Preferences for Conditional Economic Incentives to Improve Pre-exposure Prophylaxis Adherence: A Discrete Choice Experiment Among Male Sex Workers in Mexico.

Pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV but requires sustained adherence. Conditional economic incentives (CEIs) can improve medication-taking behaviors, yet preferences for programs that employ CEIs to increase PrEP use among male sex workers (MSWs) have not been investigated. We conducted a discrete choice experiment in Mexico City to elicit stated preferences for a CEI-based PrEP adherence program among MSWs. Respondents expressed their preferences for different program characteristics: incentive amount; incentive format; incentive type; and adherence-verification method. We used a random utility logit model to estimate the relative importance of each attribute and estimated willingness-to-pay. MSWs preferred a higher, fixed incentive, with PrEP adherence measured via hair sampling. MSWs were willing to forego up to 21% of their potential maximum CEI amount to ensure receipt of a fixed payment. MSWs are highly willing to accept a CEI-based intervention for PrEP adherence, if offered along with fixed payments.

RESUMEN: La profilaxis previa a la exposición (PrEP) es muy eficaz para prevenir el VIH, pero requiere una adherencia sostenida. Los incentivos económicos condicionales (IEC) pueden mejorar los comportamientos de toma de medicamentos, sin embargo, no se han investigado las preferencias por los programas que emplean IEC para aumentar el uso de PrEP entre los trabajadores sexuales masculinos (TSM). Realizamos un experimento de elección discreta con TSM en la Ciudad de México para obtener preferencias declaradas para un programa de adherencia a la PrEP basado en IEC. Los participantes expresaron sus preferencias en cuanto a diferentes características: monto del incentivo; formato del incentivo; tipo de incentivo; y método de verificación de la adherencia. Utilizamos un modelo logit de utilidad aleatoria para estimar la importancia relativa de cada atributo y la disposición a pagar estimada (DAP). Los TSM prefirieron un incentivo fijo más alto, con la adherencia a la PrEP medida a través de muestras de cabello. Los TSM estaban dispuestos a renunciar hasta el 21% de su monto máximo potencial de IEC para garantizar la recepción de un pago fijo. Los TSM están muy dispuestos a aceptar una intervención basada en IEC para la adherencia a la PrEP, si se ofrece junto con pagos fijos.

Intergenerational Replication of Teenage Pregnancy and Educational Attainment in Mexico.

Mexico ranks among the OECD countries with the highest prevalence of teenage pregnancies, exhibiting a fertility rate of 70.6 births for every 1000 adolescents. Mexican adolescents with a history of pregnancy are twice as likely to lag behind in their studies as those who have not been pregnant. Research on adolescent maternity and its explanatory mechanisms is required as a basis for implementing policies and programs that effectively curb teenage pregnancy-related behaviors, prevent educational gaps, and reduce the intergenerational transmission of poverty. Based on quasi-experimental methodology and a non-recursive structural equation model with instrumental variables, this paper analyzed the intergenerational transmission of teenage pregnancy from mothers to daughters, as well as the relationship between teenage pregnancy and educational attainment. Using data from the 2009 National Survey of Demographic Dynamics in Mexico, our estimated model indicated a unidirectional relationship from teenage pregnancy to educational attainment. An association was observed between teenage pregnancy and an increased probability of a moderate or severe educational gap (≥ 1 year) by 21% ± 5 and a severe educational gap (≥ 2 years) by 33% ± 8. Adolescents whose mothers reported teenage pregnancy at < 15 years of age were approximately 84% more likely to experience teenage pregnancy themselves than other adolescents. Relevant explanatory mechanisms included low socioeconomic status and a low level of education in the household. Mexico needs to formulate, implement, and expand comprehensive and early prevention strategies as well as teenage pregnancy care throughout its most vulnerable regions. Efforts should be made at the individual, family, and community levels; incorporate alliances with teenage networks; actively engage parents, teachers, and health care providers; and reinforce educational initiatives on sexual and reproductive health for adolescents. It would be convenient for the Government to implement public policies that emphasize the results obtained. There is no better instrument than to show the evidence of the gradual deterioration of human capital in Mexico associated with adolescent pregnancy.

