The effect of public policy on high BMI trends of Mexican children: an interrupted time series analysis.

BACKGROUND: Mexico declared an obesity epidemic in 2000, and in response, became an early adopter of public policies in the form of natural experiments, which have not been evaluated for their effect on high BMI. We focus on children younger than 5 years due to the long-term outcomes of childhood obesity. METHODS: We used the Global Burden of Disease data to evaluate time trends in high BMI, defined as being overweight or obese based on the International Obesity Task Force standards, between 1990 and 2019. Marginalisation and poverty estimates from Mexico's Government were used to identify differences in socioeconomic groups. The time variable reflects the introduction of policies between 2006 and 2011. Our hypothesis was that poverty and marginalisation modify the effects of public policies. We tested for the change in prevalence of high BMI over time using Wald-type tests, correcting for the effect of repeated measures. We stratified the sample by gender, marginalisation index, and households under the poverty line. Ethics approval was not required. FINDINGS: Between 1990 and 2019, high BMI in children younger than 5 years increased from 23·5% (95% uncertainty interval 38·6-14·3) to 30·2% (46·0-20·4). After a period of sustained increase to 28·7% (44·8-18·6) in 2005, high BMI decreased to 27·3% (42·4-17·4; p<0·001) in 2011. Afterwards, high BMI increased constantly. We found an average gender gap of 12·2%, with a higher rate in males, in 2006, which remained constant. With respect to marginalisation and poverty, we observed a reduction in high BMI across all strata, except for the uppermost quintile of marginalisation in which high BMI remained flat. INTERPRETATION: The epidemic affected groups across different socioeconomic levels, thus weakening economic explanations for the decrease in high BMI, while gender gaps point to behavioural explanations of consumption. The observed patterns warrant investigation through more granular data and structural models to isolate the effect of the policy from secular trends in the population, including other age groups. FUNDING: Tecnológico de Monterrey Challenge-Based Research Funding Program.

Burden of overweight and obesity in Mexico from 1990 to 2021.

BACKGROUND: Overweight and obesity (OW/OB) represent a serious challenge in Mexico, with effects on health, society and economy. Demographic, epidemiological, nutritional, social and economic factors have exacerbated this problem. OBJECTIVE: To analyze mortality and years of healthy life lost in Mexico due to OW/OB in the 1990-2021 period. MATERIAL AND METHODS: The Global Burden of Disease and Risk Factors 2021 study was used to analyze data on elevated body mass index (BMI) as a risk factor and its evolution in Mexico. RESULTS: In 2021, 118 thousand deaths attributable to high BMI were recorded, which accounted for 10.6% of total deaths and more than 4.2 million disability-adjusted life years lost. CONCLUSIONS: The obesogenic environment, influenced by social determinants of health, has had a significant impact on mortality, burden of disease, and economic costs. Addressing OW/OB requires multisector interventions to strengthen the Mexican health system.

ANTECEDENTES: El sobrepeso y la obesidad constituyen un grave desafío en México, con efectos en la salud, sociedad y economía. Factores demográficos, epidemiológicos, nutricionales, sociales y económicos han agravado esta problemática. OBJETIVO: Analizar la mortalidad y los años de vida saludable perdidos en México por sobrepeso y obesidad en el período de 1990 a 2021. MATERIAL Y MÉTODOS: Se utilizó el Global Burden of Disease 2021 para analizar los datos sobre índice de masa corporal elevado como factor de riesgo y su evolución en México. RESULTADOS: En 2021 se registraron 118 mil muertes atribuibles a índice de masa corporal elevado, que representaron 10.6 % del total de muertes y más de 4.2 millones de años de vida perdidos ajustados por discapacidad. CONCLUSIONES: El ambiente obesogénico, influido por determinantes sociales, ha tenido un impacto significativo en la mortalidad, la carga de enfermedad y los costos económicos. Abordar el sobrepeso y la obesidad requiere intervenciones multisectoriales para fortalecer el sistema de salud mexicano.

Characterizing health care provider knowledge: Evidence from HIV services in Kenya, Rwanda, South Africa, and Zambia.

