COVID-19 Vaccination Hesitancy in Mexico City among Healthy Adults and Adults with Chronic Diseases: A Survey of Complacency, Confidence, and Convenience Challenges in the Transition to Endemic Control.

Background. Monitoring of SARS-COV-2 vaccine hesitancy is important for epidemic control. We measured vaccine hesitancy among healthy adults and adults with chronic diseases after they had been offered the first dose of the vaccine in Mexico City. Methods. An observational cross-sectional study was undertaken among 185 healthy adults and 175 adults living with chronic diseases. Differences in means of variables for confidence, complacency, and convenience were analyzed. Aggregate indicators were constructed and their association with socioeconomic and demographic conditions and vaccination acceptance analyzed using multivariate analysis of variance and multivariate logistic analysis. Results. Up to 16.8% of healthy adults and 10.3% of sick adults reported not having received the SARS-COV-2 vaccine. Healthy adults were more complacent about COVID-19 risks than adults with chronic diseases, while no differences were found between the two groups regarding other hesitancy aggregate indicators. Among adults with chronic diseases, those with more education and enrolled with a social insurance institution were less complacent of COVID-19, while education was positively associated with convenience across both groups. Less complacency with COVID-19 and more confidence in the vaccine were associated with higher vaccine acceptance across both groups. Among adults living with chronic diseases, the odds ratios of vaccine acceptance were higher for less complacency (OR = 2.4, p = 0.007) than for confidence (OR = 2.0, p = 0.001). Odds ratios of vaccine acceptance in these two hesitancy indicators were similar among healthy adults (OR = 3.3, p = <0.005) and higher than for adults with comorbidities. Conclusions. Confidence in the vaccine and complacency regarding COVID-19 risks play an important role for vaccine acceptance in Mexico City, particularly among healthy adults. The perception of risk regarding COVID-19 is more important than confidence in vaccine safety and effectiveness. Promotion of COVID-19 vaccines needs to focus on decreasing complacency with COVID-19 and increasing vaccine confidence, particularly among healthy adults.

Barriers and facilitators to influenza vaccination observed by officers of national immunization programs in South America countries with contrasting coverage rates.

Influenza is a severe, vaccine-preventable disease. Vaccination programs across Latin American countries show contrasting coverage rates, from 29% in Paraguay to 89% in Brazil. This study explores how national influenza vaccination programs in the chosen South American countries address vaccine confidence and convenience, as well as complacency toward the disease. Barriers and facilitators to influenza vaccination programs in their relation to vaccine hesitancy were observed by documentary analysis and interviews with 38 national immunization program officers in high- (Brazil and Chile) and low-performing (Paraguay, Peru, and Uruguay) countries. Influenza vaccination policies, financing, purchasing, coordination, and accessibility are considered good or acceptable. National communication strategies focus on vaccine availability during campaigns. In Chile, Paraguay, and Uruguay, anti-vaccine propaganda was mentioned as a problem. Programming and implementation face human resource shortages across most countries. Statistical information, health information systems, and nominal risk-group records are available, with limitations in Peru and Paraguay. Health promotion, supervision, monitoring, and evaluation are perceived as opportunities to address confidence and complacency. Influenza vaccination programs identify and act on most barriers and facilitators affecting influenza vaccine hesitancy via supply-side strategies which mostly address vaccine convenience. Confidence and complacency are insufficiently addressed, except for Uruguay. Programs have the opportunity to develop integral supply and demand-side approaches.

Barriers and facilitators to influenza vaccination observed by officers of national immunization programs in South America countries with contrasting coverage rates / Barreras y facilitadores de la vacuna contra la gripe observados por funcionarios de los programas nacionales de inmunización en países de Suramérica con niveles de cobertura contrastantes / Barreiras e facilitadores da vacinação contra influenza observados por funcionários dos programas nacionais de imunização em países Sul-Americanos com diferentes níveis de cobertura

