[Embedding research into health services in Latin America and the Caribbean: experiences and challenges of the Technical Support CenterExperiências e desafios do Centro de Apoio Técnico na pesquisa integrada aos serviços na América Latina e Caribe]. / Experiencias y retos del Centro de Apoyo Técnico en la investigación integrada en los servicios en América Latina y el Caribe.

This article describes the main models for embedding research and the successful experiences and challenges faced in joint work by researchers and decisionmakers who participated in the Embedding Research for the Sustainable Development Goals (ER-SDG) initiative, and the experience of the Technical Support Center. In June 2018, funding was granted to 13 pre-selected research projects from 11 middle- and low-income countries in Latin America and the Caribbean (Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Ecuador, Guatemala, Guyana, Haiti, Paraguay, and Peru). The projects focused on the system-, policy-, or program-level changes required to improve health and build on the joint work of researchers and decisionmakers, with a view to bringing together evidence production and decision-making in health systems and services. The Technical Support Center supported and guided the production of quality results useful for decision-making. This experience confirmed the value of initiatives such as ER-SDG in consolidating bridges between research on the implementation of health policies, programs, and systems, and the officials responsible for operating health-related programs, services, and interventions. It highlighted the importance of both respecting and taking advantage of each context-and the specific arrangements and patterns in the relationships between researchers and decisionmakers-through incentives for embedded research.

Neste artigo são descritos os principais modelos de integração, as experiências de êxito e os desafios do trabalho conjunto de pesquisadores e responsáveis por tomar decisões que participam da iniciativa Incorporação da Pesquisa para Avançar no Cumprimento dos Objetivos de Desenvolvimento Sustentável (Embedding Research for the Sustainable Development Goals, ER-SDG) e da experiência do Centro de Apoio Técnico (CAT). Em junho de 2018, realizou-se a concessão de financiamento e pré-seleção de 13 projetos de pesquisa provenientes de 11 países de baixa e média renda da América Latina e Caribe (Argentina, Bolívia, Brasil, Colômbia, Equador, Guatemala, Guiana, Haiti, Paraguai, Peru e República Dominicana). Os projetos deveriam enfocar as mudanças necessárias no sistema, políticas ou programas para melhorar a saúde e fundar-se no trabalho conjunto de pesquisadores e responsáveis por tomar decisões visando aproximar a produção de evidências à tomada de decisão nos sistemas e serviços de saúde. O CAT forneceu suporte e orientação à produção de resultados úteis e de qualidade para a tomada de decisão. A experiência confirmou o valor de iniciativas como a ER-SDG para consolidar pontes entre o mundo da pesquisa voltada à implementação de políticas, programas e sistemas de saúde e o mundo dos encarregados de gerir estes programas, serviços e intervenções de saúde. Deve-se enfatizar a necessidade de respeitar e aproveitar cada contexto e os arranjos e padrões próprios da relação entre pesquisadores e responsáveis por tomar decisões criando incentivos à integração.

Experiencias y retos del Centro de Apoyo Técnico en la investigación integrada en los servicios en América Latina y el Caribe / Embedding research into health services in Latin America and the Caribbean: experiences and challenges of the Technical Support Center / Experiências e desafios do Centro de Apoio Técnico na pesquisa integrada aos serviços na América Latina e Caribe

RESUMEN En este artículo se describen los principales modelos de integración, las experiencias de éxito y los retos del trabajo conjunto de los investigadores y los tomadores de decisiones participantes en la iniciativa Incorporación de la Investigación para Avanzar en el Cumplimiento de los Objetivos de Desarrollo Sostenible (ER-SDG), y la experiencia del Centro de Apoyo Técnico (CAT). En junio de 2018 se otorgó financiamiento, previa selección, a 13 proyectos de investigación de 11 países de ingresos medios y bajos de América Latina y el Caribe (Argentina, Bolivia, Brasil, Colombia, Ecuador, Guatemala, Guyana, Haití, Paraguay, Perú y República Dominicana). Los proyectos debían estar centrados en los cambios que se requieren a nivel de sistema, políticas o programas para mejorar la salud y basarse en el trabajo conjunto de investigadores y tomadores de decisiones, a fin de acercar la generación de evidencias a la toma de decisiones en los sistemas y servicios de salud. El CAT apoyó y orientó la producción de resultados de calidad y de utilidad para la toma de decisiones. La experiencia confirmó el valor de iniciativas como ER-SDG en la consolidación de puentes entre el mundo de la investigación sobre implementación de políticas, programas y sistemas de salud, y el mundo de los funcionarios encargados de operar esos programas, servicios e intervenciones relacionadas con la salud. Se resalta la necesidad de respetar y aprovechar cada contexto, y los arreglos y patrones específicos de relación entre investigadores y tomadores de decisiones, mediante incentivos para la integración.

