[Barriers for indigenous women to access obstetric services within the framework of integrated health services networks]. / Barreras en mujeres indígenas para acceder a servicios obstétricos en el marco de redes integradas de servicios de salud.

OBJECTIVE: To analyze the barriers that indigenous women face in access to the network of obstetric services in the context of the implementation of integrated healthcare networks (IHN). METHOD: We designed a cross-sectional descriptive study including quantitative and qualitative methods. Sampling was intentional, no probabilistic. Data collection was carried out in Oaxaca, Mexico, during 2017-2018. A total of 149 indigenous women who used obstetrical services were surveyed and sociodemographic characteristics were obtained. Later were selected 30 cases that had complications during pregnancy and childbirth for a semi-structured interview. Non-participant observation was conducted. RESULTS: The network of obstetric services comprises four institutions with different models of care and therefore different types of facilities and human resources to assist indigenous women. Nearly 20% of women did not start prenatal care in the first trimester of pregnancy and 27.2% had complications during the gestational period. The main barriers were availability (hours of operation, geographical aspects), accessibility (lack of financial resources), acceptability (ancestral practices vs. medical recommendations), and continuity of service (difficulties for admit patients in hospitals referred from first line of care). CONCLUSIONS: The networks model allows access to obstetric services but does not guarantee care. For this it is necessary to improve both: the infrastructure of the obstetric service providers, and the care processes. It is necessary to broaden the vision of the IHN management model considering the perspective of human rights and equity in health.

A Performance Analysis of Public Expenditure on Maternal Health in Mexico.

We explore the relationship between public expenditure, coverage of adequate ANC (including timing, frequent and content), and the maternal mortality ratio--adjusted by coverage of adequate ANC--observed in Mexico in 2012 at the State level. Additionally, we examine the inequalities and concentration of public expenditure between populations with and without Social Security. Results suggest that in the 2003-2011 period, the public expenditure gap between women with and without Social Security decreased 74%, however, the distribution is less equitable among women without Social Security, across the States. Despite high levels of coverage on each dimension of ANC explored, coverage of adequate ANC was lower among Social Security than non-Social Security women. This variability results in differences up to 1.5 times in State-adjusted maternal mortality rate at the same level of expense and maternal mortality rate, respectively. The increase in the economic resources is only a necessary condition for achieving improved health outcomes. Providing adequate health services and achieving efficient, effective and transparent use of resources in health, are critical elements for health systems performance. The attainment of universal effective coverage of maternal health and reducing maternal mortality in Mexico, requires the adjustment of policy innovations including the rules of allocation and execution of health resources. Health policies should be designed on a more holistic view promoting a balance between accessibility, effective implementation and rigorous stewardship.

Redesigning primary care to tackle the global epidemic of noncommunicable disease.

Noncommunicable diseases (NCDs) have become the major contributors to death and disability worldwide. Nearly 80% of the deaths in 2010 occurred in low- and middle-income countries, which have experienced rapid population aging, urbanization, rise in smoking, and changes in diet and activity. Yet the health systems of low- and middle-income countries, historically oriented to infectious disease and often severely underfunded, are poorly prepared for the challenge of caring for people with cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We have discussed how primary care can be redesigned to tackle the challenge of NCDs in resource-constrained countries. We suggest that four changes will be required: integration of services, innovative service delivery, a focus on patients and communities, and adoption of new technologies for communication.

[The health system of Peru]. / Sistema de salud de Perú

This paper describes the health conditions in Peru and, with greater detail, the Peruvian health system, including its structure and coverage, its financial sources, its physical, material and human resources, and its stewardship functions. It also discusses the activities developed in the information and research areas, as well as the participation of citizens in the operation and evaluation of the health system. The article concludes with a discussion of the most recent innovations, including the Comprehensive Health Insurance, the Health Care Enterprises system, the decentralization process and the Local Committees for Health Administration. The main challenge confronted by the Peruvian health system is the extension of coverage to more than I0% of the population presently lacking access to basic health care.

