Governance and mental health: contributions for public policy approach

OBJECTIVE

To analyze the conceptualization of the term governance on public mental health programs.

METHODS

In this systematic review, we analyzed the scientific literature published in the international scenario during 15 years (from 2000 to 2015). The databases analyzed were: Medline, CINAHL, PsycINFO and PubMed. Governance and mental health were the descriptors. We included relevant articles according to our subject of study and levels of analysis: (i) the concept of governance in mental health; (ii) process and decision spaces; (iii) strategic and pertinent actors who operate in the functioning of the health system, and (iv) social regulations. We excluded letters to the editor, news articles, comments and case reports, incomplete articles and articles whose approach did not include the object of study of this review.

RESULTS

We have found five conceptualizations of the term governance on mental health in the area of provision policies and service organization. The agents were both those who offer and those who receive the services: we identified several social norms.

CONCLUSIONS

The concept of governance in mental health includes standards of quality and attention centered on the patient, and incorporates the consumers of mental healthcare in the decision-making process.

OBJETIVO

Analizar la conceptualización del término gobernanza en las políticas de salud mental.

MÉTODOS

En esta revisión sistemática se analizó literatura científica publicada en el ámbito internacional durante 15 años (de 2000 hasta 2015). Las bases de datos analizadas fueron: Medline, CINAHL, PsycINFO y PubMed. Los descriptores fueron gobernanza y salud mental. Fueron incluidos artículos relevantes de acuerdo a nuestro objeto de estudio y niveles de análisis: (i) concepto de gobernanza en salud mental; (ii) proceso y espacios de decisión; (iii) actores estratégicos y de interés que intervienen en el funcionamiento del sistema de salud, y (iv) normas sociales. Se excluyeron cartas al editor, noticias, comentarios y reporte de caso, artículos incompletos y artículos que no incluyeran en su abordaje el objeto de estudio de esta revisión.

RESULTADOS

Se reportaron cinco conceptualizaciones del término gobernanza en salud mental en el ámbito de políticas de provisión y organización de servicios. Los actores fueron desde proveedores a usuarios de servicios; se identificaron diversas normas sociales.

CONCLUSIONES

El concepto de gobernanza en salud mental incorpora estándares de calidad y atención centrada en el paciente, e incluye a los usuarios en la toma de decisiones.

[Indicators of governance in mental health policies and programmes in Mexico: a perspective of key actors]

OBJECTIVE

To analyse the role of Mexico's mental health system governance in the development of mental health policies and programmes, from the perspective of its own actors.

METHODS

A map was developed for identifying the actors in Mexico's mental health system. A guide was designed for in-depth interviews, which were recorded and arranged in categories for their analysis. The Atlas-ti v.7 software was used for the organisation of qualitative data and Policy Maker v.4 was used to determine the position and influence of actors within the health system.

RESULTS

The actors were identified according to their level of influence in mental health policies: high, medium and low. Actors with a high level of influence participate in national policies, actors with medium influence are involved in regional or local policies and the participation of actors with a low level of influence is considered marginal.

CONCLUSIONS

This study facilitated understanding of governance in mental health. The level of influence of the actors directly affects the scope of governance indicators. Relevant data were obtained to improve policies in mental health care.

[Availability of indicators for monitoring the achievement of "Universal Health" in Latin America and the Caribbean]

Objective The objective of this study was to identify the availability of health indicators for validly measuring advances in the attainment of "universal health" in Latin America and the Caribbean (LAC). Methods A systematic search was undertaken for scientific evidence and available technical and scientific documents on assessing health system performance and advances in universal health in the following phases: phase 1, mapping of indicators; phase 2, classification of indicators; and phase 3, mapping the availability of selected indicators in LAC. Results Sixty-three (63) national sources of information and eight international sources were identified. A total of 749 indicators were selected from the different databases and studies evaluated, 619 of which were related to the attainment of universal health and 130 to the burden of disease. The following indicators were identified: financial protection, 42 (6%); coverage of service delivery, 415 (55.4%); population coverage, 6 (0.8%); health determinants, 101 (14%); assessment of inequalities in health, 55 (7.3%); and estimation of burden of disease, 130 (17.3%). Finally, the availability of 141 indicators was mapped for each LAC country. Conclusions The results of this study will help establish a framework for measuring the achievements, obstacles, and rate of progress toward universal health in LAC.