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

OBJECTIVE: To describe the temporal and geographical patterns of the continuum of maternal health care in Mexico, as well as the sociodemographic characteristics that affect the likelihood of receiving this care. METHODS: We conducted a pooled cross-sectional analysis using the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics, collating sociodemographic and obstetric characteristics of 93 745 women aged 12-54 years at last delivery. We defined eight variables along the antenatal-postnatal continuum, both independently and conditionally. We used a pooled fixed-effects multivariable logistic model to determine the likelihood of receiving the continuum of care for various properties. We also mapped the quintiles of adjusted state-level absolute change in continuum of care coverage during 1994-2018. FINDINGS: We observed large absolute increases in the proportion of women receiving timely antenatal and postnatal care (from 48.9% to 88.2% and from 39.1% to 68.7%, respectively). In our conditional analysis, we found that the proportion of women receiving adequate antenatal care doubled over this period. We showed that having social security and a higher level of education is positively associated with receiving the continuum of care. We observed the largest relative increases in continuum of care coverage in Chiapas (181.5%) and Durango (160.6%), assigned human development index categories of low and medium, respectively. CONCLUSION: Despite significant progress in coverage of the continuum of maternal health care, disparities remain. While ensuring progress towards achievement of the health-related sustainable development goal, government intervention must also target underserved populations.

Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia.

Few studies have assessed the efficiency and quality of HIV services in low-resource settings or considered the factors that determine both performance dimensions. To provide insights on the performance of outpatient HIV prevention units, we used benchmarking methods to identify best-practices in terms of technical efficiency and process quality and uncover management practices with the potential to improve efficiency and quality. We used data collected in 338 facilities in Kenya, Nigeria, Rwanda, South Africa, and Zambia. Data envelopment analysis (DEA) was used to estimate technical efficiency. Process quality was estimated using data from medical vignettes. We mapped the relationship between efficiency and quality scores and studied the managerial determinants of best performance in terms of both efficiency and quality. We also explored the relationship between management factors and efficiency and quality independently. We found levels of both technical efficiency and process quality to be low, though there was substantial variation across countries. One third of facilities were mapped in the best-performing group with above-median efficiency and above-median quality. Several management practices were associated with best performance in terms of both efficiency and quality. When considering efficiency and quality independently, the patterns of associations between management practices and the two performance dimensions were not necessarily the same. One management characteristic was associated with best performance in terms of efficiency and quality and also positively associated with efficiency and quality independently: number of supervision visits to HIV units.

Barriers and facilitators to pre-exposure prophylaxis uptake among male sex workers in Mexico: an application of the RE-AIM framework.

BACKGROUND: The ImPrEP México demonstration project is the first to distribute free HIV pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM) and transgender women living in Mexico. In Mexico City, MSM who are also male sex workers (MSWs) face a disproportionately high risk of HIV infection. PrEP is highly effective for HIV prevention, yet "real-life" implementation among MSWs is a challenge due to the unique adherence barriers faced by this population. METHODS: This study uses the RE-AIM implementation science framework to characterize the unique barriers to and facilitators of PrEP uptake among MSWs in Mexico City. We conducted 9 in-depth key informant interviews and 2 focus group discussions with MSWs across 5 clinic and community sites. Qualitative data were analyzed using inductive, open coding approaches from grounded theory. We supplemented findings from the primary qualitative analysis with quantitative indicators derived from ImPrEP program records to describe the current Reach of the ImPrEP program among MSWs in Mexico City and the potential for wider PrEP Adoption among other high-risk populations in Mexico. RESULTS: The Reach of the ImPrEP program was 10% of known HIV-negative MSWs in Mexico City. Program Reach was lowest among MSWs who were street-based sex workers, of lower socioeconomic status, migrants from other states and self-identified as heterosexual. Barriers to program Reach included limited PrEP knowledge, HIV-related stigma, and structural barriers; facilitators included in-person program recruitment, patient-centered care, and spread of information through word of mouth among MSWs. Two out of the four eligible institutions had adopted the ImPrEP protocol. Barriers to wider program Adoption included HIV- and sexual identity- related stigma, protocol limitations, and lack of a national policy for PrEP distribution; facilitators of Adoption included existing healthcare infrastructure, sensitized providers, and community support from non-governmental organizations. CONCLUSIONS: Increasing the ImPrEP program's Reach among MSWs will depend on improving PrEP education and addressing HIV-related stigma and access barriers. Future Adoption of the ImPrEP program should build on existing clinical infrastructure and community support. Creation of a national policy for PrEP distribution may improve the Reach and Adoption of PrEP among highest-risk populations in Mexico.

The Relationship Between Psychological Temporal Perspective and HIV/STI Risk Behaviors Among Male Sex Workers in Mexico City.

