Derecho a la salud en México / Right to health in Mexico

Examina a situación de las condiciones que determinan la salud de la población y analiza las opciones que a corto plazo pueden mejorar la salud de grupos específicos y aliviar sus ingentes necesidades sanitarias.

Derecho a la salud en México / Right to health in Mexico

Examina a situación de las condiciones que determinan la salud de la población y analiza las opciones que a corto plazo pueden mejorar la salud de grupos específicos y aliviar sus ingentes necesidades sanitarias

El trabajo y los Tumores del Sistema Nervioso Central, en población de la ciudad de México / The work and the Central Nervous System tumors in population of Mexico city

El cáncer es un padecimiento que se incrementa en todo el mundo. Existen factores de riesgo bien identificados, no obstante, su aparición es controvertida. Los Tumores del Sistema Nervioso Central (TSNC) son un grupo de neoplasias, no se conoce su causa, algunos autores señalan exposiciones ambientales, causas genéticas y la ocupación; no existen estudios que evalúen el proceso del trabajo en relación a los riesgos y exigencias laborales y la presencia de los TSNC. Se realizó un estudio de casos y controles. Se incluyeron TSNC del Instituto Nacional de Neurología y Neurocirugía de la Ciudad de México. Se obtuvo información de factores de riesgo ambientales, y de riesgos y exigencias laborales. Se calcularon frecuencia simples, razones de momios e intervalos de confianza al 95%, se consideró estadísticamente significativo una p≤0.05, se realizó regresión logística condicional. Se encontró una asociación entre la presencia de los TSNC y las actividades que demandan niveles altos de atención [RM = 4,25; IC 95% (2,44-7,38)] p = 0,001, así como entre el empleo de fertilizantes e insecticidas y el lugar de residencia (p<0,05). Se debe profundizar en el estudio de las exigencias laborales que demandan intensos niveles de atención y concentración y su relación con el estrés y los daños a la salud.

Cancer is increasing worldwide. There are wellestablished risk factors; however, their appearance is controversial. Tumors of the central nervous system (CNST) are a group of neoplasms of unkown cause, and some authors suggest environmental exposures, genetic factors and occupation as possible causal factors, yet, there are no studies evaluating the risks and demands of work and the presence of CNST. A case-control study was performed, using. CNST from the National Institute of Neurology and Neurosurgery of Mexico City. Information on environmental risk factors, and workplace hazards and demands was obtained. Simple frequency, odds ratios and 95% confidence intervals were calculated, with statistical significance set at p ≤ 0.05, using conditional logistic regression. An association between the presence of CNST and activities that require high levels of care was found [OR = 4.25; (95% CI 2.44 to 7.38)] p = 0.001, and between the use of fertilizers and insecticides and place of residence (p <0.05). Further study of the association between those job requirements that require high levels of attention and concentration and both stress and adverse health effects.

[Changes in perceived health in war-displaced population, Ayacucho, Peru: 1980-2004]. / Cambios en la percepción de salud en población desplazada por la guerra, Ayacucho, Perú: 1980-2004.

The current study aims to show the individual and familiar changes in health patterns suffered by indigenous communities which were displaced from their Andean communities to Ayacucho city, Peru, for war-related political reasons, during the period of 1980 and 2004. Information about health self-perception was collected from displaced farmers living in Ayacucho city, and analyzed by using ethnographic research tools in: origin communities; during the displaced process to town, and during the integration process once the war was over in 1993. It was found out that these poor Andean communities had traditionally lived under severe social exclusion conditions, and were characterized by low access to health services and high childhood and maternal mortality rates. Vulnerability to disease, malnutrition and death reached a higher impact during the early years after the displacement, followed by a reconstructive process in order to set up a new social network. It gets consolidated once the war is over. At that time, life conditions start becoming more favorable, identification documents were regularized, and an improvement in access to health programs and services is detected. These changes also reflected the improvement on health self-perception. Nevertheless, mental health will remain causing distress in every age group of the population.

