Socioeconomic, Political, and Demographic Overview
The United Mexican States territory extends for 1,967,183 km2. The country is made up of 31 states and the Federal District, recently designated as a state.
In December 1994, Mexico experienced the worst economic recession in several decades. Its national currency devaluated and inflation soared from 7% to 52%. In 1995, the gross domestic product (GDP) was US$ 246.4 billion. In the 19951996 biennium, real wages fell by 22%, employment in the formal sector shrank, and short-term interest rates soared.
In 1996, the principal macroeconomic variables yielded positive balances and the GDP, boosted by the rise in exports, grew by 5.1%; inflation was 27.7%; short-term interest rates dropped to their lowest levels since December 1994; employment in the formal sector grew by 2.1% while the open unemployment rate fell to 10.5% (in 1995 it was 11.2%). In 1997, signs of economic recovery became widespread; the economy grew by 7% in the first half of the year.
It was estimated that in 1997 the population was 94.7 million, with 2.3 million births and approximately 425,000 deaths, which, when added to the negative migratory balance of 300,000 people, yields a net growth of slightly over 1.5 million people and an annual growth rate of 1.62%. In 1996, the number of children per woman 2.73. The crude birth rate dropped from 26.8 per 1,000 population in 1992 to 24.5 per 1,000 in 1996.
Between 1990 and 1995, the percentage of the population living in rural localities fell from 28.7% to 26.5%, and the percentage inhabiting cities of over 500,000 inhabitants rose from 22.0% to 25.0%.
In 1995, 60.4% of the population lived in poverty. The states with the greatest proportions of people living in poverty (between 70% and 76%) are those with higher numbers of indigenous population. The literacy rate for the population was 89.3% (87.6% in 1990)91.4% for men and 87.2% for women.
Life expectancy at birth changed little between 1992 and 1996, increasing from 72.1 to 73.3 years (73.2 to 76.4 years for women and 68.9 to 70.1 years for men)
Mortality and Morbidity Profile
The total mortality rate continues to decline, dropping from 4.8 deaths per 1,000 population in 1992 to 4.7 in 1995. The number of deaths in 1995 was greater in males than in females for all age groups aged under 65 and lower after that.
In 1995, the national excess male mortality rate was 129.2; this indicator topped 100 in every state. The infant mortality rate in 1995 was 17.5 per 1,000 live births. Early neonatal mortality (under 7 days) was 7.7 per 1,000 live births and late neonatal mortality (7 to 28 days) was 2.3 per 1,000, while postneonatal mortality was 7.5 and perinatal mortality was 14.5. Health authorities consider the adjusted infant mortality rate to be more reliable, which shows a decline between 1994 (26.5) and 1995 (25.9).
In 1995, maternal mortality was 5.3 per 10,000 registered live births, which is higher than in 1994, when it was 4.8, and at levels similar to those in 1990 (54). The increase in maternal mortality in 1995 was attributed to better registration of deaths with the new death certificate. The highest maternal mortality rates in 1995 were in Puebla (11.2 per 10,000 live births).
In general, the most frequent causes of death continue to be cardiovascular disease (69.4 per 100,000 in 1995), followed by malignant neoplasms (52.6), accidents (38.8), and diabetes mellitus (36.4). Cerebrovascular disease was the sixth leading cause of death in 1992 (at a rate of 24.7) and it moved to fifth place in 1993 (a rate of 25.5 in 1995); disorders originating in the perinatal period, which occupied fifth place in 1992, dropped to seventh in 1995 (a rate of 22.4), and cirrhosis and other chronic diseases of the liver ranked sixth in 1995 (a rate of 23.2).
Deaths from heart disease are more frequent in men than in women, but the difference between the sexes is diminishing. Malignant neoplasms are becoming predominant as a cause of death in women, due to the high number of deaths from cervical tumors, although this is decreasing. In 1995 the death rate from due to malignancy was 54.6 in women and 50.6. Mortality from accidents is higher in men than in women (60.3 and 17.6, respectively, in 1995), whereas mortality from diabetes mellitus is higher in women than in men (40.4 and 32.3, respectively); the same pattern holds for cerebrovascular disease (27.1 and 23.9).
Respiratory infections ranked first in outpatient visits in 1996, with 22.5 million new cases (rate of 24 cases per 100 population), followed by intestinal infectious diarrhea, (rate of 4 per 100), and intestinal amebiasis ( rate of 1,5 per 100). In 1995, there were 3,619,341 public hospital discharges, 65.6% of these were social security recipients and the remaining were the open or uninsured population served by Secretariat of Health clinics. Of hospital discharges, 56.6% corresponded to the 15 to 44 age group, 13.8% to the 45 to 64 age group, 11% to persons over 65, 7.6 % to children under 1, 5.9% to the 5 to 14 age group, and 5.1 % to children aged 1 to 4. Women accounted for the largest number of discharges (68.9% of the total), and the average stay in 1995 was 4.0 days per patient. The most frequent reasons for hospitalization in 1995 were direct obstetric conditions (17% of the total), normal deliveries (13.6%), injuries and poisonings (7.3%), diseases of the urinary tract (4.7%), diseases of the circulatory system (4.6%), fractures (3.2%), abortions (3.1%), and malignant neoplasms (2.7%), the most frequent of which are cervical neoplasms (12.1% of all malignant tumors), leukemia (11.2%), and breast cancer (9.4%).