BACKGROUND: Identifying approaches to improve levels of health care provider knowledge in resource-poor settings is critical. We assessed level of provider knowledge for HIV testing and counseling (HTC), prevention of mother-to-child transmission (PMTCT), and voluntary medical male circumcision (VMMC). We also explored the association between HTC, PMTCT, and VMMC provider knowledge and provider and facility characteristics. METHODS: We used data collected in 2012 and 2013. Vignettes were administered to physicians, nurses, and counselors in facilities in Kenya (66), Rwanda (67), South Africa (57), and Zambia (58). The analytic sample consisted of providers of HTC (755), PMTCT (709), and VMMC (332). HTC, PMTCT, and VMMC provider knowledge scores were constructed using item response theory (IRT). We used GLM regressions to examine associations between provider knowledge and provider and facility characteristics focusing on average patient load, provider years in position, provider working in another facility, senior staff in facility, program age, proportion of intervention exclusive staff, person-days of training in facility, and management score. We estimated three models: Model 1 estimated standard errors without clustering, Model 2 estimated robust standard errors, and Model 3 estimated standard errors clustering by facility. RESULTS: The mean knowledge score was 36 for all three interventions. In Model 1, we found that provider knowledge scores were higher among providers in facilities with senior staff and among providers in facilities with higher proportions of intervention exclusive staff. We also found negative relationships between the outcome and provider years in position, average program age, provider working in another facility, person-days of training, and management score. In Model 3, only the coefficients for provider years in position, average program age, and management score remained statistically significant at conventional levels. CONCLUSIONS: HTC, PMTCT, and VMMC provider knowledge was low in Kenya, Rwanda, South Africa, and Zambia. Our study suggests that unobservable organizational factors may facilitate communication, learning, and knowledge. On the one hand, our study shows that the presence of senior staff and staff dedication may enable knowledge acquisition. On the other hand, our study provides a note of caution on the potential knowledge depreciation correlated with the time staff spend in a position and program age.

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.

Influence of supply-side factors on voluntary medical male circumcision costs in Kenya, Rwanda, South Africa, and Zambia.

BACKGROUND: In this study, we described facility-level voluntary medical male circumcision (VMMC) unit cost, examined unit cost variation across facilities, and investigated key facility characteristics associated with unit cost variation. METHODS: We used data from 107 facilities in Kenya, Rwanda, South Africa, and Zambia covering 2011 or 2012. We used micro-costing to estimate economic costs from the service provider's perspective. Average annual costs per client were estimated in 2013 United States dollars (US$). Econometric analysis was used to explore the relationship between VMMC total and unit cost and facility characteristics. RESULTS: Average VMMC unit cost ranged from US$66 (SD US$79) in Kenya to US$160 (SD US$144) in South Africa. Total cost function estimates were consistent with economies of scale and scope. We found a negative association between the number of VMMC clients and VMMC unit cost with a 3% decrease in unit cost for every 10% increase in number of clients and we found a negative association between the provision of other HIV services and VMMC unit cost. Also, VMMC unit cost was lower in primary health care facilities than in hospitals, and lower in facilities implementing task shifting. CONCLUSIONS: Substantial efficiency gains could be made in VMMC service delivery in all countries. Options to increase efficiency of VMMC programs in the short term include focusing service provision in high yield sites when demand is high, focusing on task shifting, and taking advantage of efficiencies created by integrating HIV services. In the longer term, reductions in VMMC unit cost are likely by increasing the volume of clients at facilities by implementing effective demand generation activities.

Efficiency of HIV services in Nigeria: Determinants of unit cost variation of HIV counseling and testing and prevention of mother-to-child transmission interventions.

