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.

[Exploring facilitators and barriers to implementing expanded nursing roles in MexicoEstudo de facilitadores e barreiras para a implementação de funções ampliadas de enfermagem no México]. / Exploración de facilitadores y barreras para implementar los roles ampliados de enfermería en México.

Objective: To explore the perceptions of nursing professionals regarding facilitators and barriers to the implementation of expanded nursing functions in a state in central Mexico. Methods: Qualitative descriptive phenomenological study. During 2022, 18 semi-structured interviews were conducted with three types of informants: a) head nurses at state-level facilities; b) head nurses at local-level facilities; and c) heads of health units and operational nursing staff who have direct contact with patients. Results: The following facilitators were identified: willingness to adopt the strategy (seen as favorable by managers and acceptable by nursing staff); reorganization of functions (simplification of processes and analysis of the situation of health units); access to training; and characteristics of nursing staff (professionalization, work experience, and favorable attitude). Barriers included: conditions at the first level of care (personnel shortages, too many administrative activities, lack of physical space, materials, supplies, and consumables), resistance to change (professional jealousy of other disciplines and duplication of tasks), staff salaries, lack of training, not trusted with expanded duties, and attitude of patients (resistance to nursing care). Conclusions: By understanding the perceptions of nursing professionals, we can identify key elements for the successful expansion of nursing functions through expansion of the competencies of operational staff. Reorganization and proper management at different levels of decision-making will be necessary.

Objetivo: Explorar as percepções dos profissionais de enfermagem sobre os facilitadores e as barreiras à implementação de funções ampliadas de enfermagem em um estado do México. Métodos: Estudo qualitativo descritivo com abordagem fenomenológica. Em 2022, foram realizadas 18 entrevistas semiestruturadas com três tipos de informantes: a) chefes estaduais de enfermagem; b) chefes jurisdicionais de enfermagem; e c) chefes de unidades de saúde e profissionais de enfermagem que fazem atendimento direto aos pacientes. Resultados: Os seguintes facilitadores foram identificados: disposição para adotar a estratégia (atitude favorável dos gerentes e aceitação da equipe de enfermagem), reorganização das funções (simplificação dos processos e análise da situação das unidades de saúde) e acesso a capacitação e características da equipe de enfermagem (profissionalização, experiência de trabalho e atitude favorável). As barreiras encontradas incluem: contexto do primeiro nível de atenção (falta de pessoal, excesso de atividades administrativas, falta de espaço físico, falta de materiais, insumos e consumíveis), resistência à mudança (zelo profissional de outras disciplinas e duplicação de tarefas), salários do pessoal, falta de atualização, pouca confiança na expansão das funções e atitude dos pacientes (resistência ao atendimento por profissionais de enfermagem). Conclusões: Entender as percepções dos profissionais de enfermagem permite a identificação de elementos-chave para a expansão bem-sucedida das funções de enfermagem por meio da expansão das competências de trabalho dos profissionais que atendem pacientes; serão necessários reorganização e gerenciamento adequado nos diferentes níveis de tomada de decisão.

Exploración de facilitadores y barreras para implementar los roles ampliados de enfermería en México / Exploring facilitators and barriers to implementing expanded nursing roles in Mexico / Estudo de facilitadores e barreiras para a implementação de funções ampliadas de enfermagem no México

