- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
Mexico, officially known as the United Mexican States, is a representative democratic republic, made up of 2,456 municipalities distributed throughout 32 autonomous federal states. Mexico City, which recently became the country’s 32nd state, has 16 delegaciones (or boroughs), is the headquarters of the nation’s government and its capital. The country borders the United States of America on the north, and the Republic of Guatemala and Belize on the south.
The country had a population of 119,530,753 in 2016, of which 51.2% were women. The median age was 27 years, the fertility rate was 5.2 per 1,000 women, and life expectancy at birth was 72.6 years for men and 77.8 years for women. Between 1990 and 2015, the Mexican population grew by 48.4%, with a marked increase in the over-15 age group and a reduction in the under-15 population, reflecting the aging of the population over the last two decades as a result of declining fertility and mortality rates.
Between 2010 and 2015, the population increased by 7 million, representing average annual growth of 1.4%. Urban areas account for 77.8% of the population; states with the highest population density are Veracruz, Mexico state, and Mexico City. In 2015, children under age 15 constituted 27.0% of the population, though this figure is projected to decline to 20.7% by 2050. The over-65 population currently represents 7.2% of the population but is projected to increase to 21.5% by 2050 (). Figure 1 shows the changes in Mexico’s population structure between 1990 and 2015.
Figure 1. Population structure, by age and sex, Mexico, 1990 and 2015
Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Population Division. New York; 2015.
Data from the 2015 Inter-Census Survey classifies 1.2% of the population as being of African descent and 21.5% as indigenous. The data show that, among the 3-year-old-and-above population, 6.5% speak an indigenous language. The states with the largest indigenous population at the time of the survey were, in descending order, Oaxaca, Yucatán, Campeche, Quintana Roo, Hidalgo, and Chiapas ().
With a nominal gross domestic product (GDP) of 17,391,045 million Mexican pesos in 2015, the country was one of the world’s 20 largest economies.
Mexico’s economy is largely dominated by the service sector, which represented 62.0% of GDP in 2014, with the primary and secondary sectors accounting for 34.0% and 4.0% of the economy, respectively. The informal economy produced 24.0% of GDP and employed 57.8% of the economically active population, a segment that lacks access to social security ().
Mexico has 12 free trade agreements with 46 countries, of which the United States is Mexico’s largest trading partner. At the time this document was written, the official text of the Trans-Pacific Partnership (TPP) was in the process of being reviewed by the United States Senate, whose approval is required for the agreement to enter into effect ().
In 2015, the wealthiest 1.0% of the population accounted for 21.0% of income nationally (). This income disparity is reflected in the human development index, which was 0.756 in 2013, placing Mexico 71st among the 187 countries ranked. The index was highest in the state of Mexico City (0.830), while the three lowest-ranked states were Oaxaca (0.681), Guerrero (0.679), and Chiapas (0.667) (). Special economic areas were created in 2015 to promote development, by providing tax benefits for investment, instituting special customs procedures, and making infrastructure improvements, among other measures ().
Violence and Security
Between 2012 and 2015, rates of intentional homicide continued to decline, from 18.4 to 13.0 per 100,000 inhabitants. In the last half of 2015, however, this trend reversed, ending the year with a rate of 14.0 per 100,000 inhabitants. Guerrero, at 56.5 per 100,000 inhabitants, had the highest number of intentional homicides ().
Health Policies, Plans, and Programs
The Health Sector Program 2013-2018 (PROSESA), which is based on National Development Plan 2013-2018, is the main planning instrument for the health sector. Through policies designed to affect the social determinants of health, it focuses principally on reducing health inequities between different population groups and improving the conditions of the most vulnerable people ().
Social Determinants of Health
The National Anti-hunger Campaign, a strategy targeting people living in extreme poverty and those with food deficiencies, was implemented in 2013, and consists of 70 federal programs across 1,012 municipalities. An Inter-secretarial Commission was created to carry out the strategy and includes 16 secretariats, the National Commission of Indigenous Peoples, the National Institute of Women, and the National System for Integral Family Development. A 2015 evaluation showed that there had been an increase in access to health services, from 9.2% in 2013 to 32.9% in 2015, with a decline in the rate of food deficiencies, from 100% to 42.5%.
The social inclusion program known as Prospera targets the population living in extreme poverty, providing monetary transfers based on educational, health, nutritional, and income levels. The secretariats of Education, Social Development, and Health, along with the Mexican Social Security Institute (IMSS) and state and municipal governments, participate in the program. Launched in 1988, the name and objectives of the program have changed a number of times. Between 1988 and 2002 it was named Solidaridad (Solidarity); from 2002 to 2007 it was called Progresa (Advancing); and between 2007 and 2014 it was known as Oportunidades (Opportunities). In 2014 it was renamed Prospera, and assumed the mandate of job creation and the inclusion of women in productive activities. Its achievements in the 2010-2014 period include increased school retention rates (a 10-month increase for boys and an 8-month increase for girls) ().
Between 2012 and 2014, the percentage of the population living in poverty rose from 45.5% to 46.2%, while the percentage living in extreme poverty dropped from 9.8% to 9.5%. In rural areas, the poverty index declined from 61.6% to 61.1%, while increasing in urban areas from 40.6 to 41.7% ().