Sistema de salud de Perú / The health system of Peru

En este trabajo se describen las condiciones generales de salud de la población peruana y, con mayor detalle, el sistema peruano de salud: su estructura y cobertura, sus fuentes de financiamiento, los recursos físicos, materiales y humanos con los que cuenta, y las actividades de rectoría que en él se desarrollan. Asimismo se discute el estado en el que se encuentran la generación de información y la investigación, y la participación de los ciudadanos en la gestión y evaluación del sistema. El artículo concluye con una discusión de las innovaciones más recientes, dentro de las que destacan el Seguro Integral de Salud, el sistema de Empresas Prestadoras de Salud, el proceso de descentralización y los Comités Locales de Administración de Salud. El reto principal que enfrenta este sistema es ampliar la atención a la salud a poco más de 10 por ciento de la población que todavía no recibe servicios básicos.

This paper describes the health conditions in Peru and, with greater detail, the Peruvian health system, including its structure and coverage, its financial sources, its physical, material and human resources, and its stewardship functions. It also discusses the activities developed in the information and research areas, as well as the participation of citizens in the operation and evaluation of the health system. The article concludes with a discussion of the most recent innovations, including the Comprehensive Health Insurance, the Health Care Enterprises system, the decentralization process and the Local Committees for Health Administration. The main challenge confronted by the Peruvian health system is the extension of coverage to more than I0 percent of the population presently lacking access to basic health care.

[National health policies and local decisions in Mexico: the case of an intercultural hospital in Cuetzalan, Puebla]. / Políticas nacionales de salud y decisiones locales en México: el caso del Hospital Mixto de Cuetzalan, Puebla.

OBJECTIVE: To identify the changes brought about by various national and international factors in an intercultural hospital of the municipality of Cuetzalán, Puebla. MATERIAL AND METHODS: A case study was conducted during 2000 and 2001 in two Intercultural Hospitals of Mexico; the Cuetzalán Hospital in Puebla and the Jesús María Hospital in Nayarit State. Data were collected by means of 72 semi-structured interviews with allopathic therapists, indigenous therapists, and authorities of the different health care levels. Moreover, documental research was carried out on national policies for indigenous peoples as well as on indigenist policies. These policies were related with the five organizational stages of the hospital. State authorities gave their permission and interviewees signed informed consent. RESULTS: The hospital was created in 1958 by the Ministry of Health as a biomedical institution, in agreement with the integrationist indigenist policies going on at the time. It remained so during the beginning of the administration by the National Indigenist Institute. In 1990, the new participative indigenist policy trends and the creativity and sensitivity of some authorities, under the influence of international strategies, helped to transform the hospital into an Intercultural Hospital (offering both types of medicine, indigenous and allopathic) with regional coverage. In 2000, the devolution of the hospital to the State Ministry of Health, based on financial rather than socio-cultural considerations, caused the temporary loss of its intercultural character. The last stage as an Integral Hospital with Traditional Medicine (from 2003 onwards) was due to a combination of state official initiatives and the new political stance acquired by the Mexican indigenous movement. The hospital is now part of a regional project of five such hospitals officially denominated Integral Hospitals with Traditional Medicine, to be financed by the Puebla-Panama Plan of regional development. CONCLUSIONS: Our results confirmed that health organizations follow a historical process in which selected national and international forces open opportunities to promote intercultural health models that respond to the needs of indigenous populations. Despite the formerly held belief that traditional and scientific medicines were incompatible, this study demonstrates the viability of intercultural health care models that may become a real possibility in the country, based on new conventions to establish alternative and intercultural health services, thereby setting an example for other regions and countries. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

Políticas nacionales de salud y decisiones locales en México: el caso del Hospital Mixto de Cuetzalan, Puebla / National health policies and local decisions in Mexico: the case of an intercultural hospital in Cuetzalan, Puebla

