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Doubova SV, Leslie HH, Pérez-Cuevas R, Kruk ME, Arsenault C. Users' perception of quality as a driver of private healthcare use in Mexico: Insights from the People's Voice Survey. PLoS One 2024; 19:e0306179. [PMID: 38917130 PMCID: PMC11198766 DOI: 10.1371/journal.pone.0306179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 06/11/2024] [Indexed: 06/27/2024] Open
Abstract
OBJECTIVE The Mexican government has pursued multiple initiatives to improve healthcare coverage and financial protection. Yet, out-of-pocket health spending and use of private sector providers in Mexico remains high. In this paper, we sought to describe the characteristics of public and private healthcare users, describe recent visit quality across provider types, and to assess whether perceiving the public healthcare sector as poor quality is associated with private health sector use. METHODS AND FINDINGS We analyzed the cross-sectional People's Voice Survey conducted from December 2022 to January 2023. We used Chi-square tests to compare contextual, individual, and need-for-care factors and ratings of most recent visits between users of public (social security and other public providers) and private sector providers (stand-alone private providers and providers adjacent to pharmacies). We used a multivariable Poisson regression model to assess associations between low ratings of public healthcare sources and the use of private care. Among the 811 respondents with a healthcare visit in the past year, 31.2% used private sources. Private healthcare users were more educated and had higher incomes than public healthcare users. Quality of most recent visit was rated more highly in private providers (70.2% rating the visit as excellent or very good for stand-alone private providers and 54.3% for pharmacy-adjacent doctors) compared to social security (41.6%) and other public providers (46.6%). Those who perceived public health institutions as low quality had a higher probability of seeking private healthcare. CONCLUSION Users rated public care visits poorly relative to private care; at the population level, perceptions of poor quality care may drive private care use and hence out-of-pocket costs. Improving public healthcare quality is necessary to ensure universal health coverage.
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Affiliation(s)
- Svetlana V. Doubova
- Epidemiology and Health Services Research Unit CMN Siglo XXI, Mexican Institute of Social Security, Mexico City, Mexico
| | - Hannah H. Leslie
- Division of Prevention Science, University of California San Francisco, San Francisco, California, United States of America
| | - Ricardo Pérez-Cuevas
- Division of Social Protection and Health, Interamerican Development Bank, Washington, DC, United States of America
| | - Margaret E. Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Catherine Arsenault
- Department of Global Health, Milken Institute School of Public Health, The George Washington University, Washington, DC, United States of America
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Ramli FI, Thokala P, Tong T, Unger-Saldaña K. Understanding breast cancer patient pathways and their impact on survival in Mexico. J Cancer Policy 2024; 40:100482. [PMID: 38663531 DOI: 10.1016/j.jcpo.2024.100482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/08/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Understanding patient pathways from discovery of breast symptoms to treatment start can aid in identifying ways to improve access to timely cancer care. This study aimed to describe the patient pathways experienced by uninsured women from detection to treatment initiation for breast cancer in Mexico City and estimate the potential impact of earlier treatment on patient survival. METHODS We used process mining, a data analytics technique, to create maps of the patient pathways. We then compared the waiting times and pathways between patients who initially consulted a private service versus those who sought care at a public health service. Finally, we conducted scenario modelling to estimate the impact of early diagnosis and treatment on patient survival. RESULTS Our study revealed a common pathway followed by breast cancer patients treated at the two largest public cancer centres in Mexico City. However, patients who initially sought care in private clinics experienced shorter mean wait times for their first medical consultation (66 vs 88 days), and diagnostic confirmation of cancer (57 vs 71 days) compared to those who initially utilized public clinics. Our scenario modelling indicated that improving early diagnosis to achieve at least 60% of patients starting treatment at early stages could increase mean patient survival by up to two years. CONCLUSION Our study highlights the potential of process mining to inform healthcare policy for improvement of breast cancer care in Mexico. Also, our findings indicate that reducing diagnostic and treatment intervals for breast cancer patients could result in substantially better patient outcomes. POLICY SUMMARY This study revealed significant differences in time intervals along the pathways of women with breast cancer according to the type of health service first consulted by the patients: whether public primary care clinics or private doctors. Policies directed to reduce these inequities in access to timely cancer care are desperately needed to reduce socioeconomic disparities in breast cancer survival.