Influenza is a severe, vaccine-preventable disease. Vaccination programs across Latin American countries show contrasting coverage rates, from 29% in Paraguay to 89% in Brazil. This study explores how national influenza vaccination programs in the chosen South American countries address vaccine confidence and convenience, as well as complacency toward the disease. Barriers and facilitators to influenza vaccination programs in their relation to vaccine hesitancy were observed by documentary analysis and interviews with 38 national immunization program officers in high- (Brazil and Chile) and low-performing (Paraguay, Peru, and Uruguay) countries. Influenza vaccination policies, financing, purchasing, coordination, and accessibility are considered good or acceptable. National communication strategies focus on vaccine availability during campaigns. In Chile, Paraguay, and Uruguay, anti-vaccine propaganda was mentioned as a problem. Programming and implementation face human resource shortages across most countries. Statistical information, health information systems, and nominal risk-group records are available, with limitations in Peru and Paraguay. Health promotion, supervision, monitoring, and evaluation are perceived as opportunities to address confidence and complacency. Influenza vaccination programs identify and act on most barriers and facilitators affecting influenza vaccine hesitancy via supply-side strategies which mostly address vaccine convenience. Confidence and complacency are insufficiently addressed, except for Uruguay. Programs have the opportunity to develop integral supply and demand-side approaches.

La gripe es una enfermedad grave, prevenible mediante vacunas con sus correspondientes programas en países latinoamericanos, informando sobre tasas contrastadas de cobertura, desde el 29% en Paraguay al 89% en Brasil. Este artículo investiga cómo los programas nacionales contra la gripe en países seleccionados de Suramérica abordan la confianza en la vacuna y su conveniencia, así como también la complacencia hacia la enfermedad. Las barreras y facilitadores del programa de vacunación de la gripe, en su relación con la vacilación hacia la vacuna, se observaron mediante análisis documental y entrevistas a 38 a cargo de los programas nacionales de inmunización en países con alto (Brasil y Chile) y bajo desempeño (Paraguay, Perú y Uruguay). Políticas de vacunación contra la gripe, financiamiento, compras coordinación y accesibilidad fueron consideradas como buenas o aceptables. Las estrategias nacionales de comunicación se centran en la disponibilidad de la vacuna durante las campañas. En Chile, Paraguay y Uruguay la propaganda antivacunas fue mencionada como un problema. La planificación e implementación enfrentan escasez de recursos humanos en la mayoría de países a través de la mayoría de países. Los sistemas de información en salud, estadísticas y registros nominales por grupos de riesgo se encuentran disponibles con limitaciones en Perú y Paraguay. La promoción de la salud, supervisión, monitoreo y evaluación son percibidos como oportunidades para abordar la confianza y complacencia. Los programas de vacunación contra la gripe actúan principalmente sobre las barreras y facilitadores que afectan la vacilación a vacunarse mediante estrategias del lado de la demanda, las cuales en su mayor parte van dirigidas a contrarestar la conveniencia. La confianza y complacencia son insuficientemente abordadas en todos los países, excepto en Uruguay. Los programas tienen la oportunidad de desarrollar estrategias que aborden tanto el lado de la oferta como de la demanda.

A influenza é uma doença grave, imunoprevenível, para a qual os programas de vacinação nos países latino-americanos apresentam taxas de cobertura contrastantes, desde 29% no Paraguai até 89% no Brasil. O artigo explora de que maneira os programas nacionais de influenza em países selecionados da América do Sul lidam com a confiança e a conveniência da vacina, assim como, a acomodação em relação à doença. As barreiras e facilitadores dos programas de vacinação contra influenza foram observados em relação à hesitação vacinal, através de análise documental e entrevistas com 38 autoridades de programas nacionais de imunização em países com desempenho alto (Brasil e Chile) e baixo (Paraguai, Peru e Uruguai). As políticas de vacinação contra influenza, financiamento da compra de vacinas, coordenação e acessibilidade são consideradas boas ou aceitáveis. As estratégias nacionais de comunicação estão concentradas na disponibilidade durante campanhas. No Chile, Paraguai e Uruguay, a propaganda antivacina foi mencionada enquanto problema. A programação e a implementação enfrentam escassez de recursos humanos na maioria dos países. Dados estatísticos, sistemas de informação em saúde e registros nominais de grupos de risco estão disponíveis, com limitações no Peru e no Paraguai. A promoção da saúde, supervisão, monitoramento e avaliação foram percebidas como oportunidades para tratar da confiança e da acomodação. Os programas de vacinação contra influenza identificam e agem sobre a maioria das barreiras e facilitadores que afetam a hesitação vacinal através de estratégias do lado da oferta, tratando principalmente da conveniência da vacina. A confiança e a acomodação não são tratadas de maneira suficiente, com exceção notável do Uruguai. Os programas têm a oportunidade de desenvolver abordagens que integram os lados da oferta e da procura.

