Cost-effectiveness analysis of a multidisciplinary health-care model for patients with type-2 diabetes implemented in the public sector in Mexico: A quasi-experimental, retrospective evaluation.

OBJECTIVE: In 2007, the Ministry of Health (MoH) in Mexico implemented a multidisciplinary health-care model (MHC) for patients with type-2 diabetes (T2D), which has proven more effective in controlling this condition than the conventional health-care model (CHC). RESEARCH DESIGN AND METHODS: We compared the cost-effectiveness of the MHC vs. the CHC for patients with T2D using a quasi-experimental, retrospective design. Epidemiologic and cost data were obtained from a randomly selected sample of health-care units, using medical records as well as patient- and facility-level data. We modelled the cost-effectiveness of the MHC at one, 10 and 20 years using a simulation model. RESULTS: The average cumulative costs per patient at 20 years were US$4,225 for the MHC and US$4,399 for the CHC. With a willingness to pay one gross domestic product (GDP) per capita per quality-adjusted life year (QALY) (US$8,910), the incremental net benefits per patient were US$1,450 and US$3,737 at 10 and 20 years, respectively. The MHC was cost-effective from the third year onward; however, increasing coverage to 500 patients per year rendered it cost-effective at year one. CONCLUSIONS: The MHC is cost-effective at 10 and 20 years. Cost-effectiveness can be achieved in the short term by increasing MHC coverage.

[Drug supplies in primary care units at the Ministry of Health in Mexico]. / Abastecimiento de medicamentos en unidades de primer nivel de atención de la Secretaría de Salud de México.

OBJECTIVE: To identify the availability of some essential drugs (ED) at primary health care units of the Mexican Ministry of Health (SSA), using data from a research work conducted in 1996 and 1997. MATERIALS AND METHODS: A random sample of the 18 sanitary jurisdictions of states participating in the Extension of Coverage Program (ECP) was drawn. All primary care units from selected jurisdictions were evaluated through an inspection visit, using a checklist that included 36 ED. In phase I of the analysis, the absolute number and proportion of units without a single item of any of the 36 drugs were calculated. In the units with available drugs, the median of the distribution was also calculated. In phase II, the medians according to the type of health unit and state was obtained. The statistic utilized for the comparison of the medians was the Scheffé test with one way variance analysis. In addition, the drugs were classified according to their therapeutic indication and the medians and proportion of available drugs were calculated. The differences in proportion were evaluated with the statistic chi 2. RESULTS: During the visits, on average, 18 of the 36 drugs included in the list of the study were found in the health units. The availability of antibiotics, antituberculosis drugs, and antimalarial drugs was particularly poor. In contrast, oral rehydration salts, family planning methods and vaccines were usually available. In general, the PAC3 states presented the best availability figures. CONCLUSIONS: The Ministry of Health of México will have to develop an enormous effort to overcome the obstacles related to the supply of essential drugs in primary health care units. Otherwise, all other efforts directed to meet the needs of the non-insured population will end up being useless, and enormous amounts of the already scarce resources of the health sector will be wasted since drugs are a vital component of the long chain of health care.

[Availability of essential medications at primary level units of the Health Department of Tamaulipas, Mexico]. / Disponibilidad de medicamentos esenciales en unidades de primer nivel de la Secretaría de Salud de Tamaulipas, México.

OBJECTIVE: To describe the availability of some essential drugs at the primary health care units of the Ministry of Health of Tamaulipas, Mexico. MATERIAL AND METHODS: Between September and October 1998, all first level healthcare units of Tamaulipas' three sanitary jurisdictions were surveyed. Drug availability was assessed. The measurement instrument was a checklist of 56 drugs and 10 different supplies. For each drug and input the absolute number and the proportion of units with this drug or input was calculated. In the units where the drugs were available, the medians were calculated. The median of the total number of drugs available in all units was used as a global indicator. This same exercise was developed for each unit. Comparisons between the availability of these inputs in the units and stockrooms were also done. Stata 5.0 was used for statistical analysis. RESULTS: None of the inspected units had full availability of all checklist drugs. The highest percentage of drug availability was 84% and the lowest was 32%. There was limited availability of antibiotics, antihypertensive, hypoglycemic, and iron deficiency drugs. The availability of oral rehydration salts and contraceptive and vaccine agents was acceptable. CONCLUSIONS: Healthcare organizations must find alternative ways to improve access to drugs nationwide, in general, and availability of essential drugs in first level healthcare units, in particular. Two recent initiatives provide an optimistic outlook: decentralization of health services for the uninsured and the Generic Exchangeable Drugs Program, established nationwide in 1998.

[The regulation of medical practice in Mexico]. / La regulación de la práctica médica en México.

The recent evolution and present situation of the regulation of medical practice in Mexico is discussed. In part one the regulation function is defined in the context of the main functions of a health system. In part two, sanitary regulation and health care regulation are distinguished and discussed. Finally, the present situation of the regulation of medical practice in Mexico is discussed in detail in part three, more specifically, two of the most developed forms of regulation: i) legal regulation and ii) regulation through licensing and certification of general practitioners and medical specialists, respectively. A set of measures to develop a mixed and participatory regulatory system is presented in the section on conclusions.

[Assessment of a health program for the non-insured population]. / Evaluación de programa de salud para población no asegurada.