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Affiliation(s)
- Fatin Izzati Ramli
- Health Economics and Decision Science, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom; Faculty of Industrial Management, University Malaysia Pahang, Gambang, Malaysia
| | - Praveen Thokala
- Health Economics and Decision Science, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Thaison Tong
- Health Economics and Decision Science, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
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Unger-Saldaña K, Lajous M, Reich MR. Improving health system performance in Mexico. Lancet 2023; 402:674-676. [PMID: 37562421 DOI: 10.1016/s0140-6736(23)01454-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/07/2023] [Indexed: 08/12/2023]
Affiliation(s)
| | - Martín Lajous
- Center for Research on Population Health, National Institute of Public Health, Mexico City, Mexico; Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Michael R Reich
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
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Miranda-Novales MG, Flores-Moreno K, Rodríguez-Álvarez M, López-Vidal Y, Soto-Hernández JL, Solórzano Santos F, Ponce-de-León-Rosales S. The Real Practice Prescribing Antibiotics in Outpatients: A Failed Control Case Assessed through the Simulated Patient Method. Antibiotics (Basel) 2023; 12:antibiotics12050915. [PMID: 37237818 DOI: 10.3390/antibiotics12050915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
The first level of medical care provides the largest number of consultations for the most frequent diseases at the community level, including acute pharyngitis (AP), acute diarrhoea (AD) and uncomplicated acute urinary tract infections (UAUTIs). The inappropriate use of antibiotics in these diseases represents a high risk for the generation of antimicrobial resistance (AMR) in bacteria causing community infections. To evaluate the patterns of medical prescription for these diseases in medical offices adjacent to pharmacies, we used an adult simulated patient (SP) method representing the three diseases, AP, AD and UAUTI. Each person played a role in one of the three diseases, with the signs and symptoms described in the national clinical practice guidelines (CPGs). Diagnostic accuracy and therapeutic management were assessed. Information from 280 consultations in the Mexico City area was obtained. For the 101 AP consultations, in 90 cases (89.1%), one or more antibiotics or antivirals were prescribed; for the 127 AD, in 104 cases (81.8%), one or more antiparasitic drugs or intestinal antiseptics were prescribed; for the scenarios involving UAUTIs in adult women, in 51 of 52 cases (98.1%) one antibiotic was prescribed. The antibiotic group with the highest prescription pattern for AP, AD and UAUTIs was aminopenicillins and benzylpenicillins [27/90 (30%)], co-trimoxazole [35/104 (27.6%)] and quinolones [38/51 (73.1%)], respectively. Our findings reveal the highly inappropriate use of antibiotics for AP and AD in a sector of the first level of health care, which could be a widespread phenomenon at the regional and national level and highlights the urgent need to update antibiotic prescriptions for UAUTIs according to local resistance patterns. Supervision of adherence to the CPGs is needed, as well as raising awareness about the rational use of antibiotics and the threat posed by AMR at the first level of care.
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Affiliation(s)
- María Guadalupe Miranda-Novales
- Unidad de Investigación en Análisis y Síntesis de la Evidencia, Instituto Mexicano del Seguro Social, Centro Médico Nacional Siglo XXI, Mexico City 06720, Mexico
| | - Karen Flores-Moreno
- Laboratorio de Microbioma, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - Mauricio Rodríguez-Álvarez
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - Yolanda López-Vidal
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - José Luis Soto-Hernández
- Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City 14269, Mexico
| | - Fortino Solórzano Santos
- Unidad de Investigación en Enfermedades Infecciosas, Hospital Infantil de México Federico Gómez, Secretaría de Salud, Mexico City 06720, Mexico
| | - Samuel Ponce-de-León-Rosales
- Programa Universitario de Investigación Sobre Riesgos Epidemiológicos y Emergentes, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
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Morán Pérez AV. ["What choice do people have other than us?": The role of doctors' offices adjacent to private pharmacies in the Covid-19 pandemic]. Salud Colect 2023; 19:e4280. [PMID: 37311142 DOI: 10.18294/sc.2023.4280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
With the arrival of coronavirus in Mexico, doctors' offices adjacent to private pharmacies (DAPPs) played a major role in the diagnosis, care, and prevention of Covid-19, providing treatment for 11.7% to 23% of people with Covid-19 symptoms according to national surveys. Therefore, this article seeks to identify the role of DAPPs as a private health system providing care for patients with Covid-19 symptoms in the city of Oaxaca, and to describe and analyze the factors that influenced their utilization. Using a qualitative methodology, twelve physicians were interviewed and 59 users responded to a questionnaire at doctors' offices adjacent to pharmacies in the municipality of Oaxaca de Juárez between September 2020 and August 2022. Secondary data were also collected. Among the findings, the function of these offices at the front line of care for Covid-19 and other health needs that emerged with the public health crisis is described, and the determining factors in care trajectories of users that sought care there are analyzed, such as the increase in perception of risk and mistrust towards public services or strategies implemented by the federal government.
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Affiliation(s)
- Ana Victoria Morán Pérez
- Doctora en Antropología. Profesora, Escuela Nacional de Antropología e Historia, Ciudad de México, México
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Healthcare System Distrust and Non-Prescription Antibiotic Use: A Cross-Sectional Survey of Adult Antibiotic Users. Antibiotics (Basel) 2023; 12:antibiotics12010079. [PMID: 36671280 PMCID: PMC9854942 DOI: 10.3390/antibiotics12010079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/22/2022] [Accepted: 12/24/2022] [Indexed: 01/03/2023] Open
Abstract
Antibiotic resistance is a major public health concern driven by antibiotic overuse. Antibiotic stewardship programs are often limited to clinical settings and do little to address non-prescription antibiotic use in community settings. This study investigates the association between non-prescription antibiotic use and healthcare system distrust in the United States and Mexico. An online survey was deployed in the United States and Mexico with enhanced sampling through in-person recruiting in the border region. Non-prescription antibiotic use was defined as having bought or borrowed non-prescription oral or injectable antibiotics within the last 3 years. The survey included a previously validated 10-item scale to measure healthcare system distrust. Logistic regression was used to model the use of non-prescription antibiotics by the level of healthcare system distrust, adjusted for demographic characteristics and antibiotic knowledge. In total, 568 survey participants were included in the analysis, 48.6% of whom had used non-prescription oral or injectable antibiotics in the last 3 years. In the fully adjusted regression model, the odds of using non-prescription antibiotics were 3.2 (95% CI: 1.8, 6.1) times higher for those in the highest distrust quartile versus the lowest. These findings underscore the importance of community-based antibiotic stewardship and suggest that these programs are particularly critical for communities with high levels of healthcare system distrust.