SPECIFIC HEALTH PROBLEMS
Analysis by Population Group
Health of Children
Child health has continued to improve, as evidenced by the eradication of polio in 1991; the drastic reduction in morbidity and mortality from measles, whooping cough, diphtheria, and neonatal tetanus; and the continuing drop in mortality in infants and children under 5, as well as in deaths from diarrheal and respiratory diseases. These achievements are attributable to a combination of demographic and socioeconomic factors in addition to specific health sector interventionshigh coverage of a complete vaccination program, the increased use of oral rehydration salts, and provision of a basic package of services to the population without regular access to health services. However, child health varies throughout the country, with higher mortality rates in the northern and southern parts of the country.
The most frequent causes of death among children under one year of age were perinatal conditions (7.5 deaths per 1,000 live births in 1995); congenital anomalies (2.7 per 1,000); pneumonia and influenza, (1.3); nutritional deficiencies (0.5); and accidents (0.5).
In 1995, public hospitals reported that the most frequent reasons associated with discharge in children under 1 were perinatal conditions, with 157,454 cases and 57.3% of all discharges; diseases of the respiratory system (10.6%; infectious and parasitic diseases (8.3%); and congenital anomalies (7.3%).
Accidents remain the leading cause of death in children between 1 and 4, with rates of 22.8 per 100,000 in 1995, followed by pneumonia and influenza (16.4), intestinal infectious diseases (15.4), congenital anomalies (10.4), and nutritional deficiencies (8.0).
In 1995, the hospital discharge records for children in that same age group show that 32.8% of the total were for respiratory diseases, 16.6% were for infectious and parasitic diseases, and 10.7% were for injuries and poisonings.
Health of Schoolchildren
The leading cause of death for this group in 1995 was accidents, with a rate of 11.8 per 100,000 population (16.2 in men and 7.3 in women), the most frequent being motor vehicle accidents (42% of the total). Malignant neoplasms were in second place, with 4.3 per 100,000, the most frequent form of which was leukemia. The third leading causes of death in women was congenital anomalies (2.0), and in men it was homicides (2.5). In fourth place were pneumonias and influenza for women (1.7) and congenital anomalies for men (2.0). In a comparison of the leading causes of death in 1995 and 1992, the most notable aspect is the 20% reduction in the death rate from accidents (a rate of 14.8 in 1992).
In 1995, injuries and poisoning in children aged 5 to 14 accounted for 20.5% of hospitalizations, followed by diseases of the respiratory system, with 17.1%; diseases of the digestive system, with 13.1%; and diseases of the genitourinary system, with 7.4% of all discharges.
In 1995, 14,324 minors were living on the street and were cared for by the National System for the Integral Development of the Family through a strategy of shared responsibility among children, the family, and the community, which includes an economic incentivesupplying of essential provisionsand medical checkups at least three times a year.
Health of Adolescents
The majority of deaths in young people between 15 and 24 are from injuries (61.6% in 1995); noncommunicable diseases (32.1%); and communicable diseases (6.2%).
Analysis of the reproductive behavior of young people shows that the average age for first marriage (19 years) and the average age for the birth of a first child (21 years) have not changed in the past five years. In 1996, 16% of births were to teenage mothers. The prevalence of contraceptive use among sexually active adolescents, which increased significantly between 1986 and 1992, has remained at roughly 36% since then, far from the 60% laid out as a goal for the year 2000.
A problem of growing importance in this group is alcohol and drug use. Surveys conducted in the Federal District show that the number of young people between 12 and 18 who have consumed alcohol at some time has risen (55.8% in 1986, 65.5 % in 1991, and 73.8% in 1994). The typical drug user is a male aged 15 to 19, particularly an unattached man with little education. It further shows that marijuana and inhalants are the drugs most frequently used by adolescents and that use of these substances has risen to 4% in recent years.
Health of Adults
In 1995 mortality in persons between 15 and 64 years of age was 296.9 per 100,000. The leading cause of death was accidents, with a rate of 42.7 per 100,000 in 1995 (the most frequent were motor vehicle accidents, which were responsible for 40% of all accidents). This was followed by malignant neoplasms, with 39.3 per 100,000. The third leading cause is heart disease, with 31.4 per 100,000, and fourth is cirrhosis and other diseases of the liver, with 27.2 per 100,000. Deaths from homicide fell from fifth place in 1991 (25.9) to sixth in 1995 (25.3), and deaths from AIDS, which occupied twelfth place in 1991, with a rate of 3.8 per 100,000, climbed to ninth place in 1995, with a rate of 7.0 per 100,000.
In 1995, the most frequent cause of hospital discharge among persons between 15 and 44 years of age was complications of pregnancy, childbirth, and the puerperium, which accounted for 60% of all discharges, followed by problems of the digestive system (7.3%), diseases of the genitourinary system (6.5%), and injuries and poisonings (6.2%). For the group aged 45 to 64, the most frequent causes of hospitalization in 1995 were diseases of the genitourinary system (18.3%); diseases of the digestive system (17.5%); diseases of the circulatory system (11.7%); and neoplasms (10.7%).