ABSTRACT This article describes the main models for embedding research and the successful experiences and challenges faced in joint work by researchers and decisionmakers who participated in the Embedding Research for the Sustainable Development Goals (ER-SDG) initiative, and the experience of the Technical Support Center. In June 2018, funding was granted to 13 pre-selected research projects from 11 middle- and low-income countries in Latin America and the Caribbean (Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Ecuador, Guatemala, Guyana, Haiti, Paraguay, and Peru). The projects focused on the system-, policy-, or program-level changes required to improve health and build on the joint work of researchers and decisionmakers, with a view to bringing together evidence production and decision-making in health systems and services. The Technical Support Center supported and guided the production of quality results useful for decision-making. This experience confirmed the value of initiatives such as ER-SDG in consolidating bridges between research on the implementation of health policies, programs, and systems, and the officials responsible for operating health-related programs, services, and interventions. It highlighted the importance of both respecting and taking advantage of each context—and the specific arrangements and patterns in the relationships between researchers and decisionmakers—through incentives for embedded research.

RESUMO Neste artigo são descritos os principais modelos de integração, as experiências de êxito e os desafios do trabalho conjunto de pesquisadores e responsáveis por tomar decisões que participam da iniciativa Incorporação da Pesquisa para Avançar no Cumprimento dos Objetivos de Desenvolvimento Sustentável (Embedding Research for the Sustainable Development Goals, ER-SDG) e da experiência do Centro de Apoio Técnico (CAT). Em junho de 2018, realizou-se a concessão de financiamento e pré-seleção de 13 projetos de pesquisa provenientes de 11 países de baixa e média renda da América Latina e Caribe (Argentina, Bolívia, Brasil, Colômbia, Equador, Guatemala, Guiana, Haiti, Paraguai, Peru e República Dominicana). Os projetos deveriam enfocar as mudanças necessárias no sistema, políticas ou programas para melhorar a saúde e fundar-se no trabalho conjunto de pesquisadores e responsáveis por tomar decisões visando aproximar a produção de evidências à tomada de decisão nos sistemas e serviços de saúde. O CAT forneceu suporte e orientação à produção de resultados úteis e de qualidade para a tomada de decisão. A experiência confirmou o valor de iniciativas como a ER-SDG para consolidar pontes entre o mundo da pesquisa voltada à implementação de políticas, programas e sistemas de saúde e o mundo dos encarregados de gerir estes programas, serviços e intervenções de saúde. Deve-se enfatizar a necessidade de respeitar e aproveitar cada contexto e os arranjos e padrões próprios da relação entre pesquisadores e responsáveis por tomar decisões criando incentivos à integração.

Impact of the 'Seguro Médico Siglo XXI' medical insurance programme on neonatal and infant mortality in Mexico, 2006-14: an ecological approach to estimation.

The 'Seguro Médico Siglo XXI' (SMSXXI), a universal coverage medical insurance programme for children under 5 years of age, started in 2006 to help avoid catastrophic health expenditures in poor families without social security in Mexico. The study used information from the National Health Information System for the 2006-14 period. An ecological approach was followed with a panel of the 2457 municipalities of Mexico as the units of analysis. The outcome variables were the municipality-level neonatal mortality and infant mortality rates in population without access to social security. The programme variable was the coverage of the SMSXXI programme at the municipality level, expressed as a proportion. Demographic and economic variables defined at the municipality level were included as covariates. Impact was estimated by fitting a fixed-effects negative binomial regression model. Results reveal that the SMSXXI significantly reduced both infant and neonatSal mortality in the target population, although in a non-linear fashion, with minimum mortality levels found around the 70% coverage range. The effect is mostly given by the transition from the first quintile to the fourth quintile of coverage (<13% vs 70.5-93.7% coverage), and it is attenuated significantly at coverage levels very close to or at 100%. The observed risk reduction amounted to an estimated total of 11 358 infant deaths being avoided due to the SMSXXI during the 2006-14 period, of which 48% were neonatal. In conclusion, we found a significant impact of the SMSXXI programme on both infant mortality and neonatal mortality. An attenuation of the effect of the insurance on mortality rates at levels close to 100% coverage may reflect the saturation of health units in detriment of the quality of care.

[The health of Mexicans living in localities with less than 100 000 inhabitants]. / La salud de los mexicanos que habitan en localidades de menos de 100 000 habitantes.