Cambios en la percepción de salud en población desplazada por la guerra, Ayacucho, Perú: 1980-2004 / Changes in perceived health in war-displaced population, Ayacucho, Peru: 1980-2004

El presente trabajo pretende señalar los cambios operados en la percepción de salud de las poblaciones indígenas desplazadas por razones de guerra de sus comunidades de origen hacia la ciudad de Ayacucho, Perú, en el periodo comprendido de 1980 al año 2004. A través del uso de técnicas etnográficas de investigación se procesó información proporcionada por la población desplazada en la ciudad de Ayacucho sobre la percepción de su salud individual y familiar, considerando tres momentos: la comunidad de origen; durante el desplazamiento y durante el proceso de inserción definitiva a la ciudad una vez terminada la guerra en 1993. Comprobamos que estas poblaciones andinas, indígenas y pobres vivieron históricamente en la exclusión social, sin servicios de salud en sus comunidades de origen y con alta mortalidad infantil y materna. Durante los años iniciales al desplazamiento la vulnerabilidad a la enfermedad, la desnutrición y la muerte fueron mayores. Luego se inicia un proceso de recomposición de una nueva red social que se consolida al finalizar la guerra. En ese momento se modifican favorablemente las condiciones de vida, se regularizan los documentos de identidad y se accede a los servicios y programas de salud. Sin embargo, la salud mental, diferenciada por generaciones, permanecerá ocasionando sufrimiento.

The current study aims to show the individual and familiar changes in health patterns suffered by indigenous communities which were displaced from their Andean communities to Ayacucho city, Peru, for war-related political reasons, during the period of 1980 and 2004. Information about health self-perception was collected from displaced farmers living in Ayacucho city, and analyzed by using ethnographic research tools in: origin communities; during the displaced process to town, and during the integration process once the war was over in 1993. It was found out that these poor Andean communities had traditionally lived under severe social exclusion conditions, and were characterized by low access to health services and high childhood and maternal mortality rates. Vulnerability to disease, malnutrition and death reached a higher impact during the early years after the displacement, followed by a reconstructive process in order to set up a new social network. It gets consolidated once the war is over. At that time, life conditions start becoming more favorable, identification documents were regularized, and an improvement in access to health programs and services is detected. These changes also reflected the improvement on health self-perception. Nevertheless, mental health will remain causing distress in every age group of the population.

[Organization of the drug supply chain in state health services: potential consequences of the public-private mix]. / Organización del abasto de medicamentos en los servicios estatales de salud: potenciales consecuencias de la mezcla público-privada.

OBJECTIVE: To assess the consequences of private outsourcing on the overall supply and filling of prescriptions in state health services. MATERIAL AND METHODS: The research was conducted using quantitative and qualitative techniques in 13 states. The information was collected through interviews and direct observation. The interviews were carried on staff of state health services related to the drug supply chain and users of health services. The quantitative approach examined the percentage of stocked full recipes in a sample of users. RESULTS: States that have opted for the fully outsourced model, and properly monitored this choice, have increased the supply of drugs to their users and guaranteed the supply in the care units in charge. Other states with the outsourced model have multiple problems: direct purchase of drugs not included in the basic drugs catalogue, failure of suppliers and shortage of supplies in the laboratories that provide the company. The main disadvantages identified in all models were: the subordination of the medical criteria to administrative criteria, insufficient planning based on local care needs, heterogeneous procedures, insufficient knowledge of regulations and lack of normativity. CONCLUSION: The results indicate that the incorporation of private providers in the drug supply chain may not be the solution to bring down the shortage faced by health services, especially at the hospital level. The shift to outsourcing models has developed without incorporating evaluation mechanisms and the consequences that this transition can have on state health systems must be investigated more deeply.

Organización del abasto de medicamentos en los servicios estatales de salud: potenciales consecuencias de la mezcla público-privada / Organization of the drug supply chain in state health services: potential consequences of the public-private mix.