The greatest amount of information on womens health is related to the reproductive issues. In 1995, there were 1,454 maternal deaths (1,477 in 1990); 87.1% were due to direct obstetric causes (92.1% in 1990), mainly toxemia of pregnancy, hemorrhage during pregnancy and childbirth, and complications in the puerperium. Coverage by the national family-planning program increased between 1987 and 1996 from 52.7% to 66.5% of women of childbearing age; the greatest increases were in women who had not completed primary school, with coverage rising from 23.7% in 1987 to 48.4% in 1995. The distribution of contraception users according to method was bilateral tubal ligation (41.3%), intrauterine device (21.9%), traditional methods (13.4%), oral contraceptives (12.7%), and parenteral contraceptives (4.6%).
Cervical and breast cancer are public health problems that demand urgent and more effective action. Mortality from cervical cancer fell from 10.2 per 100,000 women in 1990 to 9.5 per 100,000 in 1995, and mortality from breast cancer was 6.6.
Health of the Elderly
The proportion of hospitalized persons over 65 has steadily increasedgoing from 7.2% in 1991 to 11.0% in 1995. The most frequent causes of hospitalization in 1995 were diseases of the circulatory system (17.8% of all discharges for this age group), diseases of the genitourinary system (16.0%), diseases of the digestive system (13.8%), and diseases of the respiratory system (9.5%).
In 1995, the leading causes of death in persons over 65 were heart disease (at a rate of 1,188 per 100,000 persons) and malignant neoplasms (655.3 per 100,000), the most frequent of which were those of the trachea, bronchi, and lungs (101.0 per 100,000); stomach (75.4); and prostate (71.0). These are followed by diabetes mellitus (501.9), cerebrovascular disease (449.4), pneumonia and influenza (224.6), nutritional deficiencies (163.9), and chronic bronchitis, asthma, and emphysema (163.8).
Health of Indigenous People
In 1995, the indigenous population was calculated at 9.17 million persons, with an average growth rate of 1.23 % compared with 1990, which is almost half that of the rest of the population (2.13%). In 1995, life expectancy at birth for the indigenous population was estimated at 69.5 years (67.6 for men and 71.5 for women), which is more than three years shorter than that of the rest of the population.
The infant mortality rate was almost double that that of the rest of the population (54 compared with 29 deaths per 1,000 live births). The average number of children born to indigenous women was 4.1, compared with 2.9 for nonindigenous women.
In 1995, the per capita years of potential life lost (YPLL) from the three leading groups of causes of death showed premature mortality of 19.0 years for indigenous men compared with 15.3 for nonindigenous men and 15.4 for indigenous women compared with 11.2 for nonindigenous women. Among indigenous peoples there are still differences that have not been adequately explained: there is a lower level of infant mortality among children whose mothers speak Chontal (33 per 1,000 live births), Mayan (36), Chinanteco (40), and Zapoteco (40) than in those who speak Chatino (77), Popoluca (79), Tarahumara (79), Tepehunán (80), Tzotzil (81), and Tojolabal (87). Differences are also observed in the number of children the women have; the two extremes are 3.7 children for the Chontals and 4.5 for the Tojolabals.
Analysis by Type of Disease
Malaria continues to be endemic, although the number of cases dropped by more than half between 1992 and 1996 (18.6 and 6.8 cases per 100,000 population, respectively). The last epidemic outbreak was in the 1985; (134,000) was recorded. In 1996, 6,293 cases were reported; the states with the highest incidence were Sinaloa, with a rate 63.5 per 100,000, and Chiapas, with 42.7 per 100,000. There were 69 cases of infection from Plasmodium falciparum in 1995 and 60 in 1996, all of which were in the states of Chiapas and Tabasco.
There was an epidemic outbreak of dengue in 1980, with nearly 51,000 cases; in subsequent years the number of cases fell somewhat irregularly, with 20,056 cases of dengue fever and 884 cases of dengue hemorrhagic fever in 1996. Over 60% of the cases were in the 15- to 44-year age group, and 50% of the affected persons resided in two statesVeracruz (26.6% of the cases), Tamaulipas (23.3%). In 1994, dengue serotype 3 was isolated and in 1996 there were four serotypes in circulation. In 1994 Aedes albopictus was found in the northern states bordering Texas. The incidence rate for dengue hemorrhagic fever rose from 0.03 per 100,000 population in 1994 (30 cases) to 0.95 in 1996, the year when the largest number of cases were reported in Veracruz (358), Tamaulipas (198).
Onchocerciasis remained stable in the last few years with 25,500 cases; health authorities believe that the use of ivermectin since 1989 has helped to contain the spread of the disease. The endemic area encompasses 16,900 km2 in the states of Oaxaca and Chiapas in the southeastern part of the country, and the at-risk population is calculated at 280,000 persons distributed in 947 localities.
Trypanosomiasis is increasing in frequency and virulence. The National Institute of Cardiology estimates that cardiopathies related to Chagas disease have increased and that 15 million people are at risk of infection. It puts the annual potential number of these cardiopathies at 500. Deaths from this cause rose from 11 in 1992 to 18 in 1995, and the serological prevalence in blood banks was 0.8% in 1995. Routine screening of Chagas disease and onchocerciasis in donated blood is conducted only in endemic localities in the country. Scorpion bites are a problem in 16 states, and in 1996 108,359 cases were recorded. It is estimated that over 300 people die annually from this cause.
