Human resources for health and maternal mortality in Latin America and the Caribbean over the last three decades: a systemic-perspective reflections.

BACKGROUND: The role of human resources for health in the operation of health systems is crucial. However, training and incorporating them into institutions is a complex process due to the continuous misalignment between the supply and demand of health personnel. Taking the case of the Latin American and Caribbean region countries, this comment discusses the relationship between the availability of human resources for health and the maternal mortality ratio for the period 1990-2021. It proposes the need to resume planning exercises from a systemic perspective that involves all areas of government and the private sector linked to the training and employment of health workers. MAIN TEXT: We used secondary data from a global source to show patterns in the relationship between these two aspects and identify gaps in the Latin American and Caribbean regions. The results show enormous heterogeneity in the response of regional health systems to the challenge of maternal mortality in the region. Although most countries articulated specific programs to achieve the reduction committed by all countries through the Millennium Development Goals, not all had the same capacity to reduce it, and practically none met the target. In addition, in the English Caribbean countries, we found significant increases in the number of health personnel that do not explain the increases in the maternal mortality rate during the period. CONCLUSIONS: The great lesson from the data shown is that some countries could articulate responses to the problem using available resources through effective strategies, considering the specific needs of their populations. Although variations in maternal mortality rate cannot be explained solely through the provision of health personnel, it is important to consider that it is critical to find new modalities on how human resources for health could integrate and create synergies with other resources to increase systems capacity to deliver care according to conditions in each country.

Gender and non-communicable diseases in Mexico: a political mapping and stakeholder analysis.

BACKGROUND: Mexico and other low- and middle-income countries (LMICs) present a growing burden of non-communicable diseases (NCDs), with gender-differentiated risk factors and access to prevention, diagnosis and care. However, the political agenda in LMICs as it relates to health and gender is primarily focused on sexual and reproductive health rights and preventing violence against women. This research article analyses public policies related to gender and NCDs, identifying political challenges in the current response to women's health needs, and opportunities to promote interventions that recognize the role of gender in NCDs and NCD care in Mexico. METHODS: We carried out a political mapping and stakeholder analysis during July-October of 2022, based on structured desk research and interviews with eighteen key stakeholders related to healthcare, gender and NCDs in Mexico. We used the PolicyMaker V5 software to identify obstacles and opportunities to promote interventions that recognize the role of gender in NCDs and NCD care, from the perspective of the political stakeholders interviewed. RESULTS: We found as a political obstacle that policies and stakeholders addressing NCDs do not take a gender perspective, while policies and stakeholders addressing gender equality do not adequately consider NCDs. The gendered social and economic aspects of the NCD burden are not widely understood, and the multi-sectoral approach needed to address these aspects is lacking. Economic obstacles show that budget cuts exacerbated by the pandemic are a significant obstacle to social protection mechanisms to support those caring for people living with NCDs. CONCLUSIONS: Moving towards an effective, equity-promoting health and social protection system requires the government to adopt an intersectoral, gender-based approach to the prevention and control of NCDs and the burden of NCD care. Despite significant resource constraints, policy innovation may be possible given the willingness among some stakeholders to collaborate, particularly in the labour and legal sectors. However, care will be needed to ensure the implementation of new policies has a positive impact on both gender equity and health outcomes. Research on successful approaches in other contexts can help to identify relevant learnings for Mexico.

Segmentation and fragmentation of health systems and the quest for universal health coverage: conceptual clarifications from the Mexican case.

Health systems are complex entities. The Mexican health system includes the private and public sectors, and subsystems that target different populations based on corporatist criteria. Lack of unity and its consequences can be better understood using two concepts, segmentation and fragmentation. These reveal mechanisms and strategies that impede progress toward universality and equity in Mexico and other low- and middle-income countries. Segmentation refers to separation of the population by position in the labour market. Fragmentation refers to institutions, and to financial aspects, health care levels, states' systems of care, and organizational models. These elements explain inequitable allocation of resources and packages of health services offered by each institution to its population. Overcoming segmentation will require a shift from employment to citizenship as the basis for eligibility for public health care. Shortcomings of fragmentation can be avoided by establishing a common package of guaranteed benefits. Mexico illustrates how these two concepts characterize a common reality in low- and middle-income countries.

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.

Understanding the social determinants of child mortality in Latin America over the last two decades: a machine learning approach.

