Population data come from INEGI^[1], while population data projections come from the World Population Prospects of 2017, the latest demographic estimates and projections prepared by the Population Division of the Department of Economic and Social Affairs of the Secretariat of the United Nations.

[1] In Mexico, the National Institute of Statistics and Geography (Instituto Nacional de Estadística y Geografia, INEGI) is an autonomous public organisation responsible for regulating and coordinating the national system of statistical and geographic information, as well as capturing and disseminating information about the country in terms of territory, resources, population, and the economy. It also coordinates the National Population Census, carried out every 10 years and inter-census surveys every 5 years. The 2010 Census is the most recent and currently is the most complete source of sociodemographic information in the country, describing the demographic, social and economic characteristics of the population. An inter-census survey conducted in 2015 aimed to generate updated statistical information on the population and housing in the country, which maintains historical comparability with national censuses and surveys.

According to the 2015 Inter-census Survey, the total population in Mexico was 119,938,473 persons, of which 51.4% were women and 48.6% men. There are 94.4 men for every 100 women. The median age of the population was 27 years (INEGI, 2015b). The structure of the population reflects the interaction between the birth rate and mortality over time. Comparing the population structure by age in the years 2000 and 2015, we observe the typical pattern followed by ageing societies where the younger population groups decrease (the base starts shrinking) while middle age and older age groups increase. For the first time in 2015, the numbers of people aged 60 years and older is larger than the numbers aged 0 to 4 years old, which indicates a decrease in the proportion of children and an increase in older adults. Older people represent 5% of the total population for the year 2000, and 6.2% in 2010, and 7.2% in 2015 (INEGI, 2015c).

The median age for 2015 was 27 years, a notable increase from the 22 years reported in the year 2000. However, there are notable differences between the different states, reflecting the heterogeneous development, economic transition, and ageing process in each state. For example, in the state of Chiapas, located in the south of the country, the median age is 23 years, while for Mexico City it is 33 (INEGI, 2018b). This heterogeneity is also observed in the aging index^[2]. In 2015, while on average there were 38 adults 60 years and older per 100 children, there were 62 in Mexico City and 24 in the state of Chiapas (González, 2015). 

Old-age dependency ratio

The total dependency ratio^[3] in Mexico in 2015 was 53 older adults per 100 younger individuals. Traditionally international organisations have used this ratio to express how those who are assumed to be not economically independent (the youngest and the oldest population groups) depend on those who are (adolescent and younger adults), it is clear that worldwide this is not necessarily true as both groups have changed significantly. On one hand, young adults in many countries do not move out of the parental household as early as they did in the past, continuing to be dependent on their parents, and on the other hand, large percentages of older adults continue to be physically and economically independent well beyond the age of 60 or 65, and therefore alternative estimations have been considered (United Nations, Department of Economic and Social Affairs, 2017b).

There is variation in the dependency ratio between states within the country, the state of Chiapas has the highest total ratio of dependence, 64 per 100 people of working age, and this can be attributed to a high level of fertility. On the other hand, migration also affects this indicator, since there are states with a high reception of working-age population, such as Quintana Roo, Baja California Sur, and Queretaro. While Mexico City has a low ratio of total dependence, it has the highest dependency ratio in old age compared to the other states of the country (INEGI, 2015c).

Fertility

The rapid demographic transition currently taking place in the country reflects the decline in fertility in the last decades, going from a Global Fertility Rate (GFR) of 5.73 children born alive per women 15 to 49 years old, to a GFR of 1.9 in the year 2000, and 1.7 in 2015, with a total decrease of 31.8% in the number of children born alive (INEGI, 2015b). Socioeconomic situation and women’s education have a differentiated impact on GFR, while women with low or no educational attainment have an average of 3.2 children, women with medium and higher level of education have 1.1 (INEGI, 2015b). However, Mexico had an increment in adolescent pregnancies (among women aged 15 to 19) which grew by almost 6 points between 2009 and 2015 (INEGI, 2015b). Women living in larger urban areas had lower global fertility rates than those living in urban centres with less than 100,000 in habitants (2.0 vs 2.8 respectively) (INEGI, 2015b).

[2] The aging Index is estimated as the ratio of population 60 years and older for every 100 individuals less than 15 years.

[3] For Mexico, INEGI estimates the dependency ratio by dividing total of household members who are not of working age (0 to 14 and 60 years and older) by the total of those considered of working age (15 to 59 years old).

References:

González, K. (2015). Envejecimiento demográfico en México: análisis comparativo entre las entidades federativas. In La Situación Demográfica de México 2015 (pp. 113–129). Consejo Nacional de Población. http://www.conapo.gob.mx/work/models/CONAPO/Resource/2702/06_envejecimiento.pdf

INEGI. (2015a). Censo de Alojamientos de Asistencia Social. https://www.inegi.org.mx/programas/caas/2015/

INEGI. (2015b). Encuesta Intercensal 2015 Estados Unidos Mexicanos. Instituto Nacional de Estadística y Geografía, 1, 85–90. http://internet.contenidos.inegi.org.mx/contenidos/Productos/prod_serv/contenidos/espanol/bvinegi/productos/nueva_estruc/702825078966.pdf

INEGI. (2015c). Mortalidad. Esperanza de vida al nacimiento por entidad federativa.

INEGI. (2018b). INEGI. Datos. https://www.inegi.org.mx/datos/

United Nations, Department of Economic and Social Affairs, P. D. (2017b). World population prospects: the 2017 revision. Volume II: Demographic Profiles, 2, 1–883. https://population.un.org/wpp/publications/Files/WPP2017_Volume-II-Demographic-Profiles.pdf

Geography^[1]

Mexico’s territory covers 1.9 million square kilometres of continental surface, 5,127 square kilometres of island surface, and 3.1 million square kilometres of exclusive zone in the oceans, resulting in a total area exceeding five million squared kilometres. The country shares a 5,000-kilometre border in the North with the United States, and in the South, Mexico shares an 871-kilometre border with Guatemala and a 251-kilometre border with Belize. Geopolitically, Mexico is generally considered to be part of North America.

