Jaime Sepúlveda

Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

Harvard School of Public Health, Boston, MA, USA (Prof J Frenk MD); China Medical Board, Cambridge, MA, USA (L Chen MD); Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta PhD); George Washington University Medical Center, Washington, DC, USA (Prof J Cohen MD); Independent member of House of Lords, London, UK (N Crisp KCB); James P Grant School of Public Health, Dhaka, Bangladesh (Prof T Evans MD); US Institute of Medicine, Washington, DC, USA (H Fineberg MD, P Kelley MD); School of Public Health Universidad Peruana Cayetano, Heredia, Lima, Peru (Prof P Garcia MD); Peking University Health Science Centre, Beijing, China (Prof Y Ke MD); National Health Laboratory Service, Johannesburg, South Africa (B Kistnasamy MD); School of Nursing, University of Pennsylvania, Philadelphia, PA, USA (Prof A Meleis PhD); University of Toronto, Toronto, ON, Canada (Prof D Naylor MD); The Rockefeller Foundation, New York, NY, USA (A Pablos-Mendez MD); Public Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

The Quest for Universal Health Coverage: Achieving Social Protection for All in Mexico

Mexico is reaching universal health coverage in 2012. A national health insurance programme called Seguro Popular, introduced in 2003, is providing access to a package of comprehensive health services with financial protection for more than 50 million Mexicans previously excluded from insurance. Universal coverage in Mexico is synonymous with social protection of health. This report analyses the road to universal coverage along three dimensions of protection: against health risks, for patients through quality assurance of health care, and against the financial consequences of disease and injury. We present a conceptual discussion of the transition from labour-based social security to social protection of health, which implies access to effective health care as a universal right based on citizenship, the ethical basis of the Mexican reform. We discuss the conditions that prompted the reform, as well as its design and inception, and we describe the 9-year, evidence-driven implementation process, including updates and improvements to the original programme. The core of the report concentrates on the effects and impacts of the reform, based on analysis of all published and publically available scientific literature and new data. Evidence indicates that Seguro Popular is improving access to health services and reducing the prevalence of catastrophic and impoverishing health expenditures, especially for the poor. Recent studies also show improvement in effective coverage. This research then addresses persistent challenges, including the need to translate financial resources into more effective, equitable and responsive health services. A next generation of reforms will be required and these include systemic measures to complete the reorganisation of the health system by functions. The paper concludes with a discussion of the implications of the Mexican quest to achieve universal health coverage and its relevance for other low-income and middle-income countries.Mexico is reaching universal health coverage in 2012. A national health insurance programme called Seguro Popular, introduced in 2003, is providing access to a package of comprehensive health services with financial protection for more than 50 million Mexicans previously excluded from insurance. Universal coverage in Mexico is synonymous with social protection of health. This report analyses the road to universal coverage along three dimensions of protection: against health risks, for patients through quality assurance of health care, and against the financial consequences of disease and injury. We present a conceptual discussion of the transition from labour-based social security to social protection of health, which implies access to effective health care as a universal right based on citizenship, the ethical basis of the Mexican reform. We discuss the conditions that prompted the reform, as well as its design and inception, and we describe the 9-year, evidence-driven implementation process, including updates and improvements to the original programme. The core of the report concentrates on the effects and impacts of the reform, based on analysis of all published and publically available scientific literature and new data. Evidence indicates that Seguro Popular is improving access to health services and reducing the prevalence of catastrophic and impoverishing health expenditures, especially for the poor. Recent studies also show improvement in effective coverage. This research then addresses persistent challenges, including the need to translate financial resources into more effective, equitable and responsive health services. A next generation of reforms will be required and these include systemic measures to complete the reorganisation of the health system by functions. The paper concludes with a discussion of the implications of the Mexican quest to achieve universal health coverage and its relevance for other low-income and middle-income countries.

