Evidencias y tendencias para tomar decisiones sobre medidas de contención y mitigación de Covid-19 en Jalisco, México

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Barriers and Facilitators in Timely Detection of Chronic Kidney Disease: Evidences for Decision-Makers

Chronic Kidney Disease (CKD) is classified, according to the glomerular filtratation rate. Timely diagnosis during the first three stages represents a lower expenditure for health systems in the treatment of this disease. Thus, this study intends to identify barriers and facilitators in timely detection of CKD, from the perspective of healthcare providers. This is an exploratory study of the qualitative type. A mapping of the literature was carried out in order to develop the following topics: perceptions of the implications of CKD for the health system at an international level and in Mexico, as well as experience related to barriers and facilitators in timely CKD detection in Mexico. Based on the identified topics, semi-structured interviews were carried out with decision-makers, operational personnel, civil and academic associations representatives in Mexico City and Cuernavaca, Morelos. The main identified barriers were: system fragmentation; overload of services at first and second levels of care; insufficient human resources; lack of updating of the clinical practice guide and scarce training. With respect to facilitators, we found there are civil society actions. Finally, requirements for timely detection of CKD are consistent with what is described in the international guides. The identification of barriers and facilitators in timely CKD detection gives us an outlook of the problem in Mexico and leads to proposals for action. The development of a national program with a strategy for timely detection of CKD may help unify inter-institutional criteria considering the protocols for clinical practice that take into account each institution's organization and resources.

Barreras y facilitadores para una alimentación saludable y actividad física en mujeres embarazadas con sobrepeso y obesidad

Objetivo:

identificar barreras y facilitadores sobre dieta saludable y actividad física en mujeres embarazadas con sobrepeso y obesidad que viven en entornos de vulnerabilidad social y económica, destacando determinantes socioeconómicos y culturales.

Metodología:

estudio cualitativo longitudinal, donde las entrevistadas corresponden a mujeres embarazadas seleccionadas de una cohorte prospectiva en México. Se aplicó una guía semiestructurada de entrevista que exploró barreras y facilitadores para llevar una dieta saludable y poder realizar actividad física. Las entrevistas se transcribieron y codificaron en Atlas Ti, generando 23 códigos temáticos.

Resultados:

existen barreras y facilitadores contextuales y sociales que predisponen un mayor riesgo de padecer sobrepeso y obesidad durante el embarazo. Destacan conocimientos limitados sobre una dieta saludable, condiciones de vulnerabilidad social, así como un sentido de fragilidad en las mujeres que incrementa su sedentarismo.

Conclusiones:

en el diseño e implementación de intervenciones en promoción de la salud es fundamental considerar las barreras y facilitadores culturales y socioeconómicas sobre alimentación saludable y actividad física durante el embarazo, para desarrollar intervenciones de salud pública que favorezcan una mayor prevención de sobrepeso y obesidad en mujeres embarazadas.

[Socioeconomic determinants of maternal obesity in Mexico and France. Comparative analysis of two cohorts]

OBJECTIVE

To identify and analyze the socioeconomic indicators of maternal obesity in Mexico and France.

MATERIAL AND METHODS

Comparative study of two cohorts: EDEN (France) and NUTTSEA (Mexico). The study population consisted of women who requested prenatal consultation at week 24 of pregnancy. Data were collected using questionnaires and semi-structured interviews. The variables of interest were socioeconomic aspects, nutrition, anthropometry and food security. The quantitative analysis was performed using Stata and the qualitative analysis with Atlas-ti.

RESULTS

In the EDEN cohort, 68.6% were aged 25-34 years, 73% had paid employment and 53% completed high school. In addition, 6.6% reported having difficulty accessing food and the mean gestational BMI was 23.23 ± 4.6. In the NUTTSEA cohort, 55% were in the age range 18-24 years, 15% reported having paid employment, 42% had completed secondary education, 32.1% presented a degree of food insecurity, and the mean BMI was 27.8 ± 4.8.

CONCLUSIONS

The qualitative and quantitative results of both cohorts suggest that populations with greater socio-economic vulnerability are more prone to maternal obesity, which leads to determine guidelines on barriers and facilitators to strengthen programs to prevent it maternal obesity.