Almost all the country’s territory is on the North American Plate, with small parts of the Baja California Peninsula in the Northwest on the Pacific and Cocos Plates. Situated atop three of the large tectonic plates that constitute the Earth’s surface, Mexico is one of the most seismologically active regions on Earth. The motions of these plates cause earthquakes and volcanic activity.

Mexican Territory gave rise to numerous mountain systems, mainly the Sierra Madre Oriental, Sierra Madre Occidental, Sierra Madre del Sur, and the Cordillera Neovolcánica or Eje Volcánico Transversal (Trans-Mexican Volcanic Belt). In the country, much of the volcanic activity is related to the subduction zone formed by the tectonic plates of Rivera and Cocos in contact with the great North American plate and has its volcanic expression in the Trans-Mexican Volcanic Belt. These are part of the Pacific Ring of Fire, also called the Circum-Pacific Belt that surrounds the Pacific and gives the area a continuous high volcanic activity.

Population density

According to the 2010 Census (INEGI, 2010b), 78% of the total population lived in urban areas and 22% in rural areas (rural populations are defined as localities with less than 2,500 inhabitants, and urban localities as those with total population of 2,500 or above). In 1950 just under 43% of the population in Mexico lived in urban areas, by 1990 it was 71% and by 2010 this figure increased to almost 78% (INEGI, 2010b).

In 2010 the population density at national level was estimated at 57.3 inhabitants per square kilometre, this increased to 61 by 2015. The capital of the country, Mexico City, stands out with the highest density at 5,967 inhabitants/km2, followed by the state of Mexico, with a density of 724 inhabitants/km². On the other hand, the populations with the lowest number of inhabitants per square kilometre are Baja California Sur with 10 and Durango with 14 inhabitants/km2 (INEGI, 2010b, 2015c).

[1] Data presented is a summary of the following sources: INEGI. 2008. Referencias geográficas y extensión territorial de México, INEGI: Mexico; López de Llergo, R. Principales rasgos geográficos de la República Mexicana. Investigaciones Geográficas, Boletín del Instituto de Geografía, UNAM No. 50, 2003, pp. 26-41; the Mexican Geological System (https://www.sgm.gob.mx/Web/MuseoVirtual/Riesgos-geologicos/Volcanes-de-Mexico.html )

References:

INEGI. (2010b). Principales resultados del Censo de Población y Vivienda 2010. In Principales resultados del Censo de Población y Vivienda 2010. (Vol. 1).

INEGI. (2015c). Mortalidad. Esperanza de vida al nacimiento por entidad federativa.

Spanish is the official language of Mexico but there are also 68 indigenous languages originated in Mexico. The predominant and currently most spoken indigenous languages are Nahuatl (23.4%), Maya (11.6%), Tseltal (7.5%), and Mixteco (7.0%). Those who speak these four languages represent almost 50% of total population that speaks an indigenous language (INEGI, 2015b).

Classification of indigenous populations in national surveys and administrative records is done in two ways. The first asks individuals aged 3 years or above if they speak an indigenous language. In 2015, using this classification, 7.2 million indigenous people were identified, representing 6.6% of the total population of the country (INEGI, 2015b). Although the majority also speaks Spanish, 11.3% of the indigenous population speaks only their indigenous language. The states with the highest proportion of indigenous population are in the South of the country in the states of Oaxaca, Yucatán, and Chiapas, where the indigenous population represents one third of total population (INEGI, 2015b).

Another indicator to classify the indigenous population is self-recognition as indigenous or belonging to an indigenous group, even if an indigenous language is not spoken. Using this indicator, 27.5 million people self-recognise as indigenous or belonging to an indigenous group, which is greater than the number of people who speak an indigenous language (21.5% vs. 6.6% of the population). Another important group comprehends those who consider themselves Afro descendants, which are 1.4 million people, and represent 1.2% of the national population. Belonging to or self-identifying as indigenous or Afro-descendant, is associated with a lower number of years of schooling, especially in women, and limited access to health services (INEGI, 2015b).

References:

INEGI. (2015b). Encuesta Intercensal 2015 Estados Unidos Mexicanos. Instituto Nacional de Estadística y Geografía, 1, 85–90. http://internet.contenidos.inegi.org.mx/contenidos/Productos/prod_serv/contenidos/espanol/bvinegi/productos/nueva_estruc/702825078966.pdf

The 2017 Revision of the World Population Prospects^[1] (United Nations, Department of Economic and Social Affairs, 2017a) has estimated that the total population in Mexico will be 147.5 million in the year 2030, 164.3 in 2050, and 151.5 in 2100.

[1] The World Population Prospects present global demographic profiles of the official United Nations population estimates and projections prepared by the Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. Information from Mexico in the report is obtained through several official data sources such as the Population Census and National Demographic Surveys, among others.

References:

United Nations, Department of Economic and Social Affairs, P. D. (2017a). World Population Prospects. Key findings & advance tables. Working Paper No. ESA/P/WP/248. https://population.un.org/wpp/publications/files/wpp2017_keyfindings.pdf

According to INEGI (INEGI, 2010a), life expectancy in Mexico in the year 2010 was 77 years for women and 71 for men, while 2016 estimates show an increment to 78 and 73 years for women and men, respectively. There are important differences by states, in parallel with socioeconomic development in the country with northern states showing notably higher life expectancy than southern states. For example, in northern states like Nuevo León, Coahuila, and Baja California life expectancy in 2015 was 76.4, 75.7 and 76 years, in southern states like Chiapas, Guerrero and Oaxaca was 72.8, 72.9 and 73, respectively (INEGI, 2015c). The latest World Population Prospects (United Nations, Department of Economic and Social Affairs, 2017b) estimate that by the year 2050 life expectancy in Mexico will be 82.6 years, 84.2 years for women and 81 for men. By 2100 this is expected to increase to and 88.9 years, with 90.1 and 87.7, for men and women, respectively (Table 1).