OBJETIVO. Evaluar las consecuencias de la subrogación privada sobre el proceso general de abasto y el surtimiento completo de recetas en los servicios estatales de salud. MATERIAL Y MÉTODOS. La investigación se realizó utilizando técnicas cuantitativas y cualitativas en 13 entidades federativas. La información se recolectó mediante entrevistas y observación directa. Las entrevistas se aplicaron a personal de los servicios estatales de salud relacionados con la cadena de abasto de medicamentos y a usuarios de los servicios de atención. La aproximación cuantitativa examinó, en una muestra por conveniencia de usuarios, el porcentaje de recetas completas surtidas. RESULTADOS. Las entidades que han optado por el modelo tercerizado en su totalidad y lo controlan adecuadamente han incrementado el suministro de medicamentos entre sus usuarios y garantizado el abasto en las unidades de atención a su cargo. Otras entidades con modelo tercerizado tienen múltiples problemas: compra directa de medicamentos no incluidos en el cuadro básico, incumplimiento de proveedores y escasez de insumos en los laboratorios que proveen a la empresa. Como principales inconvenientes de todos los modelos se identificaron la subordinación de los criterios médicos a los criterios administrativos; la insuficiente planeación basada en las necesidades locales de atención; la heterogeneidad de los procedimientos; el conocimiento insuficiente de la normatividad y la falta de regulación. CONCLUSIÓN. Los resultados indican que la incorporación de proveedores privados en la cadena de abasto de medicamentos podría no ser la solución para abatir el desabasto que padecen los servicios de salud, especialmente a escala hospitalaria. El cambio hacia modelos subrogados (tercerizados) se ha desarrollado sin incorporar mecanismos de evaluación, y las consecuencias que esta transición puede acarrear sobre los sistemas estatales de salud deben ser investigadas con mayor profundidad.

OBJECTIVE. To assess the consequences of private outsourcing on the overall supply and filling of prescriptions in state health services. MATERIAL AND METHODS. The research was conducted using quantitative and qualitative techniques in 13 states. The information was collected through interviews and direct observation. The interviews were carried on staff of state health services related to the drug supply chain and users of health services. The quantitative approach examined the percentage of stocked full recipes in a sample of users. RESULTS States that have opted for the fully outsourced model, and properly monitored this choice, have increased the supply of drugs to their users and guaranteed the supply in the care units in charge. Other states with the outsourced model have multiple problems: direct purchase of drugs not included in the basic drugs catalogue, failure of suppliers and shortage of supplies in the laboratories that provide the company. The main disadvantages identified in all models were: the subordination of the medical criteria to administrative criteria, insufficient planning based on local care needs, heterogeneous procedures, insufficient knowledge of regulations and lack of normativity. CONCLUSION. The results indicate that the incorporation of private providers in the drug supply chain may not be the solution to bring down the shortage faced by health services, especially at the hospital level. The shift to outsourcing models has developed without incorporating evaluation mechanisms and the consequences that this transition can have on state health systems must be investigated more deeply.

[Socioeconomic inequality and mental health: a Latin American literature review]. / Desigualdad socioeconómica y salud mental: revisión de la literatura latinoamericana.

This study provides a review of the scientific output in Latin America concerning the impact of socioeconomic status (SES) on mental disorders and drug use or addiction. International and regional databases were analyzed. According to the majority of the studies, adults and adolescents with low SES showed increased risk of mental disorders, and alcohol consumption was higher among individuals with high SES, while low SES was associated with alcohol abuse and addiction, although the evidence was less conclusive. Smoking was more frequent among young people with high SES, but in adults it was more common with low SES. Illicit drug use was more frequent among adults (but not adolescents) with low SES. Prescription drugs tended to be consumed by adults and adolescents with higher SES. Use of solvents was more frequent among low SES adolescents. The studies' observed trends and methodological aspects are also discussed.

Desigualdad socioeconómica y salud mental: revisión de la literatura latinoamericana / Socioeconomic inequality and mental health: a Latin American literature review

El objetivo fue analizar la producción científica realizada en América Latina que indaga el impacto de la condición socioeconómica sobre los trastornos mentales y el uso o dependencia a sustancias. Se revisaron bases de datos internacionales y regionales. En la mayoría de los estudios se ha observado que en adultos y adolescentes pertenecer a estratos socioeconómicos bajos se asocia con mayor riesgo de trastornos mentales. El consumo de alcohol es mayor entre las personas con mejores condiciones socioeconómicas; en el caso del abuso y la dependencia al alcohol se observa una tendencia opuesta, aunque la evidencia para los últimos es menos contundente. En adolescentes el tabaquismo es más frecuente entre los que provienen de hogares con mejores condiciones socioeconómicas; sin embargo, entre los adultos la mayor probabilidad se encuentra entre los de peor situación económica. En adultos el consumo de drogas ilegales es más frecuente entre las personas de nivel socioeconómico inferior. Las drogas médicas tienden a ser más consumidas por adultos y adolescentes con mejor situación socioeconómica. El uso de solventes es más frecuente entre adolescentes de estratos bajos.

