The Sustainable Development Goals and Technological Capacity / Los Objetivos de Desarrollo Sostenible y las capacidades tecnológicas / Os Objetivos de Desenvolvimento Sustentável e a capacidade tecnológica

SUMMARY In order to achieve the Sustainable Development and Health Goals, it is essential to increase the technological capacity of the most disadvantaged populations. In the 21st century, the necessary technologies for this exist. The gap in technological capacity reflects the existence of a technological gradient between large- and small-scale production, due to an absence of incentives for innovation and a lack of technological dissemination in small businesses and communities. Technological change is central to development, but it is a public good that the market economy does not provide efficiently. Providing it requires the implementation of public policies aimed at technological innovation and dissemination. Reducing the technological gradient is therefore a major part of the United Nations 2030 Agenda for Sustainable Development and the Pan American Health Organization's 2018-2030 Sustainable Health Agenda for the Americas. This also applies to the development of health systems, which function as a redistribution mechanism to break poverty traps. In addition, experiences in these systems are relevant to the implementation of policies that increase technological capacities aimed at reducing poverty, improving social determinants of health, and thereby reducing the scale of the human development trap.

RESUMEN Para lograr los objetivos de desarrollo y salud sostenibles, es esencial incrementar las capacidades tecnológicas de las poblaciones más desfavorecidas. Entrado el siglo XXI, existen las tecnologías necesarias para ello. El déficit en capacidades tecnológicas se debe a la existencia de un gradiente tecnológico entre la producción de gran y de pequeña escalas, debido a la falta de incentivos para la innovación y la difusión en empresas y comunidades pequeñas. En estos ámbitos el cambio tecnológico, punto medular del desarrollo, es un bien público que la economía de mercado no provee eficientemente. Su provisión requiere la aplicación de políticas públicas de innovación y difusión tecnológicas. La reducción del gradiente tecnológico constituye, pues, parte medular de la Agenda 2030 para el Desarrollo Sostenible, de las Naciones Unidas, y la Agenda de Salud Sostenible para las Américas 2018-2030, de la Organización Panamericana de la Salud. Esto es aplicable, así mismo, al desarrollo de los sistemas de salud, que funcionan también como mecanismos de redistribución para romper las trampas de pobreza. Asimismo, las experiencias en esos sistemas tienen relevancia para aplicar políticas de incremento de capacidades tecnológicas que disminuyan la pobreza, mejoren los determinantes sociales de la salud y, con ello, reduzcan la magnitud de la trampa de desarrollo humano.

RESUMO Para alcançar os objetivos de desenvolvimento e saúde sustentáveis, é fundamental aumentar a capacidade tecnológica das populações mais desfavorecidas. Com a entrada do século XXI, há tecnologias necessárias para isso. O déficit em capacidade tecnológica decorre de um gradiente tecnológico entre a produção em pequena e larga escala pela falta de incentivos à inovação e difusão em empresas e comunidades pequenas. Nestas esferas, a evolução tecnológica, que é o eixo do desenvolvimento, é um bem público que não é provido de forma eficiente pela economia de mercado. Políticas públicas de inovação e difusão tecnológicas são necessárias. Diminuir o gradiente tecnológico constitui, portanto, a base da Agenda 2030 para o Desenvolvimento Sustentável, da Agenda das Nações Unidas e da Agenda de Saúde Sustentável para as Américas 2018-2030 da Organização Pan-Americana da Saúde. Requer também o desenvolvimento dos sistemas de saúde que servem como mecanismos de redistribuição para romper com as armadilhas da pobreza. Ademais, a experiência adquirida nesses sistemas é indispensável para instituir políticas de aumento da capacidade tecnológica que diminuam a pobreza, melhorem os determinantes sociais da saúde e, assim, reduzam a dimensão da armadilha do desenvolvimento humano.

Lung cancer in Mexico: findings from the Global Burden of Disease Study, 1990-2016 / Cáncer de pulmón en México: hallazgos del estudio de Carga Global de la Enfermedad 1999-2016

Abstract: Objective: To show lung cancer (LC) mortality and disability-adjusted life years (DALYs) in Mexico. Materials and methods: With the visualization tools at the Global Burden of Disease Study website, we analyzed LC mortality and disability-adjusted life years (DALYs) by state, sex, sociodemographic index (SDI), age, and risk factors between 1990 and 2016. Results: Mortality rate decreased from 13.9 to 9.1 per 100 000 between 1990 and 2016. This reduction is greater among men. However, deaths by LC rose from 5 478 to 8 470. DALYs rate also decreased. Northern states with higher SDI face a larger burden from LC but exhibited greater reductions compared with southern, less developed states. The burden of LC is concentrated among older population. Smoking is the main risk factor for LC. Conclusions: The burden by LC has decreased but is differential between states. LC threatens financially both the health system and individuals, since an important fraction of the population is not protected.