Epidemiological and financial indicators of hypertension in older adults in Mexico: challenges for health planning and management in Latin America

This study estimated the epidemiological and financial indicators of hypertension in order to identify challenges in strategic planning and management for health systems in Latin America. This is a longitudinal study with a population base of 187 326 reported cases of older adults with hypertension, diagnosed at public health institutions in Mexico. The cost-evaluation method that was used was based on the instrumentation and consensus techniques. To estimate the epidemiological changes and financial consequences for 2015-2017, time series analyses and probabilistic models were constructed according to the Box-Jenkins technique. Regarding epidemiological changes for 2015 versus 2017, an increase of 8-12% is expected (p < 0.001). Comparing the economic impact in 2015 versus 2017 (p < 0.001), there is a 22% increase in financial requirements. The total amount estimated for hypertension in 2015 (in US dollars) was $1 575 671 330. It included $747 527 259 as direct costs and $829 144 071 as indirect costs. If the risk factors and the different healthcare services for older adults remain as they are currently, the financial consequences of epidemiological changes in older adults will have a major impact on the users' pockets, following in order of importance, on social security providers and on public assistance providers. The challenges and implications of our findings in the context of universal coverage reforms in Latin America reinforce the urgent need to develop more and better strategic planning for the prevention of chronic diseases. Copyright © 2016 John Wiley & Sons, Ltd.

Improving access to health care for undocumented immigrants in the United States

OBJECTIVE

To identify policies that increase access to health care for undocumented Mexican immigrants.

MATERIALS AND METHODS

Four focus groups (n=34 participants) were conducted with uninsured Mexican immigrants in Los Angeles, California. The feasibility and desirability of different policy proposals for increasing access were discussed by each group.

RESULTS

Respondents raised significant problems with policies including binational health insurance, expanded employer-provided health insurance, and telemedicine. The only solution with a consensus that the change would be feasible, result in improved access, and they had confidence in was expanded access to community health centers (CHC's).

CONCLUSIONS

Given the limited access to most specialists at CHC's and the continued barriers to hospital care for those without health insurance, the most effective way of improving the complete range of health services to undocumented immigrants is through immigration reform that will bring these workers under the other health care reform provisions.

Challenges of the epidemiological and economic burdens associated with hypertension in middle income countries: evidence from Mexico

BACKGROUND

In order to identify the challenges resulting from hypertension in a middle income country, this study has developed probabilistic models to determine the epidemiological and economic burden of hypertension in Mexico.

METHODS

Considering a population base of 654,701 reported cases of adults with hypertension, we conducted a longitudinal analyses in order to identify the challenges of epidemiological changes and health care costs for hypertension in the Mexican health system. The cost-evaluation method used was based on the instrumentation technique. To estimate the epidemiological changes for 2015-2017, probabilistic models were constructed according to the Box-Jenkins technique.

RESULTS

Regarding changes in expected cases for 2015 vs. 2017, an increase of 12 % is expected (p < 0.001). Comparing the economic impact in 2015 versus 2017 (p < 0.001), there is a 23 % increase in financial requirements. The total amount for hypertension in 2016 (US dollars) will be $6306,685,320 Of these, $ 2990,109,035 will be as direct costs and $ 3316,576,285 as indirect costs.

CONCLUSIONS

If the risk factors and care models remain as they are currently in the health system, the financial consequences will have a major impact on the out-of-pocket users, following in order of importance, on social security providers and on public assistance providers.

Evidence on equity, governance and financing after health care reform in Mexico: lessons for Latin American countries

This article includes evidence on equity, governance and health financing outcomes of the Mexican health system. An evaluative research with a cross-sectional design was oriented towards the qualitative and quantitative analysis of financing, governance and equity indicators. Taking into account feasibility, as well as political and technical criteria, seven Mexican states were selected as study populations and an evaluative research was conducted during 2002-2010. The data collection techniques were based on in-depth interviews with key personnel (providers, users and community leaders), consensus technique and document analysis. The qualitative analysis was done with ATLAS TI and POLICY MAKER softwares. The Mexican health system reform has modified dependence at the central level; there is a new equity equation for resources allocation, community leaders and users of services reported the need to improve an effective accountability system at both municipal and state levels. Strategies for equity, governance and financing do not have adequate mechanisms to promote participation from all social actors. Improving this situation is a very important goal in the Mexican health democratization process, in the context of health care reform. Inequality on resources allocation in some regions and catastrophic expenditure for users is unequal in all states, producing more negative effects on states with high social marginalization. Special emphasis is placed on the analysis of the main strengths and weaknesses, as relevant evidences for other Latin American countries which are designing, implementing and evaluating reform strategies in order to achieve equity, good governance and a greater financial protection in health.

Costs and epidemiological changes of chronic diseases: implications and challenges for health systems

BACKGROUND

The need to integrate economic and epidemiological aspects in the clinical perspective leads to a proposal for the analysis of health disparities and to an evaluation of the health services and of the new challenges which are now being faced by health system reforms in middle income countries.

OBJECTIVE

To identify the epidemiological changes, the demand for health services and economic burden from chronic diseases (diabetes and hypertension) in a middle income county.