Table 1. Life expectancy In México for several years and projections to 2100

Source: (United Nations, Department of Economic and Social Affairs, 2017b)

References:

INEGI. (2010a). Banco de indicadores.

INEGI. (2015c). Mortalidad. Esperanza de vida al nacimiento por entidad federativa.

United Nations, Department of Economic and Social Affairs, P. D. (2017b). World population prospects: the 2017 revision. Volume II: Demographic Profiles, 2, 1–883. https://population.un.org/wpp/publications/Files/WPP2017_Volume-II-Demographic-Profiles.pdf

Mexico has a long history of migration patterns including internal and international migration. Internal migration, defined as the displacement of the population within the same territory (within a municipality or federative entity) (INEGI, 2010b), continues to be an important demographic factor in Mexico. According to the 2015 Intercensal Survey (INEGI, 2015b), it is estimated that 17.4% of the residents of Mexico were born in a different entity (state, municipality, or locality) from the one they reside in or were born abroad. There are important differences among states, for example, this percentage in the state of Quintana Roo reaches 54.1% of total population in the state, followed by Baja California with 44.1%. On the other hand, the state of Chiapas presents the lowest percentage of residents reporting being born elsewhere at 3.4% of total population, followed by Guerrero with 4.9%.

Regarding international migration history, starting in the 1940s with the Bracero Program and most importantly from the 1970s onward was largely one of flows to the United States, and today, Mexico is one of the countries with the largest accumulated outwards migration in the world. More recently, Mexico has become an important transit migration country, mainly by Central Americans headed to the U.S. some of which, while they wait on their application/obtaining refugee status in the US, choose to settle temporarily or permanently within the country (INEGI, 2010b).

In 2015, just over one million people living in Mexico reported being born in another country, which is equivalent to 0.84% of the total population of the country. Showing an increasing trend in foreign immigration, this percentage has doubled in the last fifteen years (INEGI, 2015b). According to the International Migration Outlook 2017 (OECD, 2017b) immigration to Mexico increased sharply over the past two decades, while the inter-census survey (INEGI, 2015b) indicates that the number of foreign-born population has reached the level of one million, double the number than in 2000. In 2015, 34,500 foreigners were issued a new permanent resident permit, and it is estimated that 377,000 Central Americans migrants transited through Mexico in route to the USA (OECD, 2017b).

References:

INEGI. (2010b). Principales resultados del Censo de Población y Vivienda 2010. In Principales resultados del Censo de Población y Vivienda 2010. (Vol. 1).

INEGI. (2015b). Encuesta Intercensal 2015 Estados Unidos Mexicanos. Instituto Nacional de Estadística y Geografía, 1, 85–90. http://internet.contenidos.inegi.org.mx/contenidos/Productos/prod_serv/contenidos/espanol/bvinegi/productos/nueva_estruc/702825078966.pdf

OECD. (2017b). “Mexico” in International Migration Outlook 2017. https://dx.doi.org/10.1787/migr_outlook-2017-29-en

Global Burden of disease in Mexico

In the recent decades, Mexico has experienced an epidemiological transition, while common infections, in particular respiratory and intestinal tracts, are the most frequent causes of morbidity, chronic degenerative diseases such as diabetes and hypertension are reasons for seeking attention, especially in older ages.

Table 2 presents the first ten causes of disease in Mexico by age group in 2017, reported by the General Directorate of Epidemiology (DGE) agency of the Secretary of Health. The most frequent causes are acute respiratory infections, followed by intestinal infections, especially in the young population (>1-24 years of age) (DGE, 2018).

Table 2. Ten main causes of morbidity by age group. Mexico 2017.

Source: (Dirección General de Epidemiología & Secretaria de Salud, 2018).

(Notes: ICD-10: International Classification of Disease (https://icd.who.int/browse10/2010/en). Data show rates per 100 thousand inhabitants. Numbers in parenthesis in each cell indicate the place in which that specific disease is located within the ten main causes of disease in a specific age group).

In relation to mortality, diabetes, heart and cerebrovascular disease, cirrhosis, and cancer dominate the mortality picture, particularly among adults over the age of 40. In contrast, external injuries are the leading causes of death among young people aged 15-19, with homicides, traffic accidents and suicides being the most prominent (Secretaría de Salud, 2015b).

According to global burden of disease reports, in Mexico, the main causes of death have been remained unchanged between 2007-2017 (ischemic heart disease, chronic kidney disease, and diabetes), while interpersonal violence increased its relevance moving to the fourth cause of death. Relevance of neonatal disorders and road injuries decreased their relevance as main causes of Years of Life Lost (YLLs), while interpersonal violence, moved up and now represents the first cause of YLLs. Diabetes and headache disorders remain unchanged as causes of Years Lived with Disability (YLDs), while low back pain moved up to the third place.

In 2013, updated estimations of Burden of Disease in Mexico were generated by age groups, sex, regions of the country (North, Centre, and South), by major disease group (communicable, non-communicable, and injuries) (Lozano Asencio et al., 2013). Main results show a heterogeneous situation of the GBD in Mexico, divided into health risks and problems by different regions in the country. The Southern states, which lag in social development, show prevailing health problems related to transmissible diseases linked to nutrition, housing, and education disparities, whereas the Northern states of the country present an advanced epidemiological transition accompanied by much higher rates of violence. Table 3 shows the main causes of years of life lost due to premature death for all ages, by region, where it is observed that they are a combination of chronic diseases, infectious diseases, and injuries.