Men who have sex with men (MSM) face a disproportionate burden of HIV incidence and HIV prevalence, particularly young men who have sex with men. The aim of this article was to analyze the relation between a psychological temporal perspective and HIV/sexually transmitted infection (STI) risk behaviors among male sex workers (MSWs), a potentially highly present-oriented group of MSM. A total sample of 326 MSWs were included and responded to a validated psychological scale: the Zimbardo's Time Perspective Inventory; they also reported how frequently they engaged in protective behaviors against HIV and other STI risks behaviors, including condom use with casual and regular partners, as well as prior HIV testing. We adjusted structural equation models to analyze the relation between a psychological temporal perspective and HIV/STI risk behaviors. We found that orientation toward the past was correlated with decreased condom use with casual partners (ß = - 0.18; CI95% - 0.23, - 0.12). Future orientation was not associated with condom use with casual partners. Regarding condom use with regular partners, past and present orientation were related to lower likelihood of condom use (ß = - 0.23; CI95% - 0.29, - 0.17; ß = - 0.11; CI95% - 0.19, - 0.02), whereas future orientation increased the likelihood of condom use with regular partners (ß = 0.40; CI95% 0.31, 0.50). Time orientation (past, present, or future) did not predict the probability of having an HIV test. The design of HIV/STI prevention programs among vulnerable populations, such as MSM and MSWs, should consider specific time-frame mechanisms that can importantly affect sexual risk behavior decisions.

Punto Seguro: A Randomized Controlled Pilot Using Conditional Economic Incentives to Reduce Sexually Transmitted Infection Risks in Mexico.

Randomized controlled pilot evaluated effect of conditional economic incentives (CEIs) on number of sex partners, condom use, and incident sexually transmitted infections (STIs) among male sex workers in Mexico City. Incentives were contingent on testing free of new curable STIs and/or clinic attendance. We assessed outcomes for n = 227 participants at 6 and 12 months (during active phase with incentives), and then at 18 months (with incentives removed). We used intention-to-treat and inverse probability weighting for the analysis. During active phase, CEIs increased clinic visits (10-13 percentage points) and increased condom use (10-15 percentage points) for CEI groups relative to controls. The effect on condom use was not sustained once CEIs were removed. CEIs did not have an effect on number of partners or incident STIs. Conditional incentives for male sex workers can increase linkage to care and retention and reduce some HIV/STI risks such as condomless sex, while incentives are in place.

True Love: Effectiveness of a School-Based Program to Reduce Dating Violence Among Adolescents in Mexico City.

Dating violence is a significant problem in Mexico. National survey data estimated 76 % of Mexican youth have been victims of psychological aggression in their relationships; 15.5 % have experienced physical violence; and 16.5 % of women have been the victims of sexual violence. Female adolescents perpetrate physical violence more frequently than males, while perpetration between genders of other types of violence is unclear. Furthermore, poor, marginalized youth are at a higher risk for experiencing dating violence. "Amor… pero del Bueno" (True Love) was piloted in two urban, low-income high schools in Mexico City to prevent dating violence. The intervention consisted of school-level and individual-level components delivered over 16 weeks covering topics on gender roles, dating violence, sexual rights, and strategies for coping with dating violence. The short-term impact was assessed quasi-experimentally, using matching techniques and fixed-effects models. A sample of 885 students (381 students exposed to the classroom-based curriculum of the individual-level component (SCC, IL-1) and 540 exposed only to the school climate component (SCC)) was evaluated for the following: changes in dating violence behaviors (psychological, physical and sexual), beliefs related to gender norms, knowledge, and skills for preventing dating violence. We found a 58 % (p < 0.05) and 55 % (p < 0.05) reduction in the prevalence of perpetrated and experienced psychological violence, respectively, among SCC, IL-1 males compared to males exposed only to the SCC component. We also found a significant reduction in beliefs and attitudes justifying sexism and violence in dating relationships among SCC, IL-1 females (6 %; p < 0.05) and males (7 %; p < 0.05).

Preventing HIV Transmission Among Partners of HIV-Positive Male Sex Workers in Mexico City: A Modeling Study.

