Unpacking participation in healthcare governance: Lessons from two local health councils in Brazil and Spain.

This paper describes and compares the integration of cross-sector actors' participation into the governance of two local health councils, one located in Salvador de Bahia (Brazil) and the other in the Canary Islands (Spain). Based on the cross-national comparative research conducted as part of a doctoral thesis, a qualitative design based on secondary data analysis was proposed on the three stages of the organisational integration process of participation. We used information from individual semi-structured interviews (n = 70), situational observation, focus groups, literature review, and field notes to understand participatory processes of networking between multiple cross-sector actors and to show how such processes might be associated with innovative practices. For these innovations to be successfully implemented, stakeholders need to acquire adequate competencies in cross-sector collaboration, enabling them to learn about new organisational practices and to adapt the network of actors to the often unpredictable influences of contextual factors.

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

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

The challenges facing indigenous communities in Latin America as they confront the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-2019) pandemic struck Latin America in late February and is now beginning to spread across the rural indigenous communities in the region, home to 42 million people. Eighty percent of this highly marginalized population is concentrated in Bolivia, Guatemala, Mexico and Peru. Health care services for these ethnic groups face distinct challenges in view of their high levels of marginalization and cultural differences from the majority. Drawing on 30 years of work on the responses of health systems in the indigenous communities of Latin America, our group of researchers believes that countries in the region must be prepared to combat the epidemic in indigenous settings marked by deprivation and social disparity. We discuss four main challenges that need to be addressed by governments to guarantee the health and lives of those at the bottom of the social structure: the indigenous peoples in the region. More than an analysis, our work provides a practical guide for designing and implementing a response to COVID-19 in indigenous communities.

La judicialización del derecho a la protección de la salud desde la óptica de los actores clave.

 Objetivo. Conocer la opinión de actores clave respecto del proceso de judicialización del derecho a la protección de la salud en México. Material y métodos. Se realizaron 30 entrevistas semiestructuradas a representantes de los pode-res Judicial (PJ), Legislativo (PL), Sector Salud (SS), industria farmacéutica, academia y organizaciones de la sociedad civil (OSC) durante mayo de 2017 a agosto de 2018, en distintos lugares de la Ciudad de México. Se transcribieron las graba-ciones y se analizó el contenido con base en categorías de interés. Resultados. Las posturas respecto al fenómeno de la judicialización del derecho a la salud son disímiles. Hay tensiones entre quienes ven su potencial efecto como agente de cambio del sector y quienes la perciben como una interferencia ilegítima del PJ. No existe una estrategia coordinada entre los sectores para promover un cambio en el SS. Conclusiones. Las posturas respecto al fenómeno de la judicialización en México son disímiles. Hay tensiones entre quienes ven su potencial efecto como agente de cam-bio del sector y quienes la perciben como una interferencia ilegítima del PJ en el SS. Otros argumentan que no existe una estrategia coordinada entre los sectores para promover un cambio en el SS.

[The Health of Indigenous Peoples: Agenda for research, teaching and linking]. / Programa Institucional Salud de los Pueblos Indígenas: agenda para la investigación, la docencia y la vinculación.

The Health of Indigenous Peoples Program is a transversal axis of institutional policy. Its objective is to contribute to the well-being of indigenous peoples by doing research about their health needs, training human resources for their care, and innovating in policy development. This document presents the program's theoretical framework, which focuses on the structural determination of inequalities. It also describes its main lines of action, which contribute to the development of policies and programs aimed at the well-being of this population.

El Programa Salud de los Pueblos Indígenas es un eje transversal de la política institucional. Su objetivo es contribuir al bienestar de los pueblos indígenas mediante la investigación de sus necesidades de salud, la formación de personal para su atención y la innovación para el desarrollo de políticas. En este documento se presenta el marco teórico que sustenta este programa, centrado en la determinación estructural de las desigualdades, y menciona las principales líneas de acción en las que se basa para contribuir al desarrollo de políticas y programas, orientados al bienestar de esta población como principal meta.

[Collateral effect of transnational migration: the transformation of medical habitus]. / Efecto colateral de la migración transnacional:la transformación del habitus médico.