The illiteracy rate in the over-15 age group was 6.9%, but fell to 5.5% in 2015, at which point 4% of males and 6% of females lacked the ability to read or write. Average schooling in 2015 was 9.1 years. The states with the highest illiteracy rates were Chiapas (14.8%) and Guerrero (13.6%), while unemployment rates were 3.9% among economically active men and 4.0% among economically active women ().
In 2010, 76.4% of the population were homeowners. That proportion had declined to 67.7% by 2015, while the proportion of rented dwellings increased from 14.0% to 15.9% ().
The Health System
The public sector social security institutions—the Mexican Social Security Institute (Instituto Mexicano de Seguridad Social, or IMSS), the Institute of Safety and Social Services for Government Workers (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, or ISSSTE), Petróleos Mexicanos, the Secretariat of National Defense, the Secretariat of the Navy, and others—provide services to workers in the economy’s formal sector. The System for Social Protection in Health (SPSS), the Secretariat of Health, the State Health Services, and the IMSS Prospera program serve those not covered by social security, while the private sector provides services for the population that is able to pay ().
Leading Health Challenges
Critical Health Problems
The presence of the vector that transmits dengue has kept the disease in circulation in 30 of the 32 states, with four serotypes. In 2012, Mexico ranked second in the Region of the Americas in number of reported dengue cases ().
In 2014, entomological surveillance was conducted using readings from ovitraps to monitor the vector’s resistance to pesticides in 62 localities across 24 states. The findings made it possible to identify localities with mosquitoes resistant to the pesticides (pyrethroids) used in the national vector control programs. Recommendations were made to replace these substances with carbamates and organophosphorus compounds, in order to target the vector’s susceptibility ().
The first imported case of chikungunya virus fever was identified in June 2014, during epidemiological week 45. The first confirmed case of indigenous transmission, in Chiapas, was also reported that year. Zika virus was detected in an imported case in Querétaro in 2015, while November of that year marked the first recorded autochthonous case, in the state of Nuevo León ().
The first local transmission of cholera since the 1991-2001 epidemic was reported in 2013, with 180 confirmed cases of infection by the toxigenic Vibrio cholerae O1 Ogawa and one reported death. The strains that circulated in 2013 were genetically similar to those in the Caribbean countries—different from the strain found in the 1991-2001 epidemic ().
Neglected Diseases and other Infections Related to Poverty
No human cases of dog-transmitted rabies have occurred since 2006; rabies in the wild, however, still requires control measures. Between 2010 and 2015, nine cases of the latter type occurred in highly marginalized rural municipalities where there was no access to health services ().
Malaria is in the pre-elimination phase in Mexico, although transmission is still present in localities in the northern and western states of Chihuahua, Durango, Jalisco, and Sinaloa—areas where, for a variety of reasons, there is a shortage of health workers, leading to lags in diagnosing and treating patients. In the states of Chiapas, Tabasco, and Quintana Roo, the priority for the National Epidemiological Surveillance System is to control the migratory flow of people from countries in which the causative agent, Plasmodium Falciparum, is endemic. In 2010, the only territory that received malaria-free certification was Tlaxcala ().
The “less than 1 per 10,000 inhabitants” indicator for leprosy recommended by the World Health Organization (WHO) has been achieved. For over five years, the states of Baja California Sur, Puebla, Tabasco, and Tlaxcala have reported no cases. The challenge is to reach elimination at the municipal level. As of the end of 2014, 28 municipalities had prevalence in excess of 1 case per 10,000 inhabitants ().
In 2014, Mexico prepared a technical dossier in support of its request to WHO for external verification of the elimination of onchocerciasis. In 2015, Mexico was the third country in the Region to reach this goal.
River blindness was endemic in five municipalities in Chiapas. Consequently, implementation of the SAFE strategy (Surgery, Antibiotics, Facial cleanliness, and Environmental improvements) began in 2001. By 2013, only 85 cases were reported. With the WHO elimination goal achieved, the request for confirming the elimination of trachoma was initiated in 2014. The epidemiological studies and documentation demonstrating elimination were conducted in 2015, and in the following year the Dossier Review Group visited Mexico and recommended to WHO’s Director-General that the Organization recognize Mexico as the first country in the Region to eliminate river blindness as a public health problem ().
Since 2013, purchase of the drug used to treat leishmaniasis has been guaranteed; thus, treatment coverage has remained above 95.0%. In 2014, weekly reporting of cases of leishmaniasis began, including indications of whether the disease presented in cutaneous or visceral form. Between 2010 and 2015, seven deaths were reported for which the underlying cause was leishmaniasis.
As of 2012, screening for Chagas disease became mandatory in state-run blood transfusion centers, resulting in an increase in the number of cases diagnosed. The next year, the National Center for Preventive Programs and Disease Control created the Specific Action Program 2013-2018 targeting Chagas disease, which included serological screening of children under age 15 in at-risk areas ().