This study provides a review of the scientific output in Latin America concerning the impact of socioeconomic status (SES) on mental disorders and drug use or addiction. International and regional databases were analyzed. According to the majority of the studies, adults and adolescents with low SES showed increased risk of mental disorders, and alcohol consumption was higher among individuals with high SES, while low SES was associated with alcohol abuse and addiction, although the evidence was less conclusive. Smoking was more frequent among young people with high SES, but in adults it was more common with low SES. Illicit drug use was more frequent among adults (but not adolescents) with low SES. Prescription drugs tended to be consumed by adults and adolescents with higher SES. Use of solvents was more frequent among low SES adolescents. The studies' observed trends and methodological aspects are also discussed.

Utilización de servicios médicos por una población desplazada en Bucaramanga, Colombia / Displaced people’s healthcare use in Bucaramanga, Colombia

Objetivo: Analizar los factores y barreras asociadas a la utilización de servicios médicos por la población desplazada, como consecuencia del conflicto armado colombiano, residente en Bucaramanga, Colombia. Material y Métodos A partir de datos procedentes del estudio “Diagnóstico de Salud de las Poblaciones Desplazadas y no Desplazadas en Bucaramanga y su área Metropolitana” diseñado y ejecutado por la Universidad Industrial de Santander y financiado por la Organización Panamericana de la Salud, se analizó la utilización de los servicios médicos en individuos mayores de 15 años de edad de acuerdo con el modelo de Andersen y Newman y se evaluó el efecto de los factores asociados mediante regresión logística múltiple. Resultados Una de cada cinco personas que enfermó en los quince días previos a la encuesta usó los servicios médicos. Este porcentaje es menor a los encontrados en la población general de Colombia. Pertenecer al régimen contributivo de seguridad social, el antecedente de visita a los servicios de salud y ser originario de la misma región se encontraron asociados a la mayor utilización de los servicios. Los desplazados que tienen derecho al seguro de salud subsidiado no presentaron diferencias en el uso de los servicios con respecto a los que no cuentan con seguro. La distancia a la institución de salud fue otra barrera para la utilización de servicios (RM=0,64; IC 0,42-0,97). Conclusión Existe un uso de servicios médicos diferencial entre los desplazados, determinado por sus condiciones de aseguramiento y su capacidad económica.

Objective: Analysing the factors and barriers associated with the population displaced by armed conflict using medical services in Bucaramanga, Colombia. Material and Methods Data from the “Diagnosing the health of both displaced and non-displaced populations in Bucaramanga and its metropolitan area” study, designed and executed by the Industrial University of Santander and financed by the Pan-American Health Organisation, analysed medical service use in individuals aged over 15 years. This agreed with Andersen and Newman’s model and evaluated the effect of associated factors by means of multiple logistical regression Results One out of each five people who became ill during the fifteen days prior to the survey had used the medical services. This percentage was smaller than that found in the Colombian population as a whole. The type of social security regime (contributory health insurance), previous service use and being from the region were associated with greater service use. Displaced people having subsidised health insurance did not present differences in service use compared to those who had no access to such insurance. The distance from dwelling to institution was another barrier against using health services (RM=0.64; IC 0.42-0.97). Conclusions There was differential medical service use amongst the displaced population, determined by their health insurance coverage and economic position.

[Displaced people's healthcare use in Bucaramanga, Colombia]. / Utilización de servicios médicos por una población desplazada en Bucaramanga, Colombia.

OBJECTIVE: Analysing the factors and barriers associated with the population displaced by armed conflict using medical services in Bucaramanga, Colombia. MATERIAL AND METHODS: Data from the "Diagnosing the health of both displaced and non-displaced populations in Bucaramanga and its metropolitan area" study, designed and executed by the Industrial University of Santander and financed by the Pan-American Health Organisation, analysed medical service use in individuals aged over 15 years. This agreed with Andersen and Newman's model and evaluated the effect of associated factors by means of multiple logistical regression. RESULTS: One out of each five people who became ill during the fifteen days prior to the survey had used the medical services. This percentage was smaller than that found in the Colombian population as a whole. The type of social security regime (contributory health insurance), previous service use and being from the region were associated with greater service use. Displaced people having subsidised health insurance did not present differences in service use compared to those who had no access to such insurance. The distance from dwelling to institution was another barrier against using health services (RM = 0.64; IC 0.42-0.97). CONCLUSIONS: There was differential medical service use amongst the displaced population, determined by their health insurance coverage and economic position.