BACKGROUND: Like most countries with a substantial HIV burden, Nigeria continues to face challenges in reaching coverage targets of HIV services. A fundamental problem is stagnated funding in recent years. Improving efficiency is therefore paramount to effectively scale-up HIV services. In this study, we estimated the facility-level average costs (or unit costs) of HIV Counseling and Testing (HCT) and Prevention of Mother-to-Child Transmission (PMTCT) services and characterized determinants of unit cost variation. We investigated the role of service delivery modalities and the link between facility-level management practices and unit cost variability along both services' cascades. METHODS: We conducted a cross-sectional, observational, micro-costing study in Nigeria between December 2014 and May 2015 in 141 HCT, and 137 PMTCT facilities, respectively. We retrospectively collected relevant input quantities (personnel, supplies, utilities, capital, and training), input prices, and output data for the year 2013. Staff costs were adjusted using time-motion methods. We estimated the facility-level average cost per service along the HCT and PMTCT service cascades and analyzed their composition and variability. Through linear regressions analysis, we identified aspects of service delivery and management practices associated with unit costs variations. RESULTS: The weighted average cost per HIV-positive client diagnosed through HCT services was US$130. The weighted average cost per HIV-positive woman on prophylaxis in PMTCT services was US$858. These weighted values are estimates of nationally representative unit costs in Nigeria. For HCT, the facility-level unit costs per client tested and per HIV-positive client diagnosed were US$30 and US$1,364, respectively; and the median unit costs were US$17 and US$245 respectively. For PMTCT, the facility-level unit costs per woman tested, per HIV-positive woman diagnosed, and per HIV-positive woman on prophylaxis were US$46, US$2,932, and US$3,647, respectively, and the median unit costs were US$24, US$1,013 and US$1,448, respectively. Variability in costs across facilities was principally explained by the number of patients, integration of HIV services, task shifting, and the level of care. DISCUSSION: Our findings demonstrate variability in unit costs across facilities. We found evidence consistent with economies of scale and scope, and efficiency gains in facilities implementing task-shifting. Our results could inform program design by suggesting ways to improve resource allocation and efficiently scale-up the HIV response in Nigeria. Some of our findings might also be relevant for other settings.

Old principles, persisting challenges: Maternal health care market alignment in Mexico in the search for UHC.

The purpose of this study is to analyze the alignment of supply and demand for antenatal care (ANC) in Mexico based on the definition of access provided by Donabedian: the "degree of adjustment" between resources and needs. Alignment was studied in the teenage and adult population of Mexico that lacked conventional social security between 2008 and 2015, a period of expanding financial resources for health and public health insurance coverage. Spatial econometric methods were used to analyze data from the Ministry of Health on the supply and demand for ANC in 2,314 municipalities (94% of all municipalities in Mexico). During this period, the relative weight of ANC demand among adolescents increased 37% while the production of antenatal consultations for adolescent and adult women remained unchanged. Bivariate spatial analyses of correlation between supply and demand for ANC services yielded a minimal spatial correlation, or lack of territorial correspondence, between supply and demand among women in both age groups. Spatial econometric analysis confirmed a non-significant association between supply and demand for ANC services. Our findings suggest the existence of misalignment between supply and demand for these services. This requires a reassessment of the management and delivery of ANC services at the local level in order to increase effective coverage and improve the overall performance of the health system.

Explaining the heterogeneity in average costs per HIV/AIDS patient in Nigeria: The role of supply-side and service delivery characteristics.

OBJECTIVE: We estimated the average annual cost per patient of ART per facility (unit cost) in Nigeria, described the variation in costs across facilities, and identified factors associated with this variation. METHODS: We used facility-level data of 80 facilities in Nigeria, collected between December 2014 and May 2015. We estimated unit costs at each facility as the ratio of total costs (the sum of costs of staff, recurrent inputs and services, capital, training, laboratory tests, and antiretroviral and TB treatment drugs) divided by the annual number of patients. We applied linear regressions to estimate factors associated with ART cost per patient. RESULTS: The unit ART cost in Nigeria was $157 USD nationally and the facility-level mean was $231 USD. The study found a wide variability in unit costs across facilities. Variations in costs were explained by number of patients, level of care, task shifting (shifting tasks from doctors to less specialized staff, mainly nurses, to provide ART) and provider´s competence. The study illuminated the potentially important role that management practices can play in improving the efficiency of ART services. CONCLUSIONS: Our study identifies characteristics of services associated with the most efficient implementation of ART services in Nigeria. These results will help design efficient program scale-up to deliver comprehensive HIV services in Nigeria by distinguishing features linked to lower unit costs.

HIV prevention costs and their predictors: evidence from the ORPHEA Project in Kenya.