Resumen: Objetivo: Mostrar la mortalidad y los años de vida saludables (Avisas) perdidos por cáncer de pulmón (CP) en México. Material y métodos: Con la herramienta de visualización del estudio de la Carga Global de la Enfermedad, se analizó mortalidad y Avisas por CP según diferentes criterios entre 1990 y 2016. Resultados: La tasa de mortalidad disminuyó de 13.9 a 9.1 por 100 000. Dicha reducción fue mayor entre hombres. Las muertes por CP crecieron de 5 478 a 8 470. La tasa de Avisas se redujo. La carga del CP se concentra en grupos de edad avanzada. Los estados del norte, con mayor nivel sociodemográfico, enfrentan mayor carga, pero presentaron mayores reducciones comparados con estados menos desarrollados. Fumar es el principal factor de riesgo para CP. Conclusiones: La carga por CP ha disminuido pero es diferencial entre estados. El CP amenaza financieramente el sistema de salud y la población, pues una fracción importante no está protegida.

¿El aseguramiento público en salud mejora la atención en los servicios? El caso de la atención prenatal en adolescentes en México / Does public health insurance improve health care? The case of prenatal care for adolescents in Mexico

Resumen: Objetivo: Comprobar la asociación entre el aseguramiento público en salud y la atención prenatal adecuada en mujeres adolescentes. Material y métodos: Análisis transversal de datos de 3 978 mujeres (N=4 522 296) que reportaron embarazo en la adolescencia (12-19 años), derivados de las Encuestas Nacional de Salud 2000 y de Salud y Nutrición 2006 y 2012. Mediante modelos de regresión logística se analizó oportunidad, frecuencia y contenido de la atención prenatal. Resultados: La probabilidad de recibir atención prenatal oportuna y frecuente aumentó de 0.60 (IC95%:0.56;0.64) en 2000 a 0.71 (IC95%:0.66;0.76) en 2012. En 2012 la probabilidad de recibir atención oportuna, frecuente y con contenido básico fue 0.54 (IC95%:0.49;0.58) siendo mayor en mujeres con Seguridad Social que en aquéllas afiliadas al Seguro Popular o sin aseguramiento. Conclusión: Contar con seguridad social incrementa la probabilidad de recibir atención prenatal adecuada en adolescentes en México.

Abstract: Objective: To test the association between public health insurance and adequate prenatal care among female adolescents in Mexico. Materials and methods: Cross-sectional study, using the National Health and Nutrition Survey 2000, 2006, and 2012.We included 3 978 (N=4 522 296) adolescent (12-19) women who reported a live birth.We used logistic regression models to test the association of insurance and adequate (timeliness, frequency and content) prenatal care. Results: The multivariable predicted probability of timely and frequent prenatal care improved over time, from 0.60 (IC95%:0.56;0.64) in 2000 to 0.71 (IC95%:0.66;0.76) in 2012. In 2012, the probability of adequate prenatal care was 0.54 (IC95%:0.49;0.58); women with Social Security had higher probability than women with Seguro Popular and without health insurance. Conclusion: Having Social Security is associated with receipt of adequate prenatal care among adolescents in Mexico.

Eficiencia de los recursos humanos en salud: una aproximación a su análisis en México / Efficiency of human resources for health: an approach to its analysis in Mexico

Resumen: Objetivo: Analizar indicadores de eficiencia de los recursos humanos (RH) de la Secretaría de Salud de México. Material y métodos: Utilizando información secundaria se exploraron tres dimensiones de eficiencia: a) desperdicio de fuerza laboral, b) distribución de RH entre niveles de atención, y c) productividad. Resultados: El grupo de trabajadores de salud analizado se caracteriza por presentar niveles importantes de desempleo y subempleo de RH, una distribución distante de las recomendaciones internacionales y niveles de producción heterogéneos entre los estados. Conclusiones: Es imperativo diseñar e implementar un plan de RH en salud alineado a las necesidades y demandas de las poblaciones cubiertas que contemple medidas regulatorias del mercado de formación de estos recursos, su distribución entre y al interior de los sistemas estatales de salud y la generación de incentivos para el desempeño.

Abstract: Objective: To analyze efficiency indicators of human resources working at Mexico's Ministry of Health. Materials and methods: Three dimensions of efficiency were explored: a) labor wastage, b) distribution of human resources (HR) across levels of care, and c) productivity. Results: Health workers present significant levels of unemployment and underemployment; distribution does not meet international recommendations, and heterogeneous levels of productivity were found among states. Conclusions: Health and educational authorities should develop and implement a HR plan that takes into consideration the needs and demands of the covered population, and includes a clearly defined set of measures to regulate the future production of HR as well as their distribution among and within state health systems, and that allocates incentives to improve performance.

