PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Case study from Mexico

Transcription

1 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Case study from Mexico

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3 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Case study from Mexico Jacqueline Alcalde-Rabanal, a Victor Becerril-Montekio, a Julio Montañez-Hernandez, a Olga Espinosa-Henao, a Rafael Lozano, b Luis García-Bello, a Elliot Lagunas-Alarcon, a Alejandro Torres-Grimaldo a a. National Institute of Public Health, Centre for Health Systems Research b. Institute for Health Metrics and Evaluation, UW

4 WHO/HIS/HSR/17.26 World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Primary health care systems (PRIMASYS): case study from Mexico. Geneva: World Health Organization; Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at Sales, rights and licensing. To purchase WHO publications, see To submit requests for commercial use and queries on rights and licensing, see Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Editing and design by Inís Communication PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

5 Contents Abbreviations Background to PRIMASYS case studies Objectives General objective Specific objectives Methods Sources of information Key informants Overview of Mexican health care system Timeline of key developments in Mexican health system Governance Financing Human resources for health Planning and implementation Regulatory process Monitoring and information system Policy considerations and ways forward Annex 1. Key informants for Mexico PRIMASYS case study References CASE STUDY FROM MEXICO

6 Figures Figure 1. Structure of the Mexican health system Figure 2. Timeline of key developments in the Mexican health system Figure 3. Primary health care in Mexico Figure 4. IMSS primary health care organization Figure 5. Percentage of public expenditure on primary health care, national and by source of financing, Mexico Figure 6. Percentage of total public health expenditure on PHC by state, Mexico Figure 7. Per capita PHCE by state (US$), Mexico Figure 8. Distribution of health personnel in hospitals and primary health facilities (%) Figure 9. Density of physicians per 1000 inhabitants, , in various categories Figure 10. Density of physicians per 1000 inhabitants in primary health facilities by state, Figure 11. Density of nurses per 1000 inhabitants, , in various categories Figure 12. Density of nurses per 1000 inhabitants in primary health facilities by state, Figure 13. Rural/urban density of physician and nurses per 1000 inhabitants in primary health facilities, Ministry of Health, by state, Figure 14. Density of community health workers per 1000 inhabitants in Ministry of Health first-level care facilities, Figure 15. Density of community health workers per 1000 inhabitants in Ministry of Health first-level care facilities, by state, Figure 16. Number and percentage density of traditional midwives by state, Mexico, Tables Table 1. Sources of information for Mexico PRIMASYS case study Table 2. Number of primary health facilities and hospitals in Mexico, Table 3. Mexico: demographic and health indicators Table 4. Distribution of total health expenditure on primary health care, by financing agent Table 5. Ministry of Health expenditure on PHC for population with no social security, by health programme (US$), Mexico Table 6. Categories of personnel in primary health facilities in Mexico Table 7. Physicians and nurses availability in primary health facilities by institution Table 8. Health care services: infrastructure offered, by institution, Mexico Table 9. Follow-up and outcome indicators related to PHC iv PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

7 Abbreviations AFASPE CAUSES CLUES Public Health Actions in Federated Entities Universal Health Services Catalogue National Catalogue of Health Facilities MAI MOPS OECD Comprehensive Health Care Model Health Promotion Operational Model Organisation for Economic Co-operation and Development COFEPRIS CONEVAL CPG DGIS ENSANUT FASSA GDP ICD-10 IMSS INEGI ISSFAM ISSSTE Federal Commission for Protection against Sanitary Risks National Council for the Evaluation of Social Development Policy clinical practice guide General Directorate of Health Information National Health and Nutrition Survey Health Care Services Contributions Fund gross domestic product International Classification of Diseases and Related Health Problems, 10th Revision Mexican Social Security Institute National Statistics and Geography Institute Social Security Institute for the Mexican Armed Forces Institute for Social Security and Services for State Workers PHC PHCE PHCE% PPP primary health care primary health care expenditure PHC expenditure as a percentage of total health expenditure purchasing power parity PROGRESA Education, Health and Nutrition Conditional Cash Transfer Programme SEMAR SESA Marine Secretariat States Health Services SICUENTAS Federal and State Health Accounts Subsystem SiNaCEAM National System for the Certification of Medical Care Establishments SINAIS National System of Health Information SINERHIAS Information System on Medical Equipment, Infrastructure and Human Resources for Health Care SIODM SPSS Millennium Development Goals Information System Social Protection for Health System CASE STUDY FROM MEXICO 1

8 Background to PRIMASYS case studies Health systems around the globe still fall short of providing accessible, good-quality, comprehensive and integrated care. As the global health community is setting ambitious goals of universal health coverage and health equity in line with the 2030 Agenda for Sustainable Development, there is increasing interest in access to and utilization of primary health care in low- and middle-income countries. A wide array of stakeholders, including development agencies, global health funders, policy planners and health system decision-makers, require a better understanding of primary health care systems in order to plan and support complex health system interventions. There is thus a need to fill the knowledge gaps concerning strategic information on front-line primary health care systems at national and subnational levels in low- and middle-income settings. The Alliance for Health Policy and Systems Research, in collaboration with the Bill & Melinda Gates Foundation, is developing a set of 20 case studies of primary health care systems in selected low- and middle-income countries as part of an initiative entitled Primary Care Systems Profiles and Performance (PRIMASYS). PRIMASYS aims to advance the science of primary health care in lowand middle-income countries in order to support efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system, tailored to a primary audience of policymakers and global health stakeholders interested in understanding the key entry points to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems in selected low- and middle-income countries. Furthermore, the case studies will serve as the basis for a multicountry analysis of primary health care systems, focusing on the implementation of policies and programmes, and the barriers to and facilitators of primary health care system reform. Evidence from the case studies and the multi-country analysis will in turn provide strategic evidence to enhance the performance and responsiveness of primary health care systems in low- and middle-income countries. 2 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

