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.

[Public policy-making on breast cancer in Latin America]. / Formulación de políticas públicas sobre el cáncer de mama en América Latina.

OBJECTIVE: To understand the public policy-making process as it relates to breast cancer care in five Latin American countries. METHODS: An exploratory-evaluative study was conducted in Argentina, Brazil, Colombia, Mexico, and Venezuela in 2010, with the selection of countries based on convenience sampling. Sixty-five semi-structured interviews were conducted with government officials, academics, and representatives of trade associations and civil society organizations. A content analysis of secondary sources was performed. Information sources, data, and informants were mixed using the triangulation method for purposes of analysis. RESULTS: The countries that have made the most progress in public policy-making related to breast cancer are Brazil and Mexico. Although Argentina, Colombia, and Venezuela do not have policies, they do have breast cancer care programs and activities. Two perspectives on the development of public policies became evident: the first includes the broad participation of both governmental and nongovernmental sectors, whereas the second, more narrow approach involves government authorities alone. CONCLUSIONS: The results point to significant differences in public policy-making related to breast cancer in the Region. They also show that greater progress has been made in countries where policies have been developed through inclusive participation processes.

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.

Health information technologies for sexual and reproductive health: Mapping the evidence in Latin America and the Caribbean.

In Latin America and the Caribbean (LAC), the sexual and reproductive health (SRH) of populations is a high priority for governments. Health information technologies (HITs) have been proposed as tools to close access gaps for SRH services. We developed an "evidence map" through a systematic search of articles published between 2005 and 2015 about the use of HITs to enhance SRH services in LAC countries. Two hundred and thirty-two registries were identified and screened. Thirty-one were eligible for full-text assessment. Most of the documents retrieved correspond to information provided by technology developers, targeting primarily the prevention of sexually transmitted infections and adolescent health. Although there has been clear progress in the use of HITs for SRH in the region, many institutional and technological challenges persist. Further studies should be carried out to test the beneficial effects of HITs on improving access to SRH services.

The regional distribution of doctors in Mexico, 1930-1990: a policy assessment.

The results of the doctor distributional policy in Mexico is evaluated. Despite the government's efforts to achieve a better distribution of doctors throughout the country between 1930 and 1990, important disparities still exist among geographic areas. Diverse factors ranging from the underdevelopment of some areas, to the resistance of doctors to leave the urban areas, are related to this unequal distribution. Early programmes aimed at redressing the original distribution in the 1930's had limited effects. In subsequent years, additional programmes were implemented. However, a lack of coordination and the short time span of many programmes produced only minor changes to the distributional pattern. Although in recent years the distribution has improved, southern states still suffer an acute scarcity while northern states have a relative abundance. Finally, the paper discusses how economic, political and social variables, as well as the structure of the health system, have shaped the current distribution of Mexican doctors.

The role of priority programmes in the provision of health services in the state of Oaxaca, Mexico.

An assessment of the performance of five priority health programmes (basic sanitation, tuberculosis, vaccination, acute respiratory infections and acute diarrheal diseases) was carried out using ethnographic techniques in the region of La Cañada in the state of Oaxaca, Mexico. The region presents a large percentage of Indian and peasant population living in extreme poverty and health care is mainly provided by the Ministry of Health. Both characteristics of the population and the health services are used to analyze the performance of the programmes. With access to abundant resources, vaccination and diarrheal disease programmes have been highly successful in involving the population and achieving their operative targets. Consequently this capacity to concentrate resources results in a lack of resources for other programmes. Despite partial successes, all programmes face serious operational difficulties demonstrating, in turn, the lack of capacity of health services to respond to the specific demands of local populations. The information presented is relevant for the discussion of selective versus comprehensive PHC.

Formulación de políticas públicas sobre el cáncer de mama en América Latina / Public policy-making on breast cancer in Latin America