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Morán Pérez AV. Riesgo, incertidumbre y covid-19 entre el personal médico de consultorios adyacentes a farmacias de Oaxaca de Juárez. REVISTA PUEBLOS Y FRONTERAS DIGITAL 2022. [DOI: 10.22201/cimsur.18704115e.2022.v17.600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Durante la pandemia de covid-19, el personal médico de los consultorios adyacentes a farmacias (CAF), un servicio de salud privado, desempeñó un rol fundamental en la medida que el 76 % de las personas con síntomas de covid-19 acudieron al sector privado. A partir de un abordaje teórico provisto por la antropología médica, se analiza cómo se configura la percepción del riesgo de médicos(as) de consultorios ubicados en Oaxaca de Juárez. Con base en entrevistas a profundidad realizadas a ocho médicos(as), se muestra que la percepción del riesgo está motivada, entre otros factores, por su condición de vulnerabilidad, la percepción del consultorio como entorno «peligroso» o las conductas de rol definidas por la profesión médica. Además se plantea que, ante la incertidumbre, la reproducción del saber médico se constituye como la práctica de reducción del daño más efectiva.
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Garcia-Diaz R. Effective access to health care in Mexico. BMC Health Serv Res 2022; 22:1027. [PMID: 35962375 PMCID: PMC9373534 DOI: 10.1186/s12913-022-08417-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
Objectives This paper assesses the impact of effective access on out-of-pocket health payments and catastrophic health expenditure. Effective access cannot be attained unless both health services and financial risk protection are accessible, affordable, and acceptable. Therefore, it represents a key determinant in the transition from fragmented health systems to universal coverage that many low- and middle-income countries face. Methods We use a definition of effective access as the utilization of health insurance when available. We conducted a cross-sectional analysis using the 2018 Mexican National Health Survey (ENSANUT) at the household level. The analysis is performed in two stages. The first stage is a multinomial analysis that captures the factor associated with choosing effective access against the alternative of paying privately. The second stage consists of an impact analysis regarding the decision of not choosing effective access in terms of out-of-pocket (OOP) health payments and catastrophic health expenditures (CHE). The analysis corrects for both the decision to buy insurance and the decision to pay for health care. Results We found that, on average, not choosing effective access increases OOP health payments by around 2300 pesos annually. Medicine payments are the most common factor in this increase. Nevertheless, outpatient and medicines health care are the main drivers of the increase in OOP health payments in all insurance beneficiaries. Not having effective access increases the probability of CHE health expenditures by 2.7 p.p. for the case of Social Security Insurance and 4.0 p.p. for Social Government insurance. Household enrolled in Prospera program for the poor are more likely to choose effective access while having household heads with more education and assets value does the opposite. Diabetes illnesses are associated with a higher probability of effective access. Conclusion Improving effective access is a middle step that cannot be disregarded when seeking universal coverage because OOP health payments and catastrophic outcomes are direct consequences. Public insurance in general, has around 50% effective access which remains a challenge in terms of health services utilization and health public policy design, calling for the need of better coordination across insurance types and pooling mechanisms to increase sustainability of needed health services. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08417-0.
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Affiliation(s)
- Rocio Garcia-Diaz
- Tecnologico de Monterrey, Ave. Eugenio Garza Sada 2501, Monterrey, N.L., Mexico.
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Ortiz MI, Flores-Ceron KI, Muñoz-Pérez VM. Self-Medication Practice in Mexico. Sr Care Pharm 2022; 37:266-283. [DOI: 10.4140/tcp.n.2022.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective To determine the prevalence and features of self-medication (SM) in Mexican populations. Data Sources An electronic bibliographic search was carried out from databases and indexing services including Scopus, PubMed, International Pharmaceutical
Abstracts (Clarivate Analytics), Embase, Web of Science and Google Scholar addressing SM practice in Mexican populations, SM with allopathic or conventional medicines (CM) or complementary and alternative medicine (CAM), and features of SM (diseases-related, factors-associated, and drugs).
Study Selection A total of 33 studies addressing SM practice in Mexican populations. SM with allopathic or CM and/or CAM, and features of SM (diseases-related, factors-associated, and drugs) were included. Data Extraction Two independent reviewers evaluated
the titles and abstracts. After that, eligible studies were fully assessed. Quality evaluation was realized by the Mix Methods Appraisal Tool. Data Synthesis SM prevalence ranged from 6.1 to 100%. SM prevalence was 42.3% with CM and 30.7% with CAM. Respiratory and gastrointestinal
affectations such as disorders or injuries were the main conditions for which SM was realized. The main reasons for practicing SM were prior experience and less costly. Antibiotics, anti-inflammatory drugs, and antidiarrheal were the main drugs used as SM. Chamomile (Matricaria chamomilla),
peppermint (Mentha piperita), and gordolobo (Verbascum thapsus) infusions were the plant-derived alternative medications mainly used. CMs were obtained mainly through pharmacies and home/family. SM was mainly suggested by relatives, pharmacists, and own decision. Conclusion
SM was a common practice in the Mexican population, and it has some similar characteristics to other reports worldwide.