METHODS

We conducted longitudinal analyses of costs and epidemiological changes for diabetes and hypertension in the Mexican health system. The study population included both the insured and uninsured populations. The cost-evaluation method was used, based on the instrumentation and consensus techniques. To estimate the epidemiological changes and financial consequences for 2014-2016, six models were constructed according to the Box-Jenkins technique, using confidence intervals of 95%, and the Box-Pierce test.

RESULTS

Regarding epidemiological changes expected in both diseases for 2014 vs. 2016, an increase is expected, although results predict a greater increase for diabetes, 8-12% in all three studied institutions, (p < .05). Indeed, in the case of diabetes, the increase was 41469 cases for uninsured population (SSA) and 65737 for the insured population (IMSS and ISSSTE). On hypertension cases the increase was 38109 for uninsured vs 62895 for insured. Costs in US$ ranged from $699 to $748 for annual case management per patient in the case of diabetes, and from $485 to $622 in patients with hypertension. Comparing financial consequences of health services required by insured and uninsured populations, the greater increase (23%) will be for the insured population (p < .05). The financial requirements of both diseases will amount to 19.5% of the total budget for the uninsured and 12.5% for the insured population.

CONCLUSIONS

If the risk factors and the different health care models remain as they currently are, the economic impact of expected epidemiological changes on the social security system will be particularly strong. Another relevant challenge is the appearance of internal competition in the use and allocation of financial resources with programs for other chronic and infectious diseases.

Type 2 diabetes and health care costs in Latin America: exploring the need for greater preventive medicine

BACKGROUND

Despite advances in medicine, health systems in Latin America are not coping with the challenges of chronic diseases. Incidence of disease and the economic burdens as a consequence have both increased in recent years. We have chosen Type 2 diabetes as an example to highlight the challenges posed by chronic diseases, in terms of the epidemiological transition and the economic burden of the demand for services to treat such problems.

DISCUSSION

Current health systems are not prepared to respond in a comprehensive manner to all phases of the natural history of the disease. There are new models of universal coverage, but resources and models of care are focused on programs aimed at healing/rehabilitation, and very sparsely at detection/prevention.

SUMMARY

In this scenario, chronic problems have alarmingly increased direct costs (medical care) and indirect costs (temporary disability, permanent disability and premature mortality). If more resources are not assigned to preventive medicine, these trends, in addition to not meeting the needs of the population, will financially collapse health systems and the patients' pockets. This Opinion piece outlines some possible changes that can be implemented to better prepare the health services in Latin American countries.

Health disparities from economic burden of diabetes in middle-income countries: evidence from México

The rapid growth of diabetes in middle-income countries is generating disparities in global health. In this context we conducted a study to quantify the health disparities from the economic burden of diabetes in México. Evaluative research based on a longitudinal design, using cost methodology by instrumentation. For the estimation of epidemiological changes during the 2010–2012 period, several probabilistic models were developed using the Box-Jenkins technique. The financial requirements were obtained from expected case management costs by disease and the application of an econometric adjustment factor to control the effects of inflation. Comparing the economic impact in 2010 versus 2012 (p<0.05), there was a 33% increase in financial requirements. The total amount for diabetes in 2011 (US dollars) was $7.7 billion. It includes $3.4 billion in direct costs and $4.3 in indirect costs. The total direct costs were $.4 billion to the Ministry of Health (SSA), serving the uninsured population; $1.2 to the institutions serving the insured population (Mexican Institute for Social Security–IMSS-, and Institute for Social Security and Services for State Workers-ISSSTE-); $1.8 to users; and $.1 to Private Health Insurance (PHI). If the risk factors and the different health care models remain as they currently are in the analyzed institutions, health disparities in terms of financial implications will have the greatest impact on users’ pockets. In middle-income countries, health disparities generated by the economic burden of diabetes is one of the main reasons for catastrophic health expenditure. Health disparities generated by the economic burden of diabetes suggests the need to design and review the current organization of health systems and the relevance of moving from biomedical models and curative health care to preventive and socio-medical models to meet expected challenges from diseases like diabetes in middle-income countries.

Diabetes in Mexico: cost and management of diabetes and its complications and challenges for health policy

BACKGROUND

Mexico has been experiencing some of the most rapid shifts ever recorded in dietary and physical activity patterns leading to obesity. Diabetes mellitus has played a crucial role causing nearly 14% of all deaths. We wanted to make a comprehensive study of the role of diabetes in terms of burden of disease, prevalence, cost of diabetes, cost of complications and health policy.

METHOD

We review the quantitative data that provides evidence of the extent to which the Mexican health economy is affected by the disease and its complications. We then discuss the current situation of diabetes in Mexico with experts in the field.