Each year more than 19,000 cases of various forms of tuberculosis occur, including pulmonary TB, which accounts for 80.0% of the total and was the cause of 1,800 to 2,000 annual deaths reported between 2010 and 2015. Incidence varied widely within the country in 2015, ranging from 3 cases per 100,000 inhabitants in Jalisco to 58.5 per 100,000 in Baja California. According to the Secretariat of Health of the State of Baja California, the national focus of attention is the city of Tijuana, which registered 50.9 cases per 100,000 inhabitants in 2010, 57.6 in 2012, and 55.6 in 2015. The diseases and disorders most frequently associated with tuberculosis are diabetes mellitus (19.0%), malnutrition (10.0%), HIV/AIDS (6.0%), and alcoholism (4.0%) ().
According to the General Directorate of Health Information, the maternal mortality ratio (MMR) declined by 21.6% between 2010 and 2015: from 992 deaths per 100,000 live births to 778 deaths per 100,000 live births. The ten states that had MMRs above the national average (34.6) were, in descending order, Chiapas, Mexico City, Nayarit, Guerrero, Oaxaca, Chihuahua, Tabasco, Yucatán, Michoacán, Campeche.
The MMR varies widely within the country. In 2014, according to the National Institute of Statistics, Geography, and Informatics, the states with the highest levels of marginalization—Chiapas, Guerrero, and Oaxaca—had an aggregate MMR of 59 deaths per 100,000 live births (figures based on mother’s residence), with an incidence of 56.8 deaths per 100,000 live births. In 2015, these figures were 57.2 and 54.7 per 100,000 live births, respectively. By contrast, the states with the lowest levels of marginalization—Baja California, Coahuila, Nuevo León, and Mexico City—had an aggregate MMR of 32.3 deaths per 100,000 live births and an incidence of 37.5 deaths per 100,000 live births in 2014. The following year, these values were 33.6 and 39.7 per 100,000, respectively.
Since 2011, the number of birth certificates appearing in the Birth Information Subsystem has provided the denominator for the MMR. This has provided a record of live births with information on mothers, disaggregated by municipality, affiliation, place of birth, schooling, and indigenous language.
Despite progress at the national level, the effort failed to achieve the goal of 22.2 per 100,000 set for 2015 by the Millennium Development Goals, with the figure dropping only as far as 34.6 per 100,000 (Figure 2) ().
Figure 2. Evolution of the maternal mortality ratio, México, 1990-2015
MMR: Maternal mortality ratio. Number of maternal deaths per 100,000 live births; MDG: Millenniium Development Goals.
Source: INEGI/SSA-DGIS, Mortality Database 1990-2015. DGIS, adjusted live births from the Birth Information Subsystem (SINAC) starting in 2011. CONAPO, estimated live births (Population Projections 2005-2030, based on the 2005 count, and Population Projections 2010-2030, based on the 2010 Census+K32). Methodology for adjusting live births and deaths of children under 5 years old, for use calculating indicators. DGIS, 2015.
Female adolescents (15 to 19 years old) showed a fertility rate of 77 live births per 1,000 women in 2013. This indicator, too, varied within the country: Coahuila had a fertility rate of 113 live births per 1,000, followed by Nayarit at 111 per 1,000 and Zacatecas at 105.5 per 1,000, while Mexico City had the lowest adolescent fertility rate (51.8 per 1,000). At the national level, 83.9% of female adolescent hospital admissions were for obstetric causes.
Analysis of the relation between fertility rates and schooling indicated that girls between the ages of 10 and 14 with no schooling had a fertility rate of 11.5 live births per 1,000, while those who had completed primary school had a rate of only 1.7 per 1,000. Indigenous adolescent girls had a rate of 96.7 live births per 1,000, while the rate for the corresponding non-indigenous age group was 68 per 1,000. Analysis of the relation between fertility and degree of marginalization indicated that figures were highest in municipalities with a very high (21.4%) or high (19.5%) degree of marginalization. There was also a positive correlation between marginalization and low age of pregnancy: the highest number of births by women under age 15 occurred in the most marginalized municipalities ().
In 2012, the national prevalence of low height-for-age in children under 5 was 13.6%, a reduction of 1.9% from 2006, when the figure was 15.5%. However, the state of Colima, which had the lowest prevalence of low height-for-age that year, showed an increase from 0 cases in 2006 to 5.2% in 2012. Overall, acute malnutrition declined by 1.6%, while severe malnutrition registered a slight drop—from 0.5% in 2006 to 0.4% in 2012—although it increased by 1.0% in the states of Campeche, Chiapas, and Guerrero, and declined sharply in Aguascalientes, Baja California, and Coahuila. Malnutrition decreased from 0.7% in 2006 to 0.6% in 2012 in rural areas, while it remained at 0.4% in urban areas ().
According to data for 2013 on the overall disease burden, diabetes mellitus was the leading cause of loss of health, and accounted for 7.1% of years of healthy life lost (YHLL)—10.3% if diabetic nephropathy is taken into account. In Mexico, diabetes mellitus is the third most frequent cause of premature death and of years lived with disability (YLD). The state of Guerrero ranks highest in YHLL ().
This ranked second as a cause of loss of health in 2013, accounting for 6.5% of YHLL, 14.5% of all deaths, and 9.7% of premature deaths. The gap between the states with the highest YHLL (Chihuahua) and the lowest (Tlaxcala) was 230.0% ().