OBJECTIVE: To describe the health and nutritional status of Mexican population living in localities under 100 000 inhabitants (100k) in year 2018 in comparison it with a sample of similar characteristics in 2012. MATERIALS AND METHODS: The more relevant results analyzed in 19 articles about health and nutrition of the population are presented. This included information on access and utilization of health services, health and nutrition status by age groups and households affected by food insecurity (FI). RESULTS: Information was obtained about the health and nutrition status of the population from <100k localities, which is characterized by its higher poverty levels. CONCLUSIONS: Great inequities prevails the health and nutrition conditions of the Mexican population. The findings are useful for the devel- opment of public policies capable of reducing health inequities conditions, in order to achieve social equity.

OBJETIVO: Describir la situación de salud y nutrición de la población mexicana que habita en localidades de menos de 100 000 habitantes (100k) para el año 2018 y compararla con una muestra con características similares en 2012. MATERIAL Y MÉTODOS: Se presentan los resultados sobre la salud y nutrición de la población, analizados en 19 artículos sobre el acceso y utilización de los servicios de salud, la situación de salud y nutrición por grupos de edad y sobre los hogares afectados por inseguridad alimentaria. RESULTADOS: Se obtuvo información de salud y nutrición a nivel nacional en población de localidades <100k, caracterizada por tener mayores con- diciones de pobreza. CONCLUSIONES: En México prevalecen desigualdades en las condiciones de salud y nutrición de la po- blación. Los hallazgos son de utilidad para desarrollar políticas públicas capaces de reducir las desigualdades en salud, con el objeto de lograr la equidad social.

[Inequalities in access to services, basis for policies to reduce the health gap]. / Desigualdades en el acceso a servicios, base de las políticas para la reducción de la brecha en salud.

OBJECTIVE: To estimate inequalities in access to health services among Mexican population living in localities of 100 000 or less inhabitants. MATERIALS AND METHODS: Cross-sectional analysis using the National Health and Nu- trition Survey 100k 2018 survey data. Access was estimated using health insurance and care for the last health condition. As inequality measure, we estimated the concentration index using an imputation of household per capita income. RESULTS: Among studied population, health insurance was 82.42% and access to care 60.03%. We identified inequalities in both indicators; marginal and pro-poor for insurance and pro-rich for access to care. CONCLUSIONS: In Mexico, even within the popuation living in poverty there are inequalities in access to health care. More granular public interventions are needed to address inequalities in an effective way.

OBJETIVO: Estimar la desigualdad en acceso a servicios de salud en poblaciones de localidades menores de 100 000 habitantes en México. MATERIAL Y MÉTODOS: Análisis de la Encuesta Nacional de Salud y Nutrición 100k 2018. Se estimó el acceso con base en la afiliación a un esquema de aseguramiento (acceso potencial) y la atención para el más reciente problema de salud (acceso a atención) mediante el índice de concentración, utilizando una imputación del ingreso per cápita. RESULTADOS: La afiliación a algún esquema de ase- guramiento en salud fue de 82.42% y el acceso a atención de 60.03%. Se identificaron desigualdades en ambos indicadores, marginales para acceso potencial y con mayor concentración entre la población de menor ingreso; para acceso a atención se encontró desigualdad con mayor concentración entre la población de mayor ingreso. CONCLUSIONES: En México prevalecen desigualdades en acceso a servicios de salud para la población en condiciones de pobreza. Es necesario desarrollar intervenciones públicas con mayor granularidad para incidir de forma efectiva en la desigualdad.

La salud de los mexicanos que habitan en localidades de menos de 100 000 habitantes / The health of Mexicans living in localities with less than 100 000 inhabitants

Resumen: Objetivo: Describir la situación de salud y nutrición de la población mexicana que habita en localidades de menos de 100 000 habitantes (100k) para el año 2018 y compararla con una muestra con características similares en 2012. Material y métodos: Se presentan los resultados sobre la salud y nutrición de la población, analizados en 19 artículos sobre el acceso y utilización de los servicios de salud, la situación de salud y nutrición por grupos de edad y sobre los hogares afectados por inseguridad alimentaria. Resultados: Se obtuvo información de salud y nutrición a nivel nacional en población de localidades <100k, caracterizada por tener mayores condiciones de pobreza. Conclusiones: En México prevalecen desigualdades en las condiciones de salud y nutrición de la población. Los hallazgos son de utilidad para desarrollar políticas públicas capaces de reducir las desigualdades en salud, con el objeto de lograr la equidad social.

Abstract: Objective: To describe the health and nutritional status of Mexican population living in localities under 100 000 inhabitants (100k) in year 2018 in comparison it with a sample of similar characteristics in 2012. Materials and methods: The more relevant results analyzed in 19 articles about health and nutrition of the population are presented. This included information on access and utilization of health services, health and nutrition status by age groups and households affected by food insecurity (FI). Results: Information was obtained about the health and nutrition status of the population from <100k localities, which is characterized by its higher poverty levels. Conclusions: Great inequities prevails the health and nutrition conditions of the Mexican population. The findings are useful for the development of public policies capable of reducing health inequities conditions, in order to achieve social equity.