Taking mortality rates into account, regardless of the region of the country, non-communicable diseases predominate, accounting for 63% of health losses due to premature death. However, in relation to communicable diseases, nutrition and reproduction, there are important differences by region, as the risk of dying prematurely from these causes is 36% higher in the South than in the North of the country. In contrast, with intentional and accidental injuries, the risk of premature loss of life is 92% higher (almost double) for people living in the North compared to those living in the South.

Table 3 Main causes of years of life lost to premature death in Mexico by region.

Source: (Lozano Asencio et al., 2014, p. 33)

Mexico is therefore a heterogeneous country in relation to its health problems. Three important characteristics (Lozano Asencio et al., 2014) are identified as:

• A social gap in the South where communicable health problems remain as many are linked to basic deficiencies in housing, nutrition, education, and access to health services.
• A risk transition process, where non-communicable diseases predominate in any region of the country and in all age groups.
• A region living in situations of extreme violence, where the risk of intentional and accidental injuries is almost twofold among people living in the North, compared to those living in the South.

References:

Dirección General de Epidemiología, & Secretaria de Salud (DGE). (2018). Anuario de morbilidad 1984-2017.

Lozano Asencio, R., Gómez Dantés, H., Pelcastre Villafuerte, B. E., Montañez, J. C., Campuzano, J. C., Franco, F., & González Vilchis, J. J. (2013). Carga de la Enfermedad en México 1990-2010: Nuevos resultados y desafíos Contenido. 122.

Lozano Asencio, R., Gómez-Dantés, H., Pelcastre, B., Ruelas, M., Montañez, J., Campuzano, J., Franco, F., & González, J. (2014). Carga de la enfermedad en México 1990-2010. Nuevos resultados y desafíos (Vol. 91). Instituto Nacional de Salud Pública, Secretaría de Salud, 2014.

Secretaría de Salud. (2015b). Prontuario de la Salud. Informe sobre la salud de los Mexicanos 2015.

Diabetes

The main non-communicable diseases in Mexico are diabetes, hypertension, and obesity. The prevalence of diabetes reached very high levels at the beginning of this century and has been steadily increasing. In 2000, 6.5% of the population aged 20 or over was diagnosed as diabetic, rising to 7.5% in 2006 and to 9.4% in 2016 (Rojas-Martínez et al., 2017).

In an actualisation of the GBD reported in 2016, in Mexico diabetes was the first cause of YLDs, similar to other countries in Latin America like Barbados, Jamaica, Puerto Rico, Saint Vincent and the Grenadines, Trinidad and Tobago, and the Virgin Islands (Vos et al., 2016). This emphasises the necessity of intensive long-term management to prevent fatal and disabling complications in those countries.

The National Health and Nutrition Survey (ENSANUT), a national probabilistic survey, reported in 2016 that 9.4% of the adults interviewed (10.3% of women and 8.4% of men), reported a diagnosis of diabetes by a physician or other health professionals (Table 4), a slight increase from ENSANUT 2012’s reported prevalence of 9.2%, and 7.25% in ENSANUT 2006. The majority (87.8%) reported receiving medical treatment to control their illness. Most people with a previous medical diagnosis of diabetes were between 60 and 70 years of age (INSP & Secretaría de Salud, 2016).

Table 4. Percentage of adults who reported having received a prior medical diagnosis of diabetes

(Source: ENSANUT MC, 2016)

The report of diabetes by previous medical diagnosis was higher among women than among men, both nationally (10.3% vs 8.4%), in urban (10.5% vs 8.2%) or rural (9.5% vs 8.9%) localities (INSP & Secretaría de Salud, 2016).

Hypertension

According to ENSANUT 2016 (Campos-nonato et al., 2018), current prevalence of hypertension[1] is 25.5%, although 40.0% of these did not know they had hypertension before the survey. Of the total adults 20 years and older with a previous diagnosis of hypertension who were receiving treatment, only 45.6% had controlled or normal hypertension (SBP≤140mmHg; DBP≤90mmHg) when measured at the time of the survey. By sex, 26.1% of men and 24.9% of women reported having hypertension. The prevalence was highest among people aged 70 to 79 years. In ENSANUT 2016, no statistically significant differences were observed in the prevalence of arterial hypertension between geographic regions, nor between rural and urban localities (INSP & Secretaría de Salud, 2016).

Table 5. Prevalence of hypertension, by sex and age group. Mexico 2015

Source: (Campos-nonato et al., 2018)

Obesity

In Mexico it is considered that there is an epidemic of being overweight and obesity, which began in the 90’s and has presented a growing trend, especially in children under 20 (Secretaría de Salud, 2015b). By sex, the prevalence of obesity (BMI ≥30 kg/m2) is higher in females (38.6%, 95% CI 36.1, 41.2) than males (27.7%, 95% CI 23.7, 32.1) (Secretaría de Salud, 2015b).

The prevalence of abdominal obesity (defined as having a waist circumference in men ≥90 cm and in women ≥80 cm) in adults 20 years of age or older is 76.6%. Prevalence is higher for women than for men and increases with age, except for the very old (INSP & Secretaría de Salud, 2016).

Table 6. Prevalence of abdominal obesity* in adults 20 years of age or older, categorised by sex and age groups

Source: (Secretaría de Salud, 2015b)

According to national data, the combined prevalence of being overweight and obese in the school-age population in 2016 was 33.2%. The prevalence of being overweight was 17.9% and obesity 15.3%. In contrast with the adult population, a higher prevalence of obesity was observed in boys 18.3%, compared to girls 12.2% (INSP & Secretaría de Salud, 2016).

[1] Hypertension is classified as those who reported have been previously given a diagnosis of hypertension by a health professional or that presented, when interviewed, measures of systolic blood pressure (SBP) ≥140mmHg and diastolic blood pressure ≥90mmHg.