The reduction of child mortality rates remains a significant global public health challenge, particularly in regions with high levels of inequality such as Latin America. We used machine learning (ML) algorithms to explore the relationship between social determinants and child under-5 mortality rates (U5MR) in Brazil, Ecuador, and Mexico over two decades. We created a municipal-level cohort from 2000 to 2019 and trained a random forest model (RF) to estimate the relative importance of social determinants in predicting U5MR. We conducted a sensitivity analysis training two more ML models and presenting the mean square error, root mean square error, and median absolute deviation. Our findings indicate that poverty, illiteracy, and the Gini index were the most important variables for predicting U5MR according to the RF. Furthermore, non-linear relationships were found mainly for Gini index and U5MR. Our study suggests that long-term public policies to reduce U5MR in Latin America should focus on reducing poverty, illiteracy, and socioeconomic inequalities. This research provides important insights into the relationships between social determinants and child mortality rates in Latin America. The use of ML algorithms, combined with large longitudinal data, allowed us to evaluate the effects of social determinants on health more carefully than traditional models.

Design and validation of indicators for the comprehensive measurement of quality of care for type 2 diabetes and acute respiratory infections in ambulatory health services.

Developing ambulatory health services (AHS) of optimal quality is a pending issue for many health systems at a global level, especially in middle- and low-income countries. An effective health response requires indicators to measure the quality of care that are context-specific and feasible for routine monitoring. This paper aimed to design and validate indicators for assessing the technical and interpersonal quality dimensions for type 2 diabetes (T2D) and acute respiratory infections (ARI) care in AHS. The study was conducted in two stages. First, technical and user-centered-based indicators of quality of care for T2D and ARI care were designed following international recommendations, mainly from the American Diabetes Association standards and the National Institute for Health and Care Excellence guidelines. We then assessed the validity, reliability, relevance, and feasibility of the proposed indicators implementing the modified Delphi technique. A panel of 17 medical experts from five countries scored the indicators using two electronic questionnaires, one for each reason for consultation selected, sent by email in two sequential rounds of rating. We defined the levels of consensus according to the overall median for each performance category, which was established as the threshold. Selected indicators included those with scores equal to or higher than the threshold. We designed 36 T2D indicators, of which 16 were validated for measuring the detection of risks and complications, glycemic control, pharmacological treatment, and patient-centered care. Out of the 22 indicators designed for ARI, we validated 10 for diagnosis, appropriate prescription of antimicrobials, and patient-centered care. The validated indicators showed consistency for the dimensions analyzed. Hence, they proved to be a potentially reliable and valuable tool for monitoring the performance of the various T2D and ARI care processes in AHS. Further research will be needed to verify the applicability of the validated indicators in routine clinical practice.

Proximal determinants of suboptimal early child development during the first three years of life in socially deprived Mexican contexts.

Assessing the status and determinants of early child development (ECD) requires accurate and regularly updated measurements. Yet, little information has been published on the subject in low- and middle-income countries, particularly regarding the proximal determinants of childhood development in contexts of high social marginalization. This article analyzes the factors that favor or mitigate suboptimal ECD outcomes in Mexico. A cross-sectional study was conducted using recently collected data for 918 children aged 0-38 months from socially marginalized communities in 23 Mexican municipalities. The ECD outcomes of the children were estimated based on indicators of chronic undernutrition and neurodevelopment (normal, lagging and at risk of delay). The distribution of outcomes was described across the ECD proximal determinants analyzed, including the co-occurrence of chronic undernutrition and suboptimal neurodevelopment. Covariate-adjusted prevalence of the ECD outcomes and co-occurrences were calculated as post-estimations from a multiple multinomial logistic regression. The prevalence of chronic undernutrition was 23.5%; 45.9% of children were classified with neurodevelopmental lag, and 11% at risk of neurodevelopmental delay. The prevalence of stunting co-occurring with suboptimal neurodevelopment came to 15.4%. The results of the multinomial logistic regression model indicated that early gestational age, low birth weight, a low household socioeconomic level, being male and having numerous siblings were all associated with the co-occurrence of chronic undernutrition and suboptimal child neurodevelopment. This study identified important predictors of child development in the first three years of life, specifically in two of its principal indicators: nutritional and neurodevelopmental status. Most of the predictors observed can be improved by means of social programs and interventions. Trial registration: ClinicalTrials.gov ID: NCT04210362.

Increase of catastrophic and impoverishing health expenditures in Mexico associated to policy changes and the COVID-19 pandemic.