OBJETIVO: Conocer el proceso de formulación de política pública sobre la atención del cáncer de mama en cinco países de América Latina. MÉTODOS: Estudio evaluativo exploratorio realizado en Argentina, Brasil, Colombia, México y Venezuela en 2010. La muestra de países seleccionados fue de conveniencia. Se realizaron 65 entrevistas semiestructuradas a funcionarios gubernamentales, académicos y representantes de gremios profesionales y de organizaciones de la sociedad civil. Se realizó un análisis de contenido para fuentes secundarias. Se integraron fuentes de información, datos e informantes para el análisis mediante el método de triangulación. RESULTADOS: Los países con mayor avance en la formulación de políticas públicas sobre el cáncer de mama son Brasil y México. Argentina, Colombia y Venezuela, pese a no tener una política definida, disponen de programas y acciones para su atención. Se distinguen dos perspectivas de desarrollo para estas políticas públicas: una con amplia participación de los sectores gubernamental y no gubernamental, y otra más restringida a la participación exclusiva de autoridades gubernamentales. CONCLUSIONES: Los resultados traducen importantes diferencias entre países en la formulación de políticas públicas sobre el cáncer de mama en la Región y destacan el mayor avance en aquellos países donde se han desarrollado a través de procesos de participación incluyente.

OBJECTIVE: To understand the public policy-making process as it relates to breast cancer care in five Latin American countries. METHODS: An exploratory-evaluative study was conducted in Argentina, Brazil, Colombia, Mexico, and Venezuela in 2010, with the selection of countries based on convenience sampling. Sixty-five semi-structured interviews were conducted with government officials, academics, and representatives of trade associations and civil society organizations. A content analysis of secondary sources was performed. Information sources, data, and informants were mixed using the triangulation method for purposes of analysis. RESULTS: The countries that have made the most progress in public policy-making related to breast cancer are Brazil and Mexico. Although Argentina, Colombia, and Venezuela do not have policies, they do have breast cancer care programs and activities. Two perspectives on the development of public policies became evident: the first includes the broad participation of both governmental and nongovernmental sectors, whereas the second, more narrow approach involves government authorities alone. CONCLUSIONS: The results point to significant differences in public policy-making related to breast cancer in the Region. They also show that greater progress has been made in countries where policies have been developed through inclusive participation processes.

[Physician payment mechanisms. An instrument of health policy]. / Mecanismos de pago a los médicos. Instrumento de política sanitaria.

Payment mechanisms for physicians have always been subject of debate. The profession tends to prefer fee-for-services, while health care institutions prefer to pay doctors by salary or capitation. The definition of the payment mechanism is not an administrative decision, it is frequently the output of an intense political negotiation. Recently an increase in salaried physicians has been observed, even in countries where the profession is powerful. In nations like Mexico, where the State is the dominant actor, salary or capitation can be used as an instrument to encourage quality of care and better geographic distribution. In this paper, several country cases are reviewed.

[The autodehelminthizing capacity of the soil]. / Capacidad de autodeshelmintización del suelo.

A description of the methodology used for the study of soil deshelminthizing processes is presented, as well as some of the results already obtained. This method has already been tested on the soil of different countries, including Mexico, and it is still in an experimental stage; notwithstanding, the results obtained are encouraging. Further research is needed for its successful application as a tool on the control of human soilborne diseases.

Doctors and corporatist politics: the case of the Mexican medical profession.

This study advances our understanding of the relationship between the state and the medical profession in countries where health care services are used as instruments of economic and political control. As a general argument, we maintain that the corporatist nature of the Mexican state impedes the medical profession from achieving autonomy and control over its professional activities. In contraposition to medical professions in developed societies, the nature of the Mexican profession is shaped by state policies and by its reiterated efforts to act independently of the state's tutelage. We analyze this dynamic interaction through three different historical epochs that reflect the complexity and uniqueness of the Mexican medical profession. Whatever attempts the profession has made to control the medical curriculum, the licensing process, the market, or the specific laws that affect its own field, the Mexican state has responded with measures that systematically divide and antagonize the different factions of medical associations. The result is a highly fragmented and disenfranchised medical profession with dissimilar political, professional, personal, and academic aims. In the final analysis, the interests of the corporatist Mexican state prevail over the interests of the groups, including doctors. The evisceration of the medical corps by the Mexican state results in a profession with low salaries, higher rates of unemployment, atomization in terms of political representation, and heavily co-opted medical organizations that seem to neglect the overwhelming health care needs of the Mexican people.

Health sector reform and reproductive health in Latin America and the Caribbean: strengthening the links.