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Affiliation(s)
- Mario I. Ortiz
- Área Académica de Medicina del Instituto de Ciencias de la Salud, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico
| | - Karla I. Flores-Ceron
- Área Académica de Medicina del Instituto de Ciencias de la Salud, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico
| | - Víctor M. Muñoz-Pérez
- Área Académica de Medicina del Instituto de Ciencias de la Salud, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico
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Montañez-Hernández JC, Díaz-Portillo SP, Guerra G, Reyes-Morales H. [Job conditions and precarious work among Mexican physicians: an analysis based on a national survey]. CAD SAUDE PUBLICA 2022; 38:ES042321. [PMID: 35544876 DOI: 10.1590/0102-311xes042321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 10/22/2021] [Indexed: 11/22/2022] Open
Abstract
The study aimed to describe the socioeconomic characteristics and job conditions of medical personnel in Mexico. This was a cross-sectional study based on the Mexican National Occupational and Employment Survey (ENOE) for all four quarters of 2019 and the first quarter of 2020. We included all physicians who had concluded their university training. The variable "cumulative precarious labor" was constructed as the sum of five binary variables related to minimum wage, workweek, and lack of employment contract, job security, and labor benefits. Using this unweighted sum, we classified their labor conditions as absence of (0) or low (1), medium (2 to 3), or high (4 to 5) precarious labor. In the public sector, 13.4% and 3.3% of physicians were engaged in medium or high precarious labor, respectively; the percentages were higher in the private sector, with 38.5% and 7.7% (p < 0.01), respectively, due mainly to the lack of formal contracts and medical insurance. These conditions were exacerbated in women working in medical offices in private-sector companies, where 75.2% and 6% worked in medium or high precarious conditions, respectively, while the proportions in men were 15.6% and 7.7%, respectively (p < 0.01). Precarious labor exists in the Mexican health sector; labor conditions for physicians are more precious in the private sector than in the public sector, especially in private-sector offices where female physicians are more exposed to precarious employment.
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Affiliation(s)
| | | | - Germán Guerra
- Instituto Nacional de Salud Pública, Cuernavaca, México.,Université de Genève, Geneva, Switzerland
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Lags in the provision of obstetric services to indigenous women and their implications for universal access to health care in Mexico. Sex Reprod Health Matters 2021; 28:1778153. [PMID: 32757830 PMCID: PMC7888012 DOI: 10.1080/26410397.2020.1778153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Through quantitative and qualitative methods, in this article the authors describe the perspectives of indigenous women who received antenatal and childbirth medical care within a care model that incorporates a non-governmental organisation (NGO), Partners in Health. They discuss whether the NGO model better resolves the care-seeking process, including access to health care, compared with a standard model of care in government-subsidised health care units (setting of health services networks). Universal health coverage advocates access for the most disadvantaged and vulnerable populations as a priority. However, the issue of access includes problems related to the effect of certain structural social determinants that limit different aspects of the obstetric care process. The findings of this study show the need to modify the structure of organisational values in order to place users at the centre of medical care and ensure respect for their rights. The participation of agents outside the public system, such as NGOs, can be of great value for moving in this direction. Women’s participation is also necessary for learning how they are being cared for and the extent to which they are satisfied with obstetric services. This research experience can be used for other countries with similar conditions.
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Gutierrez JP, Agudelo-Botero M, Garcia-Saiso S, Zepeda-Tena C, Davila-Cervantes CA, Gonzalez-Robledo MC, Fullman N, Razo C, Hernández-Prado B, Martínez G, Barquera S, Lozano R. Advances and challenges on the path toward the SDGs: subnational inequalities in Mexico, 1990-2017. BMJ Glob Health 2021; 5:bmjgh-2020-002382. [PMID: 33122296 PMCID: PMC7597504 DOI: 10.1136/bmjgh-2020-002382] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/07/2020] [Accepted: 05/28/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The sustainable development goals (SDGs) have generated momentum for global health, aligning efforts from governments and international organisations toward a set of goals that are expected to reflect improvements in life conditions across the globe. Mexico has huge social inequalities that can affect access to quality care and health outcomes. The objective of this study is to analyse inequalities among Mexico's 32 states on the health-related SDG indicators (HRSDGIs) from 1990 to 2017. METHODS These analyses rely on the estimation of HRSDGIs as part of the Global Burden of Disease study 2017. We estimated the concentration index for 40+3 HRSDGI stratified by Socio-demographic Index and marginalisation index, and then for indicators where inequalities were identified, we ran decomposition analyses using structural variables such as gross domestic product per capita, poverty and health expenditure. FINDINGS Mexico has made progress on most HRSDGIs, but current trends in improvement do not appear to fast enough to meet 2030 targets. Out of 43 HRSDGIs, we identified evidence of inequality between Mexico's states for 30 indicators; of those, 23 HRSDGIs were unequal distributed affecting states with lower development and seven affecting states with higher development. The decomposition analysis indicates that social determinants of health are major drivers of HRSDGI inequalities in Mexico. INTERPRETATION Modifying current trends for HRSDGIs will require subnational-level and national-level policy action, of which should be informed by the latest available data and monitoring on the health-related SDGs. The SDGs' overarching objective of leaving no-one behind should be prioritised not only for individuals but also for communities and other subnational levels.