[RESUMEN]. Objetivo. Explorar la percepción de los profesionales de enfermería respecto a los facilitadores y las barreras para la implementación de funciones ampliadas de enfermería en una entidad federativa de México. Métodos. Estudio cualitativo de tipo descriptivo con enfoque fenomenológico. Durante el 2022 se realizaron 18 entrevistas semiestructuradas a tres tipos de informantes: a) jefaturas estatales de enfermería, b) jefaturas jurisdiccionales de enfermería, y c) jefaturas de unidad de salud y personal de enfermería operativo (atención directa a pacientes). Resultados. Se identificaron los siguientes facilitadores: disposición de adopción de la estrategia (postura favorable de directivos y aceptabilidad del personal de enfermería), reorganización de funciones (simplificación de procesos y análisis de la situación de unidades de salud) y acceso a la capacitación y características del personal de enfermería (profesionalización, experiencia laboral y actitud favorable). Entre las barreras se encontraron: contexto del primer nivel de atención (falta de personal, exceso de actividades administrativas, falta de espacio físico, carencia de material, insumos y consumibles), resistencia al cambio (celo profesional por otras disciplinas y duplicidad de tareas), salarios del personal, falta de actualización, poca confianza para el incremento de funciones y actitud de los pacientes (resistencia a la atención por enfermería). Conclusiones. Comprender la percepción de los profesionales de enfermería permite identificar elementos clave para la ampliación exitosa de las funciones de enfermería a partir de la expansión de competencias laborales del personal operativo; será necesaria una reorganización y una gestión adecuada en los diferentes niveles de toma de decisiones.

[ABSTRACT]. Objective. To explore the perceptions of nursing professionals regarding facilitators and barriers to the imple- mentation of expanded nursing functions in a state in central Mexico. Methods. Qualitative descriptive phenomenological study. During 2022, 18 semi-structured interviews were conducted with three types of informants: a) head nurses at state-level facilities; b) head nurses at local-level facilities; and c) heads of health units and operational nursing staff who have direct contact with patients. Results. The following facilitators were identified: willingness to adopt the strategy (seen as favorable by managers and acceptable by nursing staff); reorganization of functions (simplification of processes and analy- sis of the situation of health units); access to training; and characteristics of nursing staff (professionalization, work experience, and favorable attitude). Barriers included: conditions at the first level of care (personnel shortages, too many administrative activities, lack of physical space, materials, supplies, and consumables), resistance to change (professional jealousy of other disciplines and duplication of tasks), staff salaries, lack of training, not trusted with expanded duties, and attitude of patients (resistance to nursing care). Conclusions. By understanding the perceptions of nursing professionals, we can identify key elements for the successful expansion of nursing functions through expansion of the competencies of operational staff. Reorganization and proper management at different levels of decision-making will be necessary.

[RESUMO]. Objetivo. Explorar as percepções dos profissionais de enfermagem sobre os facilitadores e as barreiras à implementação de funções ampliadas de enfermagem em um estado do México. Métodos. Estudo qualitativo descritivo com abordagem fenomenológica. Em 2022, foram realizadas 18 entrevistas semiestruturadas com três tipos de informantes: a) chefes estaduais de enfermagem; b) chefes jurisdicionais de enfermagem; e c) chefes de unidades de saúde e profissionais de enfermagem que fazem atendimento direto aos pacientes. Resultados. Os seguintes facilitadores foram identificados: disposição para adotar a estratégia (atitude favo- rável dos gerentes e aceitação da equipe de enfermagem), reorganização das funções (simplificação dos processos e análise da situação das unidades de saúde) e acesso a capacitação e características da equipe de enfermagem (profissionalização, experiência de trabalho e atitude favorável). As barreiras encontradas incluem: contexto do primeiro nível de atenção (falta de pessoal, excesso de atividades administrativas, falta de espaço físico, falta de materiais, insumos e consumíveis), resistência à mudança (zelo profissional de outras disciplinas e duplicação de tarefas), salários do pessoal, falta de atualização, pouca confiança na expansão das funções e atitude dos pacientes (resistência ao atendimento por profissionais de enfermagem). Conclusões. Entender as percepções dos profissionais de enfermagem permite a identificação de ele- mentos-chave para a expansão bem-sucedida das funções de enfermagem por meio da expansão das competências de trabalho dos profissionais que atendem pacientes; serão necessários reorganização e gerenciamento adequado nos diferentes níveis de tomada de decisão.

Recruitment of nursing students in the context of the COVID-19 pandemic in Mexico. A rapid response to the health emergency. / Contratación de estudiantes de enfermería en el contexto de la pandemia por COVID-19 en México. Una respuesta rápida a la emergencia de salud.