In 2013, cerebrovascular diseases were responsible for 6.2% of deaths nationally, and represented 2.4% of YHLL ().
The percentage of HYLL due to hypertension was 6.2% in 2013 in the state of Chiapas and 9.9% in the state of Coahuila. Nationally, 8.0% of YHLL was associated with this disease ().
Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) represented 3.2% of the disease burden in Mexico in 2013. With regard to YHLL, 61.0% was due to premature death and 39.0% to disability. An estimated 10.0% of the population suffered from COPD caused by smoke inhalation (from firewood and as a result of tobacco consumption) ().
Depression was the leading cause of YLD (9.8% of the total), and represented 3.8% of the country’s disease burden; it also ranked fifth as the cause of YHLL ().
In 2015, Mexico had 2.2 physicians per 1,000 inhabitants, with 2.6 nursing professionals (including those in the private sector) attending patients per 1,000 inhabitants. Both indicators were below the average proposed by the Organization for Economic Cooperation and Development (OECD)—3.2 and 9.7 per 1,000, respectively. The allocation of human resources also varied markedly within the country ().
The training of health workers is governed by educational and health regulations at both the undergraduate and graduate levels. The Interinstitutional Commission for the Training of Human Resources in Health serves as an advisory group for the Secretariat of Education, the Secretariat of Health, and other public sector entities. Its functions include issuing assessments of the education of human resources for health, and defining professional profiles.
Medical education is skewed toward specialization: 80.0% of general practitioners enter hospital-based specialties, 9.0% specialize in family medicine, and 3.0% enter specialty fields related to public health. In 2012, the National Residency System included approximately 24,500 residents: 50.0% assigned to the IMSS, 37.0% to the Secretariat of Health, 6.0% to the ISSSTE, 4.0% to Petróleos Mexicanos, and 3.0% to private institutions or university hospitals ().
Health Knowledge, Technology, and Information
According to data from the 2015 Global eHealth Survey, Mexico has no national policy to promote the use of information and communications technology in the health sector. In 2013, however, a National Digital Strategy was implemented to promote the adoption and development of these technologies in health information systems, and to promote telehealth and telemedicine as a means of increasing service coverage. The telehealth program in the health centers of 21 states has led to an increase in the number of consultations: from 12,126 in 2013 to 25,000 in 2014. Moreover, 2016 marked the beginning of the establishment of telehealth programs in 671 medical units, which has benefited approximately 4 million people to date.
The National Board of Science and Technology is responsible for developing science and technology policy. In 2016, spending on scientific research and experimental development increased by 1.7% over its 2015 level, and by 17.5% compared to 2012, representing 0.54% of GDP. The country has a National System of Researchers that covers all scientific disciplines; 1,034 of its members are health sciences researchers.
Both states and institutions serve as primary providers of information; however, their technological platforms differ, as do their levels of connectivity, due to the fragmentation of national health services. The General Directorate of Health Information established a Technological Platform for the formation of the National Basic Health Information System, in order to standardize the criteria and procedures used in processing health data. This initiative was still being rolled out in 2016 ().
The Environment and Human Security
The Secretariat of Environment and Natural Resources presented a National Climate Change Strategy in 2013, regulating environment-related activity nationwide. According to the National Institute of Ecology and Climate Change, average temperatures nationally increased by 0.85ºC, while winter temperatures rose by 1.3ºC. Mathematical models estimate that by the year 2100 temperatures will increase 4ºC in the area bordering the United States, and by between 2.5ºC and 3.5ºC across the rest of the nation. Precipitation declined in the southeast, and as of the mid-century point, an average drop of between 5.0% (2.2 mm/month) and 10.0% (4.5 mm/month) is expected. In 2015, the National Institute of Statistics, Geography, and Informatics estimated that the aggregate cost of atmospheric contamination, water pollution, soil degradation, and solid waste generation accounted for 5.7% of national GDP ().
Deforestation and Soil Degradation
An estimated 500,000 hectares of forest and jungle area are degraded annually, making Mexico the fifth most deforested place in the world. The leading causes are changing land use and illegal logging; the states most affected are, in descending order, Michoacán, Durango, Oaxaca, and Chiapas ().
Air pollution constitutes a health problem in Mexico. As of 2014, 176 stations, distributed across 19 of the country’s states, had been established to monitor atmospheric particulates, ozone, sulfur dioxide, nitrogen dioxide, and carbon monoxide ().
In several states, the levels recorded by at least one monitoring station exceeded the annual limit of PM10 (50 µg/m3) established by regulation: Chihuahua (131 µg/m3), Nuevo Leo´n (88 µg/m3), Jalisco (87 µg/m3), the state of Mexico (82 µg/m3), and Guanajuato (77 µg/m3) ().
Moreover, the average annual limit of PM2.5 (65 µg/m3) was exceeded in Hidalgo (294 µg/m3), Mexico City and its surrounding urban area (83 µg/m3), and the state of Mexico (74 µg/m3). Some states also exceeded the ozone limit of 0.110 ppm for one hour: Mexico City and its surrounding urban area (0.185 ppm), Nuevo León (0.167 ppm), Puebla (0.165 ppm), Guanajuato (0.164 ppm), and Hidalgo (0.145 ppm) ().