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Affiliation(s)
- Juan Pablo Gutierrez
- Center for Policy, Population & Health Research, Universidad Nacional Autónoma de México, Coyoacan, Mexico
| | - Marcela Agudelo-Botero
- Center for Policy, Population & Health Research, Universidad Nacional Autónoma de México, Coyoacan, Mexico
| | - Sebastian Garcia-Saiso
- Center for Policy, Population & Health Research, Universidad Nacional Autónoma de México, Coyoacan, Mexico
| | - Carolina Zepeda-Tena
- Center for Policy, Population & Health Research, Universidad Nacional Autónoma de México, Coyoacan, Mexico
| | | | | | - Nancy Fullman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Christian Razo
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | | | - Gabriel Martínez
- Departamento Académico de Economía, ITAM, Alvaro Obregon, Mexico
| | | | - Rafael Lozano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
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Mancilla-Galindo J, García-Méndez JÓ, Márquez-Sánchez J, Reyes-Casarrubias RE, Aguirre-Aguilar E, Rocha-González HI, Kammar-García A. All-cause mortality among patients treated with repurposed antivirals and antibiotics for COVID-19 in Mexico City: A real-world observational study. EXCLI JOURNAL 2021; 20:199-222. [PMID: 33628159 PMCID: PMC7898041 DOI: 10.17179/excli2021-3413] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/01/2021] [Indexed: 12/15/2022]
Abstract
The aim of our study was to evaluate all-cause mortality risk in patients with laboratory-confirmed COVID-19 in Mexico City treated with repurposed antivirals and antibiotics. This real-world retrospective cohort study contemplated 395,343 patients evaluated for suspected COVID-19 between February 24 and September 14, 2020 in 688 primary-to-tertiary medical units in Mexico City. Patients were included with a positive RT-PCR for SARS-CoV-2; those receiving unspecified antivirals, excluded; and groups of antivirals prescribed in < 30 patients, eliminated. Survival and mortality risks were determined for patients receiving antivirals, antibiotics, both, or none. We assessed the effect of early (<2 days) versus late (>2 days) use of antivirals on mortality in a sub-cohort of patients. Multivariable adjustment, propensity score matching, generalized estimating equations, and calculation of E-values were performed to limit confounding. 136,855 patients were analyzed; mean age 44.2 (SD:16.8) years; 51.3 % were men. 16.6 % received antivirals (3 %), antibiotics (10 %), or both (3.6 %). Antivirals studied were Oseltamivir (n=8414), Amantadine (n=319), Lopinavir-Ritonavir (n=100), Rimantadine (n=61), Zanamivir (n=39), and Acyclovir (n=36). Survival with antivirals (73.7 %, p<0.0001) and antibiotics (85.8 %, p<0.0001) was lower than no antiviral/antibiotic (93.6 %). After multivariable adjustment, increased risk of death occurred with antivirals (HR=1.72, 95 % CI: 1.61-1.84) in ambulatory (HR=4.7, 95 % CI: 3.94-5.62) and non-critical (HR=2.03, 95 % CI: 1.86-2.21) patients. Oseltamivir increased mortality risk in the general population (HR=1.72, 95 % CI: 1.61-1.84), ambulatory (HR=4.79, 95 % CI: 4.01-5.75), non-critical (HR=2.05, 95 % CI: 1.88-2.23), and pregnancy (HR=8.35, 95 % CI: 1.77-39.30); as well as hospitalized (HR=1.13, 95 % CI: 1.01-1.26) and critical patients (HR=1.22, 95 % CI: 1.05-1.43) after propensity score-matching. Early versus late oseltamivir did not modify the risk. Antibiotics were a risk factor in general population (HR=1.13, 95 % CI: 1.08-1.19) and pediatrics (HR=4.22, 95 % CI: 2.01-8.86), but a protective factor in hospitalized (HR=0.81, 95 % CI: 0.77-0.86) and critical patients (HR=0.67, 95 % CI: 0.63-0.72). No significant benefit for repurposed antivirals was observed; oseltamivir was associated with increased mortality. Antibiotics increased mortality risk in the general population but may increase survival in hospitalized and critical patients.
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Affiliation(s)
- Javier Mancilla-Galindo
- Unidad de Investigación UNAM-INC, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
- Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Jorge Óscar García-Méndez
- Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Departamento de Posgrado y Educación Médica Continua, Instituto Nacional de Cancerología, Mexico City, Mexico
- Departamento de Infectología, Fundación Clínica Médica Sur, Mexico City, Mexico
| | | | - Rodrigo Estefano Reyes-Casarrubias
- Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Departamento de Posgrado y Educación Médica Continua, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Eduardo Aguirre-Aguilar
- Departamento de Atención Institucional Continua y Urgencias, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Héctor Isaac Rocha-González
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Ashuin Kammar-García
- Departamento de Atención Institucional Continua y Urgencias, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico
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Leslie HH, Doubova SV, Pérez-Cuevas R. Assessing health system performance: effective coverage at the Mexican Institute of Social Security. Health Policy Plan 2019; 34:ii67-ii76. [DOI: 10.1093/heapol/czz105] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 12/21/2022] Open
Abstract
Abstract
Universal health coverage is a national priority in Mexico, with active efforts to expand public healthcare system access, increase financial protection and improve quality of care. We estimated effective coverage of multiple conditions within the Mexican Institute of Social Security (IMSS), which covers 62 million individuals. We identified routinely collected performance indicators at IMSS from 2016 related to use and quality of care for conditions avertable with high-quality healthcare; where candidate indicators were available, we quantified need for service from a population-representative survey and calculated effective coverage as proportion of individuals in need who experience potential health gains. We assessed subnational inequality across 32 states, and we weighted conditions by relative contribution to national disease burden to estimate composite effective coverage. Conditions accounting for 51% of healthcare-avertable disability-adjusted life years lost in Mexico could be assessed: antenatal care, delivery care, newborn care, childhood diarrhoea, cardiovascular disease and diabetes. Estimated effective coverage ranged from a low of 27% for childhood diarrhoea to a high of 74% for newborn care. Substantial inequality in effective coverage existed between states, particularly for maternal and child conditions. Overall effective coverage of these six conditions in IMSS was 49% in 2016. Gaps in use and quality of care must be addressed to ensure good health for all in Mexico. Despite extensive monitoring of health status and services in Mexico, currently available data are inadequate to the task of fully and routinely assessing health system effective coverage. Leaders at IMSS and similar healthcare institutions must be more purposeful in planning the assessment of population need, utilization of care and quality impacts of care to enable linkage of these data and disaggregation by location or population sub-group. Only then can complex health systems be fairly and fully evaluated.
