Primary health care utilization by the mexican indigenous population: the role of the Seguro popular in socially inequitable contexts

Away from home, into the fields: Assessing the health of undocumented and indigenous farmworkers

A large and growing literature argues that the agricultural labor market is stratified by ethnicity and legal status. However, other markers of distinction, such as indigeneity, may overlap with legal status to reveal additional health inequalities. Our study contributes to this scholarly dialogue by assessing the relation between indigeneity, legality, and health among immigrant-origin farmworkers from Latin America. To this end, we use data from the National Agricultural Worker Survey (N = 21,092) to examine health outcomes among indigenous and non-indigenous immigrants. Results indicate that indigenous farmworkers experience higher rates of pain-but not chronic conditions-than their non-indigenous counterparts. While undocumented farmworkers who are not indigenous exhibit especially favorable health, indigenous workers who are documented are significantly more likely to suffer from pain. Finally, there is limited evidence that differences in insurance coverage can fully explain the patterning between legal status, indigeneity, and health. This project sheds light on the well-being of indigenous migrant laborers in the U.S. food system, a population that experiences pervasive barriers to socioeconomic advancement at home and abroad.

Utilisation of public healthcare services by an indigenous group: a mixed-method study among Santals of West Bengal, India

A barrier to meeting the goal of universal health coverage in India is the inequality in utilisation of health services between indigenous and non-indigenous people. This study aimed to explore the determinants of utilisation, or non-utilisation, of public healthcare services among the Santals, an indigenous community living in West Bengal, India. The study holistically explored the utilisation of public healthcare facilities using a framework that conceptualised service coverage to be dependent on a set of determinants - viz. the nature and severity of the ailment, availability, accessibility (geographical and financial), and acceptability of the healthcare options and decision-making around these further depends on background characteristics of the individual or their family/household. This cross-sectional study adopts ethnographic approach for detailed insight into the issue and interviewed 422 adult members of Santals living in both rural (Bankura) and urban (Howrah) areas of West Bengal for demographic, socio-economic characteristics and healthcare utilisation behaviour using pre-tested data collection schedule. The findings revealed that utilisation of the public healthcare facilities was low, especially in urban areas. Residence in urban areas, being female, having higher education, engaging in salaried occupation and having availability of private allopathic and homoeopathic doctors in the locality had higher odds of not utilising public healthcare services. Issues like misbehaviour from the health personnel, unavailability of medicine, poor quality of care, and high patient load were reported as the major reasons for non-utilisation of public health services. The finding highlights the importance of improving the availability and quality of care of healthcare services for marginalised populations because these communities live in geographically isolated places and have low affordability of private healthcare. The health programme needs to address these issues to improve the utilisation and reduce the inequality in healthcare utilisation, which would be beneficial for all segments of Indian population.

Socioeconomic Inequalities and Ethnic Discrimination in COVID-19 Outcomes: the Case of Mexico

In Mexico, Indigenous people were hospitalised and killed by COVID-19 at a disproportionate rate compared to the non-Indigenous population. The main factors contributing to this were poor health conditions and impoverished social and economic circumstances within the country. The objective of this study is to examine the extent to which ethnic disparities are attributable to processes of structural discrimination and further explore the factors that exacerbate or mitigate them. Using administrative public data on COVID-19 and Census information, this study uses the Oaxaca-Blinder decomposition method to examine the extent to which disparities are illegitimate and signal discrimination against Indigenous people. The results show that although ethnic disparities were mainly attributable to observable differences in individual and contextual characteristics, 22.8% (p < 0.001) of the ethnic gap in hospitalisations, 17.5% in early deaths and 16.4% in overall deaths remained unexplained and could potentially indicate systemic discrimination. These findings highlight that pre-existing and longstanding illegitimate disparities against Indigenous people jeopardise the capacity of multi-ethnic countries to achieve social justice in health.