The Mexican government implemented a strategy to increase nursing staff in response to COVID-19, including the early graduation of university students, to incorporate them into the care frontline. This exploratory qualitative study aimed to analyze nursing students' experiences recruited by health institutions to care for COVID patients. It included 12 participants who received and accepted job proposals in health institutions for patient care during their internship. Data were collected through semi-structured interviews with prior informed consent. The experiences of the participants were integrated into three themes: the students took advantage of the modified social service regulations to be recruited by an institution and integrate into COVID-19 care; the recruitment and remuneration conditions were plagued with anomalies and important informalities in the process; and the preparation for care was very incipient, so learning occurred in the very care process. The pandemic allowed the participants to enter the nursing labor market in extraordinary and substandard conditions.

El gobierno mexicano, como parte de la respuesta al COVID-19, puso en juego una estrategia para aumentar la dotación de personal de enfermería que incluyó la graduación prematura de estudiantes universitarios para incorporarlos en el frente de la atención. El objetivo del estudio fue analizar las experiencias de estudiantes de enfermería contratados por instituciones de salud para la atención de pacientes COVID. El estudio es cualitativo exploratorio. Incluyó 12 participantes que durante la pasantía recibieron y aceptaron propuestas de empleo en instituciones de salud para la atención de pacientes. Los datos se recolectaron a través de entrevistas semiestructuradas, previo consentimiento informado. Las experiencias de los participantes se integraron en tres temas: los estudiantes aprovecharon la modificación de los reglamentos del servicio social para poder contratarse con una institución e integrarse a la atención del COVID-19; las condiciones de contratación y remuneración estuvieron plagadas de anomalías con importantes informalidades en el proceso; y la preparación para la atención fue muy incipiente por lo que el aprendizaje se llevó a cabo en el proceso mismo de la atención. La pandemia representó para los participantes una oportunidad de ingresar en condiciones extraordinarias y precarias al mercado laboral de enfermería.

Contratación de estudiantes de enfermería en el contexto de la pandemia por COVID-19 en México. Una respuesta rápida a la emergencia de salud / Recruitment of nursing students in the context of the COVID-19 pandemic in Mexico. A rapid response to the health emergency

Resumen El gobierno mexicano, como parte de la respuesta al COVID-19, puso en juego una estrategia para aumentar la dotación de personal de enfermería que incluyó la graduación prematura de estudiantes universitarios para incorporarlos en el frente de la atención. El objetivo del estudio fue analizar las experiencias de estudiantes de enfermería contratados por instituciones de salud para la atención de pacientes COVID. El estudio es cualitativo exploratorio. Incluyó 12 participantes que durante la pasantía recibieron y aceptaron propuestas de empleo en instituciones de salud para la atención de pacientes. Los datos se recolectaron a través de entrevistas semiestructuradas, previo consentimiento informado. Las experiencias de los participantes se integraron en tres temas: los estudiantes aprovecharon la modificación de los reglamentos del servicio social para poder contratarse con una institución e integrarse a la atención del COVID-19; las condiciones de contratación y remuneración estuvieron plagadas de anomalías con importantes informalidades en el proceso; y la preparación para la atención fue muy incipiente por lo que el aprendizaje se llevó a cabo en el proceso mismo de la atención. La pandemia representó para los participantes una oportunidad de ingresar en condiciones extraordinarias y precarias al mercado laboral de enfermería.

Abstract The Mexican government implemented a strategy to increase nursing staff in response to COVID-19, including the early graduation of university students, to incorporate them into the care frontline. This exploratory qualitative study aimed to analyze nursing students' experiences recruited by health institutions to care for COVID patients. It included 12 participants who received and accepted job proposals in health institutions for patient care during their internship. Data were collected through semi-structured interviews with prior informed consent. The experiences of the participants were integrated into three themes: the students took advantage of the modified social service regulations to be recruited by an institution and integrate into COVID-19 care; the recruitment and remuneration conditions were plagued with anomalies and important informalities in the process; and the preparation for care was very incipient, so learning occurred in the very care process. The pandemic allowed the participants to enter the nursing labor market in extraordinary and substandard conditions.

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.

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.

