No easy answer for how to tackle Mexico's health challenges
Authors: Juan Pablo Gutiérrez, Sebastián García-Saisó
Journal: The Lancet Global Health (2016)

In their Article, Eduardo González-Pier and colleagues1González-Pier E Barraza-Lloréns M Beyeler N et al.Mexico's feasible path towards the Sustainable Development Goal for health: an assessment of the feasibility of reducing premature mortality by 40% by 2030.Lancet Glob Health. 2016; (published online Aug 30.)http://dx.doi.org/10.1016/S2214-109X(16)30181-4Google Scholar estimate the magnitude of Mexico's challenge to accomplish the committed goal on mortality reduction as a component of the Sustainable Development Goals (SDG) in 2015. According to the authors' estimations, Mexico's present mortality trend will fall short of the committed goal and so there is a need to improve public policies that might result in a faster decrease in mortality. González-Pier and colleagues propose a set of potential interventions that the country should implement for this purpose.1González-Pier E Barraza-Lloréns M Beyeler N et al.Mexico's feasible path towards the Sustainable Development Goal for health: an assessment of the feasibility of reducing premature mortality by 40% by 2030.Lancet Glob Health. 2016; (published online Aug 30.)http://dx.doi.org/10.1016/S2214-109X(16)30181-4Google Scholar Although already reported, the magnitude of the challenge that chronic disorders and injuries represents for Mexico is still striking. As highlighted in the report from the Global Burden of Disease (GBD) study,2Lozano R Gómez-Dantés H Garrido-Latorre F et al.La carga de enfermedad, lesiones, factores de riesgo y desafíos para el sistema de salud en México.Salud Pública Méx. 2013; 55: 580-594Crossref PubMed Scopus (72) Google Scholar the main causes of disability-adjusted life-years in Mexico are diabetes, chronic kidney disease, and ischaemic heart diseases. This shift to non-communicable diseases as main causes of death is a worldwide phenomenon reported by the GBD study.3GBD 2013 Mortality and Causes of Death-Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 385: 117–71.Google Scholar The study by González-Pier and colleagues contributes to a better understanding of the magnitude of the challenge that non-communicable diseases pose for Mexico and for other countries. These diseases defy traditional approaches to health care and demand innovative interventions. Understanding of mortality from chronic disease requires discussion about the quality of health care as a major driver. Although the high prevalence of diabetes in Mexico is a result of a combination of genetic predisposition and lifestyle choices, it is the quality of health care that could prevent or delay mortality. An analysis4Lugo-Palacios DG Cairns J Masetto C Measuring the burden of preventable diabetic hospitalisations in the Mexican Institute of Social Security (IMSS).BMC Health Serv Res. 2016; 16: 1-8Crossref PubMed Scopus (7) Google Scholar of diabetes care has provided evidence that there is a relevant burden of disease attributable to preventable hospital admissions for diabetes in Mexico. Shifting the health service provision paradigm from sporadic and episodic care (a characteristic trend in the late 20th century health service provision) to continuous, community-based health care, might be challenging. Reorientation of health-care funding priorities towards a more efficient and effective primary care level would be needed. Nevertheless, within the health sector, structural changes are needed to improve the provision of health services. Such changes are feasible at the institutional level, as some examples have shown, such as decisions on staff shifts to ensure availability of trained physicians 24 h a day, 7 days a week in some hospitals. In Mexico, presenting with an acute health condition during the weekend (or even at night) might result in a negative prognosis, even at the best hospitals. Well trained physicians are available during the day on week days, but other shifts are covered by physicians under training. This traditional setup is subject to change, with administrative decisions that could ensure that trained staff are available at any time. The same problem applies to ambulatory care facilities, where rural settings are staffed with undergraduate medical students in their last year of training who are unsupervised and, in many cases, do not have the option to request advice when faced with conditions they haven't yet experience. Although this has been a low-cost mechanism to increase the reach of health service coverage, this model needs to change in order to address the present challenge. Similarly, although Mexico has recently introduced fiscal policies to target underlying risk factors such as alcohol use, smoking, and consumption of sugar-sweetened non-alcoholic beverages and high-calorie processed foods, a great challenge remains in the availability of drinking water, particularly for the populations at highest risk of disease. To address global health challenges in general, and in Mexico in particular, requires a response as complex as the challenges. In the past few years, developments in behavioural science have highlighted alternative mechanisms to incentivise population-level behavioural changes.5Thaler RH Sunstein CR Nudge: improving ecisions about health, wealth, and happiness. Penguin Books, New York2009: 320Google Scholar Nudges (ie, positive reinforcement and indirect suggestions) from the health sector might have a role on this behavioural change at both levels: from the demand and from the supply of health services. Patients would be nudged to comply with treatments and attend their appointments, both of which are present challenges related to adequate management of chronic diseases, and which González-Pier and colleagues report to be major drivers of mortality in Mexico (and all over the world). From the supply perspective, health suppliers would be nudged to make decisions based on the relevant evidence available. The authors mention that for injuries, there are several challenges in place regarding road-traffic deaths and those related to violence. One of them is the widespread perception of impunity in the country. This is clearly an issue that goes beyond the health sector but is key to consider bec ause stronger legislation might not generate a change in the context of limited enforcement. As González-Pier and colleagues suggest, there are examples of stronger legislation but also evidence of limited enforcement. We declare no competing interests. Mexico's path towards the Sustainable Development Goal for health: an assessment of the feasibility of reducing premature mortality by 40% by 2030Urgent action is now required to control non-communicable diseases and reduce fatal injuries in Mexico, making a 40% reduction in premature mortality by 2030 feasible and putting Mexico back on a track of substantial life expectancy convergence with better performing countries. Our study provides a roadmap for setting national health priorities. Further analysis of the equity implications of following the suggested pathway remains a subject of future research. Full-Text PDF Open Access