Mortalidad temprana por sida en México durante el periodo 2008-2012 / AIDS-related early mortality in Mexico between 2008 and 2012

Objetivo. Describir la distribución de la mortalidad por sida (2008-2012) en usuarios de unidades de atención de la Secretaría de Salud de México, en el Sistema de Administración, Logística y Vigilancia de Antirretrovirales (SALVAR). Material y métodos. Análisis descriptivo del tipo de mortalidad y el perfil clínico y sociodemográfico relacionado, de 41847 pacientes registrados en el SALVAR. Resultados. Se identificaron 3195 (8.1%) pacientes que fallecieron en el periodo de estudio, de los cuales 59% murió durante los primeros seis meses de seguimiento en el sistema. De éstos, 87.3% fue diagnosticado de manera tardía de acuerdo con su nivel de CD4 inicial (CD4<200 cel/ml³). Conclusión. Los hallazgos resaltan la importancia de fortalecer los programas de detección oportuna y la vinculación efectiva al tratamiento de las personas VIH positivas, como un componente fundamental de la política de acceso universal a tratamiento antirretroviral en México.

Objective. To describe the distribution of AIDS-related mortality according to the time of occurrence since entry to the System for the Administration, Logistics and Surveillance of Antiretrovirals (SALVAR, in Spanish), among users of Ministry of Health facilities in Mexico. Materials and methods. Descriptive analysis of AIDS mortality and the related clinical and demographic profile of 41847 patients registered in SALVAR. Results. 3195 patients (8.1%) died within the study period, 59% of these deaths occurred within six months after treatment initiation. Among those patients, 87.3% were diagnosed late, given their CD4 levels (CD4cel<200 cel/ml³). Conclusion. Our results underscore the need to strengthen programs aimed to increase opportune HIV diagnosis and linkage to care, as a key component of universal access policy to antiretroviral treatment in Mexico.

Exploración del rol de la oferta de servicios para explicar la variación de la mortalidad por sida en México / The role of supply-side characteristics of services in AIDS mortality in Mexico

Objetivo. Documentar la asociación entre factores de la oferta de servicios de atención de VIH sobre la mortalidad por sida en México en el periodo 2008-2013. Material y métodos. Se analizaron datos del sistema de administración, logística y vigilancia de antirretrovirales (SALVAR) y de una encuesta aplicada en unidades de atención. Se utilizaron modelos de regresión logit multivariados para estimar la asociación entre características de la oferta de servicios -en particular, de la gerencia de servicios y de la capacitación y experiencia de los prestadores- y la mortalidad por sida, distinguiendo entre mortalidad temprana y no temprana, y controlando por características clínicas de los pacientes. Resultados. Las características clínicas de los pacientes (CD4 inicial y carga viral) explican 44.4% de la variabilidad en la mortalidad temprana entre clínicas y 13.8% de la variabilidad de mortalidad no temprana. Las características de la oferta aumentan 16% del poder explicativo en el caso de la mortalidad temprana y 96% en el de la mortalidad no temprana. Conclusiones. Los aspectos de gerencia e implementación de los servicios de atención de VIH contribuyen significativamente a explicar la mortalidad por sida en México. Mejorar estos aspectos del programa nacional puede mejorar sus resultados.

Objective. To document the association between supply-side determinants and AIDS mortality in Mexico between 2008 and 2013. Materials and methods. We analyzed the SALVAR database (system for antiretroviral management, logistics and surveillance) as well as data collected through a nationally representative survey in health facilities. We used multivariate logit regression models to estimate the association between supply-side characteristics, namely management, training and experience of health care providers, and AIDS mortality, distinguishing early and non-early mortality and controlling for clinical indicators of the patients. Results. Clinic status of the patients (initial CD4 and viral load) explain 44.4% of the variability of early mortality across clinics and 13.8% of the variability in non-early mortality. Supply-side characteristics increase explanatory power of the models by 16% in the case of early mortality, and 96% in the case of non-early mortality. Conclusions. Aspects of management and implementation of services contribute significantly to explain AIDS mortality in Mexico. Improving these aspects of the national program, can similarly improve its results.

Movilidad poblacional y VIH/sida en Centroamérica y México / Population mobility and HIV/AIDS in Central America and Mexico