How Education Shapes Indigenous Health Inequalities in the USA and Mexico

Indigenous peoples around the world face significant health disparities relative to the dominant groups in their countries, yet the magnitude and patterns of health disparities vary across countries. We use data from the National Health Interview Survey and Mexican Family Life Survey to examine the health of Indigenous peoples in Mexico and American Indians and Alaska Natives in the USA and to evaluate how they fare relative to the majority populations in their countries (non-Indigenous Mexicans and non-Hispanic Whites, respectively). We assess disparities in self-rated health and activity limitations, with a focus on how Indigenous health disparities intersect with educational gradients in health. Regression analyses reveal three primary findings. First, Indigenous health disparities are larger in the USA than in Mexico. Second, differences in educational attainment account for most of the differences between Indigenous and non-Indigenous populations in Mexico, but less than half in the USA. Third, in both countries, health is moderated by educational attainment such that between-group disparities are largest at the highest levels of education. However, for Indigenous Mexicans there is a "cross-over" in which Indigenous Mexicans report better health at the lowest level of education. Overall, this study finds a weak relationship between education and Indigenous health, and raises the question about the validity of using traditional measures of SES in Indigenous contexts.

The relationship between individual-level socioeconomic status and preference for medical service in primary health institutions: a cross-sectional study in Jiangsu, China

Background

While China's primary health care (PHC) system covers all citizens, the use of medical services supplied by primary health institutions (PHIs) is not at ideal levels. This study explored the impact of socioeconomic status (SES) on residents' first choice of medical services provided by PHIs.

Methods

This community-based, cross-sectional study was conducted in Jiangsu Province, China, from October 2021 to March 2022. A custom-designed questionnaire was used to evaluate 4,257 adults, of whom 1,417 chose to visit a doctor when they were sick. Logistic regression was used to test the relationships among SES, other variables and the choice of medical services, and interaction effects were explored.

Results

A total of 1,417 subjects were included in this study (48.7% female; mean age 44.41 ± 17.1 years). The results showed that older age (p < 0.01), rural residence (p < 0.01), a preference for part-time medical experts in PHIs (p < 0.01), and lack of coverage by basic medical insurance (p < 0.05) were associated with the first choice to use PHIs. In the multiple logistic regression model, SES was not associated with the first choice of medical services supplied by PHIs (p > 0.05), but it interacted with three variables from the Commission on Social Determinants of Health Framework (material circumstances, behaviors and biological factors, and psychosocial factors).

Conclusion

Vulnerable individuals who are the target visitors to PHIs are older, live in rural areas, and suffer from chronic diseases. SES, as a single factor, did not impact whether medical services at PHIs were preferred, but it mediated relationships with other factors.

Equity in out-of-pocket health expenditure: Evidence from a health insurance program reform in Mexico

Background

The fragmentation of health systems in low- and middle-income countries (LMICs) deepens health inequities and shifts the economic burden of health care to families via out-of-pocket spending (OOPHE). This problem has been addressed by introducing public health insurance programs for poor people; however, there is a lack of knowledge about how equitable these programs are. We aimed to analyse the long-term effects of the Seguro Popular (SP) voluntary health insurance program, recently phased out and replaced by the Health Institute for Welfare (Instituto de Salud para el Bienestar (INSABI)), on OOPHE equity in the poor Mexican population.

Methods

We conducted a pooled cross-sectional analysis using eleven waves of the National Household Income and Expenditure Survey (2002-2020). We identified the effect of SP by selecting households without social security (with SP or without health insurance (n = 169 766)) and matched them by propensity score to reduce bias in the decision to enrol in SP. We estimated horizontal and vertical equity metrics and assessed their evolution across subpopulations.

Results

The program's entry years (2003-2010) show a positive redistributive effect associated with a focalised stage of the program, while oversaturation could have diluted these effects during 2010-2014, with adverse results in terms of vertical equity and re-ranking among insured families. SP is more horizontally inequitable than for those uninsured. Within SP, the redistributive effect could improve up to 13% if all families with similar expenditures were spending equal OOPHE and horizontal equity was eliminated. Regarding vertical equity, SP outperforms the insured population with middle-range coverage some years after the implementation, but this progress disappears.

Conclusions

To achieve universal health coverage, health authorities need to create and execute financial protection mechanisms that effectively address structural inequalities. This involves implementing a more comprehensive risk-pooling mechanism that makes social insurance sustainable in the long-run by increasing the social-economic influx of resources. It is essential to monitor oversaturation and financial sustainability to achieve optimal results. The replacement of the SP with INSABI highlights the complexity of maintaining a social insurance program where the ideology of different governments can influence the program structure, regulation, financing, and even its existence.

Accessing medical care for infertility: a study of women in Mexico

Objective

To investigate barriers in accessing care for infertility in Mexico, because little is known about this issue for low and middle-income countries, which comprise 80% of the world's population.

Design

Cross-sectional analysis.

Setting

Mexcian Teachers' Cohort.

Patients

A total of 115,315 female public school teachers from 12 states in Mexico.