Influenza vaccination hesitancy in large urban centers in South America. Qualitative analysis of confidence, complacency and convenience across risk groups.

Influenza vaccination coverage in countries of Latin America is low among priority risk groups, ranging from 5 to 75% among older people. This paper aims to describe and analyze the determinants of influenza vaccination hesitancy through the lens of the 3C model of confidence, complacency and convenience among middle-class, urban risk group populations in Brazil, Chile, Paraguay, Peru, Uruguay, countries in South America with contrasting vaccination coverage. Focus groups were conducted among four risk groups: pregnant women, mothers of children aged <6 years, adults with risk factors, and adults aged ≥60 years in samples of urban residents. Adults with risk factors expressed the most detailed perceptions about confidence in the vaccine. A wide range of perceptions regarding complacency were expressed across risk groups and countries, with pregnant women and mothers showing greater concerns while convenience had a narrower and generally more positive range of perceptions. Participants from Chile and Paraguay expressed the most contrasts regarding confidence and complacency. Information and communication strategies need to be tailored for risk groups while confidence and complacency should be addressed in synergy.

The importance of confidence, complacency, and convenience for influenza vaccination among key risk groups in large urban areas of Peru.

Influenza vaccination has been available under Peru's national immunization program since 2008, but vaccination coverage has decreased lately. Surveys and focus groups were conducted among four risk groups (pregnant women, mothers of children aged <6 years, adults with risk factors, and adults aged ≥65 years) to identify factors affecting influenza vaccine hesitancy in Peru. The 3Cs model (Confidence, Complacency, and Convenience) was used as a conceptual framework for the study. Most pregnant women and mothers of young children (70.0%), but less than half (46.3%) of older adults and adults with risk factors were vaccinated against influenza. Vaccine confidence and complacency were positively associated with educational level. Complacency was the most deficient of the 3Cs. Pregnant women and mothers were the most informed and least complacent among risk groups. Focus groups revealed the misconceptions behind the high level of complacency observed, including the perception of influenza risk and the role assigned to vaccination in preventing the disease. Interviews with officials identified that most strategies are directed to vaccination availability and hence to convenience, with opportunities for strategies to improve vaccination uptake and community engagement. The results highlight the importance of implementing in Peru communication strategies to increase perceptions of vaccine safety and effectiveness thus improving confidence and reducing complacency. The establishment of explicit incentives should also be considered to increase vaccination uptake, particularly to health personnel.

Diabetes care innovation in the Mexican Institute for Social Insurance: Scaling up the preventive chronic disease care model to address critical coverage constraints.

BACKGROUND: With diabetes prevalence in Mexico at 11.3% of adults, the Mexican Institute of Social Insurance (IMSS) is piloting the Chronic Disease Preventive Model (CDPM). CDPM includes intensive patient education, care by multidisciplinary teams and risk management in primary care. The objective of this article is to determine CDPM coverage bottlenecks and to explore facilitators and barriers to implementation. METHODS: The National Health and Nutrition Survey 2018 was processed to identify key diabetes prevalence, coverage, quality and outcome indicators. Key IMSS informant interviews and document content analyses were undertaken following the Tanahashi coverage decay model and the Consolidated Framework for Implementation Research (CFIR). RESULTS: IMSS screens 49% of adult beneficiaries for diabetes but only 26% with presumptive diagnosis proceed to confirmation. Out of 4.1 million adults with diabetes, IMSS diagnoses 94% and treats 85%. Medications are received by 90% of patients but only 63% of those requiring insulin receive it. The overall quality of care indicator attains 37% of potential. Coverage of diabetes education, monitoring with HbA1c and interdisciplinary care are 20%, 15% and 3%, respectively. Among IMSS beneficiaries treated by the institute 38.1% have HbA1c levels below 7% and 26.1% have levels above 9%. CDPM facilitators are the perceived threat of uncontrolled diabetes, compatibility of innovation values and willingness for institutional learning. Barriers are centralized decision making, functional differentiation across managers and practitioners and lack of incentives, resource shortages and the lack of measures to ensure fidelity. CONCLUSIONS: CDPM scale-up has to address organizational and process barriers while ensuring the necessary resources for sustainability.