OBJETIVO: Estimar la magnitud de la asociación entre la movilidad poblacional, medida con la tasa neta de migración (TNM) y la prevalencia de VIH en Centroamérica y México. MÉTODOS: Con modelos de series temporales se analizó dicha asociación en personas de 15 a 49 años de edad, ajustada por factores socioeconómicos (educación, educación, desempleo, esperanza de vida e ingreso) y utilizando información pública de ONUSIDA, el PNUD, la CEPAL y el Banco Mundial para el período 1990-2009. RESULTADOS: La TNM fue negativa en todos los países, excepto en Costa Rica y Panamá. Los resultados no ajustados del modelo muestran una asociación positiva y que la TNM puede explicar el 6% de la prevalencia de VIH registrada. Cuando se incluyen cofactores socioeconómicos por país (educación, salud e ingreso), la magnitud asciende a 9% (P<0,05). La TNM, incluso ajustada por factores socioeconómicos, explica modestamente la prevalencia de VIH registrada. Los factores socioeconómicos indican mejoras en todos los indicadores en Centroamérica y México, aunque persisten importantes brechas entre países. CONCLUSIONES: La modesta asociación observada entre movilidad poblacional y prevalencia de VIH está condicionada por la situación socioeconómica de los países estudiados. La información disponible limitó el alcance del análisis para establecer con mayor certeza la existencia de esta asociación. En consecuencia, con la información disponible no es posible atribuir a la migración un papel determinante en la diseminación del VIH.

OBJECTIVE: Estimate the magnitude of the association between population mobility, measured by net migration rate (NMR), and HIV prevalence in Central America and Mexico. METHODS: Using time series models, based on public information from UNAIDS, UNDP, ECLAC, and the World Bank for the period 1990-2009, this association was studied in individuals aged 15-49 years, and adjusted for socioeconomic factors (education, unemployment, life expectancy, and income). RESULTS: NMR was negative in all countries except Costa Rica and Panama. Unadjusted results of the model show a positive association and that NMR can explain 6% of recorded HIV prevalence. When socioeconomic cofactors are included by country (education, health, and income), the magnitude increases to 9% (P<0.05). NMR, even when adjusted for socioeconomic factors, explains some of recorded HIV prevalence. All socioeconomic indicators show improvements in Central America and Mexico, although large gaps persist among countries. CONCLUSIONS: The modest association observed between population mobility and HIV prevalence is conditioned by the socioeconomic status of the countries studied. Information availability limited the study’s ability to establish the existence of this association with greater certainty. Accordingly, based on available information, it is not possible to affirm that migration plays a key role in the spread of HIV.

Análisis del uso de servicios ambulatorios curativos en el contexto de la reforma para la protección universal en salud en México / Analysis of outpatient healthcare utilization in the context of the universal healthcare coverage reform in Mexico

Objetivo. Entender y cuantificar la relación entre los perfiles socioeconómico y de aseguramiento en salud y el uso de servicios médicos ambulatorios en el contexto de la universalización de la salud en México. Material y métodos. Utilizando la ENSANUT 2012, se estimaron modelos de regresión multinomial para analizar el uso de servicios ambulatorios y sus factores asociados. Resultados. La población con mayor pobreza, menor nivel educativo y residente de zonas de alta marginación tiene menor posibilidad de usar servicios de salud ambulatorios. En contraste, tener un seguro de salud y mayores ingresos favorecen el uso e influyen en la elección del proveedor. Conclusiones. Persisten barreras en el acceso a la salud asociadas con la condición de pobreza y de protección social. Sin embargo, existe espacio para disminuir el efecto de estas barreras, abordando las restricciones en la oferta de los servicios y en la calidad percibida de los mismos.

Objective. Understand and quantify the relationship between socio-economic and health insurance profiles and the use of outpatient medical services in the context of universal health care in Mexico. Materials and methods. Using ENSANUT 2012 multinomial regression models were estimated to analyze the use of outpatient services and associated factors. Results. Population with greater poverty levels, lower educational level and living in highly marginalized areas have lower odds to use outpatient health services. In contrast, health insurance and higher income increase the odds to use health services and influence the choice of provider. Conclusions. Barriers to access to health care related to poverty and social protection persist. However, there is space to lower the effect of these barriers by addressing constraints linked to the supply and the perceived quality of healthcare services.

Infecciones de transmisión sexual: Perfil de atención en zonas fronterizas de Centroamérica (2007-2010) / Sexually transmitted infections: Profile of care in border areas of Central America (2007-2010)

OBJETIVO: Analizar el perfil de atención por infecciones de transmisión sexual (ITS) en centros de salud de zonas fronterizas de Centroamérica durante el periodo 2007-2010. MATERIAL Y MÉTODOS: Estudio transversal en una muestra de 3 357 pacientes. Se capacitaron médicos y se suministraron medicamentos, condones y pruebas de VIH (paquete básico de atención [PBA]). Se analizaron las características sociodemográficas de los participantes y su asociación a la recepción del PBA. RESULTADOS: De la muestra, 66.0% tuvo de 25 a 59 años, 93.2% era mujer. El síndrome más frecuente fue el flujo vaginal asociado con candidiasis, vaginosis bacteriana, trichomoniasis y gonorrea. De las prescripciones, 60% siguió recomendaciones internacionales. Sólo 10.2% recibió el PBA. La probabilidad de recibirlo fue menor en mujeres. CONCLUSIONES: No basta con incrementar las capacidades de provisión de servicios para modificar las prácticas de atención. Éstas se encuentran enraizadas en el contexto sociocultural. Destacan prácticas médicas diferenciadas por género que influyen negativamente en la atención.

