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      When Health Systems Are Barriers to Health Care: Challenges Faced by Uninsured Mexican Kidney Patients

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          Abstract

          Background

          Chronic Kidney Disease disproportionately affects the poor in Low and Middle Income Countries (LMICs). Mexico exemplifies the difficulties faced in supporting Renal Replacement Therapy (RRT) and providing equitable patient care, despite recent attempts at health reform. The objective of this study is to document the challenges faced by uninsured, poor Mexican families when attempting to access RRT.

          Methods

          The article takes an ethnographic approach, using interviewing and observation to generate detailed accounts of the problems that accompany attempts to secure care. The study, based in the state of Jalisco, comprised interviews with patients, their caregivers, health and social care professionals, among others. Observations were carried out in both clinical and social settings.

          Results

          In the absence of organised health information and stable pathways to renal care, patients and their families work extraordinarily hard and at great expense to secure care in a mixed public-private healthcare system. As part of this work, they must navigate challenging health and social care environments, negotiate treatments and costs, resource and finance healthcare and manage a wide range of formal and informal health information.

          Conclusions

          Examining commonalities across pathways to adequate healthcare reveals major failings in the Mexican system. These systemic problems serve to reproduce and deepen health inequalities. A system, in which the costs of renal care are disproportionately borne by those who can least afford them, faces major difficulties around the sustainability and resourcing of RRTs. Attempts to increase access to renal therapies, therefore, need to take into account the complex social and economic demands this places on those who need access most. This paper further shows that ethnographic studies of the concrete ways in which healthcare is accessed in practice provide important insights into the plight of CKD patients and so constitute an important source of evidence in that effort.

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          Most cited references16

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          Equity and health sector reforms: can low-income countries escape the medical poverty trap?

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            Benchmarking of performance of Mexican states with effective coverage.

            Benchmarking of the performance of states, provinces, or districts in a decentralised health system is important for fostering of accountability, monitoring of progress, identification of determinants of success and failure, and creation of a culture of evidence. The Mexican Ministry of Health has, since 2001, used a benchmarking approach based on the WHO concept of effective coverage of an intervention, which is defined as the proportion of potential health gain that could be delivered by the health system to that which is actually delivered. Using data collection systems, including state representative examination surveys, vital registration, and hospital discharge registries, we have monitored the delivery of 14 interventions for 2005-06. Overall effective coverage ranges from 54.0% in Chiapas, a poor state, to 65.1% in the Federal District. Effective coverage for maternal and child health interventions is substantially higher than that for interventions that target other health problems. Effective coverage for the lowest wealth quintile is 52% compared with 61% for the highest quintile. Effective coverage is closely related to public-health spending per head across states; this relation is stronger for interventions that are not related to maternal and child health than those for maternal and child health. Considerable variation also exists in effective coverage at similar amounts of spending. We discuss the implications of these issues for the further development of the Mexican health-information system. Benchmarking of performance by measuring effective coverage encourages decision-makers to focus on quality service provision, not only service availability. The effective coverage calculation is an important device for health-system stewardship. In adopting this approach, other countries should select interventions to be measured on the basis of the criteria of affordability, effect on population health, effect on health inequalities, and capacity to measure the effects of the intervention. The national institutions undertaking this benchmarking must have the mandate, skills, resources, and independence to succeed.
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              Bridging the divide: global lessons from evidence-based health policy in Mexico.

              During the past 6 years, Mexico has undergone a large-scale transformation of its health system. This paper provides an overview of the main features of the Mexican reform experience. Because of its high degree of social inequality, Mexico is a microcosm of the range of problems that affect countries at all levels of development. Its health system had not kept up with the pressures of the double burden of disease, whereby malnutrition, common infections, and reproductive health problems coexist with non-communicable disease and injury. With half of its population uninsured, Mexico was facing an unacceptable paradox: whereas health is a key factor in the fight against poverty, a large number of families became impoverished by expenditures in health care and drugs. The reform was designed to correct this paradox by introducing a new scheme called Popular Health Insurance (Seguro Popular). This innovative initiative is gradually protecting the 50 million Mexicans, most of them poor, who had until now been excluded from formal social insurance. This paper reports encouraging results in the achievement of the ultimate objective of the reform: universal access to high-quality services with social protection for all.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2013
                22 January 2013
                : 8
                : 1
                : e54380
                Affiliations
                [1 ]Department of Public Health and Policy, The University of Liverpool, Liverpool, United Kingdom
                [2 ]Division of Nephrology, Hospital Civil de Guadalajara, University of Guadalajara Health Sciences Centre, Hospital 278, Jalisco, Mexico
                [3 ]Depto Salud Pública, CUCS, Universidad Guadalajara, Guadalajara, Jalisco, Mexico
                University of Sao Paulo Medical School, Brazil
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Editing, critical reading of drafts: CK CPA FM MIH GGG. Conceived and designed the experiments: CK FM. Performed the experiments: CK FM CPA. Analyzed the data: CK FM CPA. Contributed reagents/materials/analysis tools: CK FM CPA GGG MIH. Wrote the paper: CK.

                Article
                PONE-D-12-27709
                10.1371/journal.pone.0054380
                3551810
                23349868
                7c504f62-e2d5-425e-a682-6fe69d492c7a
                Copyright @ 2013

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 11 September 2012
                : 11 December 2012
                Page count
                Pages: 7
                Funding
                This work was supported by grants from The Darwin Initiative (14-032), The Cambridge Conservation Initiative (CCI 05/10/006) and The Leverhulme Trust (F/01 503/B). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine
                Global Health
                Nephrology
                Chronic Kidney Disease
                Dialysis
                Renal Transplantation
                Non-Clinical Medicine
                Health Economics
                Socioeconomic Aspects of Health
                Public Health
                Behavioral and Social Aspects of Health
                Socioeconomic Aspects of Health
                Social and Behavioral Sciences
                Anthropology
                Economics
                Human Capital
                Economics of Health

                Uncategorized
                Uncategorized

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