Challenges and dilemmas on universal coverage for non-communicable diseases in middle-income countries: evidence and lessons from Mexico

BACKGROUND

Despite more than 20 years of reform projects in health systems, the universal coverage strategy has not reached the expected results in most middle-income countries (MICs). Using evidence from the Mexican case on diabetes and hypertension as tracers of non-communicable diseases, the effective coverage rate barely surpasses half of the expected goals necessary to meet the challenges that these two diseases represent at the population level. Prevalence and incidence rates do not diminish either; they even grow. In terms of the economic burden, this means that lack of financial protection and catastrophic expense rates have increased, contrary to what could have been expected.

DISCUSSION

As any complex system, health systems present challenges and dilemmas that are difficult to solve. In terms of universal coverage, when contrasting normative coverage versus effective coverage, the epidemiological, cultural, organizational and economic challenges and barriers become evident. Such challenges have not allowed a greater effectiveness of the contributions of state of the art medicine in the resolution of health problems, particularly in relation to diabetes and hypertension.

CONCLUSIONS

Despite of the existence of many universal coverage projects, strategies and programs implemented in MICs, challenges remain and, far from disappearing, unresolved problems are still present, even with increasing trends. The model of care based on a curative biomedical approach was enough to respond to the health needs of the last century, but is no longer adapted to the needs of the present century. The dilemmas of continuity vs. rupture require to review and discuss the background and structure of health systems and their underlying models of care. These two elements have not allowed the different coverage schemes to guarantee greater effectiveness in the application of state of the art medicine, nor a greater health care financial protection for patients and their families. We thus can either accept the fragmented health systems and bio-medical-curative models of care approach or, instead, we can move towards integrated health systems that would be based on a socio-medical-preventive approach to health care.

Trends and challenges in diabetes for middle-income countries: Evidence from Mexico

The epidemiological and economic burden of diabetes poses one of the main challenges for health systems worldwide. This is particularly relevant in middle-income countries because of the constant growing trends that have been observed in recent years. In order to identify trends and challenges on epidemiological and economic burden from diabetes in a middle-income country we developed a longitudinal analysis on costs and trends in the number of cases of diabetes in Mexico. The study population included total annual cases of diabetes at national level. Regarding the annual cumulative incidence for 2016 versus 2018, depending on the institution there is an increase of 9-13% (p < 0.001). Comparing the economic burden from incidence in 2016 versus 2018 (p < 0.05), there is a 26% increase. The total amount for diabetes in 2017 (US dollars) was $9,684,780,574. It includes $ 4,292,085,964 in direct costs and $ 5,392,694,610 in indirect costs. The total direct costs are: $ 510,986,406 for uninsured population; $ 1,416,132,058 for insured population; $ 2,235,969,330 for users' pockets. This is an example of what is happening in the management of diabetes care in middle-income countries and we suggest review and rethinking strategies of prevention, planning, organisation and resource allocation.

Challenges of health services related to the population displaced by violence in Mexico

OBJECTIVE

To analyze the impacts of the care to the population displaced by violence on the health system and the challenges that this entails.

METHODS

This is a narrative review of the national and international literature in PubMed, SciELO, WHO/PAHO, and Bireme. Inclusion criteria were date of publication (from 2000), relation with the subject, and language (Spanish or English). We found 292 documents, of which 91 met the inclusion criteria.

RESULTS

The main challenges are the intersectoral, participatory, and integral approach (with emphasis on mental health and sexual and reproductive health), ensured accessibility to health services, the need for a reliable registration and information system of the population displaced by violence and its characteristics, and the addressing of the biopsychosocial problems of the different groups, especially women, persons with disabilities or infectious diseases, adolescents, children, ethnic minorities, older adults and the lesbian, gay, bisexual, transsexual, and intersexual population.

CONCLUSIONS

The lack of political will to accept and see the internal displacement by violence and its importance as a humanitarian and public health problem is an obstacle to the adequate and timely care of the population displaced by violence in Mexico.