OBJECTIVE: To analyze the profile of care for sexually transmitted infections (STIs) in health centers in border areas of Central America during 2007-2010. MATERIALS AND METHODS: Cross-sectional study in a sample of 3 357 patients. Doctors were trained and medicines, condoms and HIV testing (basic package of care [BPC]) were supplied. Sample was characterized according to sociodemographic variables. Factors associated with the probability of receiving the BPC were identified. RESULTS: Sixty six percent were 25-59 years old, and 93.2% were women. The most frequently diagnosed syndrome was vaginal discharge associated with candidiasis, bacterial vaginosis, trichomoniasis and gonorrhea. Sixty six percent of prescriptions were adhered to the international recommendations. Only 10% received the complete BPC.The likelihood of receiving it was lower in women. CONCLUSIONS: It is not enough to increase service delivery capacity to change care practices. These are deeply rooted in the sociocultural context. Highlights gendered medical practices that adversely affect the profile of care.

Brechas en la cobertura de atención continua del embarazo y el parto en México / Gaps in the continuum of care during pregnancy and delivery in Mexico

Objetivo. Construir un índice compuesto para medir la cobertura de atención continua durante el embarazo y el parto, e identificar la magnitud de las brechas entre distintas poblaciones de embarazadas en México. Material y métodos. Con información de la Encuesta Nacional de Salud y Nutrición 2012, que incluyó a 5 766 mujeres, se construyó un índice de cobertura de atención continua (Cobac), integrando cinco indicadores de cobertura de intervenciones durante el embarazo, parto y puerperio. Resultados. Las residentes en área metropolitana, afiliadas a la seguridad social, tuvieron la mejor Cobac (0.879; IC95%:0.867-0.891). Menores índices de Cobac se encontraron en mujeres de área rural con menor nivel socioeconómico (NSE-I) (0.722; IC95%: 0.700-0.745), sin aseguramiento (0.735; IC95%: 0.700-0.770) y de condición indígena (0.759; IC95%: 0.7400.779). Conclusiones. La Cobac durante el embarazo y el parto presenta diferencias importantes al interior del país, identificándose áreas en donde hay que focalizar esfuerzos para avanzar hacia la cobertura universal de salud.

Objective. To develop a composite index for coverage of antenatal and delivery continuum of care, and use it to measure the gaps among different populations of pregnant women in Mexico. Materials and methods. Based in the information of 5 766 women from the National Health and Nutrition Survey 2012, a composite index of coverage of continuum of care (Cobac in spanish) was developed, integrating five interventions for antenatal, delivery, and puerperium periods. Results. Women living in metropolitan areas who were affiliated to social security had the best Cobac (0.879; IC95%:0.867-0.891); the worst were found in women living in rural areas, with the lower socio-economic level (NSE-I), (0.722; IC95%: 0.700-0.745), women without health insurance (0.735; IC95%: 0.700-0.770), and indigenous women (0.759; IC95%: 0.740-0.779). Conclusions. The Cobac during pregnancy and childbirth has important differences within the country, which allows for the identification of areas where we must focus efforts to move towards universal health coverage.

Efectos del Seguro Popular sobre el gasto en salud en hogares mexicanos a diez años de su implementación / Effect of Seguro Popular on health expenditure in Mexican households ten years after its implementation

Objetivo. Estimar el efecto del Seguro Popular (SP) sobre la probabilidad de los hogares de incurrir en gasto en salud (GS), de presentar gastos excesivos en salud (GES) y sobre el monto gastado. Material y métodos. Análisis transversal utilizando datos de la ENSANUT 2012. El efecto del SP se estimó con métodos de pareamiento por puntaje de propensión (n=12 250). Se estimaron el efecto promedio en los hogares con SP (tratados) y diferencias en la mediana de gasto. Resultados. El SP reduce 3.6% la probabilidad del GS y en 7.1% en hogares con enfermos diabéticos o hipertensos. Para el GES la reducción fue de 36% en el ámbito nacional, y para hogares con enfermos y hospitalizados, de 46.5 y 41.7%, respectivamente. Conclusiones. El SP tiene un efecto positivo, al proteger a los hogares del GS y GES, principalmente en hogares con necesidades de salud. Sin embargo, aún existen retos para el SP que incluyen la mejora del acceso de la población de menores recursos a los servicios.

Objective. To estimate the effect of Seguro Popular Program (SP) on the probability of health spending (HE), the excessive expenditure on health (EEH) and the amount of health spending. Materials and methods. Cross-sectional analysis was carried out using data from the ENSANUT 2012. Propensity score matching was used to estimate the effect of SP (n=12.250). We estimated the average effect on SP homes (treated) and differences in median spending. Results. SP reduces the likelihood of HE in 3.6 and 7.1% in households with patients diagnosed with DM and/or hypertension, respectively. The reduction in EEH was 36% at national level. This reduction was 46.5 and 41.7% among households with hospitalized patients and those reporting a sick member. Conclusions. SP has a positive effect, protecting households from having either HE or EEH among those with greater health needs. However, there are still some challenges for the SP, which include improving access to services for low-income population.