Interventions

None.

Main Outcome Measures

The participants were asked detailed questions about their demographics, lifestyle characteristics, access to the health care system, and infertility history via a self-reported questionnaire. Log-binomial models, adjusted a priori for potential confounding factors, were used to estimate the prevalence ratios (PRs) and 95% confidence intervals ( CIs) of accessing medical care for infertility among women reporting a history of infertility.

Results

A total of 19,580 (17%) participants reported a history of infertility. Of those who experienced infertility, 12,470 (63.7%) reported seeking medical care for infertility, among whom 8,467 (67.9%) reported undergoing fertility treatments. Among women who reported a history of infertility, women who taught in a rural school (PR, 0.95; 95% CI, 0.92-0.97), spoke an indigenous language (PR, 0.88; 95% CI, 0.84-0.92), or had less than a university degree (PR, 0.93; 95% CI, 0.90-0.97) were less likely to access medical care for fertility. Women who had ever had a mammogram (PR, 1.07; 95% CI, 1.05-1.10), had a pap smear in the past year (PR, 1.08; 95% CI, 1.06-1.10), or who had used private health care regularly or in times of illness were more likely to access medical care for fertility.

Conclusions

The usage of infertility care varied by demographic, lifestyle, and access characteristics, including speaking an indigenous language, teaching in a rural school, and having a private health care provider.

Use of Outpatient Health Services by Mexicans Aged 15 Years and Older, According to Ethnicity

The aim of this study was to estimate the prevalence of health needs and use of outpatient services for indigenous (IP) and non-indigenous (NIP) populations aged ≥15 years, and to explore the associated factors and types of need. A cross-sectional study was conducted based on the 2018-19 National Health and Nutrition Survey. The population aged ≥15 years who had health needs and used outpatient services was identified. Logistic models were developed to explore the factors underlying the use of outpatient services. For both populations, being a woman increased the likelihood of using health services, and having health insurance was the most important variable in explaining the use of public health services. Compared to the NIP, a lower proportion of IP reported health needs during the month prior to the survey (12.8% vs. 14.7%); a higher proportion refrained from using outpatient services (19.6% vs. 12.6%); and a slightly higher proportion used public health services (56% vs. 55.4%). For the NIP, older age and belonging to a household that had received cash transfers from a social program, had few members, a high socioeconomic level, and a head with no educational lag, all increased the likelihood of using public health services. It is crucial to implement strategies that both increase the use of public health services by the IP and incorporate health-insurance coverage as a universal right.

A year and a half into the pandemic in Mexico: evidence of differences in COVID-19 mortality between Indigenous and non-Indigenous populations continues to accumulate

Among the groups most vulnerable to COVID-19 are Indigenous populations around the world, and in particular, the Mexican Indigenous population. We used public data made available by the General Directorate of Epidemiology of the Mexican Ministry of Health to compare the risk of COVID-19 mortality among the Indigenous and non-Indigenous Mexican population one and a half years into the pandemic. The analytical sample comprises 3,545,952 Mexicans who were diagnosed as infected with severe acute respiratory syndrome coronavirus-2 between March 18, 2020, and September 16, 2021, of which 1.0% (36,195) are Indigenous. Based on parametric survival models, our results show that the risk of death among Indigenous individuals is 52% higher than that of their non-Indigenous counterparts, regardless of age, sex, area of residence, health service, number of chronic diseases, and obesity status. These results suggest that certain structural conditions of the Mexican Indigenous population increase their vulnerability to the pandemic.

Erectile dysfunction predictors in hypertensives at a primary care clinic in Southern Nigeria

BACKGROUND

 Erectile dysfunction (ED) has been described as an important public health problem by the National Institutes of Health Consensus Development Conference Panel. It causes significant distress in men and dysfunctional family dynamics.

AIM

 This study sought to identify the relationship between level of education and ED amongst hypertensive men (aged 30-89 years) attending outpatient clinics (OPCs) at the Federal Medical Centre (FMC), Asaba.

SETTING

 This study was conducted in the OPCs at FMC, Asaba, Delta State, Nigeria.

METHODS

 After obtaining approval from the ethics and research committees in Asaba, 184 consenting hypertensive men who met the eligibility criteria were selected by systematic random sampling to participate in the study from October 2015 to January 2016. This study was a cross-sectional survey. Data were collected with a semistructured, interviewer-administered questionnaire adopted from the International Index of Sexual Health Inventory for Men. The study complied with the principles of Helsinki and Good Clinical Practice.