Influenza vaccination hesitancy in five countries of South America. Confidence, complacency and convenience as determinants of immunization rates.

INTRODUCTION: Influenza morbidity and mortality are significant in the countries of South America, yet influenza vaccination is as low as 56.7% among pregnant women, reaching 76.7% of adults with chronic diseases. This article measures the relative values for the vaccination hesitancy indicators of confidence, complacency and convenience by risk-groups in urban areas of five countries of South America with contrasting vaccination rates, analyzing their association with sociodemographic variables and self-reported immunization status. METHODS: An exit survey was applied to 640 individuals per country in Brazil, Chile, Paraguay, Peru and Uruguay, distributed equally across risk groups of older adults, adults with risk factors, children ≤6 and pregnant women. Indicators were constructed for vaccine confidence, complacency and convenience. Analysis of variance and multiple logistic analysis was undertaken. RESULTS: Adults with risk factors are somewhat more confident of the influenza vaccine yet also more complacent. Convenience is higher for mothers of minors. Children and older adults report higher levels of vaccination. The 3Cs are more different across countries than across risk groups, with values for Chile higher for confidence and those for Uruguay the lowest. Complacency is lower in Brazil and higher in Uruguay. Results suggest that confidence and complacency affect vaccination rates across risk groups and countries. CONCLUSIONS: Influenza vaccine confidence, complacency and convenience have to be bolstered to improve effective coverage across all risk groups in the urban areas of the countries studied. The role played by country contextual and national vaccination programs has to be further researched in relation to effective coverage of influenza vaccine.

Increased Risk of Hospitalization and Death in Patients with COVID-19 and Pre-existing Noncommunicable Diseases and Modifiable Risk Factors in Mexico.

BACKGROUND: The population in Mexico has high prevalence rates of noncommunicable diseases (NCDs). Hospitalization and death of COVID-19 patients in the countries most affected by the pandemic has been associated to chronic comorbidities. OBJECTIVE: To describe the prevalence of NCDs in patients with COVID-19 in Mexico and analyze the increased risk due to comorbidities and risk factors on hospitalization, utilization of intensive care units and death. METHODS: A cross-sectional study was performed from 212,802 confirmed COVID-19 cases reported by the Ministry of Health up to June 27, 2020. Odds ratios were performed using logistic regression model. RESULTS: Up to 47.40% of patients with COVID-19 diagnosis were also reported with a comorbidity, with hypertension being the most frequent (20.12%). The report of at least one NCD significantly increased the risk of death with respect to patients without such diagnoses. Chronic kidney disease increased the risk of death the most (OR 2.31), followed by diabetes (OR 1.69), immunosuppression (OR 1.62), obesity (OR 1.42), hypertension (OR 1.24), chronic obstructive pulmonary disease (OR 1.20). The comorbidities that most increased the risk of ICU and of intubation were diabetes, immunosuppression and obesity. CONCLUSION: NCD comorbidities increase the severity of COVID-19 infection. Given high NCD prevalence rates among the Mexican population, the pandemic poses a special threat to the health system and to society. Special prevention measures need to be strengthened for persons with NCD diagnoses in the short-term. In the mid-term, disease control strategies need to be improved to protect these patients against COVID-19 severity.

Health policy and systems research publications in Latin America warrant the launching of a new specialised regional journal.