Desigualdades en el acceso a servicios, base de las políticas para la reducción de la brecha en salud / Inequalities in access to services, basis for policies to reduce the health gap

Resumen: Objetivo: Estimar la desigualdad en acceso a servicios de salud en poblaciones de localidades menores de 100 000 habitantes en México. Material y métodos: Análisis de la Encuesta Nacional de Salud y Nutrición 100k 2018. Se estimó el acceso con base en la afiliación a un esquema de aseguramiento (acceso potencial) y la atención para el más reciente problema de salud (acceso a atención) mediante el índice de concentración, utilizando una imputación del ingreso per cápita. Resultados: La afiliación a algún esquema de aseguramiento en salud fue de 82.42% y el acceso a atención de 60.03%. Se identificaron desigualdades en ambos indicadores, marginales para acceso potencial y con mayor concentración entre la población de menor ingreso; para acceso a atención se encontró desigualdad con mayor concentración entre la población de mayor ingreso. Conclusión: En México prevalecen desigualdades en acceso a servicios de salud para la población en condiciones de pobreza. Es necesario desarrollar intervenciones públicas con mayor granularidad para incidir de forma efectiva en la desigualdad.

Abstract: Objective: To estimate inequalities in access to health services among Mexican population living in localities of 100 000 or less inhabitants. Materials and methods: Cross-sectional analysis using the National Health and Nutrition Survey 100k 2018 survey data. Access was estimated using health insurance and care for the last health condition. As inequality measure, we estimated the concentration index using an imputation of household per capita income. Results: Among studied population, health insurance was 82.42% and access to care 60.03%. We identified inequalities in both indicators; marginal and pro-poor for insurance and pro-rich for access to care. Conclusion: In Mexico, even within the population living in poverty there are inequalities in access to health care. More granular public interventions are needed to address inequalities in an effective way.

Quality of family planning services in Mexico: The perspective of demand.

INTRODUCTION: Family planning (FP) is one of the key services provided by health care systems. Extending beyond matters of sexual and reproductive health, its area of influence impacts directly on the development of individuals and nations. After 60 years of intense FP activities in Mexico, and in light of recent restructuring of health service supply and financing, services need to be assessed from a user perspective. OBJECTIVE: Based on a comprehensive conceptual framework, this article assesses the quality of the FP services provided by the Mexican Ministry of Health (MoH). Analysis considers not only accessibility and availability but also the users' perceptions of the care process, particularly as regards the interpersonal relations they experience with staff and the type of information they are provided. MATERIAL AND METHODS: This study used a descriptive, qualitative design based on maximum variation sampling in six Mexican states. It included visits to 12 clinics in urban and rural areas. Thematic analysis was performed on 86 semi-structured interviews administered to FP service users. RESULTS: While access was described by users as "easy," their experiences revealed normalized barriers. One of our key findings referred to inverse availability, meaning that the contraceptive methods available were generally not the ones preferred by users, with their selection therefore being shaped by shortage of supplies. Challenges included disrespect for the free choice of FP users and coercion during consultations for contraception post obstetric event. Finally, information provided to users left considerable room for improvement. CONCLUSIONS: After six decades of FP service supply, results indicate a series of quality issues that may lie at the heart of the unmet demand reported in the literature. Based on a comprehensive conceptual scheme, the present study analyzes the quality of services, highlighting areas for improvement that should be considered by the MoH in future efforts.

An explanatory analysis of economic and health inequality changes among Mexican indigenous people, 2000-2010.

INTRODUCTION: Mexico faces important problems concerning income and health inequity. Mexico's national public agenda prioritizes remedying current inequities between its indigenous and non-indigenous population groups. This study explores the changes in social inequalities among Mexico's indigenous and non-indigenous populations for the time period 2000 to 2010 using routinely collected poverty, welfare and health indicator data. METHODS: We described changes in socioeconomic indicators (housing condition), poverty (Foster-Greer-Thorbecke and Sen-Shorrocks-Sen indexes), health indicators (childhood stunting and infant mortality) using diverse sources of nationally representative data. RESULTS: This analysis provides consistent evidence of disparities in the Mexican indigenous population regarding both basic and crucial developmental indicators. Although developmental indicators have improved among the indigenous population, when we compare indigenous and non-indigenous people, the gap in socio-economic and developmental indicators persists. CONCLUSIONS: Despite a decade of efforts to promote public programs, poverty persists and is a particular burden for indigenous populations within Mexican society. In light of the results, it would be advisable to review public policy and to specifically target future policy to the needs of the indigenous population.