9 1. Objectives 1.1 General objective The general objective of this case study is to analyse the structure, processes and outcomes of the Mexican primary care system in order to draw cross-cutting lessons and to better understand the determinants of its key successes and failures. 1.2 Specific objectives The specific objectives of the case study are: to summarize key aspects of the structures, processes and outcomes of the country s primary care system that reflect their performance in the areas of service organization, governance, human resources and financing; to elaborate specific pathways that have contributed to notable successes or failures in the country s primary care system; to promote learning among relevant stakeholders in order to motivate policy change. CASE STUDY FROM MEXICO 3

10 2. Methods 2.1 Sources of information Table 1 presents sources of information used for the Mexico PRIMASYS case study. 2.2 Key informants Interviews were undertaken with key informants, who were drawn from among known academicians, commentators, civil society actors, health system officials, and bureaucrats. Care was taken to ensure that the selection of key informants was diverse, representing a spread of different constituencies and perspectives, and a range of expertise on different aspects of primary care systems (adopting a maximum variability approach). Information was gathered on how primary care services were organized and on the history and context of PHC reforms in the country. Annex 1 summarizes information on the key informants interviewed. Table 1. Sources of information for Mexico PRIMASYS case study Data collection Sources of information Outputs Review of relevant secondary sources Rules Laws Reports on Mexican health system Evaluations reports National Statistics and Geography Institute (INEGI) National System of Health Information (SINAIS) platform Information System on Medical Equipment, Infrastructure and Human Resources for Health Care (SINERHIAS) National Health Accounts Basic information on health and health systems profile of country Profile of organization of primary care services Brief narrative report on history and context of primary health care (PHC) reforms Identification of issues related to country-specific pathways of change 4 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

11 3. Overview of Mexican health care system Mexico is located between the United States of America and Central America. According to a 2015 survey (between two censuses), the estimated population of Mexico was million people in that year, with a projected 137 million by 2030 (1). In 2015, the population aged under 15 years represented 27% of the total population, people aged between 15 and 64 represented 65% and those above 65 were 7.2%. Mexico has undergone an increasing urbanization process. In 1950 around 43% of the population lived in urban areas; by 1990 this population represented 71%, attaining 79% in 2015 (2). According to the National Council for the Evaluation of Social Development Policy (CONEVAL, for its Spanish initials), 1 in 2014, 46% of the population lived in poverty, of which 36.6% lived in moderate poverty and 9.6% in extreme poverty (3). In accordance with the 10th Revision of the International Classification of Diseases and Related Health Problems (ICD 10), the main mortality causes were diabetes mellitus, ischaemic heart diseases, cerebrovascular disease, cirrhosis and other chronic liver diseases, and chronic obstructive pulmonary disease. At the same time, there has been a significant increase in risk factors, such as obesity and overweight, physical inactivity, consumption of high caloric content food, as well as use of tobacco, alcohol and illicit drugs (4). The Mexican economy has experienced a long-term decrease of its growth rate during the last three decades. In 2015, Mexico s gross domestic product (GDP) was US$ billion, while the GDP value of Mexico represented 1.84% of the world economy. According to per capita GDP, Mexico is ranked 76th among 196 countries. The Gini coefficient, measuring inequality of income, was 0.503, placing Mexico as a country with a significant income inequality. Total health expenditure as a proportion of GDP is 5.78%, below the percentage of other Latin American countries such as Uruguay and Brazil (both 8.9%). Public health expenditure is 53% of total health expenditure, while out-of-pocket expenditure accounts for 41%. Figure 1 presents the structure of the Mexican health system (5, 6). Despite the efforts of the recent reform, today Mexicans still have access to very different levels of health coverage, and receive health care from separate institutions that are independent from one another. The public sector is responsible for the health care of the beneficiaries of the social security institutions as well as of the population outside the social security system. The social insurance covers the health care of the employees and their families and offers advantages such as retirement insurance. The Mexican Social Security Institute (IMSS) covers the employees of the formal private sector; the Institute for Social Security and Services for State Workers (ISSSTE) covers the employees of the federal and states governments. The national oil company (PEMEX) covers its employees; and the employees of the army and the navy are covered by the Social Security Institute for the Mexican Armed Forces (ISSFAM) and the Marine Secretariat (SEMAR). The population outside the social security is covered by the Social Protection for Health System (SPSS) (7), through the Popular Health Insurance, which is provided by the Federal Ministry of Health and States Health Services (SESA). On the other hand, the private sector offers health care to very diverse populations (from people lacking employment in the formal sector to the wealthiest populations). All of them buy a range of health care services of varying cost and quality from private medical offices, clinics, hospitals and insurance companies (5, 8). 1 To facilitate identification, all initials of Mexican institutions are provided as they are originally written in Spanish. CASE STUDY FROM MEXICO 5

12 Figure 1. Structure of the Mexican health system SECTOR Social security Public National Ministry of Health States Health Services (SHS) Private Government contribution Employers contribution Workers contribution Federal Govt contribution States Govt contribution Individuals Employers FUNDS Popular health insurance Private insurance companies BUYERS IMSS ISSSTE PEMEX Army / Navy National MoH SHS PROSPERA Social inclusion programme PROVIDERS Hospitals, clinics, doctors and nurses of these institutions Hospitals, clinics, doctors and nurses of these institutions Hospitals, clinics, doctors and nurses of these institutions Private providers USERS Workers in the formal sector Workers families Retirees Self-employed & informal sector workers and unemployed Population with paying capacity Source: Updated from Gómez-Dantés et al. (5). In 2013, the total number of primary health facilities reached % (27739) in the public sector and only 2% (627) in the private sector. In the same year hospitals were counted, of which 69% (3070) were in the private sector. From health care facilities, 75% (20803) were considered as primary care facilities. The number of facilities decreased in 2014 and In 2015 there were health facilities, with 93% (21 025) of them classified as primary health facilities (Table 2). Table 2. Number of primary health facilities and hospitals in Mexico, N % N % N % Primary health facilities % % % Hospitals and clinical laboratories % 403 5% 421 5% Other % % % Total Source: Based on data of the General Directorate of Health Information (DGIS), Ministry of Health, PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