OBJECTIVE: To analyze health practice transformations in health providers in Mexico. MATERIALS AND METHODS: . We used qualitative data to explore transnational health practices of men with migration experience to the US, healthcare professionals in Mexico from eight rural communities, and Mexican providers in US. Data used came from a study that explored transnational health practices in the context of migration. RESULTS: Healthcare professionals provided care to migrants through remote consultations or via a family member, and in-person during migrants' visits or by health-care professionals relocating to migrants' destination com-munities in the US. The remote consultations mainly caused three changes in the field of medical practice: providing care without a patient review or clinical examination, long-distance prescription of medications, and provision of care mediated by a family member. CONCLUSIONS: Changes in their medical practice shifted roles of healthcare professionals and of migrants as patients, transforming the hegemonic biomedical model in Mexico.

OBJETIVO: Analizar las transformaciones de la práctica médica en proveedores de salud en México. MATERIAL Y MÉTODOS: Se utilizaron datos cualitativos para explorar las prácticas de salud transnacionales de hombres con ex-periencia en migración a los Estados Unidos y profesionales de la salud en México de ocho comunidades rurales y pro-veedores mexicanos en Estados Unidos. RESULTADOS: Los profesionales de la salud brindan atención a los migrantes a través de consultas remotas o a través de un miembro de la familia, y en persona, durante las visitas de los migrantes o por profesionales de la salud que se trasladan a las comunidades de destino de los migrantes en los EU. Las consultas a distan-cia causaron principalmente tres cambios en el campo de la práctica médica: proporcionar atención sin una revisión del paciente o un examen clínico, la prescripción a larga distancia de medicamentos y la prestación de atención mediada por un miembro de la familia. CONCLUSIONES: Los cambios en la práctica médica modificaron el rol de los profesionales de la salud y los migrantes como pacientes, lo que ha transformado el modelo biomédico hegemónico en México.

Los Grupos de Ayuda Mutua como posible estrategia de apoyo emocional para personas indígenas que padecen diabetes.

Objetivo. Reflexionar sobre el apoyo emocional que los Grupos de Ayuda Mutua (GAM) dan a personas indígenas con diabetes y su importancia en el apego al tratamiento. Material y métodos. Estudio cualitativo: 25 entrevistas semiestructuradas; tres grupos focales (17 participantes); y observación no participante. Se realizó análisis de contenido con el apoyo del programa Atlas-ti. Resultados. Se identificaron expresiones emocionales relacionadas con el padecimiento. La opinión sobre el trabajo grupal fue positiva. El GAM es un espacio de catarsis, pero no funciona como soporte para enfrentar las restricciones del tratamiento y el impacto emocional en caso de complicaciones mayores. Conclusiones. Con la debida capacitación del personal de salud a cargo de los grupos, los GAM pueden llegar a ser espacios de soporte emocional para las personas indígenas y contribuir a su bienestar.

[Health conditions and use of services amongindigenous peoples of Mexico]. / Condiciones de salud y uso de servicios en pueblos indígenas de México.

OBJECTIVE: To identify differences in socioeconomic indi-cators, health conditions and use of services between the indigenous (IP) and non-indigenous population (NIP) of the country. MATERIALS AND METHODS: Descriptive cross-sectional study carried out with information obtained by the 2018-19 National Health and Nutrition Survey. RESULTS: Most IP are in the lowest socioeconomic quintile and they use less health services. Indigenous women reported a higher number of children, as well as childbirth care with midwives. IP go for medical care to institutions for the population without social security as the first option but expressed less desire to return to the same place. CONCLUSIONS: IPs use less health services. An epidemiological panorama of double burden and inequity in access indicators that affect IP is configured. Reproductive health is the area where the greatest inequali-ties are observed.