Factores asociados con la utilización y el gasto en medicamentos en México / Factor associated with medicines utilization and expenditure in Mexico

Objetivo. Analizar la utilización y el gasto en medicamentos y sus factores asociados, así como discutir sus implicaciones para las políticas farmacéuticas. Material y métodos. Análisis en una muestra de 193 228 individuos, a partir de la Encuesta Nacional en Salud y Nutrición 2012. Se estimaron modelos logit, probit y modelos de regresión cuantílica, evaluando tres dimensiones de acceso a medicamentos: (1) probabilidad de utilización de medicamentos en el caso de un problema de salud; (2) probabilidad de incurrir en gasto y (3) monto gastado. Resultados. Las personas afiliadas al IMSS tuvieron mayor probabilidad de utilizar medicamentos (RM=1.2, p<0.05). Estar afiliado al IMSS, ISSSTE o SP redujo la probabilidad de gasto frente a quienes no cuentan con seguro médico (RM alrededor de 0.7, p<0.01). La mediana de gasto osciló entre 195.3 y 274.2 pesos mexicanos. Conclusiones. Los factores asociados con la utilización y el gasto indican que persisten inequidades en el acceso.

Objective. To analyze medicine utilization and expenditure and associated factors in Mexico, as well as to discuss their implications for pharmaceutical policy. Materials and methods. Analysis of a sample of 193 228 individuals from the Mexican National Health and Nutrition Survey 2012. Probability and amount of expenditure were estimated using logit, probit and quantile regression models, evaluating three dimensions of access to medicines: (1) likelihood of utilization of medicines in the event of a health problem, (2) probability of incurring expenses and (3) amount spent on medicines. Results. Individuals affiliated to IMSS were more likely to use medicines (OR=1.2, p<0.05). Being affiliated to the IMSS, ISSSTE or SP reduced the likelihood of spending compared to those without health insurance (about RM 0.7, p<0.01). Median expenditures varied between 195.3 and 274.2 pesos. Conclusions. Factors associated with the use and expenditure on medicines indicate that inequities in the access to medicines persist.

Intervenciones para dejar de fumar en México: análisis de disponibilidad a pagar por un método efectivo de cesación / Smoking cessation interventions in Mexico: analysis of the willingness to pay for an effective method to quit

OBJETIVO: Identificar factores socioeconómicos, demográficos, historia de tabaquismo y contextuales asociados con el deseo de dejar de fumar, estimar la disponibilidad a pagar (DAP) por tratamientos de cesación tabáquica (TCT) efectivos, e identificar sus factores asociados. MATERIAL Y MÉTODOS: Mediante la Encuesta Global de Tabaquismo en Adultos, México 2009, caracterizamos a 1 626 fumadores. Modelos logit y de regresión lineal múltiple permitieron identificar factores asociados con el deseo de dejar de fumar y la DAP. RESULTADOS: 82.2% de los fumadores que no deseaban dejar de fumar fueron hombres. Entre quienes deseaban dejar de fumar, 49.8% fumaba diariamente y reportó más de 16 años de fumar, 57% manifestó intentos previos de cesación y 10% conocer centros de ayuda. La DAP promedio fue 2 708 MXN, destacando diferencias por nivel socioeconómico y educativo. CONCLUSIONES: Se contribuye al diseño de estrategias de cesación diferenciadas, propiciando mejoras en la respuesta del sistema de salud al combate del tabaquismo en México.

OBJECTIVE: To identify environmental, demographic and socioeconomic factors associated with the desire to quit, estimate the willingness to pay (WTP) for smoking cessation treatments (SCT) and to identify associated factors with this valuation. MATERIALS AND METHODS: Using the Global Adult Tobacco Survey, Mexico 2009, we characterized 1 626 smokers. Logistic and multiple lineal regression models allowed to identify associated factors with the desire to quit and the WTP for SCT. RESULTS: 82.2 % of the current smokers who did not want to quit were men. Between those who wanted to quit, 49.8 % had been consuming tobacco every day, for more than 16 years, 57 % had made cessation attempts in the past, and around 10% knew about the existence of centers to help quit smoking. Average WTP was 2 708 Mexican pesos (MXP), with differences by educational and socioeconomic levels. CONCLUSIONS: This evidence supports policymakers in the design of smoking cessation interventions improving national health system interventions for quit smoking.