In 2010, the Secretariat of Environment and Natural Resources established several management programs to improve air quality and reverse the worsening trend. Mexico City and its metropolitan area were targeted by the Program to Improve Air Quality in the Metropolitan Area of the Valley of Mexico 2011-2020 (ProAire), which includes eight strategies designed to protect health, reduce energy consumption, regulate traffic and number of vehicles, and increase citizen participation.
In 2010, some 86,357 tons of urban solid waste were collected. The states that generated the most waste per day were Mexico City, with 17,043 tons; the state of Mexico, with 8,285 tons; and Jalisco, with 6,524 tons. Of the total, 89.0% was collected unsorted, while 11.0% was sorted into organic and inorganic waste. A full 93.0% of the country’s solid waste is sent to treatment plants; however, there still are dumps in open areas such as roads, glens, ravines, and streambeds ().
Natural and Manmade Disasters
Nine out of ten disasters are caused by hydrometeorological phenomena. In 2013, tropical storms Ingrid and Manuel combined to produce an intense and prolonged storm. Economic losses totaled US$4.816 billion, the second highest figure since the 1985 earthquake. In 2015, Hurricane Patricia, a category 5 storm on the Saffir-Simpson scale, was classified as the most powerful on the planet, but since it affected a low-density population area, it had little economic effect and no victims.
In 2012, a General Civil Defense Act was promulgated, establishing comprehensive risk management as a strategy, requiring states to prepare risk atlases for land use planning. The country has also moved to create instruments such as the Natural Disaster Fund and the Fund for the Prevention of Natural Disasters, which have become a model for reference at the international level. However, the allocated resources focus more on response than prevention. Ten years after the creation of the Safe Hospital Program, 200 hospitals have been certified as safe and prepared to operate during and after a natural or anthropogenic disaster ().
The rate of increase in the over-60 population for 2015-2025 is estimated at 0.039, while the increase in the overall population is estimated to be 0.009. By 2030, a 65-year-old woman will live 19.6 years longer on average, and a man of that age, 17.9 years longer, with some loss of functional capacity expected in the last five years of life ().
The most prevalent illnesses among older people were hypertension (40.0%), diabetes (24.3%), and hypercholesterolemia (20.4%). Depressive symptoms accounted for 17.6% of all disorders, cognitive deterioration for 7.3%, and dementia for 7.9%, although the prevalence of the latter was 19.2% in the over-80 age group. Difficulty seeing, even with devices to assist vision, affected some 16% of those over 60, while difficulty hearing, even with hearing aids, affected 11.3% ().
In 2014, 79.0% of older people were affiliated with some medical service, predominantly the SPSS. Despite this figure, there are, to date, no comprehensive health services programs targeting this age group. According to estimates, 23.0% of hospital care for people between ages 60 and 74 could be prevented through primary health care. During 2014, 176 hospital beds for geriatric care were available, of which 77.0% were provided by the Secretariat of Health, and 18.0% by the IMSS. There were 197 geriatricians registered in the health sector, the majority working in the Secretariat of Health and with the ISSSTE ().
The main destination for Mexican emigrants is the United States. In 2014, 26.6% of immigrants to the United States came from Mexico; 52.0% of them were men. While 7.9 million Mexican immigrants were part of the United States work force, only 3.4 million had obtained United States citizenship. An estimated 32.5% of Mexican immigrants in the United States were living in poverty and lacked medical coverage, though 80.2% of those not considered poor had health insurance.
The fundamental reasons for migrating were to seek work, reunite with family, and study. Thus, Mexico’s Secretariat of Health and Secretariat of Foreign Affairs have opened “health windows” at the country’s consulates in the United States. The initiative is designed to foster prevention and health promotion, and to refer Mexicans to community health centers. In 2015, 1,525,504 people were served, 16.8% through mobile consulates. Some 53.8% of consultations involved counseling on noncommunicable diseases (NCDs), mental health, or birth control.
Mexico is a transit country for Central Americans heading to the United States—a pattern that has marked Mexico’s migratory dynamics, as well as its relations with the countries in the northern triangle of Central America. The number of deportees increased 72.0% between 2014 and 2015; this was accompanied by an increase in the number of unaccompanied migrant children.
Mexico has permitted temporary (90-day) enrollment in the SPSS to allow international migrants to receive health care regardless of migratory status. In view of their migratory situation, however, transient migrants tend to prefer to go to shelters, non-profit organizations, and migrant housing. ().
The Frontera Saludable 2020 (Healthy Border 2020) program is an initiative of the United States-Mexico Border Health Commission created by the two countries’ governments in 2000. The program focuses on care and monitoring for public health problems that arise in border-area populations with shared living conditions. The program’s five priorities are NCDs, infectious diseases, maternal and child health, mental health, and accidents and injuries. Achievements of this binational cooperation include a 50.0% reduction in the incidence of hepatitis A in all of the northern Mexican border states ().
Monitoring the Health System’s Organization, Provision of Care, and Performance
The Secretariat of Health, through the General Health Counsel, which includes the secretariats of Education and Finance, is responsible for creating and executing national policy on social welfare, medical services, and public health, while the National Health Council oversees coordination with the states. The Secretariat of Health is also responsible for regulation, control, and health promotion, through the Federal Commission for Protection against Health Risks.