References:

Campos-nonato, I., Hernández-Barrera, L., Pedroza-Tobías, A., Medina, C., & Barquera, S. (2018). Hipertensión arterial en adultos mexicanos: prevalencia, diagnóstico y tipo de tratamiento. Ensanut MC 2016. Salud Publica de Mexico, 60(3), 233–243. https://doi.org/10.21149/8813

INSP, & Secretaría de Salud. (2016). Encuesta Nacional de Salud y Nutrición de Medio Camino, 2016 (Vol. 2016). https://doi.org/10.1111/acem.12546

Rojas-Martínez, R., Basto-Abreu, A., Aguilar-Salinas, C. A., Zárate-Rojas, E., Villalpando, S., & Barrientos-Gutiérrez, T. (2017). Prevalencia de diabetes por diagnóstico médico previo en México. Salud Pública de México, 60(3). https://doi.org/10.21149/8566

Secretaría de Salud. (2015b). Prontuario de la Salud. Informe sobre la salud de los Mexicanos 2015.

Vos, T., Allen, C., Arora, M., Barber, R. M., Brown, A., Carter, A., Casey, D. C., Charlson, F. J., Chen, A. Z., Coggeshall, M., Cornaby, L., Dandona, L., Dicker, D. J., Dilegge, T., Erskine, H. E., Ferrari, A. J., Fitzmaurice, C., Fleming, T., Forouzanfar, M. H., … Zuhlke, L. J. (2016). Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 388(10053), 1545–1602. https://doi.org/10.1016/S0140-6736(16)31678-6

Infectious diseases continue to represent a Public Health problem in Mexico, because of emerging and re-emerging infections, due to increased population mobility, overcrowding, inadequate basic sanitation, social marginalization, modification in the composition or behaviour of some infectious agents, drug resistance, and comorbidity, particularly acute respiratory, intestinal, and urinary tract infection (Soto-Estrada et al., 2016). Communicable diseases are major causes of premature death such as acute respiratory infections, and in some age groups, AIDS and tuberculosis appear as relevant causes along with Chagas disease, which stands out as a major cause of disability in older adults (Lozano Asencio et al., 2014).

HIV

Mexico has a National AIDS Cases Registry, which is the main tool for monitoring this epidemic in the country, which has led to an improvement in the registration of cases, as well as greater access to antiretroviral treatments, which in turn have been improving, giving people with HIV/AIDS a greater opportunity to live longer (Secretaría de Salud, 2015b).

The most recent epidemiologic data on HIV comes from the ENSANUT 2012 where in addition to survey questions, spot-blood tests for HIV (Western-blot) were taken from a sample of population 15-49. A prevalence of 0.15% was identified (95% CI 0.09-0.21); 0.07% (95% CI 0.03-0.11) in women, and 0.24% (95% CI 0.11-0.36) in men. The HIV positive population are more likely to be young men, with a higher socioeconomic level in relation to the general population and are also more likely to be covered by social security (49.9% in HIV positive versus 34.5% in non-positive) (Gutiérrez et al. 2014).

It was estimated that approximately 104,000 people 15 to 49 years were living with HIV in Mexico in 2012, and of these, 75% are men. Of those tested, 50.6% did not know their serological status before being tested as part of the survey. The estimated prevalence among individuals 15 to 49 years was adjusted both for selection bias correction and the usual difficulty to capture some population groups, which resulted in a slightly higher HIV serology of 0.23% and an estimated number of people with HIV of 140,000 (Gutiérrez et al., 2014).

Table 7. Serology prevalence of HIV, in population 15 to 49 years. Mexico, 2012

Source: ENSANUT, 2012

Tuberculosis and other infectious diseases

In Mexico, the Ministry of Health estimates that there are at least 2,000 to 2,500 deaths per year due to tuberculosis, as well as more than 19,000 new cases annually. Tuberculosis affects groups of all ages, but it predominates in young people and in mid-life. Not all treated cases of tuberculosis should be considered officially reported, because mistakes in clinical records should be considered, such as mix the prevalent cases (therapeutic failures, relapses, and chronic or multi-drug resistant cases) with the incidents, so it continues to be a major public health problem (Báez-saldaña et al., 2003).

Other relevant diseases are rotavirus, which is a virus that causes diarrheal disease, especially in infants between 6 and 24 months of age. Since 2006, children in Mexico have free access to rotavirus vaccine because it has been included in the basic vaccination table. Pneumonia causes bacterial meningitis in adults and is the second most common cause of meningitis in children over 2 years of age.

Vector-borne diseases

It is estimated that close to 60% of the national territory presents favourable conditions for the proliferation of insects that transmit pathogens. Malaria is about to be eradicated, dengue persists, while chikungunya and zika have recently appeared. In relation to dengue fever, it has increased in the last years in 30 states of the country. Finally, the Chagas disease, a condition caused by the protozoan parasite Trypanosoma cruzi, is among the top ten causes of life years associated with disability in older adults (Lozano Asencio et al., 2013).

References:

Báez-saldaña, A. R., Cm, M., Pérez-padilla, J. R., Salazar-lezama, M. A., Ar, B., Jr, P., & Ma, S. (2003). Discrepancias entre los datos ofrecidos por la Secretaría de Salud y la Organización Mundial de la Salud sobre tuberculosis en México , 1981-1998. 45(2).

Gutiérrez, J. P., Sucilla-Pérez, H., Conde-González, C. J., Izazola, J. A., Romero-Martínez, M., & Hernández-ávila, M. (2014). Seroprevalencia de VIH en población mexicana de entre 15 y 49 años: Resultados de la Ensanut 2012. Salud Publica de Mexico, 56(4), 323–332. https://saludpublica.mx/index.php/spm/article/view/7352/10303

Lozano Asencio, R., Gómez Dantés, H., Pelcastre Villafuerte, B. E., Montañez, J. C., Campuzano, J. C., Franco, F., & González Vilchis, J. J. (2013). Carga de la Enfermedad en México 1990-2010: Nuevos resultados y desafíos Contenido. 122.