Mexico has a concentrated HIV epidemic, with male sex workers constituting a key affected population. We estimated annual HIV cumulative incidence among male sex workers' partners, and then compared incidence under three hypothetical intervention scenarios: improving condom use; and scaling up HIV treatment as prevention, considering current viral suppression rates (CVS, 60.7 %) or full viral suppression among those treated (FVS, 100 %). Clinical and behavioral data to inform model parameterization were derived from a sample (n = 79) of male sex workers recruited from street locations and Clínica Condesa, an HIV clinic in Mexico City. We estimated annual HIV incidence among male sex workers' partners to be 8.0 % (95 % CI: 7.3-8.7). Simulation models demonstrated that increasing condom use by 10 %, and scaling up HIV treatment initiation by 50 % (from baseline values) would decrease the male sex workers-attributable annual incidence to 5.2, 4.4 % (CVS) and 3.2 % (FVS), respectively. Scaling up the number of male sex workers on ART and implementing interventions to ensure adherence is urgently required to decrease HIV incidence among male sex workers' partners in Mexico City.

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.

Assessing cost and technical efficiency of HIV prevention interventions in sub-Saharan Africa: the ORPHEA study design and methods.

BACKGROUND: Scaling up services to achieve HIV targets will require that countries optimize the use of available funding. Robust unit cost estimates are essential for the better use of resources, and information on the heterogeneity in the unit cost of delivering HIV services across facilities - both within and across countries - is critical to identifying and addressing inefficiencies. There is limited information on the unit cost of HIV prevention services in sub-Saharan Africa and information on the heterogeneity within and across countries and determinants of this variation is even more scarce. The "Optimizing the Response in Prevention: HIV Efficiency in Africa" (ORPHEA) study aims to add to the empirical body of knowledge on the cost and technical efficiency of HIV prevention services that decision makers can use to inform policy and planning. METHODS/DESIGN: ORPHEA is a cross-sectional observational study conducted in 304 service delivery sites in Kenya, Rwanda, South Africa, and Zambia to assess the cost, cost structure, cost variability, and the determinants of efficiency for four HIV interventions: HIV testing and counselling (HTC), prevention of mother-to-child transmission (PMTCT), voluntary medical male circumcision (VMMC), and HIV prevention for sex workers. ORPHEA collected information at three levels (district, facility, and individual) on inputs to HIV prevention service production and their prices, outputs produced along the cascade of services, facility-level characteristics and contextual factors, district-level factors likely to influence the performance of facilities as well as the demand for HIV prevention services, and information on process quality for HTC, PMTCT, and VMMC services. DISCUSSION: ORPHEA is one of the most comprehensive studies on the cost and technical efficiency of HIV prevention interventions to date. The study applied a robust methodological design to collect comparable information to estimate the cost of HTC, PMTCT, VMMC, and sex worker prevention services in Kenya, Rwanda, South Africa, and Zambia, the level of efficiency in the current delivery of these services, and the key determinants of efficiency. The results of the study will be important to decision makers in the study countries as well as those in countries facing similar circumstances and contexts.

[Analysis of outpatient healthcare utilization in the context of the universal healthcare coverage reform in Mexico]. / Análisis del uso de servicios ambulatorios curativos en el contexto de la reforma para la protección universal en salud en México.

OBJECTIVE: Understand and quantify the relationship between socio-economic and health insurance profiles and the use of outpatient medical services in the context of universal health care in Mexico. MATERIALS AND METHODS: Using ENSANUT 2012 multinomial regression models were estimated to analyze the use of outpatient services and associated factors. RESULTS: Population with greater poverty levels, lower educational level and living in highly marginalized areas have lower odds to use outpatient health services. In contrast, health insurance and higher income increase the odds to use health services and influence the choice of provider. CONCLUSIONS: Barriers to access to health care related to poverty and social protection persist. However, there is space to lower the effect of these barriers by addressing constraints linked to the supply and the perceived quality of healthcare services.

[Cost-benefit analysis: HIV/AIDS prevention in migrants in Central America]. / Análisis de costo-beneficio: prevención del VIH/sida en migrantes en Centroamérica.

OBJECTIVE: To quantify the costs and benefits of three HIV prevention interventions in migrants in Central America: voluntary counseling and testing, treatment of sexually transmitted infections, and condom distribution. MATERIALS AND METHODS: The methods were: a) identification and quantification of costs; b) quantification of benefits, defined as the potential savings in antiretroviral treatment of HIV cases prevented; and c) estimation of the cost-benefit ratio. RESULTS: The model estimated that 9, 21 and 8 cases of HIV were prevented by voluntary counseling and testing, treatment for sexually transmitted infections and condom distribution per 10 000 migrants, respectively. In Panama, condom distribution and treatment for sexually transmitted infections had a return of US$131/USD and US$69.8/USD. Returns in El Salvador were US$2.0/USD and US$42.3/USD in voluntary counseling and testing and condom distribution, respectively. CONCLUSION: The potential savings on prevention have a large variation between countries. Nevertheless, the cost-benefit estimates suggest that the HIV prevention programs in Central America can potentially result in monetary savings in the long run.