Background: In 2003, the Mexican Congress approved a major reform to provide health care services to the poor population through the public insurance scheme Seguro Popular. This program was dismantled in 2019 as part of a set of health system reforms and substituted with the Health Institute for Welfare (INSABI). These changes were implemented during the initial phases of the coronavirus (COVID-19) pandemic. We aimed to examine the impact of these reforms and the COVID-19 pandemic on financial risk protection in Mexico between 2018 and 2020. Methods: We performed a population-based analysis using cross-sectional data from the 2018 and 2020 rounds of the National Household Income and Expenditures Survey. We used a pooled fixed-effects multivariable two-stage probit model to determine the likelihood of catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and excessive health expenditure (EHE) among Mexican households. We also mapped the quintiles of changes in EHE in households without health insurance by state. Results: The percentage of households without health insurance almost doubled from 8.8% (three million households) in 2018 to 16.5% (5.8 million households) in 2020. We also found large increases in the proportion of households incurring in CHE (18.4%; 95% confidence interval (CI) = 6.1, 30.7) and EHE (18.7%; 95% CI = 7.9, 29.5). Significant increases in CHE, IHE, and EHE were only observed among households without health insurance (CHE: 90.7%; 95% CI = 31.6, 149.7, EHE: 73.5%; 95% CI = 25.3, 121.8). Virtually all Mexican states (n/N = 31/32) registered an increase in EHE among households without health insurance. This increase has a systematic territorial component affecting mostly central and southern states (range = -1.0% to 194.4%). Conclusions: The discontinuation of the Seguro Popular Program and its substitution with INSABI during the first stages of the COVID-19 pandemic reduced the levels of health care coverage in Mexico. This reduction and the pandemic increased out-of-pocket expenditure in health and the portion of CHE and EHE in the 2018-2020 period. The effect was higher in households without health insurance and households in central and southern states of the country. Further studies are needed to determine the specific effect both of recent policy changes and of the COVID-19 pandemic on the levels of financial protection in health in Mexico.

Inequitable Financial Protection in Health for Indigenous Populations: the Mexican Case.

BACKGROUND: There is an important gap in the literature concerning the level, inequality, and evolution of financial protection for indigenous (IH) and non-indigenous (NIH) households in low- and middle-income countries. This paper offers an assessment of the level, socioeconomic inequality and middle-term trends of catastrophic (CHE), impoverishing (IHE), and excessive (EHE) health expenditures in Mexican IHs and NIHs during the period 2008-2020. METHODS: We conducted a pooled cross-sectional analysis using the last seven waves of the National Household Income and Expenditure Survey (n = 315,829 households). We assessed socioeconomic inequality in CHE, IHE, and EHE by estimating their Wagstaff concentration indices according to indigenous status. We adjusted the CHE, IHE, and EHE by estimating a maximum-likelihood two-stage probit model with robust standard errors. RESULTS: We observed that, during the period analyzed, CHE, IHE, and EHE were concentrated in the poorest IHs. CHE decreased from 5.4% vs. 4.7% in 2008 to 3.4% vs. 2.9% in 2014 in IHs and NIHs, respectively, and converged at 2008 levels towards 2020. IHE remained unchanged from 2008 to 2014 (1.6% for IHs vs. 1.0% for NIHs) and increased by 40% in IHs and NIHs during 2016-2020. EHE plunged in 2014 (4.6% in IHs vs. 3.8% in NIHs), then rose, and remained unchanged during 2016-2020 (6.7% in IHs and 5.6% in NIHs). CONCLUSION: In pursuit of universal health coverage, health authorities should formulate and implement effective financial protection mechanisms to address structural inequalities, especially forms of discrimination including racialization, that vulnerable social groups such as indigenous peoples have systematically faced. Doing so would contribute to closing the persistent ethnic gaps in health.

Setbacks in the quest for universal health coverage in Mexico: polarised politics, policy upheaval, and pandemic disruption.

2023 marks the 20-year anniversary of the creation of Mexico's System of Social Protection for Health and the Seguro Popular, a model for the global quest to achieve universal health coverage through health system reform. We analyse the success and challenges after 2012, the consequences of reform ageing, and the unique coincidence of systemic reorganisation during the COVID-19 pandemic to identify strategies for health system disaster preparedness. We document that population health and financial protection improved as the Seguro Popular aged, despite erosion of the budget and absent needed reforms. The Seguro Popular closed in January, 2020, and Mexico embarked on a complex, extensive health system reorganisation. We posit that dismantling the Seguro Popular while trying to establish a new programme in 2020-21 made the Mexican health system more vulnerable in the worst pandemic period and shows the precariousness of evidence-based policy making to political polarisation and populism. Reforms should be designed to be flexible yet insulated from political volatility and constructed and managed to be structurally permeable and adaptable to new evidence to face changing health needs. Simultaneously, health systems should be grounded to withstand systemic shocks of politics and natural disasters.