We estimate costs and their predictors for three HIV prevention interventions in Kenya: HIV testing and counselling (HTC), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC). As part of the 'Optimizing the Response of Prevention: HIV Efficiency in Africa' (ORPHEA) project, we collected retrospective data from government and non-governmental health facilities for 2011-12. We used multi-stage sampling to determine a sample of health facilities by type, ownership, size and interventions offered totalling 144 sites in 78 health facilities in 33 districts across Kenya. Data sources included key informants, registers and time-motion observation methods. Total costs of production were computed using both quantity and unit price of each input. Average cost was estimated by dividing total cost per intervention by number of clients accessing the intervention. Multivariate regression methods were used to analyse predictors of log-transformed average costs. Average costs were $7 and $79 per HTC and PMTCT client tested, respectively; and $66 per VMMC procedure. Results show evidence of economies of scale for PMTCT and VMMC: increasing the number of clients per year by 100% was associated with cost reductions of 50% for PMTCT, and 45% for VMMC. Task shifting was associated with reduced costs for both PMTCT (59%) and VMMC (54%). Costs in hospitals were higher for PMTCT (56%) in comparison to non-hospitals. Facilities that performed testing based on risk factors as opposed to universal screening had higher HTC average costs (79%). Lower VMMC costs were associated with availability of male reproductive health services (59%) and presence of community advisory board (52%). Aside from increasing production scale, HIV prevention costs may be contained by using task shifting, non-hospital sites, service integration and community supervision.

Use of performance metrics for the measurement of universal coverage for maternal care in Mexico.

This study provides evidence for those working in the maternal health metrics and health system performance fields, as well as those interested in achieving universal and effective health care coverage. Based on the perspective of continuity of health care and applying quasi-experimental methods to analyse the cross-sectional 2009 National Demographic Dynamics Survey (n = 14 414 women), we estimated the middle-term effects of Mexico's new public health insurance scheme, Seguro Popular de Salud (SPS) (vs women without health insurance) on seven indicators related to maternal health care (according to official guidelines): (a) access to skilled antenatal care (ANC); (b) timely ANC; (c) frequent ANC; (d) adequate content of ANC; (e) institutional delivery; (f) postnatal consultation and (g) access to standardized comprehensive antenatal and postnatal care (or the intersection of the seven process indicators). Our results show that 94% of all pregnancies were attended by trained health personnel. However, comprehensive access to ANC declines steeply in both groups as we move along the maternal healthcare continuum. The percentage of institutional deliveries providing timely, frequent and adequate content of ANC reached 70% among SPS women (vs 64.7% in the uninsured), and only 57.4% of SPS-affiliated women received standardized comprehensive care (vs 53.7% in the uninsured group). In Mexico, access to comprehensive antenatal and postnatal care as defined by Mexican guidelines (in accordance to WHO recommendations) is far from optimal. Even though a positive influence of SPS on maternal care was documented, important challenges still remain. Our results identified key bottlenecks of the maternal healthcare continuum that should be addressed by policy makers through a combination of supply side interventions and interventions directed to social determinants of access to health care.

Costs along the service cascades for HIV testing and counselling and prevention of mother-to-child transmission.

OBJECTIVE: We estimate facility-level average annual costs per client along the HIV testing and counselling (HTC) and prevention of mother-to-child transmission (PMTCT) service cascades. DESIGN: Data collected covered the period 2011-2012 in 230 HTC and 212 PMTCT facilities in Kenya, Rwanda, South Africa, and Zambia. METHODS: Input quantities and unit prices were collected, as were output data. Annual economic costs were estimated from the service providers' perspective using micro-costing. Average annual costs per client in 2013 United States dollars (US$) were estimated along the service cascades. RESULTS: For HTC, average cost per client tested ranged from US$5 (SD US$7) in Rwanda to US$31 (SD US$24) in South Africa, whereas average cost per client diagnosed as HIV-positive ranged from US$122 (SD US$119) in Zambia to US$1367 (SD US$2093) in Rwanda. For PMTCT, average cost per client tested ranged from US$18 (SD US$20) in Rwanda to US$89 (SD US$56) in South Africa; average cost per client diagnosed as HIV-positive ranged from US$567 (SD US$417) in Zambia to US$2021 (SD US$3210) in Rwanda; average cost per client on antiretroviral prophylaxis ranged from US$704 (SD US$610) in South Africa to US$2314 (SD US$3204) in Rwanda; and average cost per infant on nevirapine ranged from US$888 (SD US$884) in South Africa to US$2359 (SD US$3257) in Rwanda. CONCLUSION: We found important differences in unit costs along the HTC and PMTCT service cascades within and between countries suggesting that more efficient delivery of these services is possible.