RESULTS

 The mean age ± standard deviation and range of the respondents were 55.1 (±12.4) and 30-89 years, respectively. On logistic regression, higher level of education (secondary school and above) (odds ratio [OR] = 15.943, 95% confidence interval [CI] = 1.517-167.502) was found to be a predictor of ED amongst the study participants.

CONCLUSION

 This study showed that formal education up to secondary level and use of diuretics were significantly associated with ED amongst adults with hypertension.

Hospitalisation and mortality from COVID-19 in Mexican indigenous people: a cross-sectional observational study

BACKGROUND

Despite having a large indigenous population, little is known about the differences in COVID-19-related health outcomes between indigenous and non-indigenous patients in Mexico. The aim of this study is to analyse the variation in hospitalisation and death between indigenous and non-indigenous patients with COVID-19 to guide future policies and clinical practice.

METHODS

We used data from the Mexican Ministry of Health (MoH) to study the hospitalisation and death of adults with laboratory-confirmed SARS-CoV-2 in MoH facilities between 1 March 2020 and 28 February 2021. Predicted probabilities of hospitalisation and death were adjusted for sociodemographic and presentation to care characteristics as well as municipal social deprivation index and health jurisdiction-level index of human resource and hospital equipment availability.

RESULTS

Of 465 676 hospitalised adults with COVID-19, 5873 (1.3%) were identified as indigenous. Indigenous patients had higher odds of hospitalisation (adjusted OR (aOR)=1.9, 95% CI 1.8 to 2.0), death (aOR=1.3, 95% CI 1.1 to 1. 3) and early mortality (aOR=1.2, 95% CI 1.0 to 1.4), compared with non-indigenous patients. Living in municipalities with high social deprivation was associated with a higher risk of hospitalisation and early death. Living in areas with low healthcare resources was associated with a higher risk of hospitalisation but not death. Being male, aged 51 years or older, having diabetes, hypertension and obesity were associated with an incremental probability of hospitalisation and death among indigenous patients.

CONCLUSIONS

Indigenous patients with COVID-19 in Mexico have a higher risk of hospitalisation and death than non-indigenous individuals. Our findings can guide future efforts to protect this population from SARS-CoV-2 infection and associated outcomes.

Ethnic disparities in COVID-19 mortality in Mexico: A cross-sectional study based on national data

INTRODUCTION

Across the world, the COVID-19 pandemic has disproportionately affected racial and ethnic minorities. How ethnicity affects Indigenous peoples in Mexico is unclear. The aim of this cross-sectional study was to determine the mortality associated with ethnicity, particularly of Indigenous peoples, in a large sample of patients with COVID-19 in Mexico.

METHODS

We used open access data from the Mexican Ministry of Health, which includes data of all confirmed COVID-19 cases in the country. We used descriptive statistics to compare differences among different groups of patients. Logistic regression was used to calculate odds ratios while adjusting for confounders.

RESULTS

From February 28 to August 3, 2020, a total of 416546 adult patients were diagnosed with COVID-19. Among these, 4178 were Indigenous peoples. Among all patients with COVID-19, whether hospitalized or not, a higher proportion of Indigenous peoples died compared to non-Indigenous people (16.5% vs 11.1%, respectively). Among hospitalized patients, a higher proportion of Indigenous peoples died (37.1%) compared to non-Indigenous peoples (36.3%). Deaths outside the hospital were also higher among Indigenous peoples (3.7% vs 1.7%). A higher proportion of Indigenous peoples died in both the private and public health care sectors. The adjusted odds ratio for COVID-19 mortality among Indigenous peoples with COVID-19 was 1.13 (95% confidence interval 1.03 to 1.24). The adjusted odds ratio for COVID-19 mortality among Indigenous peoples with COVID-19 was higher among those who received only ambulatory care (1.55, 95% confidence interval 1.24 to 1.92).

DISCUSSION

In this large sample of patients with COVID-19, the findings suggest that Indigenous peoples in Mexico have a higher risk of death from COVID-19, especially outside the hospital. These findings suggest Indigenous peoples lack access to care more so than non-Indigenous people during the COVID-19 pandemic in Mexico.