OBJETIVO: Identificar la evolución del hospital del municipio de Cuetzalan a partir de la influencia que diversos elementos del contexto nacional e internacional han tenido sobre ella. MATERIAL Y MÉTODOS: Estudio de caso, realizado en 2000 y 2001 sobre los Hospitales Mixtos en México -el de Cuetzalan, en el estado de Puebla, y el de Jesús María, en el estado de Nayarit-. Durante el trabajo de campo se obtuvo información a través de 72 entrevistas semiestructuradas con terapeutas alópatas e indígenas del hospital y con directivos de los diferentes niveles del sistema de salud. Además, se hizo una revisión documental, tanto de las políticas nacionales de salud para pueblos indígenas, como de las indigenistas, para relacionarlas con las cinco etapas organizacionales del hospital. Además de la autorización de los directivos estatales para el estudio, se pidió el consentimiento informado de los entrevistados. RESULTADOS: El hospital fue creado en 1958 por la Secretaría de Salud con carácter biomédico, acorde con el indigenismo integracionista de la época, y continuó con ese carácter durante la administración inicial del Instituto Nacional Indigenista. Pero las nuevas tendencias del indigenismo participativo y la sensibilidad y creatividad de algunos funcionarios del Instituto, sumadas a estrategias internacionales para lograr una mayor integración de las culturas indígenas, impulsaron su transformación, en 1990, en Hospital Mixto (que ofrecía las dos medicinas, la indígena y la alopática) con proyección regional. En la devolución del hospital a la Secretaría Estatal de Salud en 2000, que causó retrocesos temporales en el carácter mixto del hospital, primaron los criterios financieros sobre los socioculturales, mientras que en la actual versión del hospital como Hospital Integral con Medicina Tradicional influyeron, además de la iniciativa de funcionarios estatales, el reposicionamiento político de los indígenas en el país y la disponibilidad de recursos internacionales del Plan Puebla Panamá. CONCLUSIONES: El análisis ratifica el carácter histórico del desarrollo de las organizaciones de salud, y las oportunidades que las coyunturas y políticas nacionales e internacionales constituyen para impulsar modelos alternativos e interculturales de atención para la salud de los pueblos indígenas que respondan a sus necesidades. A pesar de que...

Knowledge and practice of traditional medicine in Mexico: a survey of healthcare practitioners.

A cross-sectional study combined anthropologic (ethnographic) techniques to obtain qualitative information from decision makers and a questionnaire designed to investigate the population that used health services provided by the medical centers in Mexico. The results demonstrate that non-biomedical therapists fell into three main groups: (1) practitioners of traditional medicine; (2) practitioners of alternative medicine; and (3) faith healers. The cultural affiliations, academic backgrounds, training, and preparation of these practitioners differed markedly. They employed many strategies to finance their services, create and utilize therapist networks, and provide care to different segments of the population. The authors recommend further research on non-biomedical health care models, which are becoming more important with expanding globalization.

La práctica de la medicina tradicional en américa Latina y el Caribe: el dilema entre regulación y tolerancia / The practice of traditional medicine in Latin America and the Caribbean: The dilemma between regulation and tolerance

Objetivo. Caracterizar el estado actual de la regulación de la medicina tradicional en nueve países de América Latina y el Caribe. Material y métodos. Se construyó una base de datos sobre componentes de los sistemas de salud tradicionales en nueve países de América Latina y el Caribe, mediante la creación de una red de individuos e instituciones de distintos países que estuvieran interesados en participar como informantes especializados con diferentes perfiles. La información para este estudio de tipo cualitativo se levantó, sistematizó y analizó entre marzo y diciembre de 1998. Resultados. Se exponen los resultados obtenidos del tema de regulación de la medicina tradicional dividiendo a los países en tres grupos: a) los que cuentan con algún tipo de desarrollo en materia de legislación; b) los que están trabajando en el proceso de legislación, y c) los que no tienen legislación y el proceso de regulación es incipiente. Conclusiones. Se muestra que el proceso legislativo de la medicina tradicional es variado en la región y se encuentra en diferentes etapas. Esta variedad de estadios nos muestra la complejidad de regular una práctica terapéutica de prestadores con bajos niveles de entrenamiento formal, con prácticas variadas y que sustentan su ejercicio en usos y costumbres que en las mayoría de las ocasiones son difíciles de ubicar dentro de los estándares de los sistemas de salud oficiales. El estudio se considera importante para el diseño e implementación de políticas que permitan adecuar la oferta de servicios de medicina tradicional con las necesidades de las poblaciones que más hacen uso de ella. El texto completo en inglés de este artículo está disponible en: http://www.insp.mx/salud/index.html

Modelos complementarios de atención: un componente excluido en la reforma de los sistemas de salud / Complementary health care models: a neglected complonent in the health care systems reform

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