Exploración de facilitadores y barreras para implementar los roles ampliados de enfermería en México / Exploring facilitators and barriers to implementing expanded nursing roles in Mexico / Estudo de facilitadores e barreiras para a implementação de funções ampliadas de enfermagem no México

RESUMEN Objetivo. Explorar la percepción de los profesionales de enfermería respecto a los facilitadores y las barreras para la implementación de funciones ampliadas de enfermería en una entidad federativa de México. Métodos. Estudio cualitativo de tipo descriptivo con enfoque fenomenológico. Durante el 2022 se realizaron 18 entrevistas semiestructuradas a tres tipos de informantes: a) jefaturas estatales de enfermería, b) jefaturas jurisdiccionales de enfermería, y c) jefaturas de unidad de salud y personal de enfermería operativo (atención directa a pacientes). Resultados. Se identificaron los siguientes facilitadores: disposición de adopción de la estrategia (postura favorable de directivos y aceptabilidad del personal de enfermería), reorganización de funciones (simplificación de procesos y análisis de la situación de unidades de salud) y acceso a la capacitación y características del personal de enfermería (profesionalización, experiencia laboral y actitud favorable). Entre las barreras se encontraron: contexto del primer nivel de atención (falta de personal, exceso de actividades administrativas, falta de espacio físico, carencia de material, insumos y consumibles), resistencia al cambio (celo profesional por otras disciplinas y duplicidad de tareas), salarios del personal, falta de actualización, poca confianza para el incremento de funciones y actitud de los pacientes (resistencia a la atención por enfermería). Conclusiones. Comprender la percepción de los profesionales de enfermería permite identificar elementos clave para la ampliación exitosa de las funciones de enfermería a partir de la expansión de competencias laborales del personal operativo; será necesaria una reorganización y una gestión adecuada en los diferentes niveles de toma de decisiones.

ABSTRACT Objective. To explore the perceptions of nursing professionals regarding facilitators and barriers to the implementation of expanded nursing functions in a state in central Mexico. Methods. Qualitative descriptive phenomenological study. During 2022, 18 semi-structured interviews were conducted with three types of informants: a) head nurses at state-level facilities; b) head nurses at local-level facilities; and c) heads of health units and operational nursing staff who have direct contact with patients. Results. The following facilitators were identified: willingness to adopt the strategy (seen as favorable by managers and acceptable by nursing staff); reorganization of functions (simplification of processes and analysis of the situation of health units); access to training; and characteristics of nursing staff (professionalization, work experience, and favorable attitude). Barriers included: conditions at the first level of care (personnel shortages, too many administrative activities, lack of physical space, materials, supplies, and consumables), resistance to change (professional jealousy of other disciplines and duplication of tasks), staff salaries, lack of training, not trusted with expanded duties, and attitude of patients (resistance to nursing care). Conclusions. By understanding the perceptions of nursing professionals, we can identify key elements for the successful expansion of nursing functions through expansion of the competencies of operational staff. Reorganization and proper management at different levels of decision-making will be necessary.

RESUMO Objetivo. Explorar as percepções dos profissionais de enfermagem sobre os facilitadores e as barreiras à implementação de funções ampliadas de enfermagem em um estado do México. Métodos. Estudo qualitativo descritivo com abordagem fenomenológica. Em 2022, foram realizadas 18 entrevistas semiestruturadas com três tipos de informantes: a) chefes estaduais de enfermagem; b) chefes jurisdicionais de enfermagem; e c) chefes de unidades de saúde e profissionais de enfermagem que fazem atendimento direto aos pacientes. Resultados. Os seguintes facilitadores foram identificados: disposição para adotar a estratégia (atitude favorável dos gerentes e aceitação da equipe de enfermagem), reorganização das funções (simplificação dos processos e análise da situação das unidades de saúde) e acesso a capacitação e características da equipe de enfermagem (profissionalização, experiência de trabalho e atitude favorável). As barreiras encontradas incluem: contexto do primeiro nível de atenção (falta de pessoal, excesso de atividades administrativas, falta de espaço físico, falta de materiais, insumos e consumíveis), resistência à mudança (zelo profissional de outras disciplinas e duplicação de tarefas), salários do pessoal, falta de atualização, pouca confiança na expansão das funções e atitude dos pacientes (resistência ao atendimento por profissionais de enfermagem). Conclusões. Entender as percepções dos profissionais de enfermagem permite a identificação de elementos-chave para a expansão bem-sucedida das funções de enfermagem por meio da expansão das competências de trabalho dos profissionais que atendem pacientes; serão necessários reorganização e gerenciamento adequado nos diferentes níveis de tomada de decisão.