BACKGROUND: Scientific journals play a critical role in research validation and dissemination and are increasingly vocal about the identification of research priorities and the targeting of research results to key audiences. No new journals specialising in health policy and systems research (HPSR) and focusing in the developing world or in a specific developing world region have been established since the early 1980s. This paper compares the growth of publications on HPSR across Latin America and the world and explores the potential, feasibility and challenges of innovative publication strategies. METHODS: A bibliometric analysis was undertaken using HPSR MeSH terms with journals indexed in Medline. A survey was undertaken among 2500 authors publishing on HPSR in Latin America (LA) through an online survey, with a 13.1% response rate. Aggregate indicators were constructed and validated, and two-way ANOVA tests were performed on key variables. RESULTS: HPSR publications on LA observed an average annual growth of 27.5% from the years 2000 to 2018, as against 11.4% worldwide and yet a lag on papers published per capita. A total of 48 journals with an Impact Factor publish HPSR on LA, of which 5 non-specialised journals are published in the region and are ranked in the bottom quintile of Impact Factor. While the majority of HPSR papers worldwide is published in specialised HPSR journals, in LA this is the minority. Very few researchers from LA sit in the Editorial Board of international journals. Researchers highly support strengthening quality HPSR publications through publishing in open access, on-line journals with a focus on the LA region and with peer reviewers specialized on the region. Researchers would support a new open access journal specializing in the LA region and in HPSR, publishing in English. Open access up-front costs and disincentives while waiting for an Impact Factor can be overcome. CONCLUSION: Researchers publishing on HPSR in LA widely support the launching of a new specialised journal for the region with a vigorous editorial policy focusing on regional and country priorities. Strategies should be in place to support English-language publishing and to develop a community of practice around the publication process. In the first years, special issues should be promoted through a priority-setting process to attract prominent authors, develop the audience and attain an Impact Factor.

Loss of job-related right to healthcare associated with employment turnover: challenges for the Mexican health system.

BACKGROUND: The Mexican health system segments access and right to healthcare according to worker position in the labour market. In this contribution we analyse how access and continuity of healthcare gets interrupted by employment turnover in the labour market, including its formal and informal sectors, as experienced by affiliates to the Mexican Institute of Social Security (IMSS) at national level, and of workers with type 2 diabetes (T2DM) in Mexico City. METHODS: Using data from the National Employment and Occupation Survey, 2014, and from IMSS electronic medical records for workers in Mexico City, we estimated annual employment turnover rates to measure the loss of healthcare access due to labour market dynamics. We fitted a binary logistic regression model to analyse the association between sociodemographic variables and employment turnover. Lastly we analysed job-related access to health care in relation to employment turnover events. RESULTS: At national level, 38.3% of IMSS affiliates experienced employment turnover at least once, thus losing the right to access to healthcare. The turnover rate for T2DM patients was 22.5%. Employment turnover was more frequent at ages 20-39 (38.6% national level; 28% T2DM) and among the elderly (62.4% national level; 26% T2DM). At the national level, higher educational levels (upper-middle, OR = 0.761; upper, OR = 0.835) and income (5 minimum wages or more, OR = 0.726) were associated with lower turnover. Being single and younger were associated with higher turnover (OR = 1.413). T2DM patients aged 40-59 (OR = 0.655) and with 5 minimum wages or more (OR = 0.401) experienced less turnover. Being a T2DM male patient increased the risk of experiencing turnover (OR = 1.166). Up to 89% of workers losing IMSS affiliation and moving on to other jobs failed to gain job-related access to health services. Only 9% gained access to the federal workers social security institute (ISSSTE). CONCLUSIONS: Turnover across labour market sectors is frequently experienced by the workforce in Mexico, worsening among the elderly and the young, and affecting patients with chronic diseases. This situation needs to be prospectively addressed by health system policies that aim to expand the financial health protection during an employment turnover event.

Loss of job-related right to healthcare is associated with reduced quality and clinical outcomes of diabetic patients in Mexico.

OBJECTIVES: The Mexican Institute of Social Security (IMSS) provides a package of health, economic and social benefits to workers employed in private firms within the formal labour market and to their economic dependants. Affiliates have a right to these benefits only while they remain contracted, thus posing a risk for the continuity of healthcare. This study evaluates the association between the time (in days) without the right to healthcare due to job loss in the formal labour market and the quality of healthcare and clinical outcomes among IMSS affiliates with Type 2 diabetes mellitus (T2DM). DESIGN: Retrospective cohort study 2013-2015. SETTING: Six IMSS family medicine clinics (FMC) in Mexico City. PARTICIPANTS: T2DM patients (n = 27 217) affiliated with job-related health insurance and at least one consultation with a family doctor during 2013. SOURCE OF INFORMATION: IMSS affiliation department database and electronic health records and clinical laboratory databases. MAIN OUTCOME MEASURE(S): Quality of the processes (eight indicators) and outcomes (three indicators) of healthcare. RESULTS: The results indicated that losing IMSS right to healthcare is frequent, occurring to one-third of T2DM patients during the follow-up period. The time without the right to healthcare in the observed period was of 120 days on average and was associated with a 43.2% loss of quality of care and a 19.2% reduction in clinical outcomes of T2DM. CONCLUSION: Policies aimed at ensuring access and continuity of care, regardless of job status, are critical for improving the quality of processes and outcomes of healthcare for diabetic patients.