13 In 2015, 69% (14 507) of all health care facilities corresponded to the Ministry of Health, 20% (4205) to IMSS-Prospera, 5% to IMSS and 6% (1262) to ISSSTE. This typology cannot be used to identify the kind of facilities corresponding to PEMEX, the Ministry of Defence and SEMAR. Table 3 summarizes key demographic and health indicators for Mexico. Table 3. Mexico: demographic and health indicators Indicators Year Results Source of information Total population of country National Statistics and Geography Institute (INEGI) Distribution of population (rural/urban) % / 79% World Bank data, based on United Nations Population Division (2) Life expectancy at birth years General Directorate for Health Information (DGIS) Infant mortality rate /1000 live births Millennium Development Goals Information System (SIODM) (9) Under-5 mortality rate /1000 live births SIODM (9) Maternal mortality rate / live births SIODM (9) Immunization coverage under 1 year (including pneumococcal and rotavirus) BCG HB Pentavalent Pneumococcal Rotavirus Basic scheme 94.9 % 84.7% 69.4% 80.8% 63.5% 85.29% INEGI Income or wealth inequality (Gini coefficient) CONEVAL Total health expenditure as proportion of GDP % Ministry of Health, Statistical information bulletin (4) Public expenditure as proportion of total expenditure on health Private expenditure as proportion of total expenditure on health Primary health care (PHC) expenditure as % of total health expenditure % Ministry of Health (4) % Ministry of Health (4) % Estimation from Mexico Health Accounts database % total public sector expenditure on PHC % Estimation from Mexico Health Accounts database Per capita public sector expenditure on PHC 2014 US$ 306 Estimation from Mexico Health Accounts database Out-of-pocket payment as proportion of total expenditure on health Proportion of households experiencing catastrophic health expenditures % Ministry of Health (4) % Ministry of Health (4) CASE STUDY FROM MEXICO 7

14 4. Timeline of key developments in Mexican health system Coverage Extension Programme. Launched in 1976 by the Ministry of Health, the Coverage Extension Programme aimed to extend coverage of essential health care services to rural communities with geographical access difficulties. It encompassed establishment of itinerant medical teams and construction of primary care facilities and rural hospitals in the jurisdictions (10, 11). The programme also included actions to strengthen community participation, preventive medicine, health promotion and environmental care. Physicians, nurses, basic sanitary technicians, empirical midwives and health promoters received training. In 1978, the programme was complemented by the Rural Community Programme, focused on difficult-to-reach localities with less than 2500 inhabitants. Emphasis was placed on family planning, prenatal care, and care for children aged under 5 years. Both programmes were merged in 1981 to form the Rural Health Programme, which in 1985 became the Rural Zones Coverage Extension Strategy functioning for the whole country (12). IMSS-COPLAMAR. Created in 1979, this programme was funded by the federal government and managed by IMSS. Its objective was to develop a comprehensive care model based on the recommendations of the Alma-Ata Declaration on Primary Health Care (1978). It was implemented in clinics and hospitals of difficult access, mainly in indigenous zones, and included traditional medicine. The programme was implemented in 3024 health facilities in 1981 and offered health care to 14 million people. It developed actions to strengthen community committees and health promoters and incorporated recently licensed doctors or those working in the social services, as well as nursing auxiliaries. In 1985, the programme consolidated its health promotion activities in such a way that it highly contributed to the decrease in the incidence of communicable diseases (13, 14). Constitutional reform. The General Health Law regulates the right to health protection of all Mexicans. Article 27 defines the basic health services as (a) education for health and basic sanitation promotion; (b) prevention and control of communicable and noncommunicable diseases; and (c) comprehensive care, including preventive, curative, palliative and rehabilitation activities. It also stipulates that health promotion is part of medical care, and should be provided according to the age, sex, physical and psychological determinants of each person. Article 28 refers to access to a basic package of supplies in primary care facilities of the institutions of the National Health System. Article 51 asserts the right of users to freely and voluntarily choose the doctor in the primary health care facility where they are registered. Finally, Articles 110 and 112 define the health promotion and education actions. Health services decentralization. In 1983, the decentralization of health services started in 14 states (15, 16). Health services for the uninsured population became a responsibility of the state governments. The states decided to implement a primary care model emphasizing immunization, oral rehydration, access to drinking water and education of women in reproductive and sexual health (17). In 1989 sanitary jurisdictions were created to strengthen decentralization of resources and decision-making at the local level (18). In 1993, all states, including the Federal District, participated in the decentralization process. Functions were normalized and resources were increased for the newly created States Health Services (Servicios Estatales de Salud, SESA). In order to continue increasing the access of the uninsured population to basic health care services, the Coverage Extension Programme was updated in 1995, to be implemented by each SESA. Finally, in 1996, the National Agreement for the Decentralization of Health Services was signed confirming the states responsibility for health care services and preventive medicine provision to all the insured population (15, 17, 19). 8 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