[Effect of Seguro Popular on health expenditure in Mexican households ten years after its implementation]. / Efectos del Seguro Popular sobre el gasto en salud en hogares mexicanos a diez años de su implementación.

OBJECTIVE: To estimate the effect of Seguro Popular Program (SP) on the probability of health spending (HE), the excessive expenditure on health (EEH) and the amount of health spending. Materials and methods. Cross-sectional analysis was carried out using data from the ENSANUT 2012. Propensity score matching was used to estimate the effect of SP (n=12.250). We estimated the average effect on SP homes (treated) and differences in median spending. RESULTS: SP reduces the likelihood of HE in 3.6 and 7.1% in households with patients diagnosed with DM and/or hypertension, respectively. The reduction in EEH was 36% at national level. This reduction was 46.5 and 41.7% among households with hospitalized patients and those reporting a sick member. CONCLUSIONS: SP has a positive effect, protecting households from having either HE or EEH among those with greater health needs. However, there are still some challenges for the SP, which include improving access to services for low-income population.

Equity in out-of-pocket health expenditure: Evidence from a health insurance program reform in Mexico.

Background: The fragmentation of health systems in low- and middle-income countries (LMICs) deepens health inequities and shifts the economic burden of health care to families via out-of-pocket spending (OOPHE). This problem has been addressed by introducing public health insurance programs for poor people; however, there is a lack of knowledge about how equitable these programs are. We aimed to analyse the long-term effects of the Seguro Popular (SP) voluntary health insurance program, recently phased out and replaced by the Health Institute for Welfare (Instituto de Salud para el Bienestar (INSABI)), on OOPHE equity in the poor Mexican population. Methods: We conducted a pooled cross-sectional analysis using eleven waves of the National Household Income and Expenditure Survey (2002-2020). We identified the effect of SP by selecting households without social security (with SP or without health insurance (n = 169 766)) and matched them by propensity score to reduce bias in the decision to enrol in SP. We estimated horizontal and vertical equity metrics and assessed their evolution across subpopulations. Results: The program's entry years (2003-2010) show a positive redistributive effect associated with a focalised stage of the program, while oversaturation could have diluted these effects during 2010-2014, with adverse results in terms of vertical equity and re-ranking among insured families. SP is more horizontally inequitable than for those uninsured. Within SP, the redistributive effect could improve up to 13% if all families with similar expenditures were spending equal OOPHE and horizontal equity was eliminated. Regarding vertical equity, SP outperforms the insured population with middle-range coverage some years after the implementation, but this progress disappears. Conclusions: To achieve universal health coverage, health authorities need to create and execute financial protection mechanisms that effectively address structural inequalities. This involves implementing a more comprehensive risk-pooling mechanism that makes social insurance sustainable in the long-run by increasing the social-economic influx of resources. It is essential to monitor oversaturation and financial sustainability to achieve optimal results. The replacement of the SP with INSABI highlights the complexity of maintaining a social insurance program where the ideology of different governments can influence the program structure, regulation, financing, and even its existence.

Incorporating respondent-driven sampling into web-based discrete choice experiments: preferences for COVID-19 mitigation measures.

To slow the spread of COVID-19, most countries implemented stay-at-home orders, social distancing, and other nonpharmaceutical mitigation strategies. To understand individual preferences for mitigation strategies, we piloted a web-based Respondent Driven Sampling (RDS) approach to recruit participants from four universities in three countries to complete a computer-based Discrete Choice Experiment (DCE). Use of these methods, in combination, can serve to increase the external validity of a study by enabling recruitment of populations underrepresented in sampling frames, thus allowing preference results to be more generalizable to targeted subpopulations. A total of 99 students or staff members were invited to complete the survey, of which 72% started the survey (n = 71). Sixty-three participants (89% of starters) completed all tasks in the DCE. A rank-ordered mixed logit model was used to estimate preferences for COVID-19 nonpharmaceutical mitigation strategies. The model estimates indicated that participants preferred mitigation strategies that resulted in lower COVID-19 risk (i.e. sheltering-in-place more days a week), financial compensation from the government, fewer health (mental and physical) problems, and fewer financial problems. The high response rate and survey engagement provide proof of concept that RDS and DCE can be implemented as web-based applications, with the potential for scale up to produce nationally-representative preference estimates.