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Affiliation(s)
- Hannah H Leslie
- Department of Global Health and Population, Harvard TH Chan School of Public Health, 90 Smith Street, 3rd floor, Boston, MA, USA
| | - Svetlana V Doubova
- Epidemiology and Health Services Research Unit CMN Siglo XXI, Mexican Institute of Social Security, Cuidad de México, Av. Cuauhtémoc 330, Doctores, PC, Mexico
| | - Ricardo Pérez-Cuevas
- Health System Research Center, National Institute of Public Health, Avenida Universidad 655, Santa María Ahuacatitlán, Cuernavaca, Mexico
- Division of Social Protection and Health, Jamaica Country Office, Inter-American Development Bank, 6 Montrose Road, Kingston, Jamaica
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15
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Jacobs TG, Robertson J, van den Ham HA, Iwamoto K, Bak Pedersen H, Mantel-Teeuwisse AK. Assessing the impact of law enforcement to reduce over-the-counter (OTC) sales of antibiotics in low- and middle-income countries; a systematic literature review. BMC Health Serv Res 2019; 19:536. [PMID: 31366363 PMCID: PMC6670201 DOI: 10.1186/s12913-019-4359-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/18/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Many low- and middle-income countries (LMIC) are moving towards enforcing prescription-only access to antibiotics. This systematic literature review aims to assess the interventions used to enforce existing legislation prohibiting over-the-counter (OTC) sales of antibiotics in LMICs, their impact and examine the methods chosen for impact measurement including their strengths and weaknesses. METHODS Both PubMed and Embase were systematically searched for studies reporting on impact measurement in moving towards prescription only access to antibiotics in LMICs. The PRISMA methodological review framework was used to ensure systematic data collection and analysis of literature. Narrative data synthesis was used due to heterogeneity of study designs. RESULTS In total, 15 studies were included that assessed policy impact in 10 different countries. Strategies employed to enforce regulations prohibiting OTC sales of systemic antibiotics included retention of prescriptions for antibiotics by pharmacies, government inspections, engaging pharmacists in the design of interventions, media campaigns for the general public and educational activities for health care workers. A variety of outcomes was used to assess the policy impact; changes in antimicrobial resistance rates, changes in levels of antibiotic use, changes in trends of antibiotic use, changes in OTC supply of antibiotics, and changes in reported practices and knowledge of pharmacists, medicine sellers and the general public. Differences in methodological approaches and outcome assessment made it difficult to compare the effectiveness of law enforcement activities. Most effective appeared to be multifaceted approaches that involved all stakeholders. Monitoring of the impact on total sales of antibiotics by means of an interrupted time series (ITS) analysis and analysis of pharmacies selling antibiotics OTC using mystery clients were the methodologically strongest designs used. CONCLUSIONS The published literature describing activities to enforce prescription-only access to antibiotics in LMICs is sparse and offers limited guidance. Most likely to be effective are comprehensive multifaceted interventions targeting all stakeholders with regular reinforcement of messages. Policy evaluation should be planned as part of implementation to assess the impact and effectiveness of intervention strategies and to identify targets for further activities. Robust study designs such as ITS analyses and mystery client surveys should be used to monitor policy impact.
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Affiliation(s)
- Tom G. Jacobs
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, David de Wied building, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Jane Robertson
- World Health Organization (WHO) Regional Office for Europe, UN City, Marmorvej 51, 2100 Copenhagen, Denmark
- University of Newcastle Calvary Mater Hospital, Edith St & Platt St, Waratah NSW, Newcastle, 2298 Australia
| | - Hendrika A. van den Ham
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, David de Wied building, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Kotoji Iwamoto
- World Health Organization (WHO) Regional Office for Europe, UN City, Marmorvej 51, 2100 Copenhagen, Denmark
| | - Hanne Bak Pedersen
- World Health Organization (WHO) Regional Office for Europe, UN City, Marmorvej 51, 2100 Copenhagen, Denmark
| | - Aukje K. Mantel-Teeuwisse
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, David de Wied building, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
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16
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Doubova SV, García-Saisó S, Pérez-Cuevas R, Sarabia-González O, Pacheco-Estrello P, Leslie HH, Santamaría C, Torres-Arreola LDP, Infante-Castañeda C. Barriers and opportunities to improve the foundations for high-quality healthcare in the Mexican Health System. Health Policy Plan 2018; 33:1073-1082. [PMID: 30544258 PMCID: PMC6415720 DOI: 10.1093/heapol/czy098] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2018] [Indexed: 11/15/2022] Open
Abstract
This study aimed to describe the foundations for quality of care (QoC) in the Mexican public health sector and identify barriers to quality evaluation and improvement from the perspective of the QoC leaders of the main public health sector institutions: Ministry of Health (MoH), the Mexican Institute of Social Security (IMSS) and the Institute of Social Security of State Workers (ISSSTE). We administered a semi-structured online questionnaire that gathered information on foundations (governance, health workforce, platforms, tools and population), evaluation and improvement activities for QoC; 320 leaders from MoH, IMSS and ISSSTE participated. We used thematic content and descriptive analyses to analyse the data. We found that QoC foundations, evaluation and improvement activities pose essential challenges for the Mexican health sector. Governance for QoC is weakly aligned across MoH, IMSS and ISSSTE. Each institution follows its own agenda of evaluation and improvement programmes and has distinct QoC indicators and information systems. The institutions share similar barriers to strengthening QoC: poor organizational structure at a facility level, scarcity of financial resources, lack of training in QoC for executive/managerial staff and health professionals and limited public participation. In conclusion, a stronger legal framework and policy dialogue is needed to foster governance by the MoH, to define and align health sector-wide QoC policies, and to set common goals and articulate QoC improvement actions among institutions. Robust QoC organizational structure with designated staff and clarity on their responsibilities should be established at all levels of healthcare. Investment is necessary to fund formal and in-service QoC training programmes for health professionals and to reinforce quality evaluation and improvement activities and quality information systems. QoC evaluation results should be available to healthcare providers and the population. Active public participation in the design and implementation of improvement initiatives should be strengthened.