Lozano Asencio, R., Gómez-Dantés, H., Pelcastre, B., Ruelas, M., Montañez, J., Campuzano, J., Franco, F., & González, J. (2014). Carga de la enfermedad en México 1990-2010. Nuevos resultados y desafíos (Vol. 91). Instituto Nacional de Salud Pública, Secretaría de Salud, 2014.

Secretaría de Salud. (2015b). Prontuario de la Salud. Informe sobre la salud de los Mexicanos 2015.

Soto-Estrada, G., Moreno-Altamirano, L., Pahua Díaz, D., Soto-Estrada, G., Moreno-Altamirano, L., & Pahua Díaz, D. (2016). Panorama epidemiológico de México, principales causas de morbilidad y mortalidad. Revista de La Facultad de Medicina (México), 59(6), 8–22. http://www.scielo.org.mx/pdf/facmed/v59n6/2448-4865-facmed-59-06-8.pdf

Accidents and violence

In 2013, there was a reported rate of 13 deaths due to traffic accidents and 18.3 homicide deaths, both per 100 inhabitants. Types of vehicles studied in traffic accidents are bicycles, motorcycles, and motor vehicles. Also included are hit-and-run vehicles, which account for 41% of the load associated with all traffic accidents.

The risk of premature loss of life from intentional and accidental injury is 92% (almost double) higher for people living in the north than those living in the south (Soto-Estrada et al., 2016).

According to data reported by ENSANUT 2012, from a survey among adolescents (10-19 years) and young adults (20-29 years), 4% reported health damages or health issues due to interpersonal violence. This would represent approximately 1,712,485 cases at national level. The prevalence of interpersonal violence is higher among men (5.0%) than women (3.3%) and the most vulnerable age group is that of men aged 20 to 29 years. For women, the household is still the space where one of the highest proportions of violence is suffered, with one in four women (24.5%) reporting violent incidents in their own home (Valdez-Santiago et al., 2013).

Table 8. Prevalence of young people who suffered damage to their health due to interpersonal violence

Source: Own estimates from ENSANUT 2012 data

Disability and Disability-free life expectancy

Indicators of healthy life expectancy are useful to monitor effectively whether the years of life gained with the increase in life expectancy are spent in a good state of health or not. In Mexico there are a few sources of data in older adults: the 10/66 study, the Mexican Health, the Aging Survey (MHAS), and SAGE.

The healthy life expectancy is the estimate expected years of life in good health for persons at a given age. In 2010-2015 life expectancy was 74 years for men, but healthy life expectancy was 65 years, while for women was 78.9 and 69 respectively, which means that there are almost 10 years with disease. This may be related to two factors: the decrease in premature mortality, which has an important effect on improving life expectancy at birth, and the increase in people with disabling sequelae. In other words, there are fewer premature deaths but more disability.

The 10/66 study is a large cohort study, examining health, social, and biological characteristics of older adults living in eight countries (China, Cuba, Dominical Republic, India, Mexico, Peru, Puerto Rico, and Venezuela). In this study, disability was assessed using the more than 15 disability days in the past (assessed through WHODAS 2.0 (WHO, 2010)) month criteria, and dependence was assessed by needing some or much care (Prina et al., 2019). Table 9 reports the prevalence of disability and dependence in the total sample (n=2002), both increased with older age, and women had higher prevalence in the oldest age group.

 Table 9. Prevalence of disability and dependence, stratified by age group and sex.

Source: (Prina et al., 2019)

Table 10 reports estimated disability-free life expectancy, which gradually declines with increasing age. Women tend to spend a longer period of time with disability and the proportion of remaining life spent disability-free is lower than among men. In the same way, dependence-free life expectancy, which is fundamental to achieve active life expectancy, also declined with increasing age, women had longer periods of dependence.

Table 10. Disability free life expectancy and proportion of remaining life spent in disability and dependence free, by age group and sex

Source: (Prina et al., 2019)

While in the 10/66 study, Mexico reports the highest disability free life expectancy at age 65 (compared with China, Cuba, the Dominican Republic, India, Peru, Puerto Rico, and Venezuela).

In 2018, Payne reported estimations of the rates of transitions between life without disability, life with disability, and death with data from longitudinal surveys of older adult populations in Costa Rica, Mexico, Puerto Rico, and the United States populations, and he reported that the growing older adult populations in Costa Rica, Puerto Rico, and Mexico are not experiencing a substantially higher burden of disability than the disability experienced by people of the same age in the United States (Payne, 2018).

For all these reasons, Mexico must direct its efforts to address the problems associated with the gap that still exists in relation to infectious diseases, the increase in chronic degenerative diseases and those related to injuries and violence, as well as disability and dependence that arise from all of them.

References:

Payne, C. F. (2018). Aging in the Americas: Disability-free Life Expectancy among Adults Aged 65 and Older in the United States, Costa Rica, Mexico, and Puerto Rico. Journals of Gerontology – Series B Psychological Sciences and Social Sciences, 73(2), 337–348. https://doi.org/10.1093/geronb/gbv076

Prina, A., Wu, Y., Kralj, C., Acosta, D., Acosta, I., Guerra, M., Huang, Y., Amuthavalli, T., Jimenez-Velazquez, I., Liu, Z., Llibre Rodriguez, J., Salas, A., Sosa, A., & Prince, M. (2019). Dependence- and Disability-Free Life Expectancy Across Eight Low- and Middle-Income Countries: A 10/66 Study. Journal of Aging and Health. https://doi.org/10.1093/geronb/gbv076

Soto-Estrada, G., Moreno-Altamirano, L., Pahua Díaz, D., Soto-Estrada, G., Moreno-Altamirano, L., & Pahua Díaz, D. (2016). Panorama epidemiológico de México, principales causas de morbilidad y mortalidad. Revista de La Facultad de Medicina (México), 59(6), 8–22. http://www.scielo.org.mx/pdf/facmed/v59n6/2448-4865-facmed-59-06-8.pdf

Valdez-Santiago, R., Hidalgo-Solórzano, E., Mojarro-íñiguez, M., Rivera-Rivera, L., & Ramos-Lira, L. (2013). Violencia interpersonal en jóvenes mexicanos y oportunidades de prevención. Salud Publica de Mexico, 55(SUPPL.2), 259–266. http://www.scielo.org.mx/pdf/spm/v55s2/v55s2a24.pdf

WHO. (2010). WHODAS 2.0 12-item version, interviewer-administered.