Health Sector Program 2013-2018 proposes the creation of a National Health System. In April 2016, the National Agreement toward the Universalization of Health Services was adopted, reflecting the intention of moving toward universal medical care. As of September 2016, specific agreements on implementing this agreement had been signed with only eight of the country’s 32 states ().
The percentage of prescription drugs supplied and delivered to those enrolled in the Seguro Popular health care system was 65.2% in 2012, and increased to 69.0% in 2015. Overall, 10.2% of IMSS users were unable to obtain some or all of their prescribed drugs, compared with 24.9% of ISSSTE users and 23.0% of those affiliated with the SPSS under the Secretariat of Health ().
According to the General Health Registry 2014, some 35.4 million people were affiliated with the IMSS, 7 million with ISSSTE, and 49.8 million with SPSS. Nevertheless, the National Counsel for the Evaluation of Social Development Policy reported in 2014 that 18.2% of the population experienced difficulty accessing health services. The absence of a unified system with records of members, along with high labor mobility between the formal and informal sectors, leads to cases of overlapping (double or triple) membership.
In the SPSS, the covered interventions are defined in the Universal Catalog of Health Services (acronym: CAUSES). In 2010, CAUSES listed 275 interventions and 357 drugs; by 2016 this had increased to 285 interventions and 647 drugs. The SPSS has a Fund for Catastrophic Expenditures that supplements CAUSES, and although it covered only 6 interventions in 2004, 61 were covered in 2016. However, CAUSES still does not include heart attack in people over 60 years of age or dialysis following renal failure ().
Total health expenditure represented 6.2% of GDP in 2012; however, in 2015 it declined to 5.6%. Public spending was 51.0% of this amount, less than the average for the OECD countries and less than the level recommended in resolution CD53.R14 of the Pan American Health Organization (6.0%). Administrative expenditures accounted for 8.6% of total health expenditure, while out-of-pocket expenditures represented 4.0% of household spending. In 2012, 4.6% of households in the first income quintile incurred catastrophic expenses, a figure that dropped to 4.5% in 2015 ().
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
In 2014, the average age for the onset of sexual activity was 17.7 years. Although 98.7% of women of childbearing age had knowledge of some method of contraception, only 51.6% used such a method. The unmet need for contraception at the national level was 4.5%; this figure is higher, however, among women between the ages of 15 and 19 (11.5%) and in the indigenous population (7.5%). Pregnant women between the ages of 15 and 49 had, on average, 8.5 consultations during their pregnancies, while 80.0% had their first prenatal checkup during the first trimester. Between 2009 and 2014, 46 out of 100 deliveries in Mexico were cesarean sections, with 54 out of 100 being normal deliveries ().
Between 1999 and 2012, the average duration of breastfeeding was 10 months, with a considerable decline in breastfeeding in rural areas: from 36.9% to 18.5% ().
There was a steady (35.0%) decline in the infant mortality rate (children under 1 year of age) between 2011 and 2014; in 2015 there were 12.5 deaths per 1,000 live births. Mortality in children under 5 declined between 2010 and 2014 (from 17.2 deaths per 1,000 live births to 15.1 deaths per 1,000 live births), and remained at the 2014 level in 2015 ().
Health of Schoolchildren (5 to 9 years of age)
In 2015, the leading causes of morbidity in this age group were acute respiratory infections (28,525 cases per 100,000 inhabitants), followed by intestinal infections and undefined disorders (4,583 cases per 100,000 children), and urinary tract infections (1,663 cases per 100,000 children) ().
Health of Adolescents
The most frequent disorders in this group are acute respiratory illness (11,361 cases per 100,000 adolescents), followed by urinary tract infections and intestinal infections, with 2,713 and 2,397 cases per 100,000 15- to 19-years-olds, respectively ().
Health of the Disabled
Overall, 5.1% of the population suffers from some deterioration in functioning that results in disability. This is due primarily to disease (39.4%), old age (23.0%), and congenital causes (16.0%). In 2014, 54.1% of people with functional deterioration lived in poverty and, as a result, 51.1% showed a lag in educational level. This lag is higher among the disabled population than among those with no physical disability (16.4%) ().
Health of Ethnic and Racial Populations
In the indigenous population, mortality from NCDs was nearly double (16.0%) the national rate, and infant mortality was 62.8%. Of the 6,270,934 people enrolled in health services in 2015, 85.6% were affiliated with SPSS, 9.7% with IMSS, 2.9% with ISSSTE, and 1.9 with another health institution. Deficiencies in access to health services in the states with large indigenous populations were all above 36%, with Puebla, at 41.8%, standing out ().
Half of the deaths in children under I year old were due to disorders in the perinatal period, with 25% due to malformations and chromosomal abnormalities. The third leading cause of death (9%) was flu and pneumonia ().
Malformations and chromosomal abnormalities were the leading cause of death in children under 5 years old, followed by influenza and pneumonia (17.0% of deaths) and motor vehicle accidents (13.1%) ().
Motor vehicle accidents were the leading cause of death (29.9%) in schoolchildren (5–9 years old), followed by malformations and chromosomal anomalies (16.0%), and malignant neoplasms of the lymphatic tissue 10.0% ().