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Affiliation(s)
- Svetlana V Doubova
- Epidemiology and Health Services Research Unit, CMN Siglo XXI, Mexican Institute of Social Security, Av. Cuauhtemoc 330, Col. Doctores, Del. Cuauhtemoc, Mexico City, Mexico
| | - Sebastián García-Saisó
- General Directorate for Quality of Healthcare and Education, Ministry of Health, Mexico City, Mexico
| | - Ricardo Pérez-Cuevas
- Health System Research Center, National Institute of Public Health, Cuernavaca, Mexico
| | - Odet Sarabia-González
- General Directorate for Quality of Healthcare and Education, Ministry of Health, Mexico City, Mexico
| | - Paulina Pacheco-Estrello
- General Directorate for Quality of Healthcare and Education, Ministry of Health, Mexico City, Mexico
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
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17
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Doubova SV, García-Saiso S, Pérez-Cuevas R, Sarabia-González O, Pacheco-Estrello P, Infante-Castañeda C, Santamaría C, Del Pilar Torres-Arreola L, Leslie HH. Quality governance in a pluralistic health system: Mexican experience and challenges. LANCET GLOBAL HEALTH 2018; 6:e1149-e1152. [PMID: 30196095 DOI: 10.1016/s2214-109x(18)30321-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 06/27/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Svetlana V Doubova
- Epidemiology and Health Services Research Unit CMN Siglo XXI, Mexican Institute of Social Security, Cuidad de México, PC 06725, Mexico.
| | - Sebastián García-Saiso
- General Directorate for Quality of Healthcare and Education, Ministry of Health, Cuidad de México, Mexico
| | - Ricardo Pérez-Cuevas
- Health System Research Center, National Institute of Public Health, Cuernavaca, Mexico
| | - Odet Sarabia-González
- General Directorate for Quality of Healthcare and Education, Ministry of Health, Cuidad de México, Mexico
| | - Paulina Pacheco-Estrello
- General Directorate for Quality of Healthcare and Education, Ministry of Health, Cuidad de México, Mexico
| | | | | | | | - Hannah H Leslie
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA 02115, USA
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18
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Díaz de León-Castañeda C, Gutiérrez-Godínez J, Colado-Velázquez JI, Toledano-Jaimes C. Healthcare professionals' perceptions related to the provision of clinical pharmacy services in the public health sector: A case study. Res Social Adm Pharm 2018; 15:321-329. [PMID: 29731375 DOI: 10.1016/j.sapharm.2018.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND In Mexico, the Modelo Nacional de Farmacia Hospitalaria (MNFH, or National Hospital Pharmacy Model), published in 2009, mainly aims to promote the provision of clinical pharmacy services in private and public hospitals. However, there is little scientific documentation about the quality of these services. OBJECTIVES To explore healthcare professionals' perceptions related to the quality of clinical pharmacy services provision. METHODS A case-study based on a qualitative approach was performed at the pharmaceutical services unit at a public hospital located in Mexico City, which operates under the administrative control of the Ministry of Health. Donabedian's conceptual model was adapted to explore health care professionals' perceptions of the quality of clinical pharmacy services provision. Semi-structured interviews were carried out with pharmacists, physicians and nurses and then transcribed and analyzed via discourse analysis and codification techniques, using the software package Atlas. ti. RESULTS Limitations in pharmaceutical human resources were identified as the main factor affecting coverage and quality in clinical pharmacy services provision. However, the development in pharmacy staff of technical competences and skills for clinical pharmacy service provision were recognized. Significant improvements in the rational use of medicines were associated with clinical pharmacy services provision. CONCLUSIONS The perception analysis performed in this study suggested that it is necessary to increase pharmacy staff in order to improve interprofessional relationships and the quality of clinical pharmacy services provision.
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Affiliation(s)
- Christian Díaz de León-Castañeda
- Consejo Nacional de Ciencia y Tecnología - Infotec, Circuito Tecnopolo Sur 112, Tecnopolo Pocitos, 20313, Aguascalientes, Ags., Mexico.
| | - Jéssica Gutiérrez-Godínez
- Hospital General "Dr. Manuel Gea González", Secretaría de Salud, Calzada de Tlalpan 4800, Tlalpan Centro I, 14080, Tlalpan, Ciudad de México, Mexico.
| | - Juventino Iii Colado-Velázquez
- Departamento de Ciencias de la Salud, Universidad Autónoma de Occidente, Boulevard Lola Beltrán s/n, 4 de Marzo, 80107, Culiacán, Sinaloa, Mexico.
| | - Cairo Toledano-Jaimes
- Facultad de Farmacia, Universidad Autónoma del Estado de Morelos, Avenida Universidad 1001, Chamilpa, 62210, Cuernavaca, Morelos, Mexico.