[The role of epidemiology in mental disorder research]. / El papel de la epidemiología en la investigación de los trastornos mentales.

Mental disorders, including substance abuse, are part of the Mexican epidemiologic scenario and will remain so during several decades. They may even become more prominent as causes of disease, disability, and death in our country. It is thus imperative to frame appropriate management strategies to curb these problems without delay. This paper aims at outlining epidemiology of mental diseases as a field of study, and to identify its limitations. Emphasis is made on common elements shared with other more traditional fields of epidemiology, as well as on the specific contributions made by this particular field to epidemiology and to psychiatry in general. This paper describes the main study designs and problems in this field of epidemiology, its usefulness in prevention actions, and future challenges. A unique characteristic of mental disorder epidemiology is that its target diseases manifest in two levels: behaviorally (for example, compulsive hand-washing) and as an element of the individual's mental life (e.g., obsession with bacteria being a constant, omnipresent health threat). It follows that much of the knowledge currently available on the phenomena of mental disorders in general is based on the self-reported insight of individuals. Trained clinicians have collected such reports by interview or with standardized questionnaires. This field of epidemiology is characterized by having two-sides: a mental disorder is a problem in and of itself, causing suffering and prompting the search for specialized care, as it has peculiar clinical manifestations. On the other hand, mental disorder epidemiology also focuses on determining factors (drug use, abuse, or addiction) and on the way these independent variables result in certain processes and outcomes (such as accidents, homicide, suicide, liver cirrhosis, etc.). Finally, the epidemiology of mental disorders has also been set apart by its focus in series of processes that are not suitably classified as syndromes, but which are germane to public health, for example, violence. The epidemiology of mental disorders faces great challenges in the new millennium, including a complex, changing epidemiologic scenario. Several important issues will influence the future development of mental disorder epidemiology: measurement of mental disorders and risk factors, more efficient sampling design and methods, the relationships among biological research, genetics, social studies, and epidemiology, and the interface between epidemiology and the evaluation of therapies and health services.

El papel de la epidemiología en la investigación de los trastornos mentales / The role of epidemiology in mental disorder research

Los trastornos mentales, incluyendo los trastornos del uso de sustancias, hacen ya parte del panorama epidemiológico de México y seguirán en el escenario nacional por las próximas décadas, incrementando incluso su presencia como causa de enfermedad, discapacidad y muerte en nuestro país. Por lo tanto, el manejo epidemiológico de estos problemas se hace urgente. Este trabajo busca plantear el campo de estudio de la epidemiología de los trastornos mentales y sus limitaciones, haciendo énfasis en los elementos comunes de ésta con otras áreas más tradicionales de la epidemiología y en las aportaciones particulares de este campo epidemiológico a la psiquiatría en general y a la epidemiología en particular. Planteamos a continuación los diseños y problemas más comunes en este campo de la epidemiología, su utilidad para acciones de prevención, y señalamos los retos que nos esperan en el futuro. Una característica distintiva de esta área es que los trastornos mentales se manifiestan en dos niveles, como conducta (por ejemplo, una conducta compulsiva de lavarse las manos) y como elemento de la vida mental del sujeto (por ejemplo, el pensamiento obsesivo sobre las bacterias que se encuentran presentes en todos lados y que son una fuente constante de amenaza para algunos sujetos). Debido a esto, mucho de lo que sabemos sobre estos fenómenos proviene del autorreporte que el sujeto es capaz de hacer sobre sus sentimientos (introspección), ya sea en una conversación con un clínico entrenado o expresándolos al endosar reactivos en un cuestionario estandarizado. Otro aspecto importante a resaltar es la necesidad de hablar en plural al referirnos a los trastornos mentales. Este campo de la epidemiología presenta también un carácter particular, bifacético: por un lado, este es un problema en sí mismo, que produce sufrimiento y motiva la búsqueda de atención especializada, con manifestaciones clínicas particulares. Por otro lado, esta epidemiología también se orienta hacia un dominio particular de determinantes (como el uso, abuso o dependencia hacia las drogas) y cómo estas variables independientes afectan determinados procesos y enfermedades (como los accidentes, el homicidio, el suicidio, la cirrosis hepática, etc.) Por último, la epidemiología de los trastornos mentales se ha caracterizado también por su interés en una serie de procesos que no parecen constituir síndromes propiamente dichos, pero que son a todas luces de interés...