15 Education, Health and Nutrition Conditional Cash Transfer Programme (Programa de Educación, Salud y Alimentación, PROGRESA). This was implemented in 1997 as a part of the social policy aiming to provide health care to families living in extreme poverty in rural zones. The programme integrated health, nutrition and education components and was based on conditional cash transfers to families (20). Health care was developed using mobile facilities in which a doctor, a nurse and a health promoter participated, offering (a) a basic package of health care services including 14 interventions; (b) prevention and care of malnutrition in children aged under 4 years and pregnant or breastfeeding women; and (c) an educational programme including 25 sessions. In 2000, the programme reached around 2 million families and was transformed into the Oportunidades Human Development Programme. It is presently called Prospera and reaches around 6.1 million families in rural, urban and semi-urban areas (10, 21, 22). Social Protection for Health System (SPSS). The last major reform was the incorporation of the SPSS into the General Health Law in This reform aimed to offer health protection for the population that had no social security coverage, mainly the poorest. It offers a basic services package defined in the Universal Health Services Catalogue (CAUSES), which includes preventive health and health promotion activities as well as diagnosis, treatment and rehabilitation according to the country s epidemiological profile (23). CAUSES started offering coverage for 91 interventions in 2004 and already covered 283 interventions in This practically covers 95% of the outpatient and general hospital care of the Ministry of Health. The system had affiliated around 50 million Mexicans by CAUSES continues to grow and now includes some high-cost treatments in an effort to attain universal health coverage (24 26). Health Promotion Operational Model (MOPS). This was developed in 2006 by the General Directorate for Health Promotion of the Ministry of Health in response to the need to strengthen health promotion in the country (27). The model included four major components: (a) personal risks management and identification of health determinants; (b) development of health competencies through individual counselling and community workshops; (c) social participation and fostering creation of social networks aiming to empower communities; and (d) development of healthy environments, which includes natural resources protection (27, 28). Primary Health Care Services Observatory. In 2012, the General Directorate for Performance Evaluation of the Ministry of Health published an important report on the current situation and improvement opportunities for all health care facilities of the Ministry of Health related to PHC. The report was launched in an effort to emphasize the importance of strengthening the primary health facilities as an efficient strategy to respond to the needs and expectations of the population. It provides information on the conditions and availability of PHC facilities, and their equipment and human resources (29). Comprehensive Health Care Model (MAI). This model was developed in 2015 by the General Directorate for Health Planning and Development of the Ministry of Health. Its aim is to contribute to the standardization of services and practices in the health sector and to optimize resources and health infrastructure utilization. At the same time it aims to encourage the mechanisms and processes of democratic participation of citizens in order to achieve effective and universal access to health protection. In relation to PHC, the model proposes to (a) renovate and strengthen the PHC strategy; (b) establish, reorganize and articulate the integrated health services networks; (c) reorganize, reorient and strengthen the sanitary jurisdictions; and (d) promote participation of citizens as the main agent for cultural change. The model emphasizes PHC as the main entry point to the health system and the first reference for health promotion and disease prevention. It also stresses that outpatient care is the domain in which most of the care needs should be resolved. Figure 2 presents a timeline of key developments in the Mexican health system. CASE STUDY FROM MEXICO 9

16 Figure 2. Timeline of key developments in the Mexican health system 1976 Coverage Extension Programme An effort of the Ministry of Health to bring essential health care services to rural communities 1985 Constitutional reform Recognition of citizens right to receive health protection and replacement of the old Sanitary Code by the General Health Law 1997 PROGRESA Coverage Extension Programme Cash transfer programme geared to schooling of children and attendance to periodic health care visits 2003 Social Protection for Health System 1. Financial protection offering voluntary public health insurance to the population without social security 2. Health provision for health prevention and promotion 2012 PHC Services Observatory Report on PHC units quality improvement opportunities 1979 IMSS-COPLAMAR This programme emphasized preventive health activities based on community work to promote development 1996 Health services decentralization 1. Decentralization of health services for uninsured population 2. Creation of the states health services 3. Extension of coverage 4. Improvement of efficiency and quality through sector coordination 2006 Health Promotion Operational Model This model defines the basis for health promotion 2015 Comprehensive Health Care Model The model placed PHC as the most important strategy for health care in Mexico 10 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

17 5. Governance Governance has been defined as the culture and institutional environment in which citizens and stakeholders interact among themselves and participate in public affairs (30). It addresses the ways in which a society, including its government and decision-makers, the private sector and civil society, interact and are organized to provide health care to their populations (31). Figure 3 shows the main PHC institutions, models and providers in Mexico. Despite ongoing efforts to integrate the three main public sector health institutions (Ministry of Health, IMSS and ISSSTE) through different health care services exchange agreements, they still do not regularly coordinate their actions. Concerning PHC, as the steward of the Mexican health system, the Ministry of Health has tried to provide general guidance. But, as several high-level officials recognize, the lack of a common and sufficiently clear concept of PHC has been a serious obstacle for the implementation of a coherent PHC policy across institutions. As mentioned above, even when the first objective of the National Health Sector Plan for (32) states the need to consolidate actions to protect and promote health and prevent diseases, there are still no concrete mechanisms to harmonize the efforts of the different institutions in PHC provision to their beneficiaries. This is the context in which the Ministry of Health launched MAI (6). The model was developed in the framework of the renewal of primary health care in the Americas proposed by the Pan American Health Organization (33), and is based on four strategies: (a) renewal of PHC; (b) strengthening local health systems (5); (c) development of integrated health services networks; and (d) citizens participation. Notwithstanding these efforts, the main health institutions still do not share a common concept of what is included in PHC, or how its provision can be guaranteed. In terms of the organizational structure, the National Ministry of Health does not include any high-level office or department specifically responsible for PHC. Nevertheless, two general directorates (at the third hierarchical level) are in charge of the organization of relevant aspects of PHC and, most importantly, the implementation of MAI. The General Directorate for Health Promotion, answerable to the Undersecretary for Integration and Development of the Health Figure 3. Primary health care in Mexico SECTOR Public Private INSTITUTION National MoH / SHS IMSS ISSSTE Private Providers PHC MODEL MAI Comprehensive Health Care Model PrevenIMSS Health Prevention Strategy PrevenISSSTE Prevention Healthcare Model No explicit model FACILITIES/ PROVIDERS Outpatient Health Centres General Hospitals Source: adapted from Gómez-Dantés et al. (5). Generalists & Nurses Generalists & Nurses Family Medicine Units General Hospitals Generalists & Nurses Generalists, Specialists & Nurses Family Medicine Units Hospital Clinics Generalists & Nurses Generalists & Nurses Physicians individual offices Clinics Pharmacies Medical Offices Hospitals Generalists & Specialists Generalists & Specialists Generalists Generalists & Specialists CASE STUDY FROM MEXICO 11