Many countries in Latin America and the Caribbean (LAC) are currently reforming their national health sectors and also implementing a comprehensive approach to reproductive health care. Three regional workshops to explore how health sector reform could improve reproductive health services have revealed the inherently complex, competing, and political nature of health sector reform and reproductive health. The objectives of reproductive health care can run parallel to those of health sector reform in that both are concerned with promoting equitable access to high quality care by means of integrated approaches to primary health care, and by the involvement of the public in setting health sector priorities. However, there is a serious risk that health reforms will be driven mainly by financial and/or political considerations and not by the need to improve the quality of health services as a basic human right. With only limited changes to the health systems in many Latin American and Caribbean countries and a handful of examples of positive progress resulting from reforms, the gap between rhetoric and practice remains wide.

From state to market: the Nicaraguan labour market for health personnel.

Few countries in Latin America have experienced in such a short period the shift from a socialist government and centrally planned economy to a liberal market economy as Nicaragua. The impact of such a change in the health field has been supported by the quest for reform of the health system and the involvement of external financial agencies aimed at leading the process. However, this change has not been reflected in the planning of human resources for health. Trends in education reflect the policies of past decades. The Ministry of Health is the main employer of health personnel in the country, but in recent years its capacity to recruit new personnel has diminished. Currently, various categories of health personnel are looking for new opportunities in a changing labour environment where new actors are appearing and claiming an influential role. It may take more than political willingness from the government to redefine the new priorities in the field of human resources for health and subsequently turn it into positive action.

[New trends in the regulation of medical practice in the context of health care reform: the Mexico case]. / Nuevas tendencias en la regulación de la profesión médica en el contexto de la reforma del sector salud: el caso de México.

The recent panorama of medical practice regulation in Mexico is exposed. The dynamics of regulation changes is observed in different areas, with particular intensity in the labor market. Changes seem to be moving towards the constitution of a new regulatory model. A full state regulation for the last 50 years, is being substituted by a model where private and professional corporations are increasing their influence through informal mechanisms of regulation. In the constitution of this new model, the presence of a wide variety of actors claiming regulatory authority is notorious. Three of these new actors are analyzed: The National Commission for Medical Arbitrage, managed care models of medical services, and Specialists Certification Councils. The changes that have occurred in the process of regulation and its future transformation have an intimate link with the reform of the Mexican health care system.

[Complementary health care models: a neglected component in the health care systems reform]. / Modelos complementarios de atención: un componente excluido en la reforma de los Sistemas de Salud.

Complementary health care models represent a neglected and scarcely studied area of the health services structure. Within them a myriad of medical therapies of various origins are included. Lately, their importance has grown by means of the increase in demand for such services, both in industrialized and developing countries. It is urgent to reinforce research in the area aiming at understanding the processes through which the population demands these services and the processes through which complementary practitioners are able to maintain their presence in a market environment where the forces of supply and demand are significant. The context created by the health services reform should be used to review the therapeutic value of these models, to promote its regulation, and to amplify the availability of therapeutic options for the population.

[Models for physicians' professional regulation in Latin America and theoretical elements for its analysis] / Modelos de regulación profesional de los médicos en América Latina: elementos teóricos para su análisis.

This paper reviews regulation of medical work based on concepts available in the specialized literature. It proposes the model developed by Moran and Wood to analyze the regulatory process in the Latin American context. However, any conceptual model used for the analysis of regulation should consider the changes generated by the reform in the interaction between financial and regulatory agents and health care providers. The regulatory function is involving an increasing number of groups interested in the appropriate performance of health services. Regulation of medical work is a dynamic issue requiring close analysis.

[Practice of traditional medicine in Latin America and the Caribbean: the dilemma between regulation and tolerance]. / La práctica de la medicina tradicional en América Latina y el Caribe: el dilema entre regulación y tolerancia.

OBJECTIVE: This paper characterizes the current stage of traditional medicine in nine countries of Latin America and the Caribbean. MATERIAL AND METHODS: This qualitative study was conducted between March and December 1998. Data were collected on the components of traditional health systems in countries of Latin America and the Caribbean, by means of a network of individuals and institutions from different countries that acted as expert informants from different specialty areas. RESULTS: Findings from the analysis of traditional medicine regulation are presented in three groups: a) Countries with some developments in the area of legislation; b) Countries where legislation is underway; and, c) Countries with no legislation or incipient regulation. CONCLUSIONS: Several stages of traditional medical practice legislation are found in the region. This heterogeneity shows the complexity involved in regulating the practice of providers with low levels of formal training, with different therapeutic practices, and with customs that are frequently difficult to include within the standards of the official health system. These findings are important for designing and implementing healthcare policies to adequate traditional medical practices to the needs of populations that commonly use them.