Complete vaccination coverage increased from 75.3% in 1993 to 88.2% in 1996 in children under 1 and from 90.1% to 95.8% in children between 1 and 4. Poliomyelitis was eradicated in 1991, and there are no signs of wild poliovirus circulating in the country. Cases of measles fell significantly, plummeting from 27,790 in 1990 to 12 in 1995, and deaths from this cause fell from 5,899 in 1990 to 2 in 1995. Tetanus also declined, with an incidence of 0.23 cases per 100,000 population in 1992 and 0.14 per 100,000 in 1995. Neonatal tetanus showed a downward trend, with 67 in 1995. Isolated cases of whooping cough were reported, with a rate of 0.21 per 100,000 in 1996. In recent years no cases of diphtheria have been reported.
Mortality from intestinal infectious diseases decreased from 22.0 per 100,000 population in 1991 to 10.5 per 100,000 in 1995. The same downward trend was seen in children under 5, from 91.8 to 77.8. The group of children under one year of age was the most vulnerable, with 80.2% of death in children under 5 in 1995. The drop in mortality in children under 5 is attributed to the increase in oral rehydration therapy at home, which was used in over 80% of cases in 1995. The trend for cholera varied, with a mortality rate of 6.2 per 100,000 population in 1993, 4.3 in 1994, 17.9 in 1995, and 1.2 in 1996. The case-fatality rate went from 1.2% in 1992 to 0.5 % in 1996. Only four states did not report cases of cholera in 1996 (Baja California, Baja California Sur, Zacatecas, and Sinaloa) and the most affected states were Yucatán, Veracruz, Campeche, and Tabasco.
Mortality from respiratory infections, including pneumonia and influenza, showed a downward trend, with a rate of 26.0 per 100,000 population in 1991 and 23.7 per 100,000 in 1995; that year, the greatest percentage of deaths occurred in persons over 65 (42.1%) and in children under 5, (39%). Between 1990 and 1995 mortality from these causes in children under 5 dropped by 32.8% and the states with the highest mortality were Tlaxcala (177.0), Puebla (164.3), Mexico (135.4), and Querétaro (113.0). A high proportion of the deaths occurred at home (30%); therefore, a training strategy for mothers has been implemented so that they can learn to identify warning signs and seek medical assistance at the health centers.
In Mexico rabies has been in decline, from 35 deaths in 1992, to 22 deaths in 1996; a decline in cases of canine rabies also was reported falling from 2,106 in 1992 to 859 in 1996 (-59%). In that period, over 10 million dogs were vaccinated per year and, although they remain the principal source of rabies infection in humans, transmission of the disease by bats and other wild species is also important.
Statistics on STDs in Mexico are recorded at the primary care level, and it is known that there is underreporting. The STDs that occurred with the greatest frequency in 1996 were urogenital candidiasis, and urogenital trichomoniasis. The incidence of syphilis dropped from 2.20 in 1993 to 1.51 per 100,000 inhabitants in 1996, the same trend was observed for gonococcal infection.
As of 1 January 1997, there were 29,962 AIDS cases, of whom 16,636 had died, 11,208 were still alive (37.4%), and the situation of 2,118 was unknown. A total of 25,771 cases were in men and 4,191 were in women; 83.2% of the patients were between 20 and 49 years of age (30.0% from 20 to 29; 36.0 % from 30 to 39; and 17.2% from 40 to 49). Children under 14 accounted for 2.7% of the total. The mode of transmission was reported in 71.7% of the cases: 86.5% were infected through sexual activity and 13.5% through blood transfusions. Of the reported cases, 55.3% (16,431) were concentrated in the three most populous states: the Federal District, the State of Mexico, and Jalisco. The general incidence rate for AIDS fluctuated between 3.7 per 100,000 population in 1991 (3,155 new cases), 5.7 in 1993 (5,058 new cases), and 4.8 in 1995 (4,310 new cases). The ratio of men to women in those years was 5:1, 6:1, and 7:1, respectively. On review of the cases at the end of 1991, 1995, and 1996, a trend toward an increase in cases of sexual transmission is observed, representing 87%, 94%, and 95.7% of the total, respectively.
Tuberculosis occupies 15th place among the general causes of death. The mortality rate from this cause declined from 7.6 to 5.1 per 100,000 population between 1990 and 1995. In 1995, it caused 4,648 deaths, with tuberculosis of the lung responsible for 87%, meningeal tuberculosis for 4%, and other forms for the remaining 9%. The incidence rate from tuberculosis rose slightly from 17.3 per 100,000 population in 1990 to 17.5 in 1996, with an annual average of roughly 16,000 cases. Pulmonary tuberculosis was predominant, accounting for 87% of the cases; the meningeal forms accounted for only 1% of the cases. In 1996, 85% of new cases occurred in persons over 15 years of age.
Leprosy evidenced a clear downward trend, and the prevalence rates in 1990, 1992, and 1996 were 2.1, 2.0, and 0.4 cases per 10,000 population, respectively.
Noncommunicable Diseases and Other Health-Related Problems
The 1988 National Nutrition Survey (ENN), which is the most recent, indicated that 41.9% of children under 5 were suffering from some type of malnutrition, as measured by the weight-for-age indicator, and that, according to the weight-for-height and height-for-age criteria, 29.2% of the children were suffering from some type of malnutrition. The 1993 National Survey of Chronic Diseases (ENEC) survey found that 21.5% of the population between 20 and 69 years of age had a body mass index over 30 and that the greatest prevalence of obesity (over 25% of the population) was found in the northern states of Mexico.