OBJETIVO: Identificar diferencias en indicadores socioeco-nómicos, de condiciones de salud y uso de servicios entre la población indígena (PI) y no indígena (PNI) del país. MATERIAL Y MÉTODOS: Estudio trasversal descriptivo con información de la Encuesta Nacional de Salud y Nutrición 2018-19. RESULTADOS: La mayoría de la PI se encuentra en el quintil socioeconómico más bajo y usa menos los servi-cios de salud. Las mujeres indígenas reportaron un mayor número de hijos, así como atención del parto con parteras. La PI acude por atención médica a las instituciones para población sin seguridad social como primera opción, pero manifiesta menor deseo de regresar a atenderse al mismo lugar. CONCLUSIONES: La PI utiliza menos los servicios de salud. Se configura un panorama epidemiológico de doble carga e inequidad en indicadores de acceso que afecta a la PI. La salud reproductiva es el ámbito donde se observan las mayores desigualdades.

Innovación pedagógica para mejorar la calidad del trato en la atención de la salud de mujeres indígenas.

Objetivo. Presentar los resultados de una intervención pedagógica para mejorar la calidad en el trato que brindan los prestadores de servicios de salud en regiones indígenas. Material y métodos. Se diseñó una metodología didáctica con enfoque crítico-constructivista dirigida a personal de salud que atiende a población indígena en cinco entidades de México. Resultados. Entre 09/2016 a 01/2020 se capacitó a 1 825 trabajadores de la salud que deconstruyeron las creencias que determinan prácticas de discriminación y maltrato durante la atención a la salud de los usuarios indígenas. La intervención logró un aprendizaje significativo transformador de las valoraciones y prácticas sociales, con propuestas para evitar cualquier forma de maltrato y garantizar el trato digno. Conclusiones. Para la construcción de un sistema de salud universal y equitativo, es necesario incluir intervenciones que actúen sobre las creencias determinantes de las prácticas de discriminación y maltrato en los servicios de salud hacia grupos sociales vulnerables.

[Inequalities in access to services, basis for policies to reduce the health gap]. / Desigualdades en el acceso a servicios, base de las políticas para la reducción de la brecha en salud.

OBJECTIVE: To estimate inequalities in access to health services among Mexican population living in localities of 100 000 or less inhabitants. MATERIALS AND METHODS: Cross-sectional analysis using the National Health and Nu- trition Survey 100k 2018 survey data. Access was estimated using health insurance and care for the last health condition. As inequality measure, we estimated the concentration index using an imputation of household per capita income. RESULTS: Among studied population, health insurance was 82.42% and access to care 60.03%. We identified inequalities in both indicators; marginal and pro-poor for insurance and pro-rich for access to care. CONCLUSIONS: In Mexico, even within the popuation living in poverty there are inequalities in access to health care. More granular public interventions are needed to address inequalities in an effective way.

OBJETIVO: Estimar la desigualdad en acceso a servicios de salud en poblaciones de localidades menores de 100 000 habitantes en México. MATERIAL Y MÉTODOS: Análisis de la Encuesta Nacional de Salud y Nutrición 100k 2018. Se estimó el acceso con base en la afiliación a un esquema de aseguramiento (acceso potencial) y la atención para el más reciente problema de salud (acceso a atención) mediante el índice de concentración, utilizando una imputación del ingreso per cápita. RESULTADOS: La afiliación a algún esquema de ase- guramiento en salud fue de 82.42% y el acceso a atención de 60.03%. Se identificaron desigualdades en ambos indicadores, marginales para acceso potencial y con mayor concentración entre la población de menor ingreso; para acceso a atención se encontró desigualdad con mayor concentración entre la población de mayor ingreso. CONCLUSIONES: En México prevalecen desigualdades en acceso a servicios de salud para la población en condiciones de pobreza. Es necesario desarrollar intervenciones públicas con mayor granularidad para incidir de forma efectiva en la desigualdad.

Aging in rural, indigenous communities: an intercultural and participatory healthcare approach in Mexico.