Improvement of child survival in Mexico: the diagonal approach

Public health interventions aimed at children in Mexico have placed the country among the seven countries on track to achieve the goal of child mortality reduction by 2015. We analysed census data, mortality registries, the nominal registry of children, national nutrition surveys, and explored temporal association and biological plausibility to explain the reduction of child, infant, and neonatal mortality rates. During the past 25 years, child mortality rates declined from 64 to 23 per 1000 livebirths. A dramatic decline in diarrhoea mortality rates was recorded. Polio, diphtheria, and measles were eliminated. Nutritional status of children improved significantly for wasting, stunting, and underweight. A selection of highly cost-effective interventions bridging clinics and homes, what we called the diagonal approach, were central to this progress. Although a causal link to the reduction of child mortality was not possible to establish, we saw evidence of temporal association and biological plausibility to the high level of coverage of public health interventions, as well as significant association to the investments in women education, social protection, water, and sanitation. Leadership and continuity of public health policies, along with investments on institutions and human resources strengthening, were also among the reasons for these achievements.

Evidence-based health policy: three generations of reform in Mexico

The Mexican health system has evolved through three generations of reform. The creation of the Ministry of Health and the main social security agency in 1943 marked the first generation of health reforms. In the late 1970s, a second generation of reforms was launched around the primary health-care model. Third-generation reforms favour systemic changes to reorganise the system through the horizontal integration of basic functions-stewardship, financing, and provision. The stability of leadership in the health sector is emphasised as a key element that allowed for reform during the past 60 years. Furthermore, there has been a transition in the second generation of reforms to a model that is increasingly based on evidence; this has been intensified and extended in the third generation of reforms. We also examine policy developments that will provide social protection in health for all. These developments could be of interest for countries seeking to provide their citizens with universal access to health care that incorporates equity, quality, and financial protection.

Seroepidemiología de la enfermedad de Chagas en México

The lack of information about Chagas disease in Mexico, as well as the controversy concerning its importance, was the basis for the seroprevalence study of Trypanosoma cruzi in the National Seroepidemiology Survey (NSS). This information was representative of the national situation with regard to disease prevalences and other factors related to the nations health. Unfortunately the NSS was not a very good information source for the study of trypanosomiasis americana, because its coverage in the disperse rural areas was poor. Nevertheless, the results of the NSS indicated that Chagas disease has an irregular distribution in Mexico with seroprevalences of 1.6, 0.5 and 0.2 for the different dilution levels used in the evaluation. The survey data showed Chagas disease to be less important than that mentioned by other authors. The NSS data confirmed the areas of disease transmission already reported and identified some new ones in Hidalgo, Chiapas and Veracruz. The survey also detected migratory workers with Chagas antibodies in Baja California border cities, a situation which indicates a risk for blood transfusion in areas of the country presumed to be free of the disease. Three quarters (74.5%) of the seropositive population were less than 39 years old. Moreover, the fact that children of less than four year were infected suggests that natural transmission is still very important in some areas. Although the seroprevalences were greater in the lower socio-economic groups, some persons of the higher socio-economic level were also affected. This situation may be explained by the fact that many of these persons own vacation homes in tropical areas.

Factores asociados con la actividad física en mujeres mexicanas en edad reproductiva