A study, conducted in 1994 in several parts of the country, found a 3% prevalence of goiter. Currently, salt sold for human consumption is iodized; an inspection of samples on the market in 1996 determined that 92% of the salt was effectively iodized.
The 1993 ENEC survey, which is the most recent, found a 23.6 % prevalence of hypertension, a 7.2% prevalence of diabetes mellitus, and an 8.8% prevalence of hypercholesterolemia (levels equal to or greater than 240 (µg/dl) in the population older than 20. The prevalence of these three conditions increased with age, and in the 65- to 69-year-old age group the illnesses of this type with the highest prevalence were hypertension and diabetes mellitus. The distribution by gender was similar for diabetes mellitus and was slightly higher in men for hypertension and hypercholesterolemia.
The incidence of hypertension is increasing in the public health services. In 1996, 403,582 cases were reported, at a rate of 433.1 per 100,000 inhabitants. The trend is the same for diabetes mellitus.
Mortality from chronic diseases is clearly on the rise. In 1995, cardiovascular disease accounted for 63,609 deaths (a rate of 69.4 per 100,000 population). Diabetes mellitus was responsible for 33,316 in 1995 (36.4). Deaths from cirrhosis of the liver increased was 21,245 in 1995 (23.2).
Malignant neoplasms are the second leading cause of mortality. Mortality from this cause increased by 4% between 1992 and 1995 (52.6 deaths per 100,000 population). In 1995, the most common sites were trachea, bronchi, and lungs, stomach and cervix. Compared with 1992, it can be seen that mortality increased in preschool children and in persons of productive age. It remained practically the same in children under 1 and schoolchildren and declined in the older age group.
In 1993 a Histopathological Registry of Malignant Neoplasms was established, to perform that function and whose basic data are anatomopathological. In 1994, 62,725 new cases of malignant neoplasms were reported, 64.7% of which were in women and 18% were in persons 60 and over. Cervical (23.2%), breast (10.2%), and prostate (4.9%) neoplasms had the highest prevalence.
Mortality from accidents and various types of violence fell from 44.1 deaths per 100,000 population in 1992 to 38.8 per 100,000 in 1995. In children between 0 and 14, it dropped 13.3% in 1995 compared with 1990. In 1995, mortality from these causes in children under 1 was 0.5 per 1,000 live births and ranked sixth as a cause of death, while in the group aged 1 to 14 it was 15.0 per 100,000, or a 6.5 % reduction over the 1990 rate. Accidents were the leading cause of death for persons of that age.
The most frequent accidents in infants, preschool children, and schoolchildren were traffic accidents, followed by suffocation and drowning and accidental falls, except in children under 1, for whom the second most frequent cause was accidental poisoning. In the population 65 and over, mortality from injuries and accidents also fell between 1992 and 1995.
In 1995 slightly more than 15,000 cases of child abuse were reported. The most frequent form was physical abuse, followed by emotional abuse; sexual abuse was in third place. Another problem documented in recent years is violence against women, which is the subject of governmental and nongovernmental research by a number of organizations. Various studies in specific localities documented high frequencies of domestic abuse and domestic violence against women, as well as rape and violence (verbal and physical) toward pregnant women by their partners.
The 1993 National Survey of Addictions (ENA) revealed that 25.1% of the respondents between the ages of 12 and 65 identified themselves as smokers, 20.3% as former smokers, and 54.6% as nonsmokers. The prevalence of smoking by gender was 38% in men and 14% in women. Most smokers fall in the age group 1620 years old (50%), and the highest prevalence of tobacco consumption (30%) was observed in the Mexico City metropolitan area.
The ENEC survey found that 66% of the urban population between 12 and 65 years old consumed alcohol (77.2% of men and 57.5% of women), among them, 41.6% drank occasionally but in large quantities (five or more glasses per time); 25% of the respondents abstained from drinking; 8% were considered former drinkers. The regions with the most frequent alcohol consumption were in the western part of the country and the Federal District.
Concerning drug use, 3.9% of the population between the ages of 12 and 65 responded that they had used illegal drugs at some time in their life (ENA 1993). Among the nonprescription drugs most frequently used in the 30 days before the survey are marijuana and cocaine; 3.3% of the interviewees had used marijuana at some time in their life, 0.5% had used cocaine, and another 0.5% had used some inhalant; 60% of the users between 19 and 34, for the most part men, reported having used an illegal drug at some time in their life. Study findings published in 1997 by the Secretariat of Health indicate that drug use is increasing in the country and that the highest growth is in cocaine use, although marijuana continues to be the most widely used drug. Drug use is no longer exclusively associated with high-income sectors.
For 1995, it was calculated that (96%) in urban centers had drinking water coverage, in rural localities (52.5%) had that service. Sewerage coverage in urban areas reached (85.5%), in rural areas the coverage was around (20.9%). It is estimated that 83,585 tons of waste are generated daily; 70% are collected and only 17% are disposed of in sanitary landfills. There is insufficient recycling of waste.
Another environmental health problem is exposure of the population in the Federal District to lead contamination. Lead concentration in blood dropped from 17 µg/dl in 1992 to 9 µg/dl in 1996, due mainly to the introduction of unleaded gasoline and the control of lead content in paints. In Mexico City, the levels of ozone and suspended particulate matter are serious problems. In 1995, for 324 days the ozone level exceeded 100 IMECAS (a scale developed to classify and communicate to the public air pollution levels in the valley of Mexico, in which 100 points is the limit for satisfactory air quality); the same year, ozone levels exceeded 250 IMECAS on 6 days. The total suspended particles exceeded the standard by 46.9% in 1992 and 15.6% in 1995; for breathable particulate fractions the standard was exceeded 8.3% of the time in 1992 and 12.6% in 1995.
RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
The main health policies are geared toward reorganization of the system in order to expand coverage and provide efficient and good services to the population and to treat the disorders stemming from current epidemiological and demographic problems. To address the first of these objectives, the Health Sector Reform Program was launched in 1995; for the second objective, in 1997 the Secretariat of Health defined the priority areas in disease prevention and control.
Health Sector Reform
The 19952000 Health Sector Reform Program allows social security recipients to choose the physician who will treat them at the health services; establishes family insurance coverage in the Mexican Social Security Institute (IMSS), whereby persons able to pay may voluntarily enroll; transfers health services to the states to care for the uninsured population; fosters greater local participation in health through the healthy municipios program; expands coverage through a basic package of services for persons without access to the health services; and reorganizes the system, with the Secretariat of Health exercising leadership and regulatory roles, health care for the uninsured population being integrated and coordinated, and IMSS separating the functions of financing and service delivery to introduce competition among service providers.
In August 1996 a national agreement was signed that transfers 121,000 jobs, 7,370 pieces of real estate, and US$ 1.1 billion from the central level to the states. The Federal Government retains the authority to set health standards; regulate services and sanitary control of goods, establishments, and decentralized services; and control professional certification and accreditation of health units, generation of national statistics, and international representation of the sector. The state and municipal agencies share responsibilities for the organization, operation, and monitoring of public and private health services; sanitary control of services to the population; and fulfillment of health promotion and orientation tasks.
In 1996, the Secretariat of Health implemented a program to expand coverage, based on the provision of a basic package of health services for the population with limited or no access to medical services in rural areas; this program covered 6 million people in 18 states in 1997. In addition, in July 1997, IMSS introduced family health insurance, which people may voluntarily obtain by paying a fee which is complemented with a Government contribution.
Organization of the Health Sector
Organization of the health system is still closely linked with employment sector; therefore, employees in the private sector and self-employed persons are covered by IMSS, which is financed with tripartite or bipartite contributions from employees, employers, and the Federal Government. Public sector workers are covered by the Social Security and Services Institute for Government Employees (ISSSTE) and other institutions, such as the military, petroleum, and the national university, which are financed with contributions from employees and the Government; a still undetermined segment of the population receives private care, and the remainder (over 40 million people) are treated in establishments of the Secretariat of Health and under a system known as IMSS-Solidarity, operated by that institution in specific regions. In 1995, 51% of the population had health insurance (social security in most cases). Roughly 10 million inhabitants did not have regular access to health services in 1995.
The sectors legal framework basically rests on two broad laws that the Government updates periodicallythe General Health Act and the Social Security Act. In 1997, several modifications to the Social Security Act went into effect. These changes were designed to revitalize the structure and practice of the pension and health care systems, by, among other provisions, reducing employer contributions and increasing Government contributions, offering family health insurance for those who wish to purchase it, and allowing for the transfer of employee contributions from their workplace to other providers when the employees so wish it, but with IMSS retaining the collection function. In that year, 52 reforms to the General Health Act also were introduced. They aim at making health deregulation more effective, introducing a new drug classification system and promoting the use of generic drugs in the private market, further specifying the Secretariat of Healths authority regarding the use of human tissue, improving the surveillance of biotechnology products, and granting authority to the Secretariat of Health to regulate labeling of alcoholic beverages and cigarettes.
Health regulation activities in the past four years have been geared toward prevention and control of disease, especially at the primary care level (diabetes mellitus, uterine and breast cancer, tuberculosis, HIV/AIDS, rabies); delivery of standardized services to special population groups (women during pregnancy, childbirth, and the puerperium; children and adolescents, to monitor their growth and development; family planning services; and psychiatric care); decentralization (delegation of authority to the states in public health, administration of blood banks, and issuing of authorizations and health permits); and the new structures and organs of the Secretariat of Health (the makeup of boards of trustees in hospitals, health institutes and jurisdictions as well as the National Health Council and National Medical Arbitration Commission).
Health Services and Resources
The number of outpatient clinics for the uninsured population increased from 10,443 in 1993 to 14,978 in 1997, and the hospital network grew from 329 to 372 institutions in that same period. The Secretariat of Health has 11 national institutes of health in the capital that operate in a decentralized manner and provide care at the tertiary level to patients referred from throughout the country. The social security institutes treat their members through their own service networks; outpatient clinics increased from 3,029 in 1993 to 3,208 in 1997, and the number of hospitals increased from 422 to 438. Traditional healing, whose extent has not yet been measured, is extremely widespread, particularly in areas with a high concentration of indigenous peoples and homeopathic medicine.
The volume of public services has steadily increased. Total medical consultations rose from 160 to 190 million between 1993 and 1996; hospitalizations increased from 3.6 to 3.8 million; and auxiliary diagnostic services rose from 123 to 137 million. An increase in care for both the uninsured population and Social Security members has been observed.
Because social security and the Secretariat of Health provide services consistent with their own models and schemes of care, in practice there is coverage overlap in some regions, and there are no shared criteria for technical and administrative procedures. The situation is different in the field of information, where common criteria are applied and data from different institutions are consolidated into national health statistics. In 1995, the National Epidemiological Surveillance Committee was formed, which operates a single information system in this area.