Origin, impacts, and potential solutions to the fragmentation of the Mexican health system: a consultation with key actors.

BACKGROUND: One of the central debates in health policy is related to the fragmentation of health systems. Fragmentation is perceived as a major obstacle to UHC. This article presents the results of a consultation with a group of actors of the Mexican policy arena on the origins and impacts of the fragmentation of the Mexican health system. METHODS: We used a consultation to nine key actors to collect thoughts on the fragmentation of the Mexican health system. The group included national and local decision makers with experience in health care issues and researchers with background in health systems and/or public policies. The sessions were recorded, transcribed verbatim and analyzed thematically. RESULTS: Participants defined the term 'fragmentation' as the separation of the various groups of the population based on characteristics which define their access to health care services. This is a core characteristic of health systems in Latin America (LA). In general, those affiliated to social security institutions have a higher per capita expenditure than those without social security, which translates into differential health benefits. According to the actors in this consultation, fragmentation is the main structural problem of the Mexican health system. Actors agreed that the best way to end fragmentation is through the creation of a universal health system. Defragmentation plans should include a research component to document the impacts of fragmentation, and design and test the instruments needed for the integration process. CONCLUSIONS: First, health system fragmentation in Mexico has created problems of equity since different population groups have unequal access to public resources and different health benefits. Second, Mexico needs to move beyond the fragmentation of its health system and guarantee, through its financial integration, access to the same package of health services to all its citizens. Third, defragmentation plans should include a research component to document the impacts of fragmentation, and design and test the instruments needed for the integration process. Fourth, defragmentation of health systems is not an easy task because there are vested interests that oppose its implementation. Political strategies to meet the resistance of these groups are an essential component of any defragmentation plan.

Burden of non-communicable diseases and behavioural risk factors in Mexico: Trends and gender observational analysis.

Background: There is scarce gender-disaggregated evidence on the burden of disease (BD) worldwide and this is particularly prominent in low- and middle-income countries. The objective of this study is to compare the BD caused by non-communicable diseases (NCDs) and related risk factors by gender in Mexican adults. Methods: We retrieved disability-adjusted life years (DALYs) estimates for diabetes, cancers and neoplasms, chronic cardiovascular diseases (CVDs), chronic respiratory diseases (CRDs), and chronic kidney disease (CKD) from the Global Burden of Disease (GBD) Study from 1990-2019. Age-standardized death rates were calculated using official mortality microdata from 2000 to 2020. Then, we analysed national health surveys to depict tobacco and alcohol use and physical inactivity from 2000-2018. Women-to-men DALYs and mortality rates and prevalence ratios (WMR) were calculated as a measure of gender gap. Findings: Regarding DALYs, WMR was >1 for diabetes, cancers, and CKD in 1990, indicating a higher burden in women. WMR decreased over time in all NCDs, except for CRDs, which increased to 0.78. However, WMR was <1 for all in 2019. The mortality-WMR was >1 for diabetes and cardiovascular diseases in 2000 and <1 for the rest of the conditions. The WMR decreased in all cases, except for CRDs, which was <1 in 2020. The WMR for tobacco and alcohol use remained under 1. For physical inactivity, it was >1 and increasing. Conclusions: The gender gap has changed for selected NCDs in favour of women, except for CRDs. Women face a lower BD and are less affected by tobacco and alcohol use but face a higher risk of physical inactivity. Policymakers should consider a gendered approach for designing effective policies to reduce the burden of NCDs and health inequities.

An assessment of the performance of the Mexican health system between 2000 and 2018.

This paper offers a comprehensive picture of the performance of the Mexican health system during the period 2000-18. Using high-quality and periodical data from the Organization for Economic Cooperation and Development, the World Bank, the Institute for Health Metrics and Evaluation and Mexico's National Survey of Household Income and Expenditure, we assess the evolution of seven types of indicators (health expenditure, health resources, health services, quality of care, health care coverage, health conditions and financial protection) over a period of 18 years during three political administrations. The reform implemented in Mexico in the period 2004-18-which includes the creation of 'Seguro Popular'-and other initiatives helped improve the financial protection levels of the Mexican population, expressed in the declining prevalence of catastrophic and impoverishing health expenditures, and various health conditions (consumption of tobacco in adults and under-five, maternal, cervical cancer and human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) mortality rates). We conclude that policies intended to move towards universal health coverage should count on strong financial mechanisms to guarantee the consistent expansion of health care coverage and the sustainability of reform efforts. However, the mobilization of additional resources for health and the expansion of health care coverage do not guarantee by themselves major improvements in health conditions. Interventions to deal with specific health needs are also needed.