OBJETIVO: Documentar la practica de actividades fisicas ligeras y pesadas, particularmente de deportes y ejercicios, en mujeres de 12 a 49 anos en Mexico, y evaluar su asociacion con algunas caracteristicas sociodemograficas. METODOS: Se estudio una muestra de 2 367 mujeres de 12 a 49 anos de edad residentes en Mexico en 1999 mediante el analisis secundario de los datos de la Encuesta Nacional de Nutricion de Mexico, 1999 (ENN-99). En esta encuesta se utilizo un esquema de muestreo polietapico, estratificado, por conglomerados que conformo una muestra final de 21 000 hogares de todo el pais. Mediante un cuestionario se evaluo el tiempo dedicado a las distintas formas de actividad fisica y se midio la actividad en equivalentes metabolicos (MET) segun una escala puntual. Las variables dependientes del estudio fueron el tiempo dedicado a actividades fisicas pesadas (las que exigen un gasto de energia equivalente a 5 MET/hora) y el dedicado a actividades ligeras o sedentarias (tales como estar sentada en el trabajo o fuera de el, ver television, video, cine o teatro y dormir). Las variables independientes fueron la edad, escolaridad, paridad, region del pais y area de residencia (urbana o rural), nivel socioeconomico (medido mediante un indice elaborado a partir de las condiciones de la vivienda y la posesion de enseres domesticos) y estado marital. Se evaluo la asociacion entre las variables independientes y la practica de deportes y se calcularon las razones de posibilidades brutas con intervalos de confianza de 95%. Para identificar la asociacion entre la practica de deportes y las variables independientes se utilizo un modelo de regresion logistica ajustado segun el efecto de posibles variables de confusion. Se ajusto tambien mediante un factor de ponderacion la probabilidad de que una mujer fuese seleccionada para la muestra, y para controlar el efecto de diseno producido por la agrupacion de observaciones en esta muestra se utilizo la rutina de analisis de muestras complejas svy de Stata, version 7.0. RESULTADOS: Se analizo la informacion obtenida de 2 367 mujeres. Las mujeres encuestadas dedicaron 0,08 horas diarias, en promedio, a practicar deportes y 1,25 horas diarias a actividades fisicas pesadas. Solo 16% informaron que practicaban algun deporte con regularidad. Al hacer ajustes segun todas las variables independientes, las mujeres mayores de 30 anos y las de 21 a 30 anos tuvieron una menor razon de posibilidades (RP) en lo que respecta a la practica de deportes que las de 20 anos o menos (RP = 0,53; intervalo de confianza de 95% [IC95%]: 0,33 a 0,84 y RP = 0,35; IC95%: 0,23 a 0,54, respectivamente). El mayor nivel de escolaridad y no haber tenido hijos fueron variables directamente asociadas con la practica de algun deporte. El area de residencia (urbana o rural), el estado marital y el nivel socioeconomico mostraron diferencias entre los grupos. No obstante, estas no resultaron significativas una vez que se hicieron los ajustes segun las otras variables del estudio. El tiempo dedicado al deporte contribuyo solo en 10% al total de la actividad pesada y en 0,7% al total de la actividad fisica evaluada en MET. Las mujeres de 31 anos de edad o mas y las que tenian una escolaridad de nivel secundario tuvieron menos posibilidades de estar en el 10% inferior en terminos de actividad que las menores de 21 anos o que las que tenian una escolaridad de nivel primario. CONCLUSIONES: Este estudio demuestra que la practica de deportes no es frecuente como forma de actividad fisica en mujeres en edad reproductiva en Mexico, especialmente entre las mayores de 20 anos y las de baja escolaridad, lo que a su vez puede contribuir al aumento de la prevalencia de la obesidad y de las enfermedades cronicas.

Seroprevalencia de la hepatitis C en adultos de México: ¿un problema de salud pública emergente?

Objective. Hepatitis C Virus (HCV) infection is becoming a chronic disease in 60-85% of individuals and is a cause of hepatic cirrhosis and hepatocellular carcinoma. The objective of this study was to report the seroprevalence of HCV infection in a probabilistic sample of the Mexican population. Material and Methods. This study is based on information obtained from the National Health Survey conducted in 2000. A total of 21 271 sera randomly selected for anti-HCV and RNA of HCV was studied. It was performed at the National Institute of Public Health in 2005. Results. Seroprevalence of HCV antibodies was 1.4% (IC95% 1.1%-1.6%), of which 35.7% had active infection. Risk factors for infection were using heroine (RM= 9.8, IC: 2.1-41.4), being separated from his/her spouse (RM= 2.6, IC: 1.1-5.9), being a widower (RM= 2.2, IC: 1.1-4.3) and living in the northern states in the country (RM= 1.9, IC: 1.1-3.2). Conclusion. Results from this study indicate that HCV is an emerging public health problem in Mexico. Risk factors indicate that the main route of transmission is through transfusion of blood products (previous to 1996) and the second route is through usage of intravenous drugs and sexual practices.

