95% CI: 0.58, 0.98), and more likely to believe that if everyone else were vaccinated they would not need a vaccine (RRR: 1.36, 95% CI: 1.04, 1.78). Our results suggest that health messages should emphasize the safety and efficacy of vaccines, as well as the fact that vaccinating oneself is important, even if the level of uptake in the community is high.

Not far enough: Public health policies to combat COVID-19 in Mexico's states.

BACKGROUND: Mexican state governments' actions are essential to control the COVID-19 pandemic within the country. However, the type, rigor and pace of implementation of public policies have varied considerably between states. Little is known about the subnational (state) variation policy response to the COVID-19 pandemic in Mexico. MATERIAL AND METHODS: We collected daily information on public policies designed to inform the public, as well as to promote distancing, and mask use. The policies analyzed were: School Closure, Workplace Closure, Cancellation of Public Events, Restrictions on Gatherings, Stay at Home Order, Public Transit Suspensions, Information Campaigns, Internal Travel Controls, International Travel Controls, Use of Face Masks We use these data to create a composite index to evaluate the adoption of these policies in the 32 states. We then assess the timeliness and rigor of the policies across the country, from the date of the first case, February 27, 2020. RESULTS: The national average in the index during the 143 days of the pandemic was 41.1 out of a possible 100 points on our index. Nuevo León achieved the highest performance (50.4); San Luis Potosí the lowest (34.1). The differential between the highest versus the lowest performance was 47.4%. CONCLUSIONS: The study identifies variability and heterogeneity in how and when Mexican states implemented policies to contain COVID-19. We demonstrate the absence of a uniform national response and widely varying stringency of state responses. We also show how these responses are not based on testing and do not reflect the local burden of disease. National health system stewardship and a coordinated, timely, rigorous response to the pandemic did not occur in Mexico but is desirable to contain COVID-19.

A partisan pandemic: state government public health policies to combat COVID-19 in Brazil.

INTRODUCTION: To present an analysis of the Brazilian health system and subnational (state) variation in response to the COVID-19 pandemic, based on 10 non-pharmaceutical interventions (NPIs). MATERIALS AND METHODS: We collected daily information on implementation of 10 NPI designed to inform the public of health risks and promote distancing and mask use at the national level for eight countries across the Americas. We then analyse the adoption of the 10 policies across Brazil's 27 states over time, individually and using a composite index. We draw on this index to assess the timeliness and rigour of NPI implementation across the country, from the date of the first case, 26 February 2020. We also compile Google data on population mobility by state to describe changes in mobility throughout the COVID-19 pandemic. RESULTS: Brazil's national NPI response was the least stringent among countries analysed. In the absence of a unified federal response to the pandemic, Brazilian state policy implementation was neither homogenous nor synchronised. The median NPI was no stay-at-home order, a recommendation to wear masks in public space but not a requirement, a full school closure and partial restrictions on businesses, public transportation, intrastate travel, interstate travel and international travel. These restrictions were implemented 45 days after the first case in each state, on average. Rondônia implemented the earliest and most rigorous policies, with school closures, business closures, information campaigns and restrictions on movement 24 days after the first case; Mato Grosso do Sul had the fewest, least stringent restrictions on movement, business operations and no mask recommendation. CONCLUSIONS: The study identifies wide variation in national-level NPI responses to the COVID-19 pandemic. Our focus on Brazil identifies subsequent variability in how and when states implemented NPI to contain COVID-19. States' NPIs and their scores on the composite policy index both align with the governors' political affiliations: opposition governors implemented earlier, more stringent sanitary measures than those supporting the Bolsonaro administration. A strong, unified national response to a pandemic is essential for keeping the population safe and disease-free, both at the outset of an outbreak and as communities begin to reopen. This national response should be aligned with state and municipal implementation of NPI, which we show is not the case in Brazil.