18 Figure 4. IMSS primary health care organization Directorate for Health Care Services Provision Primary Health Care Unit First level healthcare Coordination Epidemiological Surveillance Coordination Direction of Healthcare Services Provision Disease Prevention and Detection Division Information and Medical Support Division Prenatal Care and Family Planning Division Health Promotion Division Family Medicine Division Communicable Diseases Epidemiological Surveillance Division Noncommunicable Diseases Epidemiological Surveillance Division Epidemiological Informatics Division Epidemiological Surveillance and Research Laboratories Division Labour Risks Division Labour Incapacity Division Labour Risks Prevention Division Source: IMSS. Manual de Organización de la Dirección de Prestaciones Médicas. [Organization Manual of the Directorate For Health Care Services Provision] (34). Sector, is responsible for a series of specific action programmes directly linked with PHC: health promotion, social determinants of health, healthy communities and environments, nutrition and physical activity. Likewise, the General Directorate for Health Planning and Development includes structures that are responsible for ambulatory health care and extending coverage, planning health services networks, planning services exchange and even the inclusion of traditional medicine. As an expression of the federal character of the country, the autonomy of each SESA creates a wide range of modalities for PHC provision adapted to each state. As in the Federal Ministry of Health, each SESA includes several entities with PHC responsibilities. However, except in the SESA in the states of Puebla and Michoacán, they seldom include offices with explicit links to PHC. The only similar entities in the rest of the states are subdirectorates for health promotion and disease prevention (Quintana Roo), prevention and promotion departments (Hidalgo), and first-level services and health promotion regulation departments (Morelos). Generally speaking, these structures of the different states public health services do not necessarily include all the strategic elements or the activities of MAI. Concerning IMSS, the Directorate for Health Care Services Provision includes a Primary Health Care Facilities Department (Figure 4). This unit is divided into three coordination offices, responsible for comprehensive health care, epidemiological surveillance and health care services provision. IMSS has developed a prevention strategy, termed PrevenIMSS, which governs the organization of PHC-related services, mainly prevention and health promotion, nutrition surveillance, disease detection and control, reproductive and sexual health and medical care. All these activities are offered as health programmes to five age groups: children, adolescents (JuvenIMSS), adult females, adult males and the elderly (30). These services are provided in all IMSS clinics, from family medicine centres to specialty hospitals. The personnel in charge of the programmes implementation include family 12 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

19 medicine physicians and nurses, but specialists are also trained into them. ISSSTE also lacks an explicitly PHC-linked office. Nevertheless, the Subdirectorate for Health Promotion and Disease Prevention, which is part of the Medical Directorate, does have an Office of Family Medical Care Services. This office is responsible for the first-level health facilities network. Besides, another office is responsible for the prevention of chronic degenerative diseases and another department is in charge of the regional and local health systems. ISSSTE has also developed a preventive health care model PrevenISSSTE whose main objective is to provide comprehensive health care and to promote the social, biological and psychological development of beneficiaries with special emphasis on health promotion and diseases prevention activities (5). The model is a responsibility of the Subdirectorate for Health Promotion and Disease Prevention and is offered in all family medicine clinics and hospitals. A scale-up of PrevenISSSTE was launched in 2010, based on an online platform where beneficiaries can obtain information on risk factors associated with chronic diseases and recommendations on how to deal with them. A telephone hotline is also available as a support programme within the platform. The fourth public institution is the PEMEX Health Services. Its PHC-related structure includes the Administration for Preventive Medicine, which embraces the Unit for Preventive Health and Preventive Medicine. Within the latter, the Department for Primary Prevention and Community Action and the Department for Secondary Prevention and Assistance are mandated to perform PHC-related activities. Finally, the public health sector includes the health care services provided to the personnel in the army and the navy, together with their families. Though each of these institutions includes particular organisms in charge of health care in general, the available information on their structure is not enough to identify departments linked to PHC. Nevertheless, the organization manual of the army s health services or ISSFAM does mention an agreement related to the subrogation of medical care services to be provided by ISSSTE (32, 35). In the case of the navy, the General Directorate for Naval Health comes under the General Directorate for Human Resources. In this instance, in the classification of the units and facilities for naval health for 2012, a basic notion of PHC can be discerned in the way the responsibilities for what is termed the first level of care are described: aspects of health promotion and protection, outpatient early diagnosis and timely treatment [and] referral actions towards other levels of care (36). On the other hand, even if there is no structured policy, organizational measures or complete information on the role of the private sector in relation to PHC, this sector certainly plays a relevant role in offering firstcontact health care to the population, even to those who benefit from other forms of health coverage. Between 2000 and 2012, around 40% of out-ofpocket spending was dedicated to consultation with private providers, and the proportion of private consultations in the total of outpatient consultations increased from 31% to 38.9% (37). These figures are illustrative of the relevance of the private sector in providing PHC. Striving to fight self-medication, in 2010 the national health authorities restricted the sale of antibiotics only to patients who presented a medical prescription. As a result, between 2010 and 2014 the number of doctors offices adjacent to private pharmacies increased by over 240% (38, 39). In an effort to regulate this phenomenon, at the end of 2013, the Federal Commission for Protection against Sanitary Risks (COFEPRIS) of the Ministry of Health launched the Strategy for Strengthening Regulation of Pharmacies and Medical Offices. According to a 2015 report by COFEPRIS, there was an improvement in compliance with the good practice guidelines, attaining an overall percentage of 75%, with 80.27% compliance with the guidelines on doctors offices pertaining to pharmacy chains. As part of the effort, these doctors offices are also being included in the National Catalogue of Health Facilities (CLUES), which will ensure improved surveillance (38). CASE STUDY FROM MEXICO 13

20 While there is an effort to foster health promotion and preventive activities in these facilities, this regulation does not stipulate what health care services may or may not be provided. Some consider that the intrinsic commercial interests of pharmacies imply a lack of interest in preventive measures and follow-up of patients, which is contrary to goodquality PHC. Further strengthening of regulations and incorporation of the use of electronic clinical files and other mechanisms that would guarantee correct follow-up with patients have thus been proposed. Mexico has over 4500 civil society organizations involved in health promotion, sanitary and health care activities. 2 Even though they are not all in line with a clear PHC vision, and do not necessarily foster activities related to health promotion, 59% of them include social assistance among their main activities. These organizations are mostly dedicated to some sort of health care services provision or health promotion, prevention and education activities. Many of them are focused on treating addiction, chronic diseases, and mental health issues, and offer family-targeted services. 2 Information system of the federal register of civil society organizations. 14 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