Mexico is among the ten largest countries in the world, it is the second largest economy in Latin America after Brazil. It ranks as the 15th world economy, according to its Gross Domestic Product (GDP) at exchange rate, and the 11th in terms of GDP at Purchasing Power Parity (PPP). It has been classified as an upper middle-income country by the World Bank (CEPAL, 2018; OECD, 2017a; Banco Mundial, 2019). The Mexican currency is the Mexican Peso (MXN) and the current exchange rate by the Central Bank as of 18 January 2019 is 19.1 pesos per USD and 21.7 pesos per Euro (Banco de México, 2018).

Mexico has an open economy, oriented to exports and highly regulated free trade agreements with more than 40 countries including the European Union, Japan, Central and South America, as well as the North American Free Trade Agreement (NAFTA) with the United States and Canada, which is currently under revision and negotiation. This has put Mexico within the highest 10 export economies in the world. The country’s growth is projected to increase from 2.0% in 2017 to 2.2% in 2018 and 2.5% in 2019, supported by higher US growth. However, the growth forecast was lower than expected in April 2018, reflecting the impact on investment and domestic demand of prolonged uncertainty related to trade (International Monetary Fund, 2018).

While Mexico has been a member of the OECD since 1994, its per capita Gross National Income is the lowest among the Organisation for Economic Co-operation and Development (OECD) members –58% below the OECD average in 2016, in terms of Purchasing Power Parity. Compared to upper middle-income countries (UMICs), however, Mexico’s per capita Gross National Income (GNI) is 7% above the average of that group (The World Bank, 2019).

References:

Banco de México. (2018). Mercado cambiario, tipo de cambio, Banco de México.

Banco Mundial. (2019). México: proyectos.

CEPAL. (2018). Estudio Económico de América Latina y el Caribe, 2018 (LC/PUB.2018/17-P).

International Monetary Fund. (2018). World Economic Outlook Challenges to Steady Growth.

OCDE. (2017a). Estudios Económicos de la OCDE México (OCDE Publishing, Ed.). OCDE Publishing. https://www.oecd.org/eco/surveys/mexico-2017-OECD-Estudios-economicos-de-la-ocde-vision-general.pdf

The World Bank. (2019). Mexico Data. https://data.worldbank.org/country/mexico

The services (tertiary) sector is the largest part of the economy, representing 61% of GDP in the third semester of 2018. The secondary sector (comprising mining, manufacture, construction, gas, and electricity) and the primary sector (agriculture, fisheries, cattle and livestock, and forestry) represent 31.4% and 3.1% of GDP, respectively[1]. Of the primary sector, 65% corresponds to livestock activities. The primary sector is one of the sectors, which receives the least foreign investment and, while it continues to develop, it has lagged compared to other sectors of the economy.

Oil production[2] is one of the main components of the secondary sector. To date, Mexican oils (Petroleos Mexicanos), PEMEX is the largest company in Mexico, the largest tax contributor, and remains as the main source of public funds – around 30% to 40% depending on the international price of oil barrel. However, PEMEX also has a large debt (due to net losses). Within the secondary sector, the manufacture industry and construction are two areas with large participation in the overall economy, representing with 54.7% and 24.3% of the sector, respectively. Within manufacturing, the auto-industry, largely concentrated on exports, represents 22% of all manufactures and 12% of total product within this sector (INEGI, 2018d).

The third (services) sector includes commerce, restaurants, hotels, transportation, communications, financial and personal services, as well as health and education. It has grown at an average annual increase rate of 3% in the period 2003-2016. The sector is comprised by very small businesses, largely self-employed, as well as large companies and multinationals using cutting-edge technology (CEFP, 2018; INEGI, 2018d).

Despite the most recent global economic crisis, decreasing oil prices and government income, Mexico’s economy has maintained a slight economic growth. This economic performance has been supported by internal demand and is the result of important structural reforms and solid macroeconomic policies that have generated low or decreasing inflation and interest rates, and increased per capita income (OECD, 2017a).

[1] Producto Interno Bruto, PIB

[2] Production remained a government monopoly through the company Petroleos Mexicanos (PEMEX) until recent reforms in 2013 when production was open to private investment.

References:

CEFP. (2018). Evolución de la Actividad Productiva Nacional y de las Entidades Federativas 2003-2018. https://www.cefp.gob.mx/publicaciones/documento/2018/cefp0222018.pdf

INEGI. (2018d). Sistema de Cuentas Nacionales de México. Producto Interno Bruto Trimestral. Año Base 2013. Tabulados básicos. https://www.inegi.org.mx/programas/pib/2013/#Documentacion

OECD. (2017a). Estudios Económicos de la OCDE México (OCDE Publishing, Ed.). OCDE Publishing. https://www.oecd.org/eco/surveys/mexico-2017-OECD-Estudios-economicos-de-la-ocde-vision-general.pdf

Household debt

The financial position of households[1] in Mexico has maintained a growing trend in recent years. As of June 2018, the increase registered in the last 5 years represented 5% of the GDP, with a similar growth in savings, both voluntary and mandatory. This result occurred during the same period in which the indebtedness of households also increased by 2% of the GDP, driven mainly by the expansion of credit to consumption and financial inclusion (Banco de México, 2018).