[What is purchased, how and from whom by Seguro Popular in Mexico? Experience with strategic purchasing at national level and in a pioneer institution]. / ¿Qué compra, cómo y de quién el Seguro Popular de México? Experiencia con la compra estratégica nacional y en una entidad pionera.

OBJECTIVE:: To analyze the scope of demand subsidies through strategic purchasing of health services. MATERIALS AND METHODS:: Interviews and document analyses at national level and a case study of the state of Hidalgo. RESULTS:: SPSS explicitly prioritizes interventions to be financed and regulates prices and expenditure ceilings. Public providers are predominantly funded through the purchasing of inputs and the contracting of human resources, in the absence of competition and with a low degree of managerial autonomy. Seguro Popular in Hidalgo has diversified service providers and payment mechanisms. CONCLUSIONS:: SPSS has ample opportunity to extend and deepen strategic purchasing. Greater decision-making autonomy of payers and providers is required, as well as regulations to promote provider networks in competitive environments.

¿Qué compra, cómo y de quién el Seguro Popular de México? Experiencia con la compra estratégica nacional y en una entidad pionera / What is purchased, how and from whom by Seguro Popular in Mexico? Experience with strategic purchasing at national level and in a pioneer institution

Resumen: Objetivo: Analizar el alcance de los subsidios a la demanda mediante la compra estratégica de servicios de salud. Material y métodos: Entrevistas y revisión documental a nivel federal y estudio de caso en el estado de Hidalgo. Resultados: El Sistema de Protección Social en Salud (SPSS) prioriza las intervenciones por financiar de manera explícita y norma tabuladores y topes de gasto. Se financia predominantemente a prestadores públicos mediante la compra de insumos y la contratación de recursos humanos, sin competencia y con bajo grado de autonomía de gestión. El Seguro Popular en Hidalgo ha diversificado prestadores de servicios y mecanismos de pago. Conclusiones: El SPSS tiene amplia oportunidad para ampliar y profundizar la compra estratégica. Se requiere mayor autonomía de prestadores y pagadores así como reglamentación para promover redes de servicios en entornos competitivos.

Abstract: Objective: To analyze the scope of demand subsidies through strategic purchasing of health services. Materials and methods: Interviews and document analyses at national level and a case study of the state of Hidalgo. Results: SPSS explicitly prioritizes interventions to be financed and regulates prices and expenditure ceilings. Public providers are predominantly funded through the purchasing of inputs and the contracting of human resources, in the absence of competition and with a low degree of managerial autonomy. Seguro Popular in Hidalgo has diversified service providers and payment mechanisms. Conclusions: SPSS has ample opportunity to extend and deepen strategic purchasing. Greater decision-making autonomy of payers and providers is required, as well as regulations to promote provider networks in competitive environments.

[Financial allocations in the System for Social Protection in Health in Mexico: challenges for strategic purchasing]. / Asignación financiera en el Sistema de Protección Social en Salud de México: retos para la compra estratégica.

OBJECTIVE:: The financial coordination of the System of Social Protection in Health (SPSS) was analyzed to assess its support to strategic purchasing. MATERIALS AND METHODS:: Official reports and surveys were analyzed. RESULTS:: SPSS covers a capita of 2 765 Mexican pesos, equivalent to 0.9% of GDP. The Ministry of Health contributed 35% of the total, state governments 16.7% and beneficiaries 0.06%. The National Commission for Social Protection in Health received 48.3% of resources, allocating 38% to State Social Protection Schemes in Health and paying 7.4% of the total directly to providers.The state contribution is in deficit while family contributions tend not to be charged. CONCLUSION:: SPSS has not built funds specialized in strategic purchasing, capable of transforming historical budgets.The autonomy of providers is key to reduce out-of-pocket spending through the supply of quality services.