La vacunación antisarampionosa en México por el método de aerosol

En este trabajo se describen las acciones de vacunacion contra el sarampion por el metodo de aerosol inhalado llevadas a cabo en la Republica Mexicana entre 1988 y 1990. Se hace mencion pormenorizada del equipo simplificado que se empleo, del personal, de su adiestramiento, de la promocion y de la estructura de las campanas correspondientes. Tambien se precisa la vacuna usada: cepa Edmonston-Zagreb cultivada en celulas diploides, del Instituto Nacional de Virologia de la Secretaria de Salud en Mexico, con un titulo que vario, de 10(4.5) unidades formadoras de placa/ml (PFU/ml) a 10(4.8) PFU/ml, administrada en 30 segundos de inhalacion, con una descarga del nebulizador, durante este lapso, de 2 800 a 4 000 PFU por nino, estimandose la dosis retenida en 25%, por ejemplo, 700 a 1 000 PFU. En total se tiene documentada la vacunacion de 3 760 684 ninos prescolares y escolares en 13 de las 32 entidades federativas del pais. No se observaron efectos indeseables de gravedad y los estudios limitados que se realizaron, tanto serologicos como de campo, avalan la efectividad y seguridad de este metodo que es, por otra parte, mucho mas barato, rapido y aceptable por la poblacion que el de inyeccion subcutanea..

The state of global health in 2014

The global health landscape looks more promising than ever, although progress has been uneven. Here, we describe the current global burden of disease throughout the life cycle, highlighting regional differences in the unfinished agenda of communicable diseases and reproductive, maternal, and child health and the additive burden of emerging noncommunicable diseases and injuries. Understanding this changing landscape is an essential starting point for effective allocation of both domestic and international resources for health.

Dyslipidemias and obesity in Mexico

Objective. To describe in a national sample 1) the mean total cholesterol (TC), HDL-cholesterol (HDLc) and triglyceride (TG) concentrations, 2) the prevalence of the most common lipid abnormalities and 3) the association between obesity and these conditions. Material and Methods. We analyzed the nationally representative, cross-sectional Mexican Health Survey (2000). The final analytic sample used consisted of 2 351 individuals at fasting state. TC, HDLc and TG were determined. BMI was classified according to the WHO cutoff points. Sex-specific means and 95% confidence intervals (95%CI) were calculated by age group for TC, HDLc and TG. The prevalence of: a) hypercholesterolemia (HC), b) hypoalphalipoproteinemia (HA), c) hypertriglyceridemia (HT), d) HT with HA and e) HC with HT was calculated adjusting for age. Multivariate logistic regression models were estimated to analyze the association of obesity to the prevalence of dyslipidemias. Results. The mean TC, HDLc, and TG concentrations were: 197.5 mg/dl (95% CI= 194.0, 201.1), 38.4 mg/dl (95% CI= 37.2, 39.5) and 181.7 mg/dl (95% CI= 172.7, 190.6), respectively. HC was present in 40.5% of the adult females (95% CI=35.5, 45.4) and 44.6 of the adult males (95% CI=37.7, 51.4); HA was the most prevalent form of dyslipidemia, present in 64.7% (95% CI=58.7, 70.8) and 61.4% (95% CI=54.4, 68.3) of females and males, respectively. Obesity increased ~1.4 times the probability ratio (PR) of having HC among women and 1.9 among men. Conclusion. TC concentrations from our study in Mexico were similar to those found for Mexican-Americans and the prevalence of HC was slightly lower than the one reported in the US;