A Gender-Based and Quasi-Experimental Study of the Catastrophic and Impoverishing Health-Care Expenditures in Mexican Households with Elderly Members, 2000-2020.

Latin America has experienced a rise in noncommunicable diseases (NCDs) which is having repercussions on the structuring of healthcare delivery and social protection for vulnerable populations. We examined catastrophic (CHE) and excessive (EHE, impoverishing and/or catastrophic) health care expenditures in Mexican households with and without elderly members (≥65 years), by gender of head of the households, during 2000-2020. We analyzed pooled cross-sectional data for 380,509 households from eleven rounds of the National Household Income and Expenditure Survey. Male- and female-headed households (MHHs and FHHs) were matched using propensity scores to control for gender bias in systematic differences regarding care-seeking (demand for healthcare) preferences. Adjusted probabilities of positive health expenditures, CHE and EHE were estimated using probit and two-stage probit models, respectively. Quintiles of EHE by state among FHHs with elderly members were also mapped. CHE and EHE were greater among FHHs than among MHHs (4.7% vs 3.9% and 5.5% vs 4.6%), and greater in FHHs with elderly members (5.8% vs 4.9% and 6.9% vs 5.8%). EHE in FHHs with elderly members varied geographically from 3.9% to 9.1%, being greater in less developed eastern, north-central and southeastern states. Compared with MHHs, FHHs face greater risks of CHE and EHE. This vulnerability is exacerbated in FHHs with elderly members, because of gender intersectional vulnerability. The present context, marked by a growing burden of NCDs and inequities amplified by COVID-19, makes key interlinkages across multiple Sustainable Development Goals (SDGs) apparent, and calls for urgent measures that strengthen social protection in health.

Nursing practice environment and missed care at highly specialised hospitals in Mexico: A cross-sectional observational study.

BACKGROUND: The influence of the work environment on missed care and service quality has been well documented. However, available evidence concerning this relationship comes mostly from developed countries. Few studies have been conducted in low- or middle-income countries. We assessed the relationship between the work environment and missed nursing care in highly specialised hospitals in Mexico. METHODS: We conducted an observational cross-sectional study with data collected from January 2019 to February 2020 in 11 highly specialised hospitals (n = 510 nurses). We estimated missed nursing care utilising the MISSCARE questionnaire and used the Practice Environment Scale-Nursing Work Index instrument to assess the work environment. After describing the main attributes of the study sample according to the type of work environment, we constructed five adjusted fractional regression models, the first concerning the overall index of missed care, and the others pertaining to its various dimensions. RESULTS: The sample analysed was balanced as regards adjustment variables according to the type of work environment. The adjusted estimates confirmed an inverse relationship between the missed care index and enjoying an enhanced, or favourable, work environment. Overall, the difference was 9 percentage points (pp); however, by dimension of missed care, the major differences between enhanced and attenuated, or unfavourable, work environments were registered for basic care, followed by patient education and discharge planning (4pp) and individual needs (8pp). CONCLUSIONS: The work environment determines the frequency of missed nursing care, both overall and by dimension. Nursing managers need to create short- and mid-term strategies favouring positive work environments in order to improve working conditions for nursing professionals.

Out-of-pocket expenditure on medicines in Bangladesh: An analysis of the national household income and expenditure survey 2016-17.

BACKGROUND AND OBJECTIVES: High out-of-pocket expenditures (OOPE) increases the probability that households will become impoverished or will forgo needed care. The aim of this paper is to study household medicines expenditure and its associated determining factors to develop policies to protect households from financial hardship. METHODS: The present cross-sectional and population-level study used the Bangladesh 2016-17 National Household Income and Expenditure Survey (HIES). The final sample size was 46,080 households. We analyzed the probability of OOPE for medicines, the share of total OOPE due to medicines out of total OOPE in health (reported as a ratio between zero and one), the OOPE amount for medicines reported (in United States Dollars), and the share of OOPE amount on medicines out of total household expenditure (reported as a ratio between zero and one). Predictors of analyzed outcomes were identified using three regression models. RESULTS: Out of those households who spent on healthcare, the probability of having any OOPE on medicines was 87.9%. Of those who spent on medicines, the median monthly expenditure was US$3.03. The poorest households spent 9.97% of their total household expenditure as OOPE on medicines, nearly double that of the wealthiest households (5.86%). The characteristic which showed the most significant correlation to a high OOPE on medicines was the presence of chronic diseases, especially cancer. Twenty six percent of all surveyed households spend more than 10% of their OOPE on medicines. CONCLUSIONS: Our study shows that financial protection should be targeted at the poorest quintiles and such protection should include enrollment of rural households. Further, outpatient medicines benefits should include those for non-communicable diseases (NCDs).