Trends in medical employment: persistent imbalances in urban Mexico.

OBJECTIVES: This study examined the extreme medical unemployment and underemployment in the urban areas of Mexico. The conceptual and methodological approach may be relevant to many countries that have experienced substantial increases in the supply of physicians during the last decades. METHODS: On the basis of 2 surveys carried out in 1986 and 1993, the study analyzed the performance of physicians in the labor market as a function of ascription variables (social origin and gender), achievement variables (quality of medical education and specialty studies), and contextual variables (educational generation). RESULTS: The study reveals, despite some improvement, persistently high levels of open unemployment, qualitative underemployment (i.e., work in activities completely outside of medicine), and quantitative underemployment (i.e., work in medical activities but with very low levels of productivity and remuneration). The growing proportion of female doctors presents new challenges, because they are more likely than men to be unemployed and underemployed. CONCLUSIONS: While corrective policies can have a positive impact, it is clear that decisions regarding physician supply must be carefully considered, because they have long-lasting effects. An area deserving special attention is the improvement of professional opportunities for female doctors.

Patterns of medical employment: a survey of imbalances in urban Mexico.

This article quantifies the magnitude and correlates of the major imbalances affecting the employment of physicians in the urban areas of Mexico. Since the early 1970s the country has experienced a rapid increase in the supply of doctors, which its health system was unable to absorb fully. In 1986, we conducted a survey in the 16 most important cities based on a probability sample of households where someone with an MD degree lived. A total of 604 physicians were interviewed for a response rate of 97 percent. The unemployment rate was 7 percent of potentially active physicians; 11 percent held a nonmedical job, and another 11 percent exhibited low productivity and/or income. All in all, we project that 23,500 physicians in these cities were either unemployed or underemployed. This medical employment pattern was analyzed against five independent variables: generation (i.e. the year in which the physician started medical school), gender, social origin, medical school quality, and specialty. Apart from generation, type of specialty exhibited the strongest correlation with the employment situation of a physician. The results suggest that higher education and health care in Mexico may be producing rather than correcting social inequalities. Policy alternatives are discussed to restore a balance between the training of physicians, their gainful employment, and the health needs of the population.

Conceptual bases and methodology for the evaluation of women's and providers' perception of the quality of antenatal care in the WHO Antenatal Care Randomised Controlled Trial.

In this paper, we describe the conceptual bases and methodology used to assess women's and providers' perception of the quality of antenatal care, as part of a large randomised trial in four developing countries. Information has been obtained by applying both qualitative and quantitative methodologies. The focus group discussions and in-depth interviews have contributed useful insights into the cultural milieu in which care is provided, users' and providers' expectations, and their concept of quality. Based on these findings, we developed two standardised questionnaires, one being administered to a representative sample of pregnant women (n = 1600) and the other for all care providers. In this paper we present some of the findings of the focus group discussions and in-depth interviews with women in one country as an example of the kind of information we have obtained. Women expressed their point of view concerning a reduced number of visits, type of provider, information that they get during clinical encounters and interpersonal relations with health professionals. The qualitative information, together with the data we obtain from the surveys, will highlight the aspects that will have be to considered if the new model of care is to be introduced on a routine basis.

PIP: Measurement of the subjective dimension of the quality of health care, including the perceptions of patients and providers, is seldom attempted. The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial, underway in 53 clinics in Argentina, Cuba, Thailand, and Saudi Arabia, will apply both quantitative and qualitative methodologies to an assessment of client and staff satisfaction with a new prenatal care program. Specifically, the study addresses user and provider perceptions of quality in the context of a wide spectrum of ethnic backgrounds, social strata, organization of health services, and medical cultures. The research instrument consists of questions that explore the preferences of 1600 women and their providers in terms of the number of prenatal care visits, provider type and gender, time spent in the waiting room and with the provider, and amount and appropriateness of information received during the visits. Preliminary results from focus groups and in-depth interviews indicate that women are concerned about the safety of the reduced number of visits during pregnancy (four for low-risk women) inherent in the experimental regimen, prefer to receive care from specialists rather than family practitioners, are confused by the technical language used by providers, and want more information on the psychosocial aspects of pregnancy. Such qualitative information, together with data obtained from questionnaires, will highlight areas that must be addressed if the new prenatal care model is to be introduced on a routine basis.