21 6. Financing In 2014, the total health expenditure in Mexico was US$ million, 3 equivalent to 5.78% of its GDP, while the public spending represented 52.62% of this amount (US$ million). 4 As stated, funding for this expenditure comes from both the public and private sectors. In this analysis, only public expenditure on PHC will be considered (Table 4). Public financing of health care is divided into two parts: one part for the population with social security and the other for the population without social security. Social security schemes also include ISSFAM and SEMAR, but these institutions only report their total health expenditures with no possibility of distinguishing expenditure on PHC. Considering this, and with their relative size, they are not included in this study. Public health expenditure for the population with no social security is used to finance all government plans and programmes dedicated to improved access to health services for the population that, due to their employment status (self-employed, unemployed, informal workers) are excluded from social security institutions. This expenditure is financed with federal and state funds. These include Ministry of Health expenditures together with the Health Care Services Contributions Fund (FASSA), IMSS-Prospera and the states expenditures. This analysis uses the expenditure classification of health functions as defined by the Organisation for Economic Co-operation and Development (OECD) (41), which is the basis for the expenditure accounts of Mexico through the Federal and State Health Accounts Subsystem (SICUENTAS) (40). In accordance with the OECD definition of primary health care, this analysis only considers outpatient curative care and preventive health services as indicators of PHC expenditure, all of which are included in functions HC.1, curative care ; and HC.6, preventive care. Only outpatient curative care (HC.1.3) was used as an indicator of PHC expenditure Table 4. Distribution of total health expenditure on primary health care, by financing agent IMSS- PROSPERA State expenditure FASSA Ministry of Health National PEMEX Social security in the States ISSSTE IMSS Total public expenditure Preventive care services Outpatient curative care Primary health expenditure Other functions PHCE% (see text below) Source: Adapted based on information from DGIS, Ministry of Health (40). 3 Purchasing power parity 2014, US$ 1 = Mexican pesos. 4 Private spending was US$ million and public expenditure was US$ million (preliminary figures). CASE STUDY FROM MEXICO 15

22 Figure 5. Percentage of public expenditure on primary health care, national and by source of financing, Mexico 2014 IMSS-PROSPERA 0.2% 23.3% 76.5% States health services FASSA Ministry of Health 7.5% 11.9% 7.1% 17.6% 23.2% 50.7% 74.9% 64.9% 42.2% Financing Agents of Población without Social Security National 5.7% 49.3% 45.0% National PEMEX 0.6% 16.5% 82.9% Social security in the States ISSSTE 4.0% 4.1% 21.2% 35.6% 74.8% 60.3% Financing Agents of Población with Social Security IMSS 3.7% 70.1% 26.2% Preventive care services Outpatient curative care Other functions Source: Adapted based on information from DGIS, Ministry of Health (40). (Figure 5). So PHC expenditure as a percentage of total health expenditure (PHCE%) and per capita PHC expenditure are determined by the following formulas: PHCE% = Per capita PHCE = outpatient curative care expenditure (HC.1.3) + preventive care expenditure (HC.6) total health expenditure (H) outpatient curative care expenditure (HC.1.3) + preventive care expenditure (HC.6) total population x 100 The year of analysis is All monetary figures are in US dollars and the conversion from Mexican pesos was made using the purchasing power parity (PPP) for 2014, which was pesos per US dollar (42, 43). The public health expenditure allocated to PHC in Mexico is US$ million, or 29.4% of total health expenditure and 55% of public health expenditure. Figure 5 shows that 5.7% of public health expenditure goes to preventive care, while 49.3% goes to outpatient curative care. However, those percentages vary by financial source: IMSS allocated 73.8% of its total health expenditure to PHC (70.1% to outpatient care and 3.7% to preventive care), while the Ministry of Health allocated 57.8% (50.7% to outpatient care and 7.1% to preventive care). PHC expenditure (PHCE) per capita in 2014 was US$ Nevertheless, while the figure for the population without social security was US$ 201. Per capita PHCE for social security beneficiaries reached US$ 432, so for every US$ 1 spent for the first, the latter received US$ The estimated population of Mexico for 2014 was people; among these, only 45% have access to social security ( people). 16 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

23 Figure 6. Percentage of total public health expenditure on PHC by state, Mexico 2014 BC SON CHIH COAH BCS NL SIN DGO TAMPS ZAC SLP AGS NAY YUC GTO QRO JAL HGO MEX COL QROO TLAX MICH MOR PUE CAMP VER TAB (58,70] (55,58] (52,55] (46,52] [27,46] GRO OAX CHIS Source: DGIS Source: Based on information from DGIS, Ministry of Health (40). Figure 6 shows the PHC expenditure as a percentage of total health expenditure (PHCE%) in quintiles for the different states. The northern and north-western states (except Sonora and Baja California Sur) have a PHCE% between 55% and 70%. Those in the south, among which Guerrero, Oaxaca and Chiapas have the highest marginality indexes, have a PHCE% between 27% and 46%. Tabasco is the state with the lowest PHCE%, at 27.4%, while for Tamaulipas the PHCE% is 87.2%. Mexico City is the only state with a low marginality index, with the PHCE% (51.5%) below the national average (54.1%).6 Important differences in PHCE% are observed when social security beneficiaries are distinguished from non-beneficiaries. The PHCE% national average is 31.2% for the expenditure dedicated to the population without social security (excluding Ministry of Health expenditure). On the other hand, the national average of PHCE% for the population with social security is 63.2%. Per capita PCHE at the national level is US$ 233. Nevertheless, states with the lowest marginality index have a higher investment than the national average. Conversely, the states with the highest marginality index have a per capita PHCE 2 or 3 times lower than the national average. The per capita PHCE of 16 of the 32 states is lower than the national average (Figure 7). The resources that were transferred by the Ministry of Health to the states through Public Health Actions in the States (Acciones de Salud Pública en las Entidades Federativas, AFASPE) (44) and Annex IV were destined to 36 prevention, health promotion 6 The national percentage is 55%. In the analysis by states, the Ministry of Health is not considered because there is no available information of its expenditures according to health functions. CASE STUDY FROM MEXICO 17