Asignación financiera en el Sistema de Protección Social en Salud de México: retos para la compra estratégica / Financial allocations in the System for Social Protection in Health in Mexico: challenges for strategic purchasing

Resumen: Objetivo: Analizar la coordinación financiera del Sistema de Protección Social en Salud (SPSS) y su capacidad para apoyar la compra estratégica de servicios. Material y métodos: Se analizaron informes oficiales y encuestas. Resultados: El SPSS cubre una cápita por afiliado de 2 765 pesos mexicanos, equivalente a 0.9% del PIB para 2013. La Secretaría de Salud asignó 35% del total; los gobiernos estatales 16.7%, y los beneficiarios 0.06%. La Comisión Nacional de Protección Social en Salud recibió 48.3% de estos recursos, de los cuales asignó 38% a los estados y pagó directamente a prestadores 7.4% del total. El aporte estatal está en déficit mientras que las contribuciones familiares tienden a no cobrarse. Conclusión: El SPSS no ha integrado fondos especializados en la compra estratégica capaz de transformar los presupuestos históricos. La autonomía de los prestadores es clave para que puedan contribuir a reducir el gasto de bolsillo mediante la oferta de servicios de calidad.

Abstract: Objective: The financial coordination of the System of Social Protection in Health (SPSS) was analyzed to assess its support to strategic purchasing. Materials and methods: Official reports and surveys were analyzed. Results: SPSS covers a capita of 2 765 Mexican pesos, equivalent to 0.9% of GDP. The Ministry of Health contributed 35% of the total, state governments 16.7% and beneficiaries 0.06%. The National Commission for Social Protection in Health received 48.3% of resources, allocating 38% to State Social Protection Schemes in Health and paying 7.4% of the total directly to providers.The state contribution is in deficit while family contributions tend not to be charged. Conclusion: SPSS has not built funds specialized in strategic purchasing, capable of transforming historical budgets.The autonomy of providers is key to reduce out-of-pocket spending through the supply of quality services.

Medical Expenditure for Chronic Diseases in Mexico: The Case of Selected Diagnoses Treated by the Largest Care Providers.

BACKGROUND: Chronic diseases (CD) are a public health emergency in Mexico. Despite concern regarding the financial burden of CDs in the country, economic studies have focused only on diabetes, hypertension, and cancer. Furthermore, these estimated financial burdens were based on hypothetical epidemiology models or ideal healthcare scenarios. The present study estimates the annual expenditure per patient and the financial burden for the nine most prevalent CDs, excluding cancer, for each of the two largest public health providers in the country: the Ministry of Health (MoH) and the Mexican Institute of Social Security (IMSS). METHODS: Using the Mexican National Health and Nutrition Survey 2012 (ENSANUT) as the main source of data, health services consumption related to CDs was obtained from patient reports. Unit costs for each provided health service (e.g. consultation, drugs, hospitalization) were obtained from official reports. Prevalence data was obtained from the published literature. Annual expenditure due to health services consumption was calculated by multiplying the quantity of services consumed by the unit cost of each health service. RESULTS: The most expensive CD in both health institutions was chronic kidney disease (CKD), with an annual unit cost for MoH per patient of US$ 8,966 while for IMSS the expenditure was US$ 9,091. Four CDs (CKD, arterial hypertension, type 2 diabetes, and chronic ischemic heart disease) accounted for 88% of the total CDs financial burden (US$ 1.42 billion) in MoH and 85% (US$ 3.96 billion) in IMSS. The financial burden of the nine CDs analyzed represents 8% and 25% of the total annual MoH and IMSS health expenditure, respectively. CONCLUSIONS/SIGNIFICANCE: The financial burden from the nine most prevalent CDs, excluding cancer, is already high in Mexico. This finding by itself argues for the need to improve health promotion and disease detection, diagnosis, and treatment to ensure CD primary and secondary prevention. If the status quo remains, the financial burden could be higher.

Mapping the use of research to support strategies tackling maternal and child health inequities: evidence from six countries in Africa and Latin America.