Missed nursing care in highly specialized hospitals: A Mexican case study.

OBJECTIVE: To assess the status of missed nursing care and the reasons for its occurrence in a highly specialised public hospital in Mexico. MATERIALS AND METHODS: An observational cross-sectional analysis with data collected from January to June 2019 at the National Institute of Rehabilitation Luis Guillermo Ibarra Ibarra in Mexico City. We assessed missed care and its causes by conducting the MISSCARE survey among 116 nursing professionals selected from a population of 162 nurses. This work presents the estimated rates of missed care-overall and broken down into its four dimensions-as well as the reasons for its occurrence, namely limited labour resources, inadequate material resources and communication problems among work teams. RESULTS: The overall score for missed care was 16% (95% CI: 11.84%-20.15%), with the following rates by dimension: 19.48% for basic care, 14.66% for individual needs, 6.47% for patient education and discharge planning, and 4.31% for continuous patient assessment. The main reason cited for missed care was inadequate material resources, followed by limited labour resources and communication problems among work teams. CONCLUSION: Basic care and individual needs interventions were the most frequently omitted services, primarily because of inadequate material resources, limited labour resources and communication problems among work teams. An increase in the frequency of missed care can be expected in light of the high demand for health services, particularly as regards labour and material resources, imposed by the SARS-CoV-2 pandemic.

Advanced Practice Nursing Roles: A Comparison Between Mexico and the United Kingdom.

The COVID-19 pandemic has placed nursing at the forefront of public attention across the globe and has highlighted the critical role of nursing in healthcare service provision. Advanced practice nursing has been recognized for more than 50 years, but the rate of its growth and development varies significantly across the world. One of the key aims of the Better Health Programme Mexico, which commenced in 2019, was to develop advanced practice nursing in Mexico. The Programme was based on the United Kingdom model, where advanced practice nursing has been in place-though not subject to statutory regulation-for more than 40 years. The aim of this article is to compare the frameworks that underpin advanced practice nursing in the United Kingdom and in Mexico. In the present article, current practice in both countries was researched, and the structure, systems, and processes relating to nursing regulation and the frameworks to support advanced practice nursing were examined. A gap analysis report undertaken as part of the Better Health Programme identified challenges in developing advanced practice nursing in Mexico and the United Kingdom and highlighted the need for stakeholders to agree on an approach toward a rigorous regulatory framework in both settings. In summary, this article highlights the issues facing nurses and regulators in both countries in terms of advanced practice nursing and identifies strategies that can be used to strengthen the advanced practice nurse role.

Impact of a Novel Social Work Program on Access to Tertiary Care.

Background: In the movement for global health equity, increased research and funding have not yet addressed a shortage of evidence on effectively implementing context-specific interventions; one unmet need is facilitating access to specialty care within the public health sector in Mexico. Compañeros en Salud has been piloting a novel program, called Right to Healthcare (RTHC), to increase access to specialty care for the rural poor in Chiapas, Mexico. The RTHC program incorporates social work, patient navigation, referrals, direct economic support, and accompaniment for patients. Objectives: This study evaluates the effectiveness of the RTHC program. Primary outcomes analyzed included acceptance of any referral and attendance of any appointment. Secondary outcomes included acceptance of the first referral and rate of appointment attendance for patients with an accepted referral. Methods: Using referral process data for the years 2014 to 2019 from a public tertiary care hospital in Chiapas, 91 RTHC patients were matched using 2:1 optimal pair matching with a control cohort balancing covariates of patient age, sex, specialty referred to, level of referring hospital, and municipality. Findings: RTHC patients were more likely to have had an accepted referral (OR 17.42, 95% CI 3.68 to 414.16) and to have attended an appointment (OR 5.49, 95% CI 2.93 to 11.60) compared to the matched control group. RTHC patients were also more likely to have had their first referral accepted (OR 2.78, 95% CI 1.29 to 6.73). Among patients with an accepted referral, RTHC patients were more likely to have attended an appointment (OR 3.86, 95% CI 1.90 to 8.57). Conclusions: The results demonstrate that the RTHC model is successful in increasing access to specialty care by both increasing referral acceptance and appointment attendance.