24 and disease control programmes, of which six programmes received almost three quarters of transfers (Table 5). Universal immunization received almost 25%; maternal and perinatal health and family planning, together with contraception, health promotion and cancer prevention in women, received 30% of the resources; and diabetes prevention and control, obesity and cardiovascular risk received 17.2%. These latter two areas accounted for almost 30% of deaths in 2015 for the whole country (45). Figure 7. Per capita PHCE by state (US$), Mexico Baja California (BC) Coahuila (COAH) Nuevo León (NL) Ciudad de México (CDMX) México (MEX) Jalisco (JAL) Aguascalientes (AGS) Chihuahua (CHIH) Colima (COL) Sonora (SON) Dollars per capita Tamaulipas (TAMPS) Baja California Sur (BCS) Guanajuato (GTO) Tlaxcala (TLAX) Morelos (MOR) Zacatecas (ZAC) Nayarit (NAY) Querétaro (QRO) Durango (DGO) Quintana Roo (QROO) Sinaloa (SIN) Tabasco (TAB) Hidalgo (HGO) Puebla (PUE) Michoacán (MICH) Veracruz (VER) San Luis Potosí (SLP) Yucatán (YUC) Campeche (CAMP) Oaxaca (OAX) Chiapas (CHIS) Guerrero (GRO) Very low Low Medium High Very high Marginality level Per capita PHCE National: USD 233 Source: Based on information from DGIS, Ministry of Health (40). Table 5. Ministry of Health expenditure on PHC for population with no social security, by health programme (US$), Mexico 2014 Name of programme Ramo 12 CNPSS Total % Health promotion and social determinants Healthy environments and communities Nutrition and physical activity Epidemiological surveillance, national system SINAVE (component of laboratory surveillance) Mental health Transit security Accident prevention in vulnerable groups 18 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

25 Name of programme Ramo 12 CNPSS Total % Women cancer prevention and control Maternal and perinatal health Reproductive and sexual health for adolescents Family planning and contraception Family and gender violence prevention and care Gender equality in health Human rabies prevention and control Brucellosis prevention and control Rickettsiosis, rabies prevention and control Dengue and other vectors prevention and control Malaria prevention and control Onchocerciasis elimination Chagas disease prevention and control Leishmaniasis prevention and control Scorpion sting prevention and control Diabetes prevention and control Obesity and cardiovascular risk prevention and control Ageing health care Prevention, detection and control of oral health problems Tuberculosis prevention and control Leprosy elimination Epidemiological emergencies and disaster care Diarrhoeal diseases, water and cholera prevention Addiction prevention and treatment Response to HIV/AIDS and STIs Universal immunization Children and adolescent health Cancer in childhood and adolescence Total Source: AFASPE (44). CASE STUDY FROM MEXICO 19

26 7. Human resources for health The total number of health workers grew from in 2013 to in 2015, a 12% increase (including private sector health personnel). Of the 2015 figure, 27% ( ) were doctors, 35% ( ) were nurses, 4% (39 344) were other health professionals (social workers, nutritionists and psychologists), 9% (83 818) were technicians and 24% ( ) were laboratory, administration and other personnel. Figure 8 shows the distribution of all these categories, which are mainly located in hospitals (between % and 71.55%). Nearly 5% of medical interns and 3% of nursing interns worked in primary health facilities. These trends continued between 2013 and Around a third of the human resources for health in first-level facilities between 2013 and 2015 were physicians and another third were nurses (Table 6). The proportion of other health professionals, such as dentists, nutritionists and psychologists, decreased by 5% between 2014 and The proportions of other personnel remained stable. The distribution of medical and nursing personnel according to the institutions in which they work has generally been stable. The Ministry of Health has the largest proportion of physicians and nurses, followed by IMSS and then ISSSTE (Table 7). Figure 9 presents the density of physicians in the country. The total density of doctors is 1.81 per 1000 inhabitants, an increase compared to Nevertheless, this is far below OECD estimated averages of 3.2 doctors and 8.8 nurses per 1000 inhabitants (46). If when estimating the density of physicians only those who perform care activities (physicians in contact with patients) are included, this indicator is even lower. A significant proportion of physicians are dedicated to other tasks, such as administration, teaching and research. The density declines even further when considering those physicians in contact with patients at the primary health facilities. Finally, the analysis of the density of physicians in primary health facilities by state shows significant disparities and gaps for While the Ciudad de México has 1.14 doctors per 1000 inhabitants, 30 states do not even reach 1 doctor per 1000 inhabitants (Figure 10). Figure 8. Distribution of health personnel in hospitals and primary health facilities (%) Other types of personnel 2015 (N= ) Other types of personnel 2014 (N= ) Other types of personnel 2013 (N= ) Technicians 2015 (N=80 469) Technicians 2014 (N=67 072) Technicians 2013 (N=63 307) Other health professionals 2015 (N=37 317) Other health professionals 2014 (N=59 740) Other health professionals 2013 (N=56 200) Nurses 2015 (N= ) Nurses 2014 (N= ) Nurses 2013 (N= ) Physicians 2015 (N= ) Physicians 2014 (N= ) Physicians 2013 (N= ) % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Hospital graduated Hospital interns First level graduated First level interns Source: Adapted with data from DGIS, Only personnel in IMSS, ISSSTE and Ministry of Health are included. 20 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

27 Table 6. Categories of personnel in primary health facilities in Mexico Type of personnel N % N % N % Physicians Nurses Other health professionals Technicians Other types of personnel Medical interns Nursing interns Dentistry interns Total Source: Adapted with data from DGIS, Only personnel in IMSS, ISSSTE and Ministry of Health are included. Table 7. Physicians and nurses availability in primary health facilities by institution Physicians Nurses Institution N % N % N % N % N % N % Ministry of Health ISSSTE IMSS Total Note: Does not include medical, nursing and dentistry interns. Source: Adapted with data from DGIS, Figure 9. Density of physicians per 1000 inhabitants, , in various categories Physicians Physicians in contact with patients Physicians in primary health facilities Physicians in contact with patients in primary health facilities Note: Does not include medical interns and population with private health insurance Source: Adapted with data from DGIS, 2016, and from Boletín informativo de estadística, CASE STUDY FROM MEXICO 21