In recent years, private medicine evolved outside the scope of official policies. For 1995, it was calculated that the private supply of goods and services was responsible for half of all health expenditure, 30% of the bed count, 34% of employed physicians, and 32% of medical consultations. Private health insurance coverage is limited, and a traditional model involving direct collection of fees for services persists, with charges being as high as the market will bear.
Organization of Services for Care of the Population
Health Promotion is a strategic approach within the priorities for disease prevention and control defined by the Secretariat of Health. The work strategies are health education and social participation. They are carried out along six tracksfamily health, comprehensive health of schoolchildren, comprehensive health of adolescents, healthy municipios, health care exercises, and development of educational content. A key component is the healthy municipios strategy, which has fostered the political leadership of heads of municipios and the organized participation of society in defining priorities and executing local programs that deal with health promotion. Another project under way since 1996 is the "heart to heart project," which integrates initiatives of the private business sector, the Pan American Health Organization, and the Secretariat of Health under the aegis of the national health authority. This program is conducting a major mass communication campaign to reduce tobacco use and sedentary lifestyles and to promote healthy eating habits. The country recently adopted the healthy schools strategy, which works to transform environments, conditions, and lifestyles in the schools.
In 1997, the Secretariat of Health established a new priority disease prevention and control model. In this way, 10 substantive programs with a direct impact on the health status of specific population groups were defined: reproductive health, child health care, health care for adults and the elderly, vector-borne diseases, zoonoses, mycobacteriosis, cholera, epidemiological emergencies and disasters, HIV/AIDS and other STDs, and addictions.
In 1996, the countrys epidemiological surveillance system was upgraded and integrated into different public sector institutions. The unified information system for epidemiological surveillance was implemented, which generates information from the different health services at the technical-administrative levels, backed by a software package for receiving, collecting, and analyzing the information obtained. There is a morbidity registry, whose information comes from the Unified Epidemiological Surveillance System and reports on hospital discharges from health facilities. The information on mortality is based on death certificates, which are the compulsory legal mechanism for death certification. At the beginning of 1998, all health institutions in the country began to use the ICD-10 for their statistical records.
Quality of the Environment, Drinking Water and Sanitation Services, and Chemical Safety. The National Water Commission, in close collaboration with the Secretariat of Health, is carrying out a national clean water program to ascertain the quality of the water being used for human consumption. The program monitors contaminants and levels of residual chlorine, and seeks solutions to pollution. In the Mexico City metropolitan area, a multimillion-dollar investment program is under way to improve sewerage services and wastewater treatment plants. In 1997, the sectoral analysis of solid waste was concluded in the metropolitan area, yielding extensive information on the need for projects and investment.
A multisectoral program to improve air quality is being carried out in the Mexico City metropolitan area. Its general purpose is to protect health by gradually and permanently reducing the levels of air pollution. Among other measures, the program includes ongoing monitoring of pollutants; compulsory semiannual inspection of motor vehicle emissions; control of emissions from industries, gas stations, and other establishments; factory closings; and restricting the use of automobiles in environmental emergencies. The environmental situation was studied in other large cities, such as Guadalajara and Monterrey, and similar programs to improve air quality are being devised.
All procedures for obtaining authorization to use chemical substances are carried out in the General Environmental Health Directorate of the Secretariat of Health; there is an Intersecretarial Commission to Control the Processing and Use of Pesticides, Fertilizers, and Toxic Substances (CICLOPLAFEST), which coordinates regulatory and control activities, including aspects of marketing, environment, and health.
In 1996 the Secretariat of Health began modernizing health promotion and food control, seeking greater efficiency in fully and comprehensively guaranteeing food safety from production, through distribution, and to consumption.
In 1996, it reported that 92% of salt samples were properly iodized. The fluoridation of salt for domestic consumption dates back to 1994, and its distribution is limited to the regions where the water lacks fluoride. Semiannual doses of vitamin A are administered to children between 6 months and 4 years of age in 1,318 high-risk municipios.
There are food assistance programs for poor families. One of the most prominent, because of its scope, is the PROGRESA program, which in 1997 was under way in 524 municipios in 22 states, covering 400,000 families. The program provided nutritional supplements to pregnant and breast-feeding women, monetary support to mothers to improve nutrition and well-being at home, training in hygiene and caring for family health, and a basic package of health services. The National Institute for Indigenous Culture, with the backing of the Government Secretariats, conducts programs with health, food, education, and basic sanitation activities for 59 ethnic groups located in 1,000 municipios and 9,500 towns and villages.
Inputs for Health
The Secretariat of Health is responsible for overseeing the quality, safety, and efficacy of the drugs that are produced and sold in the country and for regulating the marketing of those drugs. It exercises health surveillance and control basically by issuing licenses and through health registries and verification, analytical control, and evaluation of drugs. There was a major boom in the national pharmaceutical industry, composed of over 140 companies, including the national chamber, which provides over 95% of the drugs needed in the country and also exports its products.