Performance of the Mexican nursing labor market: a repeated cross-sectional study, 2005-2019.

BACKGROUND: The close link between human resources for health and the performance of health systems calls for a comprehensive study of the labor market. This paper proposes a performance metric for the nursing labor market, measures its magnitude and analyzes its predictors over the last 15 years. DESIGN AND METHODS: A repeated cross-sectional analysis using data from the quarterly population-based National Survey of Occupation and Employment 2005-2019 (ENOE in Spanish). An aggregate total of 19,311 Mexican nurses (population N = 4,816,930) was analyzed. Nursing labor market performance was defined as the level of non-precarious employment of nurses in the health sector. After describing the sociodemographic, labor and contextual characteristics of the nurses surveyed, we identified the key correlates of market performance using repeated cross-sectional multiple logistic regression analysis. We then estimated the adjusted prevalence of market performance according to the survey period and socioeconomic region of residence. RESULTS: The exogenous indicators analyzed shed light on various aspects of the market structure. Unemployment remained stable at 5% during the period examined, but underemployment rose by 26% and precarious employment, our endogenous indicator, also grew significantly. On the whole, our indicators revealed a notable deterioration in the structure of the nursing labor market; they varied by age and sex as well as between public and private institutions. Although the steepest deterioration occurred in the private sector, we observed an increase in precarious jobs among public institutions formerly protective of employment conditions. CONCLUSIONS: The deterioration of the labor market jeopardizes the ability of nursing professionals to participate in the market as well as to obtain secure jobs once they do enter. The Mexican Health System suffers from a chronic dearth of nurses, reducing its capacity to achieve its core objectives including enhanced coverage and increased effectiveness. Nursing workforce planning requires a context where the conditions in which the market currently operates, and its potential deterioration are considered.

Labor Market Participation of Bachelor's Degree Prepared Nurses in Mexico: Lessons for Capacity Building.

BACKGROUND: Mexico has learned much from its five decades educating nurses, moving from nurses educated mostly at the technical degree level, to bachelor's degree prepared nurses educated in universities. Several salient lessons have emerged that may prove relevant for other countries seeking to increase their numbers of bachelors prepared nurses. This paper analyzes twenty years of nursing labor market data to highlight where significant social and policy changes helped facilitate increased production of bachelor's degree educated nurses in Mexico. METHODS: We conducted a two-stages analysis, starting with a descriptive stage and followed by a repeated cross-sectional analysis using data sources generated by the Secretariat of Health and the National Institute of Geography and Statistics. Data from the 2005 to 2019 period were analyzed for trends in production patterns and significant relationships in the labor market. RESULTS: Among Mexican nursing graduates, technical and bachelor nurses compete for employment in healthcare institutions. The public sector has greater success in hiring bachelors prepared nurses, but this varies by type of public sector institution. Technical degree nurses have higher underemployment rates and less job security overall. Private hospitals mainly hire technical degree nurses. The Mexican government not been able to properly regulate neither the production of new graduates nor the accreditation of schools, let alone to align roles according to the graduate's level of education. CONCLUSIONS: The success of Mexico in the twenty-first century shows that middle-income countries can increase the production and both private and public sector employment opportunities for nurses educated at both the technical and bachelor's degree level however, labor market challenges persist. The central lesson for other countries is that policies must be revised in order to optimize the use of a more educated nursing workforce.

Sociodemographic and work environment correlates of missed nursing care at highly specialized hospitals in Mexico: A cross-sectional study.