[Correcting for misclassified HIV/aids deaths in Mexico: Retrospective analysis, 1983-2012]. / Corrección de la mala clasificación de las muertes por sida en México: Análisis retrospectivo de 1983 a 2012.

OBJECTIVE: To identify and reassign misclassified AIDS deaths in Mexico, reconstructing the time series of mortality from 1983 to 2012, by state, sex, age, and affiliation to social security. MATERIALS AND METHODS: 15.5 million deaths from 1979 to 2012 were analyzed. The HIV-AIDS mortality correction was done in three phases: a) those causes directly related to AIDS; b) by miscoded deaths, and c) AIDS deaths hidden in other underlying causes of death. Age-standardized rates of mortality (SMR) were calculated by sex, affiliation to social security, and state. RESULTS: 107 981 AIDS deaths from 1983 to 2012 were accumulated, representing 11% of total deaths observed for the period. The SMR in men for all age groups begins to decline since 1996, while for women the decline started in 2008. A similar picture is observed for the population with / without social security. Heterogeneity is a feature for SMR by state. CONCLUSION: An easily replicable methodology for the correction of mortality from AIDS, which generates relevant information for decision making based on the evidence is presented.

[The role of supply-side characteristics of services in AIDS mortality in Mexico]. / Exploración del rol de la oferta de servicios para explicar la variación de la mortalidad por sida en México.

OBJECTIVE: To document the association between supply-side determinants and AIDS mortality in Mexico between 2008 and 2013. MATERIALS AND METHODS: We analyzed the SALVAR database (system for antiretroviral management, logistics and surveillance) as well as data collected through a nationally representative survey in health facilities. We used multivariate logit regression models to estimate the association between supply-side characteristics, namely management, training and experience of health care providers, and AIDS mortality, distinguishing early and non-early mortality and controlling for clinical indicators of the patients. RESULTS: Clinic status of the patients (initial CD4 and viral load) explain 44.4% of the variability of early mortality across clinics and 13.8% of the variability in non-early mortality. Supply-side characteristics increase explanatory power of the models by 16% in the case of early mortality, and 96% in the case of non-early mortality. CONCLUSIONS: Aspects of management and implementation of services contribute significantly to explain AIDS mortality in Mexico. Improving these aspects of the national program, can similarly improve its results.

The costs of inadequate breastfeeding of infants in Mexico.

BACKGROUND: Breastfeeding is vital for child survival, health, and development. Mexico has very low rates of breastfeeding and experienced a severe decrease in the prevalence of exclusive breastfeeding from 21% in 2006 to 14% in 2012. OBJECTIVE: The objective of the article was to estimate the pediatric costs of inadequate breastfeeding in Mexico associated with the following acute health conditions: respiratory infections, otitis media, gastroenteritis, necrotizing enterocolitis (NEC), and sudden infant death syndrome (SIDS). DESIGN: The authors estimated the economic costs of inadequate breastfeeding as follows: the sum of direct health care costs for diseases whose risk increases when infants are non-exclusively breastfed <6 mo or are not breastfed from ages 6 to <11 mo, lost future earnings due to premature infant death, and the costs of purchasing infant formula. Incidence cases were retrieved from national surveillance systems, except for NEC and SIDS, which were estimated from the literature. A sensitivity analysis was carried out to provide a range of costs based on different assumptions of the number of incident cases of all infant health outcomes examined. The model applied to the cohort of 1-y-old children born in 2012. RESULTS: The total annual costs of inadequate breastfeeding in Mexico for the studied cohort ranged from $745.6 million to $2416.5 million, where the costs of infant formula accounted for 11-38% of total costs. A range of 1.1-3.8 million reported cases of disease and from 933 to 5796 infant deaths per year for the diseases under study are attributed to inadequate infant breastfeeding practices; altogether these represent nearly 27% of the absolute number of episodes of such diseases. CONCLUSIONS: This study provides costs of inadequate breastfeeding that had not been quantified in Mexico. The costs presented in this article provide the minimum amount that the country should invest to achieve better breastfeeding practices.