Stewardship and governance: structuring dimensions for Implementation Primary Health Care Policies in Paraguay, 2008-2017

This study analyzes the conduction patterns of implementing Primary Health Care (PHC) in Paraguay in three government periods (2008-2012, 2012-2013 and 2013-2017) and three management levels (national, regional and local). This is a qualitative study based on grounded theory. A priori categories on PHC stewardship and governance in Paraguay were analyzed. An open-ended questionnaire was applied to a sample of social, political and technical stakeholders: ministers, coordinators, managers, consultants, and international organizations' experts. Data were processed combining the use of Atlas Ti software and sorting findings in a structured Excel matrix. Gaps in leadership, regulatory mechanisms, technical capacities for health planning and management and financial implementation methods have affected PHC continuous expansion and strengthening process. The findings show limitations and possibilities for the implementation of this health policy in Paraguay, evidencing the need for greater qualification of management and political stability in its conduction.

The cost of diabetes in Latin America and the Caribbean in 2015: Evidence for decision and policy makers

BACKGROUND

The financial implications of the increase in the prevalence of diabetes in middle–income countries represents one of the main challenges to health system financing and to the society as a whole. The objective of this study was to estimate the economic cost of diabetes in Latin America and the Caribbean (LAC) in 2015.

METHODS

The study used a prevalence–based approach to estimate the direct and indirect costs related to diabetes in 29 LAC countries in 2015. Direct costs included health care expenditures such as medications (insulin and oral hypoglycemic agents), tests, consultations, hospitalizations, emergency visits and treating complications. Two different scenarios (S1 and S2) were used to analyze direct cost. S1 assumed conservative estimates while S2 assumed broader coverage of medication and services. Indirect costs included lost resources due to premature mortality, temporary and permanent disabilities.

RESULTS

In 2015 over 41 million adults (20 years of age and more) were estimated to have Diabetes Mellitus in LAC. The total indirect cost attributed to Diabetes was US$ 57.1 billion, of which US$ 27.5 billion was due to premature mortality, US$16.2 billion to permanent disability, and US$ 13.3 billion to temporary disability. The total direct cost was estimated between US$ 45 and US$ 66 billion, of which the highest estimated cost was due to treatment of complications (US$ 1 616 to US$ 26 billion). Other estimates indicated the cost of insulin between US$ 6 and US$ 11 billion; oral medication US$ 4 to US$ 6 billion; consultations between US$ 5 and US$ 6 billion; hospitalization US$ 10 billion; emergency visits US$ 1 billion; test and laboratory exams between US$ 1 and US$ 3 million. The total cost of diabetes in 2015 in LAC was estimated to be between US$ 102 and US$ 123 billion. On average, the annual cost of treating one case of diabetes mellitus (DM) in LAC was estimated between US$ 1088 and US$ 1818. Per capita National Health Expenditures averaged US$ 1061 in LAC.

CONCLUSIONS

Diabetes represented a major economic burden to the countries of Latin America and the Caribbean in 2015. The estimates presented here are key information for decision–making that can be used in the formulation of policies and programs to achieve greater efficiency and effectiveness in the use of resources for diabetes prevention in the 29 countries of LAC.

Challenges on the epidemiological and economic burden of diabetes and hypertension in Mexico

OBJECTIVE

To analyze the epidemiological and economic burden of the health services demand due to diabetes and hypertension in Mexico.

METHODS

Evaluation study based on a time series study that had as a universe of study the assured and uninsured population that demands health services from the three main institutions of the Health System in Mexico: The Health Department, the Mexican Institute of Social Security, and Institute of Services and Social Security for State Workers. The financing method was based on instrumentation and consensus techniques for medium case management. In order to estimate the epidemiological changes and financial requirements, a time series of observed cases for diabetes and hypertension 1994–2013 was integrated. Probabilistic models were developed based on the Box-Jenkins technique for the period of 2013–2018 with 95% confidence intervals and p < 0.05.

RESULTS

Comparing results from 2013 versus 2018, in the five regions, different incremental trends of 14%–17% in epidemiological changes and 58%-66% in the economic burden for both diseases were observed.