OBJECTIVE: Present the results of the evaluation of a program for the non-insured population of the four poorest states of the country implemented by the Ministry of Health of Mexico between 1991 and 1995. METHODS: The effects of the program were evaluated in three areas: i) increase in health services coverage; ii) delivery of personal health services, and iii) changes in health conditions of the target population. The extension of coverage was measured by the increase in potential access due to the construction of health infrastructure projects and the use of additional health manpower, mainly primary health care workers. For the evaluation of the impact of the program on the delivery of services, three surveys were developed: one for service utilization, another one for accessibility, and a third for quality of care. The impact on health conditions was evaluated by changes in health indicators of children under five and women of reproductive age. RESULTS AND CONCLUSIONS: The Program had a positive impact on coverage, accessibility and quality of services. Its impact on health conditions was also positive. However, these last changes cannot be attributed only to the program, but to the sum of several concurrent activities.

Commerce in health services in North America within the context of the North American Free Trade Agreement.

This article discusses the future of commercial trade in personal health services in North America within the context of the North American Free Trade Agreement (NAFTA) and the latter's potential influence on health care for the Mexican people. It begins by defining concepts related to international trade of services, particularly health services, and then proceeds to analyze elements of NAFTA that affect the delivery, regulation, and financing of such services, as well as their future trade within the NAFTA area. It concludes with some recommendations directed at helping Mexico's national health care system confront the risks posed while taking advantage of the opportunities offered by the Mexican economy's entry into a broader market.

The New World order and international health.

PIP: New global and national health challenges require a new response. National health situations are increasingly influenced by the international transfer of health risks posed by environmental threats, overuse of resources, international migration, trade in harmful legal products (tobacco), traffic of illicit drugs, and diffusion of potentially inappropriate and costly medical technologies and treatment policies. This situation calls for reform of national health systems, and a natural extension of such reform is reform of the world health system. The first step toward this goal should be to achieve consensus about the essential core functions of international health organizations their division of labor. Currently international health agencies have overlapping mandates and duplicate efforts, and they have neglected the following essential functions: monitoring emerging diseases, setting consumer health standards, providing international coordination to control the transfer of health risks, coordinating research efforts and technological development, designing information systems to facilitate development of national and global health policies, accumulating knowledge about cost-effectiveness of medical technologies and interventions, and creating a process for sharing information about national health system reform. Reform "essentialists" identify the following core functions for international health organizations: surveillance and control of globally-threatening diseases, promotion of research and technological development, development of standards and norms for international certification, protection of international refugees, and assisting vulnerable populations. Others give international health organizations a more expansive role including redistributing resources from rich to poor countries, political advocacy, direct regulation of transnational corporations, and intervention in national health projects. Consensus must be reached to effect reform.^ieng

[The federal health expenditure on the uninsured population: Mexico 1980-1995]. / Gasto federal en salud en población no asegurada: México 1980-1995.

In the last fifteen years Mexico suffered several economic crisis which have negatively affected public expenditure in social welfare and, as a consequence, public expenditure in health. This paper discusses the relationship between the adjustment policies adopted to confront these crisis and public expenditure in health care for the non-insured population, as well as the regional distribution of this expenditure. In part one, the evolution of general public expenditure, public expenditure in social welfare, and public expenditure in health between 1980 and 1995 is described. In part two, the distribution of public health expenditure for the non-insured population among the five regions in which the country was divided by the National Health Survey II is discussed. The main conclusion of this paper is that, between 1980 and 1995, the public expenditure gaps that have existed for a long time in Mexico among regions remained unchanged. These gaps basically affect the southern states of the country, are not related to health needs, and may deepen in view of the new relative cuts in public expenditure in social welfare announced by the new administration.

Monitoring and Protecting Health and Human Rights in Mexico.

This paper describes a unique system through which health care-related human rights are now being monitored and protected in Mexico. Based on the ombudsman concept, the system focuses on identifying and responding to violations of human rights and dignity which may occur in the context of health care delivery. Experience thus far has been encouraging; the Mexican population has identified and used the National Commission of Human Rights as a forum for a variety of health-related complaints. The Mexican system, while requiring strengthening and expansion, is an effort to integrate the monitoring and protection of health-related human rights into the broader field of human rights work in Mexico.

Consequences of the North American Free Trade Agreement for health services: a perspective from Mexico.

OBJECTIVES: The purposes of the study were to assess the potential impact of the North American Free Trade Agreement (NAFTA) on medical care in Mexico and to identify internal measures Mexico could take to increase the benefits and minimize the risks of free trade. METHODS: The dual nature of the health sector is examined; the Mexican, Canadian, and US health care systems are compared; and modes and consequences of international exchange of health services are analyzed. RESULTS: Four issues require immediate attention: accreditation of health care facilities, licensing and certification of professionals, technology assessment, and financial equity. CONCLUSIONS: NAFTA offers opportunities for positive developments in Mexico, provided risks can be anticipated and preventive measures can be taken to avoid negative impacts on the health system. Medical services, like other elements of the Mexican economy, must be modernized to respond to the demands of global competition. The Mexican National Academy of Medicine has recommended to the Mexican government (1) internal strengthening of the Mexican health care system to improve its ability to respond to the new conditions created by NAFTA and (2) a gradual process to facilitate equitable and mutually beneficial interactions among the three countries.

[Monitoring and evaluating the quality of family planning services]. / Monitoreo y evaluación de la calidad de los servicios de planificación familiar.

This paper discusses some ideas useful for the implementation of programs of quality of care in family planning units. In the first part we present an analytical framework in which the place of quality of family planning services as a determinant of fertility is established. Part two deals with a set of concepts which includes the several elements of quality of care: structure, process and result elements of family planning services. Finally, the paper ends with a set of recommendations for the design of the indicators and standards needed to operationalize at field level a quality of care program in family planning units.