Unequal Impact of Structural Health Determinants and Comorbidity on COVID-19 Severity and Lethality in Older Mexican Adults: Considerations Beyond Chronological Aging

BACKGROUND

COVID-19 has had a disproportionate impact on older adults. Mexico's population is younger, yet COVID-19's impact on older adults is comparable to countries with older population structures. Here, we aim to identify health and structural determinants that increase susceptibility to COVID-19 in older Mexican adults beyond chronological aging.

METHODS

We analyzed confirmed COVID-19 cases in older adults using data from the General Directorate of Epidemiology of Mexican Ministry of Health. We modeled risk factors for increased COVID-19 severity and mortality, using mixed models to incorporate multilevel data concerning healthcare access and marginalization. We also evaluated structural factors and comorbidity profiles compared to chronological age for COVID-19 mortality risk prediction.

RESULTS

We analyzed 20 804 confirmed SARS-CoV-2 cases in adults aged 60 and older. Male sex, smoking, diabetes, and obesity were associated with pneumonia, hospitalization, and intensive care unit (ICU) admission in older adults, CKD and COPD were associated with hospitalization. High social lag indexes and access to private care were predictors of COVID-19 severity and mortality. Age was not a predictor of COVID-19 severity in individuals without comorbidities and combination of structural factors and comorbidities were better predictors of COVID-19 lethality and severity compared to chronological age alone. COVID-19 baseline lethality hazards were heterogeneously distributed across Mexican municipalities, particularly when comparing urban and rural areas.

CONCLUSIONS

Structural factors and comorbidity explain excess risk for COVID-19 severity and mortality over chronological age in older Mexican adults. Clinical decision-making related to COVID-19 should focus away from chronological aging onto more a comprehensive geriatric care approach.

Challenges, inequalities and COVID-19: Examples from indigenous Oaxaca, Mexico

COVID-19 is a challenge for indigenous communities in Mexico. Social inequalities and limited access to services combine with historical patterns of discrimination to amplify its negative impacts. Nevertheless, there are important ways in which indigenous communities organise and respond. Our paper, organised in three parts, summarises these challenges as well as the response. In the first section, we introduce indigenous Oaxaca and the challenges facing indigenous communities. In the second section, we note the ways in which indigenous communities rely on their traditions in response to the pandemic and limitations they face. In the third and concluding section, we argue that the social inequalities that define indigenous life in Oaxaca must be acknowledged in order to create an effective public health response to COVID-19.

The interaction effect of health insurance reimbursement and health workforce on health care-seeking behaviour in China

OBJECTIVE

In China, patients generally seek health care at high-level hospitals, which is leading to escalating medical costs and overloaded hospitals. Some studies have suggested that the health system is an important factor influencing individuals' health care-seeking behaviour; however, this association has not been studied in much depth. We therefore examined the impact of the health system (in terms of the interaction between health insurance reimbursement and health workforce) on health care-seeking behaviour.

METHODS

Drawing on national survey data from 2008 and 2013, we linked individual-level data on choice of health care providers (our index of health care-seeking behaviour) with county-level data on the health workforce and health insurance. We then constructed a multilevel multinomial logistic model to examine the impacts of health insurance reimbursement (indexed as average reimbursement rate [ARR]) and the health workforce (number of registered physicians per 1000 population) at county hospitals and primary health care institutions (PHCs) on choice of inpatient care providers.

RESULTS

Increases in ARR at county hospitals were associated with a greater probability of visiting such hospitals (relative risk ratio [RRR] = 1.23), and this positive impact was even greater in county hospitals with higher physician densities (RRR = 2.76). Greater ARR in PHCs was associated with a 73% lower probability of visiting municipal- and higher-level hospitals; increasing ARR was associated with an even lower probability when physician density in PHCs was considered (RRR = 0.09).

CONCLUSION

Increases in the health insurance reimbursement and health workforce are necessary to improve health care access and thereby health care-seeking behaviour. Thus, comprehensive health system reform is necessary.

We Got Your Back! Help Care Seeking and Caregiving in Mexican Indigenous Men With Ankylosing Spondylitis

This article presents a study on the care provided by 11 men from different ethnic, health, and socioeconomic backgrounds to two indigenous Rarámuri males with ankylosing spondylitis. This chronic muscular and bone disease is known to evolve progressively, causing disability and immense suffering to the affected individual. Through anthropological research involving ethnographic description and interviews conducted in an urban setting of the City of Chihuahua in the state of Chihuahua, caring practices performed by men that contest prior assumptions about how men relate to each other in relation to their health and masculinity were encountered. To interpret findings, a "caring of the self" framework, along with elements of the discussion of personhood and masculinities, was used; this led to an analysis made through the elaboration of meaningful coding of patterns of caring practices. The patterns identified in the ethnographic data were organized into four groups, all of which represented caring practices performed by these men. The first three groups involve access to food, money, and infrastructure goods, which have a material nature that holds a positive relation to the well-being of the two Rarámuri males in regard to the implications of their disease. The last group is unique in that it pertains to circumstantial factors that required improvisations in the forms of favors exchanged by these males that also positively related to their well-being.