Predictors of maternal knowledge on early childhood development in highly marginalized communities in Mexico: Implications for public policy.

INTRODUCTION: Efforts to identify the predictors of maternal knowledge on Early Child Development (ECD) have proven inconclusive thus far, particularly with respect to socially deprived contexts in Low- and Middle-Income Countries (LMICs). We quantified the extent of ECD knowledge among mothers who were the primary caregivers of 0-38-month-old infants in marginalized communities in Mexico. We also explored the characteristics of the children, both individually and with regard to their households, given the influence of these factors on childhood development. METHODS: We analyzed primary data obtained through a questionnaire administered to mothers who were the primary caregivers of 1045 girls and boys 0-38 months of age. The instrument was specifically designed for our study in order to explore the knowledge of participants about physical, neurological and psycho-affective development during childhood. We performed fractional regression analysis to assess the predictors of ECD knowledge. RESULTS: The mean score of maternal ECD knowledge increased with their age and schooling as well as with their levels of cognitive ability and self-esteem. Irrespective of age at first birth, mean knowledge was relatively high for women with high school education and low for women with elementary or no formal education, a gradient with respect to age at fist birth was more marked among women with middle school education. ECD knowledge scores increased among mothers from households enjoying higher socioeconomic levels and from households with health insurance. Scores were lower for indigenous households regardless of their participation in social programs. CONCLUSION: Public policies on ECD should promote programs that are not only adapted to specific contexts, but also designed to improve shared child-rearing, early childhood care and as well as psycho-emotional education skills as a pathway to healthier ECD. The participation of families and communities in sensitive childhood care should form part of multisectoral programs involving education, health and wellbeing.

The Role of Effective Knowledge on Contraceptive Methods Use in the Replication of Mother-Daughter Adolescent Pregnancy in Mexico.

An important gap in the literature is the analysis of the role of effective knowledge concerning use of contraceptive methods in the intergenerational reproduction of adolescent pregnancy in low- and middle-income countries. Using data from the 2014 Mexico National Survey of Demographic Dynamics, we conducted a retrospective cohort and complete case analysis of women aged ≤ 19 years cohabitating with their mothers and who self-reported having had sexual intercourse at the moment of the survey (n = 5143). We estimated instrumental variable probit models (IV-probit) to assess the association between effective knowledge concerning the use of contraceptive methods and adolescent pregnancy. We stratified our models according to parental history of adolescent pregnancy. Adolescent pregnancy prevalence in our sample was 58.7%. The IV-probit model showed that mothers with a history of adolescent pregnancy were 12.1 percentage points more likely to have daughters who experience adolescent pregnancy. In addition, daughters with effective knowledge concerning the use of contraceptive methods were 1.3 percentage points less likely to experience an adolescent pregnancy. Our findings carry relevant implications for policies seeking to reduce adolescent pregnancy. They highlight the need for policies and programs that tackle the intergenerational transmission of sexual and reproductive behaviors by increasing the information available to adolescents and enhancing their effective knowledge about the use of contraceptive methods. Identifying population groups at higher risk of adolescent pregnancy can contribute to the design of successful reproductive health policies in Mexico and other low- and middle-income countries.

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.

Overcoming the health systems' segmentation to achieve universal health coverage in Mexico.

Health is a human right that everyone should be able to exercise. Yet health systems segmentation and fragmentation are a major challenge to advancing universal health coverage (UHC) and achieving health equity. Between 2019 and 2020, Mexico launched a profound restructuration of its health system claiming its aim was to attain UHC, free healthcare services and drugs and to combat corruption. We analyse the implications of the modifications of the Mexican Constitution and the dismantling of the Seguro Popular de Salud (Popular Health Insurance) in relation to segmentation. We argue that, instead of advancing towards UHC and equality, these changes reinforce inequalities and that transforming health systems must respect human rights.