BACKGROUND: Despite its direct relevance to quality of care, little is known about missed nursing care or its sociodemographic and work environment correlates at highly specialized hospitals in low- and middle-income countries. OBJECTIVE: To analyze the frequency of missed nursing care among Mexican nursing professionals, and to assess its associated sociodemographic and labor-related predictors. DESIGN AND METHODS: A cross-sectional, observational study based on data collected from 315 nursing professionals in 11 highly specialized public hospitals in Mexico. We assessed missed nursing care both as a total figure and according to the four dimensions of the MISSCARE inventory. We estimated its sociodemographic and work-related predictors using fractional logistic analysis. RESULTS: The global score for missed nursing care was 15.21%: 7.94% concerned individual needs, 9.37% discharge planning and patient education, 18.10% basic care, and 1.59% care under continuous assessment. The odds of engaging in missed nursing care increased with age and were higher among women and night-shift workers. In contrast, they decreased among nursing professionals who were satisfied with their jobs, and among those working in suitable environments. CONCLUSIONS: Missed nursing care in highly specialized public hospitals is associated with the sociodemographic characteristics and labor-related conditions -including the work environments- of the nurses. Given its impact on both health-care users and institutions, further research on the subject is urgently needed. It is essential to improve the design, implementation and evaluation of comprehensive strategies aimed at reducing the frequency of missed nursing care and achieving universal health coverage.

Public health insurance and ethnic disparities in maternal health care: the case of vulnerable Mexican women over the last 25 years.

This article examines the coverage in the continuum of antenatal-postnatal care for vulnerable women in Mexico according to indigenous status and assesses the influence of public health insurance strategies on the evolution of coverage over the last 25 years. We studied a total of 19 613 567 Mexican women, aged 12-54 years at last birth, based on a pooled cross-sectional analysis of data from the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics. After describing sociodemographic characteristics and maternal-health coverage by indigenous status, we constructed a pooled fixed-effects and interaction multivariable regression model to assess the influence of the Seguro Popular programme on continuum of care. We estimated adjusted continuum of care coverage between 1994 and 2018 according to Seguro Popular affiliation and indigenous status. Prior to the Seguro Popular programme, crude coverage in the continuum of care for non-indigenous women stood at 14.5% [95% confidence interval (CI): 13.2-15.8%] or 11 percentage points higher than for indigenous women. During the last period of the programme, it rose to 46.5% [95% CI: 45.6-47.5%] and 34.1% [95% CI: 30.7-37.4%], respectively. Our regression analysis corroborated findings that, on average, indigenous women faced lower odds of benefiting from continuum of care [adjusted odds ratio (aOR) = 0.48, 95% CI: 0.40-0.57] than did their non-indigenous counterparts. It also revealed that coverage for indigenous women without Seguro Popular affiliation was 26.7% [95% CI: 23.3-30.1%] or 12 percentage points lower than for those with Seguro Popular affiliation (38.6%, 95% CI: 35.7-41.4%). Our regression results confirmed that the latter benefited from higher odds of continuum of care (aOR = 1.67, 95% CI: 1.36-2.26). Gaps between those of indigenous and non-indigenous status have persisted, but the Seguro Popular clearly contributed to reducing the coverage gaps between these two groups of women. Strategies yielding better outcomes are required to improve the structural conditions of indigenous populations.

The Sustainable Development Goals and Technological Capacity.

In order to achieve the Sustainable Development and Health Goals, it is essential to increase the technological capacity of the most disadvantaged populations. In the 21st century, the necessary technologies for this exist. The gap in technological capacity reflects the existence of a technological gradient between large- and small-scale production, due to an absence of incentives for innovation and a lack of technological dissemination in small businesses and communities. Technological change is central to development, but it is a public good that the market economy does not provide efficiently. Providing it requires the implementation of public policies aimed at technological innovation and dissemination. Reducing the technological gradient is therefore a major part of the United Nations 2030 Agenda for Sustainable Development and the Pan American Health Organization's 2018-2030 Sustainable Health Agenda for the Americas. This also applies to the development of health systems, which function as a redistribution mechanism to break poverty traps. In addition, experiences in these systems are relevant to the implementation of policies that increase technological capacities aimed at reducing poverty, improving social determinants of health, and thereby reducing the scale of the human development trap.