Internal migration and the health of Indigenous Mexicans: A longitudinal study

Rationale

Indigenous peoples have historically comprised a substantial part of migration streams around the world, yet our understanding of the effects of migration on indigenous health is limited.

Objective

To explore the migration-indigenous health relationship by assessing the impact of internal migration on the self-rated health trajectories of indigenous Mexicans.

Data and method

Using three waves of data (2002-2012) from the Mexican Family Life Survey, I estimated linear growth curves to examine differences in initial self-rated health and changes in self-rated health between indigenous and non-indigenous respondents (N = 12,533). Then, I investigated whether migrating domestically during the study period shaped indigenous health trajectories.

Results

At the baseline interview (before migration), indigenous migrants reported significantly better self-rated health than indigenous non-migrants and than all non-indigenous respondents. In spite of their better initial health, indigenous migrants' health deteriorated substantially after migration, such that by the time of the last interview they reported the worst health. The self-rated health of all other groups improved during the same period.

Conclusion

Findings provide evidence of pre-migration health selection and post-migration health deterioration among Mexican indigenous migrants. These results suggest that internal migration is a risk factor that has an independent effect on indigenous health even after adjusting for personal, family, socioeconomic, and health care factors.

Análise do Seguro Popular de Saúde mexicano: uma revisão integrativa da literatura

RESUMO Esse artigo objetiva analisar a reforma do sistema de saúde mexicano, a partir da implantação do Seguro Popular de Saúde, destacando seu funcionamento, aspectos positivos e negativos. Foi realizada uma revisão integrativa da literatura nas bases Lilacs e SciELO Regional no período de janeiro de 2011 a dezembro de 2018. Foram incluídas publicações que atendiam a três questionamentos: história do sistema de saúde mexicano, seu funcionamento e pontos positivos e negativos do Seguro Popular de Saúde. A literatura aponta que o Seguro Popular surgiu após um processo de reformas neoliberais no sistema de saúde mexicano, consonante com a proposta de Cobertura Universal de Saúde, que visa reduzir o empobrecimento por gastos em saúde na população sem seguridade social. O Seguro Popular oferece menor variedade de diagnósticos e tratamentos do que a seguridade social, menor número de consultas, atendimentos de urgência e medicamentos. Seu maior impacto foi nas populações indígena e rural, mas 20% da população continua descoberta e o atendimento permanece desigual. A análise do Seguro Popular permite inferir possíveis impactos que teriam os planos de saúde acessíveis no cenário brasileiro, acarretando acesso a um elenco menor de procedimentos para a população atualmente coberta pelo Sistema Único de Saúde.

Creating a preference for prevention: the role of universal health care in the demand for preventive care among Mexico's vulnerable populations

The introduction of Seguro Popular (SP)- providing health insurance to over 50 million Mexicans since the early 2000s-represents a large shift in health care delivery to the Mexican population. And yet, its impact on Mexico's marginalized communities has been little studied, and its impact on health is unclear. Using a survey of poor urban Mexicans and Mexican Ministry of Health administrative data, this article investigates SP's effect on those at the most risk for health disparities by looking at the impact of the programme on demand for preventive care services, especially among women, children and the indigenous. Three outcomes important to Mexico's burden of disease are explored: general physical exams, diabetes screening, and cervical cancer screening. Ordinary least square regressions show that the introduction of SP is associated with an increase in demand for all three services, but these results are likely biased due to selection into the programme. I then use the staggered geographic roll out of SP between 2004 and 2007 to identify the causal impact of the programme on demand. I use length of exposure to SP as an instrumental variable to predict SP affiliation in 2009. Two stage least squares estimates of the causal impact of SP on demand for preventive care services finds that SP affiliation increases adult demand for physicals, but does not affect demand for diabetes screening. Additionally, I find that female and child SP affiliates are less likely to demand physicals, while affiliates who identify as indigenous are less likely to demand physicals but more likely to demand cervical cancer screenings.