Atención prenatal en el primer nivel de atención: características de los proveedores que influyen en la satisfacción de las usuarias / Prenatal care in the primary level of healthcare: provider characteristics which influence users' satisfaction

OBJETIVO: Evaluar el nivel de satisfacción alcanzado por las usuarias de los servicios de atención prenatal en el primer nivel de atención en México, y comparar con algunas características del proveedor y del servicio. MATERIAL Y MÉTODOS: Mediante la aplicación de una encuesta transversal, en el año 2000, se investigaron 217 pares de proveedores-usuarias de servicios de salud, entrevistados en 95 unidades de atención de primer nivel de ocho entidades federativas de la República Mexicana. Se recopiló información mediante: a) observación directa de la consulta médica, b) entrevistas a proveedores y usuarias, y c) aplicación de cuestionario y examen de conocimiento a los proveedores. Se analizó la relación existente entre la capacidad de resolución clínica de los proveedores, el trato recibido durante la consulta y la satisfacción sobre la misma que la usuaria manifestó en entrevista directa. Para ello se calcularon las medidas de resumen y dispersión de las principales categorías, así como análisis bivariado y de tendencias. RESULTADOS: La satisfacción de las usuarias de los servicios de atención prenatal está relacionada con el trato recibido durante la consulta y el tiempo que esperó para recibirla, pero no con la capacidad de resolución clínica del profesional, ni con su edad o género. El trato recibido durante la consulta por la paciente también se asoció con su nivel socioeconómico y se encontró que las usuarias más pobres reciben, proporcionalmente, peor trato. CONCLUSIONES: Los servicios de salud podrían realizar evaluaciones de la satisfacción de sus pacientes en relación con la consulta recibida, en especial en aquellos lugares en los que existe escasez de recursos y/o condiciones de desigualdad económica. En estos casos la prestación de los servicios puede profundizar las diferencias entre la población, y afectar más a la población más pobre.

OBJECTIVE: To assess the satisfaction level attained by prenatal care users in primary health services in Mexico, and to compare the level of satisfaction according to characteristics of the provider and the service. MATERIAL AND METHODS: A cross-sectional survey was conducted to analyze data from 217 care provider-user pairs. Interviews were carried out in 95 primary care units in eight Mexican states. The information was collected through a) direct observation of the medical encounter, b) interviews with providers and users, and c) a questionnaire and knowledge examination to providers. Users' satisfaction was analyzed according to providers' clinical ability and the treatment received during the visit. Summary and dispersion measures of the main issues were calculated, as well as bivariate and trends analysis. RESULTS: User satisfaction in prenatal care is associated with the treatment received during the visit and to the waiting time before being attended, but not with the provider's clinical ability, nor with his or her age or gender. The treatment received during the visit was also associated with the user's socioeconomic level, where the poorer users received the worst treatment. CONCLUSIONS: Health services should assess users' satisfaction according with the type of medical encounter, particularly where resources are scarce and where economic disparities are present. In such cases, the provision of healthcare services may intensify inequality, with greater impact on the poorest.

[Prenatal care at the first level of care: characteristics of providers that affect users' satisfaction]. / Atención prenatal en el primer nivel de atención: características de los proveedores que influyen en la satisfacción de las usuarias.

OBJECTIVE: To assess the satisfaction level attained by prenatal care users in primary health services in Mexico, and to compare the level of satisfaction according to characteristics of the provider and the service. MATERIAL AND METHODS: A cross-sectional survey was conducted to analyze data from 217 care provider-user pairs. Interviews were carried out in 95 primary care units in eight Mexican states. The information was collected through a) direct observation of the medical encounter, b) interviews with providers and users, and c) a questionnaire and knowledge examination to providers. Users' satisfaction was analyzed according to providers' clinical ability and the treatment received during the visit. Summary and dispersion measures of the main issues were calculated, as well as bivariate and trends analysis. RESULTS: User satisfaction in prenatal care is associated with the treatment received during the visit and to the waiting time before being attended, but not with the provider's clinical ability, nor with his or her age or gender. The treatment received during the visit was also associated with the user's socioeconomic level, where the poorer users received the worst treatment. CONCLUSIONS: Health services should assess users' satisfaction according with the type of medical encounter, particularly where resources are scarce and where economic disparities are present. In such cases, the provision of healthcare services may intensify inequality, with greater impact on the poorest. The English version of this paper is available at:http://www.insp.mx/salud/index.html.