Among male adolescents (ages 10 to 19), the leading cause of death was motor vehicle accidents (16.9%); in females the leading cause was suicide (9.3%). The third leading cause of death also differed by gender: for males it was suicide (8.5%), while for women it was homicide (8.0%) ().
Diabetes mellitus was the leading cause of death in adults over 45 years of age, accounting for 15.0% of deaths. In the 75+ age group, it was the second highest cause of death. In the 20- to 44-year-old group, homicide was the leading cause of death, at 4 deaths per 100,000 inhabitants (see Table 1) ().
Table 1. Proportional mortality by groups of causes, per ICD-10.a Mexico, 2014
|No.||Group of causes||Deaths||%|
|1||Circulatory system diseases||154,347||25.1|
|2||Endocrine, nutritional, and metabolic disorders||107,300||17.4|
|4||External causes of morbidity and of mortality||62,107||10.1|
|5||Digestive system diseases||57,754||9.4|
|6||Respiratory system diseases||54,452||8.8|
|7||Genitourinary system diseases||20,653||3.4|
|8||Infectious and parasitic diseases||16,413||2.7|
|9||Diseases originating in the perinatal period||12,927||2.1|
|10||Nervous system diseases||10,570||1.7|
a According to the International Statistical Classification of Diseases and Related Health Problems, 2010.
Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs Population Division, 2015 revision, New York, 2015.
Regarding vector-borne diseases, 364,014 cases of dengue were reported between 2010 and 2015, with a case fatality rate was 0.52% in 2015. The states of Veracruz, Guerrero, and Chiapas (in order of prevalence) accounted for 49.0% of the cases.
In epidemiological week 39 of 2016 there were 514 confirmed cases of chikungunya, the majority in Veracruz (147), Tamaulipas (77), and Baja California Sur (57).
In epidemiological week 39 of 2016 there were 4,306 confirmed cases of Zika virus, of which 2,087 were pregnant women. The states with the highest number of cases were Veracruz (1,110), Guerrero (748), and Chiapas (609). Five cases of Zika virus with associated complications involving Guillain-Barré syndrome were confirmed in four states: Tabasco (2), Chiapas (1), Guerrero (1), and Quintana Roo (1).
In 2013, 184 cases of cholera were reported: 160 (86.9%) in Hidalgo, 11 (20.2%) in Veracruz, nine (16.5%) in the state of Mexico, two (3.6%) in Mexico City, and two (3.6%) in San Luis Potosí. In epidemiological week 37 of 2016, a hospital in Nayarit reported an isolated cholera case in a child under the age of 19 months ().
All cases of malaria since 2011 have been due to Plasmodium vivax. In that year, 1,106 cases were recorded. Up to epidemiological week 37 of 2016, however, 397 cases had been reported, 86.0% of them in the states of Chiapas and Campeche ().
In terms of neglected diseases, 525 new cases of leprosy were reported in 2011, with an incidence rate of 0.193 per 100,000 inhabitants. The number declined in 2013, with a prevalence of 453 cases and an incidence of 0.149 per 100,000 inhabitants. The incidence dropped by 17.2% between 2014 and 2015 (from 0.174 to 0.144 per 100,000). In 2015, Oaxaca (with cases in nine municipalities) accounted for 57.1% of new cases nationally (), while Sinaloa accounted for 4.0% (seven cases in one municipality), with Nuevo León accounting for 4.0% (seven cases in five municipalities) ().
The number of diagnosed cases of Chagas disease increased between 2010 and 2015 (528 in the former year, 980 cases in the latter) due to the epidemiological surveillance strategy implemented in blood banks ().
In 2010, there were 538 cases of leishmaniasis. The figure cited in the report for 2013 was one of the highest, at 970 cases; in 2015, however, the figure dropped to 447 cases ().
Between 2010 and 2011, there were six cases of human rabies transmitted by vampire bats: two in Nayarit, two in Michoacán, one in Guerrero, and one in Veracruz. A further case, caused by a skunk attack, occurred in the state of Chihuahua. In 2012, a case was reported in Nayarit, and the most recent reported case, caused by the bite of a vampire bat, occurred in September 2016 in Guerrero ().
The national vaccination series includes vaccines for 14 vaccine preventable diseases. For more than ten years, vaccination coverage has been above 95.0% for all vaccines. In 2012, the National Population Counsel adjusted population projections and increased its figure for the number of children under age 5 deemed candidates for immunization. With this change in the denominator, the coverage figure for 2013 fell to 83.0% for the third dose of the diphtheria-pertussis-tetanus (DPT) vaccine. Since then there has been an increase in coverage, reaching 87.0% in 2015. The last case of endemic rubella transmission was recorded in 2010, and the last confirmed case of neonatal tetanus occurred in 2011. On the other hand, the number of cases of pertussis in children under age 5 ranged between 252 and 1,107 in 2011-2015 ().
Chronic, Noncommunicable Diseases
In 2010, mortality from diabetes mellitus was 72.6 per 100,000 inhabitants; in 2015 it was 81.3 per 100,000. The disease affected more women than men (81.8 and 80.9 per 100,000, respectively).