From an ethno-gerontological perspective, new models are needed to fulfill the health needs of the indigenous older adult population in Mexico. In this paper we developed a comprehensive healthcare model, interculturally appropriate, designed to meet the needs of Mexican indigenous older adults. The model was constructed using a qualitative design with semi-structured interviews of older adults, health providers, and available health resources in three Mexican indigenous regions. An ethnographical review was carried out to contextually characterize these communities. At the same time, a comprehensive bibliographic revision was made to identify socio-demographic markers. Results pointed out that Mexican indigenous older adults are not covered by any type of social health insurance program. Their health problems tend in large part to be chronic in nature due to the lack of early diagnosis and treatment. There is a need for trained human resources in the field of gerontology encompassing the sociocultural context of the indigenous groups. The geographical location of these communities limits the permanent presence of healthcare givers and thus limits access to continuous care. Traditional healthcare givers, able to speak the native language, are a great asset allowing the invaluable possibility of direct verbal communication. Based upon the data gathered from indigenous older adults and service providers, in tandem with evidence from the literature, we identified key elements for successful intervention and designed an intervention model. We concluded that indigenous older adults are a more vulnerable group, given that aside from being elderly in a country where the health needs of these populations exceed the capacity of existing healthcare services, their ethnicity serves as an added barrier preventing their access to the limited available healthcare resources. To achieve uniformity in providing health care, today's health systems need to address intercultural and participative aspects of healthcare models.

[Empowerment and social support for patients with chronic kidney disease: case study in Michoacán, MexicoEmpoderamento e apoio social de pacientes com nefropatia crônica: estudo de caso em Michoacán, México]. / Empoderamiento y apoyo social en pacientes con enfermedad renal crónica: estudio de caso en Michoacán, México.

OBJECTIVE: Identify the degree of empowerment and the characteristics of the social support for individuals with chronic kidney disease (CKD). METHODS: Cross-sectional study of people with chronic kidney disease living in the municipality of Hidalgo, Michoacán, Mexico, who belong to the Association of Kidney Patients, Civil Association. The study examined the sociodemographic profile and personal characteristics associated with the disease, the degree of empowerment, the degree of social support, and family functioning. RESULTS: Close to 90% of the sample receives sufficient social support, while 40% of the participants belong to semi-cohesive or cohesive families The overall empowerment score was 117.5 ± 14.3; community empowerment was higher in the older group (P < 0.05). Positive social interaction is the social support component most strongly correlated with the degree of empowerment (r = 0.333; P < 0.01). CONCLUSIONS: Empowerment is determined by, and is a determinant of, social support and has facilitated access to renal replacement therapy in this community.

OBJETIVO: Identificar o nível de empoderamento e apoio social de pacientes com nefropatia crônica. MÉTODOS: Estudo transversal realizado com pacientes com nefropatia crônica residentes no município de Fidalgo, Michoacán, México, que participavam de uma associação civil de pacientes renais crônicos (Asociación de Enfermos del Riñón). Foram investigados aspectos pessoais e sociodemográficos dos pacientes associados à doença, nível de empoderamento e apoio social e funcionamento familiar. RESULTADOS: Cerca de 90% da amostra estudada dispõem de uma rede de apoio social satisfatória e 40% pertencem a famílias com boa coesão ou coesão média. A pontuação global de empoderamento foi de 117,5 ± 14,3 e o empoderamento comunitário foi maior no grupo com idade mais avançada (P < 0,05). Interação social positiva é o componente da rede de apoio social com correlação mais forte com o nível de empoderamento (r = 0,333; P < 0,01). CONCLUSÕES: O empoderamento é determinado pela rede de apoio social, sendo também um determinante deste apoio, e facilita o acesso à terapia renal substitutiva nesta comunidade.

Risk: For Whom? Representations of Mining Activity by Different Social Actors in the Molango Manganese District of Hidalgo, Mexico.

Previous studies have shown high levels of manganese exposure and neurocognitive damage in the population living in the mining zone in Molango, Mexico. One of the objectives of the Intersectoral Group on Environmental Management for the mining district has been to provide public participation in the risk management plan. To achieve this, it is important to know how the different social actors represent the mining activity. The objectives of this study were to characterize the social representations of the mining activity by different social actors. A qualitative design was used based on in-depth interviews of residents, public officials, and a mining company representative. The analysis was conducted according to themes for each group of actors. Essentially, distinct social representations of the different mining activities were identified. Residents viewed mining activities as synonymous with contamination and, therefore, as having affected all areas of their environment, health, and daily life. These activities were seen as a collective risk. The public officials and the mining company held that there was no evidence of harm and saw mining activities as a generator of regional development. Harm to health and the environment were seen as a stance taken by the communities in order to obtain economic benefits from the company. These images of the "other" are shaped by social, political, and cultural factors. They make it difficult for the actors to reach cooperative agreements and thereby affect progress on the risk management plan. Decisionmakers need to take these differences into account when promoting social participation.