Servicios de salud en la Mixteca: utilización y condición de afiliación en hogares de migrantes y no-migrantes a EU / Health services in the Mixteca: use and conditions of affiliation in US-migrant and non-migrant households

Objetivo. Caracterizar a los hogares de la Mixteca baja en términos socioeconómicos y demográficos y analizar las diferencias entre miembros de hogares de migrantes (HogMig) y no migrantes (HogNoMig) a Estados Unidos en torno a su afiliación y utilización de servicios de salud. Material y métodos. Estudio transversal y descriptivo en el que se realizaron encuestas a jefes de familia de una muestra representativa de 702 hogares de la Mixteca baja con (HogMig) y sin miembros migrantes (HogNoMig) a EU. Resultados. Los integrantes de los HogMig tenían más recursos personales y económicos que los HogNoMig; además recibían remesas regularmente. La mayoría de los miembros de ambos tipos de hogares no recibía beneficios del Programa Oportunidades, ni contaba con afiliación al Seguro Popular, IMSS o ISSSTE. Generalmente utilizaban el centro de salud local, aunque frecuentemente preferían pagar médicos privados. La minoría derechohabiente (IMSS/ ISSSTE) reportó una muy baja utilización de esos servicios.

Objective. To describe the socioeconomic and demographic characteristics of households in the Mixteca Baja and analyze differences in affiliation with health care programs and utilization, among members of households with migrants (HogMig) and without migrants (HogNoMig) to the United States. Material and Methods. A cross-sectional, descriptive survey was used with heads of households in a representative sample from the Mixteca Baja of 702 homes with and without migrants to the US. Results. Members of HogMig had more personal and economic resources than those of HogNoMig; they also regularly received remittances. The majority of members of both HogMig and HogNoMig did not receive benefits from the Oportunidades program or health coverage through Seguro Popular, IMSS or ISSSTE. In general, while they used the local health clinic, they often preferred to pay for private practitioners. A small proportion of those covered by IMSS or ISSSTE reported very low utilization of the health services offered by those institutions.

Eucalyptus ESTs involved in the production of 9-cis epoxycarotenoid dioxygenase, a regulatory enzyme of abscisic acid production

Abscisic acid (ABA) regulates stress responses in plants, and genomic tools can help us to understand the mechanisms involved in that process. FAPESP, a Brazilian research foundation, in association with four private forestry companies, has established the FORESTs database (https://forests.esalq.usp.br). A search was carried out in the Eucalyptus expressed sequence tag database to find ESTs involved with 9-cis epoxycarotenoid dioxygenase (NCED), the regulatory enzyme for ABA biosynthesis, using the basic local BLAST alignment tool. We found four clusters (EGEZLV2206B11.g, EGJMWD2252H08.g, EGBFRT3107F10.g, and EGEQFB1200H10.g), which represent similar sequences of the gene that produces NCED. Data showed that the EGBFRT3107F10.g cluster was similar to the maize (Zea mays) NCED enzyme, while EGEZLV2206B11.g and EGJMWD2252H08.g clusters were similar to the avocado (Persea americana) NCED enzyme. All Eucalyptus clusters were expressed in several tissues, especially in flower buds, where ABA has a special participation during the floral development process

Boron transport in Eucalyptus. 2. Identification in silico of a putative boron transporter for xylem loading in eucalypt

Boron (B) is a low mobility plant micronutrient whose molecular mechanisms of absorption and translocation are still controversial. Many factors are involved in tolerance to Boron excess or deficiency. Recently, the first protein linked to boron transport in biological systems, BOR1, was characterized in Arabidopsis thaliana. This protein is involved in boron xylem loading and is similar to bicarbonate transporters found in animals. There are indications that BOR1 is a member of a conserved protein family in plants. In this work, FORESTS database was used to identify sequences similar to this protein family, looking for a probable BOR1 homolog in eucalypt. We found five consensus sequences similar to BOR1; three of them were then used in multiple alignment analysis. Based on amino acid similarity and in silico expression patterns, a consensus sequence was identified as a candidate BOR1 homolog, helping deeper experimental assays that could identify the function of this protein family in Eucalyptus

Eucalyptus ESTs associated with resistance to herbicide inhibitors of aromatic and branched-chain amino acid synthesis

Herbicides inhibit enzymatic systems of plants. Acetolactate synthase (ALS, EC = 4.1.3.18) and 5-enolpyruvylshikimate-3-phosphate synthase (EPSPS, EC 2.5.1.19) are key enzymes for herbicide action. Hundreds of compounds inhibit ALS. This enzyme is highly variable, enabling the selective control of weeds in a number of crops. Glyphosate, the only commercial herbicide inhibiting EPSPS is widely used for non-selective control of weeds in many crops. Recently, transgenic crops resistant to glyphosate were developed and have been used by farmers. The aim of this study was the data mining of eucalypt expressed sequence tags (ESTs) in the FORESTs Genome Project database (https://forests.esalq.usp.br) related to these enzymes. Representative amino acid sequences from the NCBI database associated with ALS and EPSPS were blasted with ESTs from the FORESTs database using the tBLASTx option of the blast tool. The best blasting reads and clusters from FORESTs, represented as nucleotide sequences, were blasted back with the NCBI database to evaluate the level of similarity with available sequences from different species. One and seven clusters were identified as showing high similarity with EPSPS and ALS sequences from the literature, respectively. The alignment of EPSPS sequences allowed the identification of conserved regions that can be used to design specific primers for additional sequencings