Mortality due to ischemic cardiopathy was 61.9 per 100,000 inhabitants in 2010, and 72.8 per 100,000 in 2015.
Between 2010 and 2014, mortality from cerebrovascular diseases increased from 123.3 per 100,000 inhabitants to 132.2 per 100,000.
Malignant neoplasms also increased between 2010 and 2014, from 61.4 to 64.3 deaths per 100,000 inhabitants, with distribution differing by sex (men 67.3, women 62.8). In 2014, breast cancer accounted for 10.5 deaths per 100,000 inhabitants, prostate cancer for 13.4 per 100,000, and lung cancer for 6.5 per 100,000 ().
Accidents and Violence
In 2014, there were 15,885 confirmed deaths (13.3 deaths per 100,000 inhabitants), representing a slight reduction (0.9%) from the 2013 level. Between 2010 and 2015, road crashes declined 7.6%, with pedestrians accounting for the majority of deaths (51.7%) involving motor vehicles ().
Other Health Problems
Caries affected 90.0% of the population. In the 2- to 10-year-old age group, the average number of deciduous teeth affected by caries was 3.1, while in the 6- to 19-year-old age group, the average number of filled permanent teeth was 3.8. A high proportion of adolescents in the 10- to 14-year-old bracket (82.9%) visited health services for periodontal disease ().
Risk and Protective Factors
Regarding rates of obesity and overweight, 42.6% of 5-11 year olds were overweight, with 35.5% of females in this group being overweight and 37.5% obese; 26.8% of men older than 20 years were overweight or obese. In adults, seven out of ten people were overweight ().
Following the increase on tobacco taxes, the prevalence of tobacco use in adults age 20 and above declined by 2.4% during the 2000-2012 period ().
According to statistics on alcohol consumption, 71.3% of the population had consumed alcohol at some time. The national prevalence of alcohol consumption was 51.4%, with higher rates among men (62.7%) than among women ().
Data also determined that 1.8% of the population had used illegal drugs, and that 0.7% of these were drug-dependent. The average age of initial drug use was 18.8 years (18.5 for men and 20.1 for women), with the highest use in the states of Baja California, Baja California Sur, Sonora, and Sinaloa ().
The data showed that 16.7% of men and 18.1% of women led a sedentary lifestyle and did not engage in the minimum levels of physical activity recommended by WHO. In all age groups, women had a higher prevalence of physical inactivity ().
In order to identify health-related problems and address various threats, there must be adequate channels of communication and coordination, with established priorities, in order to facilitate targeted action for positive solutions with multiple impacts.
The elimination of neglected diseases such as leprosy, malaria, and rabies will only be achieved by establishing common objectives with the sectors involved, in order to address the social determinants of health, national development goals, and the Sustainable Development Goals.
The NCD challenge has led to the formulation of intersectoral policies that integrate promotion of healthy practices, quality of care, regulation, and legislation. The National Agreement to Combat Obesity and Overweight; the National Strategy for Overweight Prevention and Control, Obesity, and Diabetes; implementation of front labeling for high-caloric-content foods; and regulations on the advertising of unhealthy foods during peak viewing hours for children all require mechanisms to evaluate their functioning, along with a stronger regulatory framework for sanctioning noncompliance.
Implementing the National Strategy for the Prevention of Adolescent Pregnancy requires actions that empower adolescent women to exercise their sexual and reproductive rights, and programs that include access to health services adapted to their needs—employing a gender perspective and enlisting youth participation—if efforts to build healthy lives are to be successful.
Maternal mortality will continue to be a high-priority problem. Care should be taken to ensure monitoring and evaluation of current programs, continuity of community transportation brigades, the presence of maternal shelters, access to and coverage of family planning methods, best practices in prenatal care and delivery, and surveillance of cesarean section births. This calls for an intercultural approach to obstetric issues, a focus on gender equality, and actions to promote the exercise of the right to health as a basic human right.
The National Breastfeeding Strategy should establish legal and financial mechanisms, along with intersectoral actions, not only to promote exclusive breastfeeding, but also to put the issue on the domestic agenda as a priority for intersectoral investment in maternal/infant and early childhood health.
The National Accord to Seek Universal Health Services reflects the political determination to serve the population without discrimination with regard to employment status or place of residence. Successful implementation, however, requires good governance, leadership, and institutional effectiveness in the health sphere. It also requires strengthening regulatory entities by providing an integral health information system to assist decision-making and to ensure the appropriate allocation of resources throughout the country, with an emphasis on primary care. Health spending needs to be made more efficient, with greater emphasis on quality of care, and with a system in place to ensure accountability.
Given the rapid growth in the older population, preserving functional capacity should be a priority concern. Health systems need to incorporate specialized services for older people, combat “ageism,” adapt infrastructure to facilitate autonomy for this population, and provide for sustainable long-term care.
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1. As of 17 March 2017, the exchange rate was 19.996 Mexican pesos (MXN) per United States dollar (USD) (http://www.banxico.org.mx/portal-mercado-cambiario/index.html).
2. The information in this section is based on the National Development Plan, the Health Sector Plan 2013-2018, the work plans of the PAHO/WHO country office in Mexico, and discussion groups at the National Health Forum 2016.