RESULTS

There was a significant increase in the prevalence of diabetes from 1994 to 2006 with rising direct costs (2006: outpatient USD$ 717,764,787, inpatient USD$ 223,581,099) and indirect costs (2005: USD$ 177,220,390), and rising costs of complications (2010: Retinopathy USD$ 10,323,421; Cardiovascular disease USD$ 12,843,134; Nephropathy USD$ 81,814,501; Neuropathy USD$ 2,760,271; Peripheral vascular disease USD$ 2,042,601). The health policy focused on screening and the creation of self-support groups across the country.

CONCLUSIONS

The increasing diabetes mortality and lack of control among diagnosed patients make quality of treatment a major concern in Mexico. The growing prevalence of childhood and adult obesity and the metabolic syndrome suggest that the situation could be even worse in the coming years. The government has reacted strongly with national actions to address the growing burden posed by diabetes. However our research suggests that the prevalence and mortality of diabetes will continue to rise in the future.

Epidemiological changes and financial consequences of hypertension in Latin America: implications for the health system and patients in Mexico

The aim of this study was to assess the costs and financial consequences of epidemiological changes in hypertension in Mexico. The cost evaluation method to estimate costs was based on instrumentation techniques. To estimate the epidemiological changes and expected cases of hypertension in 2010-2012, three probabilistic models were constructed according to the Box-Jenkins technique. Comparing the economic impact, from 2010 to 2012 there will be a 24% increase in financial requirements (p < 0.05). The total cost of hypertension in 2011 will be US$ 5,733,350,291, including US$ 2,718,280,941 in direct costs and US$ 3,015,069,350 in indirect costs. If the risk factors and various healthcare models remain unaltered in the institutions analyzed here, the financial consequences will have a major impact on users' pockets, followed by social security providers and public healthcare providers. The authors suggest a revision in the planning, organization, and allocation of resources, particularly programs for health promotion and prevention of hypertension.

Health insurance for undocumented immigrants: opportunities and barriers on the Mexican side of the US border

OBJECTIVE

This article aims to identify opportunities, barriers and challenges in Mexico's policy networks for the development of healthcare programs for undocumented migrants in the USA and their families.

METHODS

We used policy analysis, in-depth interviews and a case study. Key stakeholders at the federal, state and municipal levels in one major migrant-sending state were interviewed. We also conducted an in-depth case study of one community to obtain the perceptions of local health workers, migrant families and local nongovernmental organizations.

RESULTS

Findings identified opportunities and barriers involving the stakeholders, institutions, social interactions and types of relationships necessary for further progress on binational policies. There was wide interest in creating binational health insurance with different degrees of potential involvement by political actors and variation in local actors' willingness to be covered by some type of health insurance scheme.

CONCLUSIONS

The use of the opportunities to overcome barriers depends on the identification of high, medium or low interaction among key stakeholders, integration of coalitions and negotiating skills of all stakeholders involved.

[The cost of diabetes in Latin America: evidence from Mexico]

The main objective was to identify economic burden from epidemiological changes and expected demand for health care services for diabetes in México. The cost evaluation method to estimate direct and indirect costs was based on instrumentation and consensus techniques. To estimate the epidemiological changes for 2009-2011, three probabilistic models were constructed according to the Box-Jenkins technique. Comparing the economic impact in 2009 versus 2011 (p< 0.05), there is a 33% increase in financial requirements. The total amount for diabetes in 2010 (US dollars) will be $778,427,475. It includes $343,226,541 in direct costs and $435,200,934 in indirect costs. The total direct costs expected are: $40,787,547 for the Ministry of Health (SSA), serving to uninsured population; $113,664,454 for insured population (Mexican Institute for Social Security-IMSS-, and Institute for Social Security and Services for State Workers-ISSSTE-); $178,477,754 to users; and $10,296,786 to Private Health Insurance (PHI).

CONCLUSIONS

If the risk factors and the different health care models remain as they are currently in the institutions analyzed, the financial consequences would be of major impact for the pockets of the users, following in order of importance, social security institutions and finally Ministry of Health. Allocate more resources to promotion and prevention of diabetes will decrease the cost increase by decreasing the demand for treatment of complications.

Equity and accessibility in health? Out-of-pocket expenditures on health care in middle income countries: evidence from Mexico

This study analyzes the results of a cross-sectional survey which set out to determine the costs to patients of searching for and receiving health care in public and private institutions. The information analyzed was obtained from the study population of the Mexican National Health Survey. The dependent variable was the out-of-pocket users' costs and the independent variables were the insurance conditions, type of institution and income. The empirical findings suggest that there is a need for a more detailed analysis of user costs in middle income countries in general, where the health system is based on social security, public assistance and private institutions. This study shows that the out of pocket costs faced by users are inequitable and fall disproportionately upon socially and economically marginalized populations.