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19
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López-Manning M, García-Díaz R. Doctors Adjacent to Private Pharmacies: The New Ambulatory Care Provider for Mexican Health Care Seekers. Value Health Reg Issues 2017; 14:81-88. [DOI: 10.1016/j.vhri.2017.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 08/08/2017] [Accepted: 08/31/2017] [Indexed: 10/18/2022]
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20
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Hoffman L, Crooks VA, Snyder J. Pills in paradise: Exploring international lifestyle and retirement migrants' perceptions of the pharmaceutical sector on Cozumel Island, Mexico. Health Place 2017; 47:139-146. [PMID: 28886440 DOI: 10.1016/j.healthplace.2017.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 07/03/2017] [Accepted: 08/22/2017] [Indexed: 11/25/2022]
Abstract
International lifestyle and retirement migration is a growing phenomenon, yet little is known about migrants' experiences of health care in destination countries. This includes use of and access to pharmaceutical selling establishments. This article explores international lifestyle and retirement migrants' experiences and perceptions of the local pharmaceutical sector on Cozumel Island, Mexico. Qualitative data, collected through semi-structured interviews (n = 26), finds that participants are concerned with accessibility, quality and communication within the island's pharmaceutical sector. Subsequent analysis suggests that these concerns arise through comparison with previous health care environments and that migrants attempt to remedy them by spatially reorganising their pharmacy engagements through practices which may contribute to adverse health outcomes.
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Affiliation(s)
- Leon Hoffman
- Department of Geography, Simon Fraser University, 8888 University Drive, Burnaby, BC, Canada V5A 1S6.
| | - Valorie A Crooks
- Department of Geography, Simon Fraser University, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
| | - Jeremy Snyder
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
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21
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Díaz-Portillo SP, Reyes-Morales H, Cuadra-Hernández SM, Idrovo ÁJ, Nigenda G, Dreser A. [Working conditions in outpatient clinics adjacent to private pharmacies in Mexico City: perspective of physicians]. GACETA SANITARIA 2017; 31:459-465. [PMID: 28473208 DOI: 10.1016/j.gaceta.2016.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 10/21/2016] [Accepted: 10/24/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyse the working conditions of physicians in outpatient clinics adjacent to pharmacies (CAFs) and their organizational elements from their own perspective. METHODS We carried out an exploratory qualitative study. Semi-structured interviews were conducted with 32 CAF physicians in Mexico City. A directed content analysis technique was used based on previously built and emerging codes which were related to the experience of the subjects in their work. RESULTS Respondents perceive that work in CAFs does not meet professional expectations due to low pay, informality in the recruitment process and the absence of minimum labour guarantees. This prevents them from enjoying the benefits associated with formal employment, and sustains their desire to work in CAF only temporarily. They believe that economic incentives related to number of consultations, procedures and sales attained by the pharmacy allow them to increase their income without influencing their prescriptive behaviour. They express that the monitoring systems and pressure exerted on CAFs seek to affect their autonomy, pushing them to enhance the sales of medicines in the pharmacy. CONCLUSIONS Physicians working in CAFs face a difficult employment situation. The managerial elements used to induce prescription and enhance pharmacy sales create a work environment that generates challenges for regulation and underlines the need to monitor the services provided at these clinics and the possible risk for users.
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Affiliation(s)
- Sandra P Díaz-Portillo
- Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México
| | | | | | - Álvaro J Idrovo
- Departamento de Salud Pública, Escuela de Medicina, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia
| | - Gustavo Nigenda
- Universidad Autónoma del Estado de Morelos, Cuernavaca, Morelos, México
| | - Anahí Dreser
- Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México
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Santa-Ana-Tellez Y, Mantel-Teeuwisse AK, Leufkens HGM, Wirtz VJ. Effects of over-the-counter sales restriction of antibiotics on substitution with medicines for symptoms relief of cold in Mexico and Brazil: time series analysis. Health Policy Plan 2016; 31:1291-6. [PMID: 27229872 DOI: 10.1093/heapol/czw066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2016] [Indexed: 11/13/2022] Open
Abstract
We evaluated changes in the use of non-steroidal anti-inflammatory drugs (NSAIDs), non-opioid analgesics and cough and cold medicines and its relation with the use of antibiotics after the over-the-counter (OTC) antibiotic sales restrictions in Mexico and Brazil. IMS Health provided retail quarterly data from the private sectors in Mexico and Brazil from the first quarter of 2007 to the first quarter of 2013. Data of each active substance of antibiotics, easily accessible medicines perceived as antibiotics substitutes (cough and cold medicines, analgesics and NSAIDs-the latter two being combined in the analyses), and medicines to control for external factors that can affect the medicines usage trend (antihypertensives) were converted from kilograms to defined daily doses per 1000 inhabitants days (DDD/TID). Interrupted time series were used to estimate changes in level of medicines use at the intervention point and slope after the regulation. The Gregory-Hansen cointegration test was used to explore the relation between the use of antibiotics and perceived substitutes. After the regulation in Mexico NSAIDs-analgesics usage level increased by 1.1 DDD/TID with a slope increase of 0.2 DDD/TID per quarter and the cough and cold medicines usage level increased by 0.4 DDD/TID. In Brazil NSAIDs-analgesics usage level increased by 1.9 DDD/TID, and cough and cold medicines did not change. In the two countries, NSAIDs-analgesics usage changes were related with antibiotic usage changes; in Mexico cough and cold medicines usage changes had a relation with the antibiotics usage changes. These results showed a substitution effect on the use of other medicines, especially NSAIDs and analgesics, after reinforcement of OTC antibiotics sales restrictions. These regulations aimed to improve the antibiotics use and as a consequence reduce antimicrobial resistance; however, this type of policies should be comprehensive and take into account the potential substitution effects on the use of other medicines.
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Affiliation(s)
- Yared Santa-Ana-Tellez
- WHO Collaborating Centre for Pharmaceutical Policy & Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- WHO Collaborating Centre for Pharmaceutical Policy & Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht, The Netherlands
| | - Hubert G M Leufkens
- WHO Collaborating Centre for Pharmaceutical Policy & Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht, The Netherlands
| | - Veronika J Wirtz
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
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