CONCLUSIONS

If the risk factors and the different models of care remained as they currently are in the three institutions analyzed, the financial consequences would be of greater impact for the Mexican Institute of Social Security, following in order of importance the Institute of Services and Social Security for State Workers and lastly the Health Department. The financial needs for both diseases will represent approximately 13%–15% of the total budget allocated to the uninsured population and 15%–17% for the population insured depending on the region.

[Cost analyses of medical care for schizophrenia and depression in México, 2005-2013]

The study aimed to analyze the costs of medical care for mental disorders in the Mexican health system. This was a retrospective cross-sectional evaluation study. As markers for the problem, the study selected two of the principal psychological processes in mental disorders in recent years: depression and schizophrenia. Annual accumulated incidence was identified based on epidemiological reporting by type of institution in 2005-2013. The mean annual case management cost was determined with the instrumentation and consensus technique, identifying the production functions, types of inputs, costs, and amounts of inputs ordered, concentrated in the mean case matrix. Finally, an econometric adjustment factor was applied to control the inflationary effect for each year in the study period. Mean annual case management cost was USD 2,216.00 for schizophrenia and USD 2,456.00 for depression. All the institutions in the Mexican health system showed upward and constant epidemiological and economic trends. The total cost for the two disorders in the last year of the period (2013) was USD 39,081,234.00 (USD 18,119,877.00 for schizophrenia and USD 20,961,357.00 for depression). The largest impact for the two disorders combined was in institutions serving the population without health insurance (USD 24,852,321.00) versus the population with private insurance (USD 12,891,977.00). The cost of meeting the demand for services for the two disorders differs considerably between institutions that treat the population with private health service versus the population without, and is higher in the latter. The study's epidemiological and economic indicators provide evidence for decision-making in the use and allocation of healthcare resources for these two disorders in the coming years.

Decision-making Process by Users and Providers of Health Care Services During the AH1N1 Epidemic Influenza in Mexico: Lessons Learned and Challenges Ahead

OBJECTIVE

The aim of the study was to analyze, using a decision analysis approach, the probability of severity of illness due to delayed utilization of health services and inappropriate hospital medical treatment during the 2009 AH1N1 influenza epidemic in Mexico.

METHODS

Patients with influenza AH1N1 confirmed by the polymerase chain reaction (PCR) test from two hospitals in Mexico City, were included. Path methodology based upon literature and validated by clinical experts was followed. The probability for severe illness originated from delayed utilization of health services, delayed prescription of neuraminidase inhibitors (NAIs) and inappropriate use of antibiotics was assessed.

FINDINGS

Ninety-nine patients were analyzed, and 16% developed severe illness. Most patients received NAIs and 85.9% received antibiotics. Inappropriate use of antibiotics was observed in 70.7% of cases. Early utilization of services increased the likelihood of non-severe illness (cumulative probability CP = 0.56). The major cumulative probability for severe illness was observed when prescription of NAIs was delayed (CP = 0.19).

CONCLUSION

Delayed prescription of NAIs and irrational use of antibiotics are critical decisions for unfavorable outcomes in patients suffering influenza AH1N1.

Diabetes, a global public health challenge with a high epidemiological and economic burden on health systems in Latin America

This manuscript presents the results of an analysis that highlights the challenges of diabetes as a global public health problem. The analysis was conducted in two phases: the first phase deals with primary data and results of a longitudinal study to provide evidence on the Mexican case. Regarding epidemiological changes between 2014 and 2016, there is an increase of 9-13% (p < .001). Comparing the economic burden from epidemiological changes in 2014 versus 2016 (p < .05), there is a 26% increase. The total amount spent on diabetes in 2015 (US dollars) was $ 8,974,662,570. This includes $ 3,981,426,810 in direct costs and $ 4993,235,752 in indirect costs. The second phase emphasises the analysis of diabetes as a major global public health challenge in the Americas. For this purpose a comparative analysis of epidemiological trends was carried out in seven selected Latin American countries (LACs). The results of both phases showed evidence leading to the conclusion that if the risk factors and models of health care remain as they currently are in LACs, there will be a high economic impact to patients' pockets and to health systems, which could lead to financial collapse.