Waiting times for surgical and diagnostic procedures in public hospitals in Mexico / Tiempos de espera para procedimientos quirúrgicos y diagnósticos en hospitales públicos de México

Objective. A retrospective evaluation of waiting times for elective procedures was conducted in a sample of Mexican public hospitals from the following institutions: the Mexican Institute for Social Security (IMSS), the Institute for Social Security and Social Services for Civil Servants (ISSSTE) and the Ministry of Health (MoH). Our aim was to describe current waiting times and identify opportunities to redistribute service demand among public institutions. Materials and methods. We examined current waiting times and productivity for seven elective surgical and four diagnostic imaging procedures, selected on the basis of their relative frequency and comparability with other national health systems. Results. Mean waiting time for the seven surgical procedures in the three institutions was 14 weeks. IMSS and ISSSTE hospitals showed better performance (12 and 13 weeks) than the MoH hospitals (15 weeks). Mean waiting time for the four diagnostic procedures was 11 weeks. IMSS hospitals (10 weeks) showed better average waiting times than ISSSTE (12 weeks) and MoH hospitals (11 weeks). Conclusion. Substantial variations were revealed, not only among institutions but also within the same institution. These variations need to be addressed in order to improve patient satisfaction.

Objetivo. Se llevó a cabo una evaluación retrospectiva de los tiempos de espera para procedimientos electivos en una muestra de hospitales públicos en México de las siguientes instituciones: Instituto Mexicano del Seguro Social (IMSS), Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) y Secretaría de Salud (SS). El propósito era describir la situación actual en materia de tiempos de espera e identificar oportunidades de redistribución de la demanda de servicios entre instituciones públicas. Material y métodos. Se analizaron los tiempos de espera y la productividad para siete procedimientos quirúrgicos y cuatro procedimientos diagnósticos seleccionados sobre la base de su frecuencia relativa y comparabilidad con otros sistemas de salud nacionales. Resultados. El tiempo de espera promedio para los siete procedimientos quirúrgicos en las tres instituciones fue de 14 semanas. Los hospitales del IMSS y el ISSSTE mostraron un mejor desempeño (12 y 13 semanas) frente a los hospitales de la SS (15 semanas). El tiempo de espera promedio para los cuatro procedimientos diagnósticos fue de 11 semanas. Los hospitales del IMSS mostraron un tiempo de espera promedio mejor (10 semanas) que los hospitales del ISSSTE (12 semanas) y la SS (11 semanas). Conclusión. Se identificaron variaciones importantes no sólo entre instituciones sino también al interior de cada una de ellas. Estas variaciones deben atenderse para así mejorar la satisfacción de los usuarios de los servicios.

Waiting times for surgical and diagnostic procedures in public hospitals in Mexico.

OBJECTIVE: A retrospective evaluation of waiting times for elective procedures was conducted in a sample of Mexican public hospitals from the following institutions: the Mexican Institute for Social Security (IMSS), the Institute for Social Security and Social Services for Civil Servants (ISSSTE) and the Ministry of Health (MoH). Our aim was to describe current waiting times and identify opportunities to redistribute service demand among public institutions. MATERIALS AND METHODS: We examined current waiting times and productivity for seven elective surgical and four diagnostic imaging procedures, selected on the basis of their relative frequency and comparability with other national health systems. RESULTS: Mean waiting time for the seven surgical procedures in the three institutions was 14 weeks. IMSS and ISSSTE hospitals showed better performance (12 and 13 weeks) than the MoH hospitals (15 weeks). Mean waiting time for the four diagnostic procedures was 11 weeks. IMSS hospitals (10 weeks) showed better average waiting times than ISSSTE (12 weeks) and MoH hospitals (11 weeks). CONCLUSION: Substantial variations were revealed, not only among institutions but also within the same institution. These variations need to be addressed in order to improve patient satisfaction.