Eucalyptus ESTs corresponding to the enzyme glutamine synthetase and the protein D1, sites of action of herbicides that cause oxidative stress

This work was aimed at locating Eucalyptus ESTs corresponding to the GS enzyme (Glutamine Synthetase, EC = 6.3.1.2) and to the D1 protein, which are directly related to resistance to herbicides that promote oxidative stress. Glutamine Synthetase corresponds to the site of action of the herbicide glufosinate. Herbicides that belong to groups such as ureas, uracils, triazines and triazinones act on the D1-Qb complex (receptor of electrons from the Photosystem II) by inactivating it. The clusters EGEQRT3302E01.g, EGEQRT3001F12.b; EGEZLV1203B04.g; EGBGFB1211H06.g and EGEZLV1205F09.g enclosed complete sequences (with 356 amino acids) of the Glutamine Synthetase enzyme. The cluster EGEQSL1054G06.g is a consensus of four reads and enclosed a complete sequence of D1 Protein (with 353 amino acids). The comparison of the sequences of Protein D1 from different species showed that the substitutions of serine (S) by glycine (G) or serine (S) by threonine (T) at the position 264 could produce plants resistant to herbicides that act on electron flow on Photosystem II. The sequence of amino acids corresponding to the cluster EGEQSL1054G06.g had a serine in position 264 indicating sensitivity of the Eucalyptus plants to herbicides that act on this site

Eucalyptus ESTs corresponding to the protoporphyrinogen IX oxidase enzyme related to the synthesis of heme, chlorophyll, and to the action of herbicides

This work was aimed at locating Eucalyptus ESTs corresponding to the PROTOX or PPO enzyme (Protoporphyrinogen IX oxidase, E.C. 1.3.3.4) directly related to resistance to herbicides that promote oxidative stress, changing the functionality of this enzyme. PROTOX, which is the site of action of diphenyl-ether (oxyfluorfen, lactofen, fomesafen), oxadiazole (oxadiazon and oxadiargyl), and aryl triazolinone (sulfentrazone and carfentrazone) herbicides, acts on the synthesis route of porphyrins which is associated with the production of chlorophyll a, catalases, and peroxidases. One cluster and one single read were located, with e-values better than e-70, associated to PROTOX. The alignment results between amino acid sequences indicated that this enzyme is adequately represented in the ESTs database of the FORESTs project

Complicaçöes iniciais do uso de dois microceratótomos automatizados / Initial complications of use of two automated microkeratomes

Objetivo: Descrever as complicaçöes per e pós-operatórias ocorridas durante o uso inicial de dois microceratótomos automatizados na realizaçäo de LASIK. Métodos: Estudo retrospectivo das primeiras cirurgias realizadas com dois microceratótomos automatizados, sendo 70 olhos de 54 pacientes utilizando o microceratótomo da Chiron modelo Automated Corneal Shaper (ACS), no período de abril de 1997 a abril de 1998 e 100 olhos de 82 pacientes com o microceratótomo automatizado Moria Carriazo-Barraquer (CB), durante o período de fevereiro de 1999 a junho de 1999. A fotoablaçäo foi realizada com excimer laser de fluoreto de argônio de 193 nm da Summit modelo Apex Plus. Foram avaliadas as complicaçöes per e pós-operatórias até um mês de seguimento. Resultados: A fotoablaçäo näo foi realizada em 3 casos (4,3 por cento) usando-se o microceratótomo ACS e em 1 caso (1 por cento) usando o microceratótomo CB. As complicaçöes mais freqüentemente encontradas com o ACS foram: falha no retorno automatizado do microceratótomo (7,1 por cento), ceratectomia parcial ("flap" incompleto): 4,3 por cento, presença de dobras estromais (14,3 por cento), desepitelizaçäo central (4,3 por cento) e crescimento epitelial na interface (4,3 por cento). Já com o CB, foram encontrados: "flap" descentralizado (3 por cento), desepitelizaçäo central (5 por cento), dobras estromais (28 por cento) e síndrome das Areias de Sahara (6 por cento). Conclusöes: O uso inicial de ambos microceratótomos foi relacionado a considerável índice de complicaçöes per e pós-operatórias, näo levando necessariamente à perda de visäo. Maior conhecimento clínico das alteraçöes ocorridas com o uso destes instrumentos, bem como maior experiência na sua utilizaçäo podem diminuir a ocorrência de complicaçöes.