28 Figure 10. Density of physicians per 1000 inhabitants in primary health facilities by state, Puebla Guanajuato 0.57 Estado de México Morelos Baja California Nuevo León Chiapas San Luis Potosí Jalisco Chihuahua Quintana Roo Michoacán Hidalgo Coahuila Sonora Durango The analysis of nursing personnel (specialists, licensed and auxiliaries) shows a general density hospitals and first-level care facilities included of over 2 per 1000 inhabitants. This density is slightly lower when limited to nurses in contact with Note: Does not include medical and dentistry interns. Source: Adapted with data from DGIS, 2016, and from Boletín informativo de estadística, Sinaloa Aguascalientes Promedio Nacional Oaxaca Querétaro Nayarit Campeche Guerrero Baja California Sur Tabasco Zacatecas Tlaxcala Yuacatán Veracruz Colima Tamaulipas Ciudad de Mx patients. When considering primary health facilities, the density dramatically falls to less than 1 nurse per 1000 inhabitants, and even less when limited to nurses in contact with patients (Figure 11). Figure 11. Density of nurses per 1000 inhabitants, , in various categories Nurses Nurses in contact with patients Nurses in primary health facilities Nurses in contact with patients in primary health facilities Note: Does not include nursing interns and population with private health insurance. Source: Adapted with data from DGIS, 2016, and from Boletín informativo de estadística, PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

29 Figure 12. Density of nurses per 1000 inhabitants in primary health facilities by state, Nuevo León Estado de México The national average of density of nurses in first-level care facilities in 31 states is below 1 nurse per 1000 inhabitants (Figure 12). Only the state of Tamaulipas has a density of nurses above 1 per 1000 inhabitants. Figure 13 presents the estimated density of physicians and nurses per 1000 inhabitants in firstlevel care facilities of the Ministry of Health, in both urban and rural areas. This estimation is based on the number of physicians and nurses divided by the population registered in SPSS plus the population with no social insurance at all. It is apparent that the density of physicians and nurses is higher in rural areas. The estimated national average of physicians and nurses in Ministry of Health facilities is very low. Community health personnel can only be identified for the Ministry of Health under the category of primary care technical personnel and health promoters. The estimation of the density for this category was made taking into account the number of primary care technical personnel and health promoters divided by the population registered under SPSS and the population with no health insurance. Even though there was a small increase between 2013 and 2015, the density of this personnel category is so low that only 1 community 0.59 Puebla Jalisco Baja California Coahuilia Sonora Morelos San Luis Potosí Chihuahua Aguascalientes Quintana Roo Michoacán Guanajuato Note: Does not include nursing interns. Source: Adapted with data from DGIS, 2016, and from Boletín informativo de estadística, Sinaloa Querétaro Promedio Nacional Chiapas Durango Hidalgo Nayarit Oaxaca Baja California Sur Tabasco Campeche Tlaxcala Ciudad de Mx Guerrero Colima Veracruz Yuacatán Zacatecas Tamaulipas health worker per inhabitants (0.154 per 1000 inhabitants) could be found (Figure 14). At the state level, the estimation of community health workers shows significant variations in density. The state with the highest density is Nuevo León, while Tlaxcala has the lowest. In any case, as mentioned above, the density of this kind of health personnel is very low in all states. This highlights the lack of these health workers in all first-level care facilities throughout the country (Figure 15). A total of traditional midwives are registered in Mexico. Six states contain 80% of them: Chiapas, Guerrero, Veracruz, Oaxaca, Tabasco and Puebla. These are the states with the highest proportion of indigenous population (Figure 16). CASE STUDY FROM MEXICO 23

30 Figure 13. Rural/urban density of physician and nurses per 1000 inhabitants in primary health facilities, Ministry of Health, by state, 2015 Coahuila Tlaxcala 6.08 Quintana Roo Colima Jalisco Oaxaca Guerrero Baja CaliforniaSur Campeche Aguascalientes Tamaulipas Tabasco Querétaro Nayarit Sinaloa Hidalgo Edo. México Michoacan 0.24 Promedio nacional Sonora 0.54 San Luis Potosí Veracruz Yucatan Baja california Nuevo León Chihuahua Puebla Guanajuato Durango Zacatecas Morelos Ciudad e Mx 0.53 Chiapas Physicians urban area Source: Adapted with data from INEGI, Physicians rural area Coahuila Colima Quintana Roo Aguascalientes Tlaxcala Jalisco Guerrero Sonora Oaxaca Baja California Sur Campeche Querétaro Yucatan Nayarit Nuevo León Tamaulipas Hidalgo Baja California Edo. México Sinaloa Tabasco Guanajuato Promedio nacional Chihuahua Veracruz Michoacan San Luis Potosí Durango Morelos Puebla Zacatecas Ciudad e Mx Chiapas Nurses urban area Nurses rural area Figure 14. Density of community health workers per 1000 inhabitants in Ministry of Health firstlevel care facilities, Source: Adapted with data from INEGI, PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

31 Figure 15. Density of community health workers per 1000 inhabitants in Ministry of Health firstlevel care facilities, by state, Tlaxcala México Nayarit San Luis Potosí Michoacán Quintana Roo Veracruz Durango Yucatán Jalisco Source: Adapted with data from INEGI, Coahuila Baja California Zacatecas Querétaro Puebla Oaxaca Tabasco Morelos Sinaloa Guanajuato Sonora Chiapas Promedio nacional 0.15 Colima Hidalgo Chihuahua Aguascalientes Campeche Tamaulipas Baja California Sur Guerrero Edo. México Nuevo Léon Figure 16. Number and percentage density of traditional midwives by state, Mexico, ,500 3,000 2,500 2,000 1,500 2,944 2,699 2,473 1,691 1,378 1, Chiapas Guerrero Veracruz Oaxaca Tabasco Puebla San Luis Potosí Hidalgo Edo. Mexico Campeche Quintana Roo Morelos Guanajuato Nayarit Michoacan Zacatecas Source: Adapted with data from the National Directorate for Gender Equality, Ministry of Health Yucatan Sonora Chihuahua Jalisco Tamaulipas Tlaxcala Durango Querétaro Nuevo León Ciudad de Mexico Aguas Calientes CASE STUDY FROM MEXICO 25