The 1996 modifications to the regulations simplified registration procedures, and a technical cooperation agreement on certifying drug registration was drawn up between the Pan American Health Organization and the Secretariat of Health; furthermore, the obligation to identify drugs by their generic name was incorporated into the General Health Act. A basic set of 50 essential generic drugs that must be available in all medical units at the primary care level was established, along with eight vaccines and two more inputs. Additional initiatives involve the definition of a standard set of allopathic, herbal, and homeopathic drugs and the preparation of a catalog with the recommended drugs for the secondary and tertiary care levels. In 1994, the sixth edition of The Pharmacopeia of the United Mexican States was published (the previous edition was from 1988) and in 1995 and 1997 supplements were published that update the specifications for the manufacture of drugs marketed domestically.
In 1993 there were 421,581 public health workers in the health sector and in 1997 there were 463,611. There was a 14.5% increase in care for the uninsured population (174,942 workers) and 7.4% in social security institutions (288,669 workers). The number of physicians increased similarly (102,125 in 1993 and 116,047 in 1997), as did the number of nursing personnel (146,802 and 161,303), and paramedics (175,895 and 190,877). In 1996, the Secretariat of Health reported that 110,804 people worked in private medicine, of whom 51.4% were professionals and 24% were nursing personnel, and that of the 178,520 physicians in the sector, 2.8% were general practitioners, 47.9% specialists, 5% dentists; the rest were residents, interns, and others.
In 1996, 7,556 graduates (11% more than in the previous year) from the 57 medical schools fulfilled their social service requirement in the National Health System. Graduates of the Military Medical School, the Naval School, and the Air Force School, who do their social service within their own institutions, were exempted. There are 70 approved medical specialties, with an enrollment of 4,400 students for 19961997. The estimated programming for 19971998 is 5,345 graduate students in the health system.
Expenditures and Sectoral Financing
Data from the national accounting system on total health expenditure show that this figure increased through 1994, which is the last year for which figures are available, and that the estimates for 1995 and 1996, based on the total budget allocated for health, held that trend. For 1994, the total expenditure of the National Health System was estimated at between US$ 19.7 and US$ 27.3 million dollars, which are the upper and lower estimates, based on an annual average exchange rate of 3.4 pesos to $US 1. Health expenditure as a percentage of GDP for 1992, 1993, and 1994 reached 5.1%, 5.6%, and 6.1%, respectively, calculated by taking an average of the high and low figures on national health expenditure. The analysis of expenditure according to this source shows that households contribute the most, with 49% of total spending in the period 19921996, compared with employers, who contribute 29% and, finally, the Federal Government, which contributes 22%.
Of the total budget allocated to health, 68% was directed toward curative care (including hospitalization); 15% to administration, policy, and planning; 7% to preventive care; 6% to infrastructure; and 4% to other categories. Between 1992 and 1994 salaries consumed almost half the budget of the institutions with the greatest volume of services48% in IMSS and 50% in the Secretariat of Health; however, in ISSSTE the figure was only 21%, and operating expenditures were the highest (51% of total expenditure). In IMSS, operating expenditures accounted for 35% of the totalthe second highestand in the Secretariat of Health they accounted for 3% of total spending for the same period.
Private expenditure is aimed predominantly at curative care, and its distribution shows that fees account for 35% of the total, drug purchases for 27%, and hospitalizations for 20%. Private out-of-pocket spending exhibited a regressive trend in all objects of expenditureeach year it represented a larger proportion than revenue. Per capita health expenditure for 1995, estimated from the budget executed by public institutions and the total population, was MN$ 499. The absolute values for private expenditure in urban areas are 10 times higher for the households with the highest income than for those with the lowest income (US$ 750 versus US$ 75 per quarter); in rural areas this difference may be 20 times ($1,294 versus $65).
Analysis of the resources utilized between 1992 and 1994 by the national accounting system through the so-called concentrated funds and funds utilized by the various institutions reveals that the sums used by social security institutions, private concerns, and establishments that serve the uninsured population increased. Social security handled the greatest proportion of resources (43%), followed by private concerns (42%). The institutions that treat the uninsured population (which are largely Government entities) used 13% of the total resources.
The health budget continued to grow, while that of the Secretariat of Health had an increase of 58%. It should also be noted that the national budget allocated for social security, based on sectoral reform and changes to the 1997 General Social Security Act, which increased state contributions more than eight times between 1996 and 1997, and increased the State contribution to the institutions total revenue from 4.5% to 28.5%. In the field of disease and maternity, state transfers rose from 5 % to 37%, substituting worker-employer contributions.
External Technical and Financial Cooperation
The Secretariat of Health is working to diversify international cooperation in health. To that end, in 1996 cooperation agreements were signed with the Governments of Cuba and Guatemala, and negotiations began with Belgium, Germany, Japan, the Kingdom of the Netherlands, and the Pacific Rim countries. The cooperation with Central America includes sending Mexican experts, providing fellowships in institutions in the country, and conducting health programs in border areas.
The volume of foreign financial aid in health declined
notably in 1995 (US$ 4 million) with respect to 1990 (US$ 493
million), 1991 (US$ 190 million), and 1992 (US$ 7.8 million)
because of the absence of large projects with international
lending banks. In 1996, a five-year loan in the amount
of US$ 310 million was obtained from the World Bank, of which US$ 60 million was provided that year.
Mexicos financial contributions to international organizations and bilateral health programs together dropped from US$ 25 million in 1992 to US$ 8 million per year between 1992 and 1995 and to US$ 6.5 million in 1996. This decline was especially visible in bilateral cooperation programs, which fell from US$ 17 million in 1992 to less than US$ 1 million in 1996.
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