Para lograr los objetivos de desarrollo y salud sostenibles, es esencial incrementar las capacidades tecnológicas de las poblaciones más desfavorecidas. Entrado el siglo XXI, existen las tecnologías necesarias para ello. El déficit en capacidades tecnológicas se debe a la existencia de un gradiente tecnológico entre la producción de gran y de pequeña escalas, debido a la falta de incentivos para la innovación y la difusión en empresas y comunidades pequeñas. En estos ámbitos el cambio tecnológico, punto medular del desarrollo, es un bien público que la economía de mercado no provee eficientemente. Su provisión requiere la aplicación de políticas públicas de innovación y difusión tecnológicas. La reducción del gradiente tecnológico constituye, pues, parte medular de la Agenda 2030 para el Desarrollo Sostenible, de las Naciones Unidas, y la Agenda de Salud Sostenible para las Américas 2018-2030, de la Organización Panamericana de la Salud. Esto es aplicable, así mismo, al desarrollo de los sistemas de salud, que funcionan también como mecanismos de redistribución para romper las trampas de pobreza. Asimismo, las experiencias en esos sistemas tienen relevancia para aplicar políticas de incremento de capacidades tecnológicas que disminuyan la pobreza, mejoren los determinantes sociales de la salud y, con ello, reduzcan la magnitud de la trampa de desarrollo humano.

Para alcançar os objetivos de desenvolvimento e saúde sustentáveis, é fundamental aumentar a capacidade tecnológica das populações mais desfavorecidas. Com a entrada do século XXI, há tecnologias necessárias para isso. O déficit em capacidade tecnológica decorre de um gradiente tecnológico entre a produção em pequena e larga escala pela falta de incentivos à inovação e difusão em empresas e comunidades pequenas. Nestas esferas, a evolução tecnológica, que é o eixo do desenvolvimento, é um bem público que não é provido de forma eficiente pela economia de mercado. Políticas públicas de inovação e difusão tecnológicas são necessárias. Diminuir o gradiente tecnológico constitui, portanto, a base da Agenda 2030 para o Desenvolvimento Sustentável, da Agenda das Nações Unidas e da Agenda de Saúde Sustentável para as Américas 2018-2030 da Organização Pan-Americana da Saúde. Requer também o desenvolvimento dos sistemas de saúde que servem como mecanismos de redistribuição para romper com as armadilhas da pobreza. Ademais, a experiência adquirida nesses sistemas é indispensável para instituir políticas de aumento da capacidade tecnológica que diminuam a pobreza, melhorem os determinantes sociais da saúde e, assim, reduzam a dimensão da armadilha do desenvolvimento humano.

Progress and challenges for advanced practice nursing in Mexico and the United Kingdom.

AIM: The aim of this study is to compare the advanced practice nursing development in Mexico with the United Kingdom. BACKGROUND: In spite of the involvement of global and local bodies to establish and develop advanced practice nursing worldwide, progress remains variable due to the lack of homogeneity in health care systems and policies. EVALUATION: Using thematic analysis from interviews of 29 health care professionals in Mexico, we identified four major issues that impact on the development of advanced practice nursing: (a) workforce, (b) organizational and institutional, (c) regulatory and legal and (d) academic and educational. KEY ISSUES: Learning from the UK experience in relation to overcoming some of these issues has been insightful in terms of how advanced practice nursing skills in Mexican nurses can be developed. CONCLUSIONS: Mexico is still in early stages of the development of APN. Based on the UK experience, the government may have to move forward to support higher level training, create labour market positions, establish new nursing functions, promote task-shifting and particularly implement solid regulation. IMPLICATIONS FOR NURSING MANAGEMENT: The development of advanced practice nursing represents important challenges for training and practice of nursing in Mexico and the United Kingdom; therefore, interested actors will have to reach key agreements that could work as the foundations of an assertive planning process.