BACKGROUND: Striving to foster collaboration among countries suffering from maternal and child health (MCH) inequities, the MASCOT project mapped and analyzed the use of research in strategies tackling them in 11 low- and middle-income countries. This article aims to present the way in which research influenced MCH policies and programs in six of these countries - three in Africa and three in Latin America. METHODS: Qualitative research using a thematic synthesis narrative process was used to identify and describe who is producing what kind of research, how research is funded, how inequities are approached by research and policies, the countries' research capacities, and the type of evidence base that MCH policies and programs use. Four tools were designed for these purposes: an online survey for researchers, a semi-structured interview with decision makers, and two content analysis guides: one for policy and programs documents and one for scientific articles. RESULTS: Three modalities of research utilization were observed in the strategies tackling MCH inequities in the six included countries - instrumental, conceptual and symbolic. Instrumental utilization directly relates the formulation and contents of the strategies with research results, and is the least used within the analyzed policies and programs. Even though research is considered as an important input to support decision making and most of the analyzed countries count five or six relevant MCH research initiatives, in most cases, the actual impact of research is not clearly identifiable. CONCLUSIONS: While MCH research is increasing in low- and middle-income countries, the impact of its outcomes on policy formulation is low. We did not identify a direct relationship between the nature of the financial support organizations and the kind of evidence utilization within the policy process. There is still a visible gap between researchers and policymakers regarding their different intentions to link evidence and decision making processes.

[Challenges in the implementation of clinical practice guidelines in major public health institutions in Mexico: A multiple case study]. / Desafíos en la implantación de guías de práctica clínica en instituciones públicas de México: estudio de casos múltiple.

OBJECTIVE: To identify, prioritize and relate barriers and facilitators in the implementation of Clinical Practice Guidelines (GPC, in Spanish). MATERIALS AND METHODS: We used qualitative methods to study and compare the introduction of GPC across the domains of the consolidated research implementation framework in hospitals of the three main public institutions in a state of Mexico. Authorities and hospital staff were interviewed using a semi-structured questionnaire. RESULTS: The main barriers to implementation are the absence of standards, training, resources and incentives. The most important implementation facilitators are the characteristics of the GPC, which are perceived as properly designed and with simple language as well as with capacity to improve the work environment. CONCLUSION: The barriers to implementation must be solved to achieve the goal of standardizing the healthcare process across the sector; the positive perception of the GPC should promote the continuous actualization of the evidence and a sectoral view from their development stage to ensure adoption in the heterogeneous environments that characterize health institutions.

Desafíos en la implantación de guías de práctica clínica en instituciones públicas de México: estudio de casos múltiple / Challenges in the implementation of clinical practice guidelines in major public health institutions in Mexico: A multiple case study

Objetivo. Identificar, jerarquizar y relacionar barreras y facilitadores en la implantación de las Guías de Práctica Clínica (GPC). Material y métodos. Estudio cualitativo que compara la implantación de GPC a través de los dominios del marco consolidado para la investigación de implementación en hospitales de las tres principales instituciones públicas de una entidad. Se entrevistaron a funcionarios estatales y personal hospitalario. Resultados. Las principales barreras son ausencia de lineamientos, de capacitación, de recursos e incentivos. Los facilitadores se relacionan con las características de las GPC, percibidas con diseño adecuado, lenguaje sencillo y ventajas para mejorar el ambiente laboral. Conclusión. Las barreras deberán resolverse para alcanzar el objetivo de homologar el proceso en todo el sector; además, la buena percepción de las GPC deberá promover investigaciones para promover la actualización continua de las evidencias y una visión sectorial desde su elaboración para su implantación en los heterogéneos contexto que caracterizan a las instituciones de salud.

Objective. To identify, prioritize and relate barriers and facilitators in the implementation of Clinical Practice Guidelines (GPC, in Spanish). Materials and methods. We used qualitative methods to study and compare the introduction of GPC across the domains of the consolidated research implementation framework in hospitals of the three main public institutions in a state of Mexico. Authorities and hospital staff were interviewed using a semi-structured questionnaire. Results. The main barriers to implementation are the absence of standards, training, resources and incentives. The most important implementation facilitators are the characteristics of the GPC, which are perceived as properly designed and with simple language as well as with capacity to improve the work environment. Conclusion. The barriers to implementation must be solved to achieve the goal of standardizing the healthcare process across the sector; the positive perception of the GPC should promote the continuous actualization of the evidence and a sectoral view from their development stage to ensure adoption in the heterogeneous environments that characterize health institutions.