[Institutional abuse toward the elderly: perceptions of health care providers and older adults]. / Maltrato institucional hacia el adulto mayor: percepciones del prestador de servicios de salud y de los ancianos.

OBJECTIVE: To analyze the health care providers (HCP) and elderly patients' perceptions about abuse of the elderly by health personnel of public health services, in selected cities in Mexico. MATERIALS AND METHODS: A qualitative study and a strategy of data triangulation were performed during 2009 and 2012; 13 HCPs and 12 elders were interviewed, in order to obtain their experience regarding elder abuse. Grounded Theory proceedings were used for the analysis. RESULTS: Elder abuse is a naturalized practice, from HCP and elderly people's point of view; these perceptions are showed in different ways. CONCLUSION: Institutionalization, historical professionalization and lack of consciousness about needs of the elderly (sociocultural and economic), require changes in planning, organization and monitoring process in the Health System; training and educational interventions on staff and exchange attitudes and behavior are necessary in order to offer a health care that is comprehensive, decent, human and with respect for the human rights.

[Health inequality among vulnerable groups in Mexico: older adults, indigenous people, and migrants]. / La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes.

Health vulnerability refers to a lack of protection for specific population groups with specific health problems, as well as the disadvantages they face in solving them in comparison with other population groups. This major public health problem has multiple and diverse causes, including a shortage of trained health care personnel and the lack of family, social, economic, and institutional support in obtaining care and minimizing health risks. Health vulnerability is a dynamic condition arising from the confluence of multiple social determinants. This article attempts to describe the health situation of three vulnerable groups in Mexico-older adults, indigenous people, and migrants-and, after defining the needs of each, explore measures that could contribute to the design and implementation of public health policies better tailored to their respective needs.

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

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

[Transnational health service utilization by Mexican immigrants in the United States]. / Utilización transnacional de servicios de salud por parte de los migrantes mexicanos en Estados Unidos.

OBJECTIVE: Document the transnational utilization of health resources and services by Mexican immigrants in the United States. MATERIALS AND METHODS: Between December 2009-February 2011, Interviews and focus groups were conducted in California and four states of México. Data were collected from 135 individuals, including return migrants, allopathic physicians and traditional healers. RESULTS: Faced with obstacles to accessing US health care and some health services within the Mexican system, many immigrants within the US make use of Mexican health resources and services, either from a distance or during visits to Mexico. These resources and services include allopathic medicine, traditional medicine, and home remedies and medicines. CONCLUSIONS: The legal status of immigrants and their access to health insurance in the US are related to whether their transnational use of Mexican health resources and services is formal or informal; immigrants who are undocumented and without health insurance are the most vulnerable.

Psychometric Properties of the Access of Older Adults to Outpatient Primary-Care Health Services Scale.

This study evaluates the psychometric properties of the Access of Older Adults to Outpatient Primary-Care Health Services Scale (AOAOPHSS), in research conducted among 707 Mexican older adults selected by convenience from 14 rural and one urban locations. The AOAOPHSS explores 10 dimensions of two integrated subscales: Accessibility and Personal Abilities. Data analysis was performed in five phases. First, potentially biased responses were identified. Second, the response efficiency of the items and their association with external variables were evaluated. Third, the basic properties of the scores for the subscales' dimensions of the AOAOPHSS were identified using non-parametric Mokken Scaling Analysis (MSA). Fourth, the Structural Equation Modeling methodology was used to identify the properties of the internal structure of the latent construct. Finally, reliability and internal consistency were evaluated at both score and item levels. The following findings emerged. 13 items with inefficient response options were removed, and 24 were retained using the MSA. The latent structure of the latter was defined based on 21 items of five Accessibility Subscale dimensions. Its internal consistency reliability ranged between 0.67 and 0.81 (omega coefficients) and between 0.61 and 0.78 (alpha coefficients). Accordingly, this paper discusses the overall implications of using the Accessibility Subscale.