Corrección de la mala clasificación de las muertes por sida en México: Análisis retrospectivo de 1983 a 2012 / Correcting for misclassified HIV/aids deaths in Mexico: Retrospective analysis, 1983-2012

Objetivo. Identificar y reasignar defunciones mal clasificadas por sida en México, y reconstruir la mortalidad 1983-2012, por entidad federativa, sexo, edad y derechohabiencia a la seguridad social. Material y métodos. Se analizaron 15.5 millones de defunciones de 1979 a 2012. La corrección de la mortalidad por sida se hizo en tres fases: a) por causas directamente relacionadas con sida, y b) por muertes mal codificadas; c) muertes por sida ocultas en otras causas. Se calcularon tasas estandarizadas por edad de mortalidad (TEM) por sexo, derechohabiencia a la seguridad social y entidad federativa. Resultados. Se acumularon 107981 muertes por sida entre 1983 y 2012 (11% más del total de muertes observadas). La TEM en hombres, para todos los grupos de edad, empieza a descender desde 1996, mientras que para las mujeres la caída inicia en 2008. Un panorama similar se observa para la población con/sin seguridad social. La heterogeneidad caracteriza la TEM estatal. Conclusión. Se presenta una metodología fácilmente replicable para la corrección de la mortalidad de sida que genera información relevante para la toma de decisiones fundamentada en la evidencia.

Objective. To identify and reassign misclassified AIDS deaths in Mexico, reconstructing the time series of mortality from 1983 to 2012, by state, sex, age, and affiliation to social security. Materials and methods. 15.5 million deaths from 1979 to 2012 were analyzed. The HIV-AIDS mortality correction was done in three phases: a) those causes directly related to AIDS; b) by miscoded deaths, and c) AIDS deaths hidden in other underlying causes of death. Age-standardized rates of mortality (SMR) were calculated by sex, affiliation to social security, and state. Results. 107 981 AIDS deaths from 1983 to 2012 were accumulated, representing 11% of total deaths observed for the period. The SMR in men for all age groups begins to decline since 1996, while for women the decline started in 2008. A similar picture is observed for the population with / without social security. Heterogeneity is a feature for SMR by state. Conclusion. An easily replicable methodology for the correction of mortality from AIDS, which generates relevant information for decision making based on the evidence is presented.

Exploración del rol de la oferta de servicios para explicar la variación de la mortalidad por sida en México / The role of supply-side characteristics of services in AIDS mortality in Mexico

Objetivo. Documentar la asociación entre factores de la oferta de servicios de atención de VIH sobre la mortalidad por sida en México en el periodo 2008-2013. Material y métodos. Se analizaron datos del sistema de administración, logística y vigilancia de antirretrovirales (SALVAR) y de una encuesta aplicada en unidades de atención. Se utilizaron modelos de regresión logit multivariados para estimar la asociación entre características de la oferta de servicios -en particular, de la gerencia de servicios y de la capacitación y experiencia de los prestadores- y la mortalidad por sida, distinguiendo entre mortalidad temprana y no temprana, y controlando por características clínicas de los pacientes. Resultados. Las características clínicas de los pacientes (CD4 inicial y carga viral) explican 44.4% de la variabilidad en la mortalidad temprana entre clínicas y 13.8% de la variabilidad de mortalidad no temprana. Las características de la oferta aumentan 16% del poder explicativo en el caso de la mortalidad temprana y 96% en el de la mortalidad no temprana. Conclusiones. Los aspectos de gerencia e implementación de los servicios de atención de VIH contribuyen significativamente a explicar la mortalidad por sida en México. Mejorar estos aspectos del programa nacional puede mejorar sus resultados.