Analysis of changes in the association of income and the utilization of curative health services in Mexico between 2000 and 2006.

BACKGROUND: A common characteristic of health systems in most developing countries is unequal access to health services. As a result, members of the poorest population groups often do not receive formal attention for health services, because they cannot afford it. In 2001 in Mexico, to address income-related differences in the use of health services, the government launched a major healthcare reform, which includes a health insurance program called Seguro Popular, aimed at improving healthcare access among poor, uninsured residents. This paper analyzes the before and after changes in the demand for curative ambulatory health services focusing on the association of income-related characteristics and the utilization of formal healthcare providers vs. no healthcare service utilization. METHODS: By using two nationally representative health surveys (ENSA-2000 and ENSANUT-2006), we modeled an individual's decision when experiencing an illness to use services provided by the (1) Ministry of Health (MoH), (2) social security, (3) private entities, or (4) to not use formal services (no healthcare service utilization). RESULTS: Poorer individuals were more likely in 2006 than in 2000 to respond to an illness by using formal healthcare providers. Trends in provider selection differed, however. The probability of using public services from the MoH increased among the poorest population, while the findings indicated an increase in utilization of private health services among members of low- and middle-income groups. No significant change was seen among formal workers -covered by social security services-, regardless of socioeconomic status. CONCLUSIONS: Overall, for 2006 the Mexican population appears less differentiated in using healthcare across economic groups than in 2000. This may be related, in part, to the implementation of Seguro Popular, which seems to be stimulating healthcare demand among the poorest and previously uninsured segment of the population. Still, public health authorities need to address the remaining income-related healthcare utilization differences, the differences in quality between public and private health services, and the general perception that MoH facilities offer inferior services.

[Impact of "Seguro Popular" on catastrophic and out-of-pocket health expenditures in rural and urban Mexico, 2005-2008]. / Impacto del Seguro Popular en el gasto catastrófico y de bolsillo en el México rural y urbano, 2005-2008.

OBJECTIVE: To estimate the effect of "Seguro Popular" (SP) on the incidence of catastrophic health expenditure (CHE) and out-of-pocket (OOP) health expenditure in the medium term. MATERIAL AND METHODS: We used the 'Encuesta de Evaluación del SP' --SP Survey Evaluation-- (2005-2008). We analyzed the SP effect on the rural cohort during two years of follow-up (2006 and 2008) and in the urban cohort during one year of follow-up (2008). RESULTS: At the local level (regional clusters) we did not find an effect of the SP. At the household level we found a protective effect of SP on CHE and the OOP health payments in outpatient and hospitalization in rural areas; and a significant effect on the reduction of OOP health payments in outpatient services in urban zones. CONCLUSIONS: SP seems to be an effective program to protect poor household against out-of-pocket health expenditures in the medium term.

[Cost-effectiveness of public health practices: a literature review of public health interventions from the Mesoamerican Health Initiative]. / Costo-efectividad de prácticas en salud pública: revisión bibliográfica de las intervenciones de la Iniciativa Mesoamericana de Salud.

OBJECTIVE: Present and analyze cost-effectiveness information of public health interventions proposed by the Mesoamerican Health Initiative in child nutrition, vaccination, malaria, dengue, and maternal, neonatal, and reproductive health. MATERIAL AND METHODS: A systematic literature review was conducted on cost-effectiveness studies published between January 2000 and August 2009 on interventions related to the health areas previously mentioned. Studies were included if they measured effectiveness in terms of Disability-Adjusted Life Year (DALY) or death averted. RESULTS: Child nutrition and maternal and neonatal health interventions were found to be highly cost-effective (most of them below US$200 per DALY averted for nutritional interventions and US$100 for maternal and neonatal health). For dengue, information on cost-effectiveness was found just for application of larvicides, which resulted in a cost per DALY averted ranking from US$40.79 to US$345.06. Malarial interventions were found to be cost-effective (below US$150 per DALY averted or US$4,000 per death averted within Africa). In the case of pneumococcus and rotavirus vaccination, cost-effectiveness estimates were always above one GDP per capita per DALY averted. CONCLUSIONS: In Mesoamerica there are still important challenges in child nutrition, vaccination, malaria, dengue and maternal, neonatal, and reproductive health, challenges that could be addressed by scaling-up technically feasible and cost-effective interventions.