Objective. To document the association between supply-side determinants and AIDS mortality in Mexico between 2008 and 2013. Materials and methods. We analyzed the SALVAR database (system for antiretroviral management, logistics and surveillance) as well as data collected through a nationally representative survey in health facilities. We used multivariate logit regression models to estimate the association between supply-side characteristics, namely management, training and experience of health care providers, and AIDS mortality, distinguishing early and non-early mortality and controlling for clinical indicators of the patients. Results. Clinic status of the patients (initial CD4 and viral load) explain 44.4% of the variability of early mortality across clinics and 13.8% of the variability in non-early mortality. Supply-side characteristics increase explanatory power of the models by 16% in the case of early mortality, and 96% in the case of non-early mortality. Conclusions. Aspects of management and implementation of services contribute significantly to explain AIDS mortality in Mexico. Improving these aspects of the national program, can similarly improve its results.

Tiempos de espera para procedimientos quirúrgicos y diagnósticos en hospitales públicos de México / Waiting times for surgical procedures and diagnoses in public hospitals in Mexico

Objetivo. Se llevó a cabo una evaluación retrospectiva de los tiempos de espera para procedimientos electivos en una muestra de hospitales públicos en México de las siguientes instituciones: Instituto Mexicano del Seguro Social (IMSS), Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) y Secretaría de Salud (SS). El propósito era describir la situación actual en materia de tiempos de espera e identificar oportunidades de redistribución de la demanda de servicios entre instituciones públicas. Material y métodos. Se analizaron los tiempos de espera y la productividad para siete procedimientos quirúrgicos y cuatro procedimientos diagnósticos seleccionados sobre la base de su frecuencia relativa y comparabilidad con otros sistemas de salud nacionales. Resultados. El tiempo de espera promedio para los siete procedimientos quirúrgicos en lastres instituciones fue de 14 semanas. Los hospitales del IMSS y el ISSSTE mostraron un mejor desempeño (12 y 13 semanas) frente a los hospitales de la SS (15 semanas). El tiempo de espera promedio para los cuatro procedimientos diagnósticos fue de 11 semanas. Los hospitales del IMSS mostraron un tiempo de espera promedio mejor (10 semanas) que los hospitales del ISSSTE (12 semanas) y la SS (11 semanas). Conclusión: Se identificaron variaciones importantes no sólo entre instituciones sino también al interior de cada una de ellas. Estas variaciones deben atenderse para así mejorar la satisfacción de los usuarios de los servicios.

Abasto y surtimiento de medicamentos en unidades especializadas en la atención de enfermedades crónicas en México en 2012 / Supply of essential drugs in units specialized in the treatment of chronic diseases in Mexico in 2012

Objetivo. Cuantificar el abasto en farmacia y el nivel de surtimiento de medicamentos en las unidades de especialidades médicas de enfermedades crónicas (UNEMES-EC) de México. Material y métodos. Los indicadores de abasto y surtimiento se midieron en 30 de 86 UNEMES-EC existentes en el país. El abasto de medicamentos se registró mediante una lista de cotejo que incluía 17 medicamentos básicos relacionados con la atención de diabetes mellitus, hipertensión y sobrepeso/obesidad. La información sobre surtimiento de recetas procede de un cuestionario aplicado directamente a 1 200 usuarios. Resultados. Sólo 13.3% de las unidades reportó abasto completo de medicamentos esenciales y dicho abasto fue más frecuente en aquellas unidades con servicio tercerizado de farmacia. Del total de pacientes entrevistados, 35% alguna vez tuvo que comprar medicamentos con recursos propios. Conclusión. Las UNEMES-EC deben mejorar su abasto de medicamentos y el surtimiento completo de recetas para evitar que sus usuarios incurran en gastos de bolsillo.

Objective. To quantify the supply of essential drugs and the fully filled-in prescription level in the Units Specialized in the Treatment of Chronic Diseases (UNEMES-EC) in Mexico. Materials and methods. The supply and prescription indicators were measured in 30 of the 86 existing UNEMES-EC. The supply of drugs was recorded using a list of 17 essential drugs related to the treatment of diabetes, hypertension, overweight and obesity. The information on fully filled-in prescriptions was obtained through a questionnaire applied to 1 200 health care users. Results. Only 13.3% of these units showed a complete supply of the 17 essential drugs: Supply levels were higher in units with external drugstore service. 35% of the interviewed patients reported out-of-pocket expenditures in medicines. Conclusion. UNEMES-EC should improve their levels of drug supply and fully filled-in prescriptions to reduce out-of-pocket expenditures.