As financial inclusion increases in Mexico, household debt[2] has increased in the past decade. According to data from the Central Bank, household debt reached 16% as a proportion of Gross Domestic Product (GDP) in 2018. This represents the highest level since the beginning of recording this information in 1994. In contrast, in 2000 one of the lowest levels of household debt in recent years were reported at 8% of total GDP (Banco de México, 2018).

Regarding household debt in 2018, approximately 60% of the total financing received corresponded to mortgage loans and 40% to consumer credit. Most mortgages are granted through the two main social security institutions’ housing institutions INFONAVIT (for private sector workers) and FOVISSSTE (for public sector employees). These two institutions granted 64.9% of all mortgages, followed by banks with close to 34% of the total. In terms of total consumption and debt/credit, credit cards represent the most frequent source of consumer credit. By June 2018, 17.4 million people in Mexico had at least one credit card. This number is 3.4% higher than the number of people with at least on credit care in the same month in 2017 (Banco de México, 2018).

While household debt has increased over the past decade, it is not considered to a high risk as it is thought that this occurs in an environment where household income has improved because of real wage recovery and higher employment.

Public Debt

Between 2012 and 2018, the growth of total foreign debt, has been very important and reflects a difference of 9 percentage points of GDP, increasing from 28% to 37%. As a percentage of GDP, total external debt in 2018 is very similar to that of 1996, which was the year of the last major financial crisis experienced in the country. Of the total external debt in 2018, which amounted to 446 million US, 306.4 million USD (26% of GDP) are public external debt (publicly/government guaranteed), and 139.7 million USD (12% of GDP) are private sector external debt (not guaranteed by the government). For that same year, the level of international reserves reported by the Central Bank was 176,648.6 million USD and total revenue from exports was 450,572.2 million USD (Banco de Mexico, 2018; Secretaría de Hacienda y Crédito Público, 2018, 2019).

In terms of monetary data (balance of public debt), by end of February 2019, the Historical Balance of the Requirements of the Public Sector Finance (SHRFSP) amounted to 10,499,200,000 pesos. The internal component of the SHRFSP was located at 6,725.1 thousand million pesos, while the external component were 3,774.1 million pesos. Net debt of the federal public sector (Federal Government, State Companies, and development banking) at the end of February 2019 stood at 10 trillion 815.7 pesos.

[1] Calculated as financial assets minus received credits as proportion of GDP.

[2] Defined as the total outstanding debt of households to banks and other financial institutions as percent of GDP.

References:

Banco de México. (2018). Mercado cambiario, tipo de cambio, Banco de México.

Secretaría de Hacienda y Crédito Público. (2018). Informes sobre la situación económica, las finanzas públicas y la deuda pública. Cuarto trimestre 2018.

Secretaría de Hacienda y Crédito Público. (2019). Informes de la situación de las finanzas públicas y la deuda pública. https://www.finanzaspublicas.hacienda.gob.mx/es/Finanzas_Publicas/Informes_al_Congreso_de_la_Union

Mexico has a much higher level of income inequality than other OECD countries, with its Gini coefficient (0.45) exceeding by far the OECD average (0.37), but closer to the Latin American average (Lambert & Park, 2019). According to the International Monetary Fund, IMF, the main reasons why poverty rates remain high are the country’s meagre per capita growth rates and deficiencies in the planning and targeting of social policies. It has also been noted that, while conditional cash transfer programs have been very effective at reducing inequality, other social programs have disproportionately benefited individuals at the top rather than at the bottom of the income distribution (Lambert & Park, 2019).

Regardless of continuing poverty alleviation strategies and other social programmes, income is highly concentrated, and the latest report of the National Council for the Evaluation of Social Policy, CONEVAL 2016, estimated that 7.6% of the Mexican population live in extreme poverty and 36% live in moderate poverty[1] (CONEVAL, 2018). Since 2009, the Mexican government has measured poverty using a multidimensional index of social deprivation (CONEVAL, 2018). The index has shown differential rates according to its subcomponents, such as access to education, social security, and access to health services, among others.

Regarding gender equality, there has been important progress since the year 2001 when President Vicente Fox created the National Institute for Women as an independent body within the federal government to coordinate compliance with national policy regarding equality and the eradication of violence against women. The institute is in charge of guaranteeing equal development and rights between men and women, through the development of public policies and other mechanisms such as media campaigns and publications. This institute also works with the legislative branch and the executive at federal and state level to follow up on the implementation and supervision of gender equality law. In addition, fundamental steps have been taken through the passing of legislation focused on eliminating discrimination and inequalities[2].

However, important challenges remain. A study in 2016 showed that, among those in paid work, women’s wages were, on average, between 17% and 47% lower than men’s. There were differences according to the state where they lived in and a wider difference by type of occupation. While the wage divide decreases as educational attainment increases, the wage divide between men and women prevails. Among those with no formal education, women’s wages are almost half of men’s, with a total difference of -50% and -33% for those with a college or university degree. In addition, among the population aged 15 years and older, 28% of women report having no own income, that is, they depend on others to subsist. Among men in this same age group, only 6% find themselves in this position, showing another facet of income inequality by gender in the country (INMUJERES, 2016).

Regarding general health inequalities, inequality in financial protection related to socioeconomic status has decreased significantly in parallel with the general decrease in the lack of financial protection. On the other hand, large inequality persists in indicators of access to health services and health indicators, both by socioeconomic status and by other social indicators (Gutierrez et al., 2014).

[1] The National Council for the Evaluation of Social Policy generates a Social Deprivation Index taking into account the following factors: educational lagging, access to health services, access to social security, space and quality of the household, basic services and access to food. Extreme poverty includes individuals that presents deprivation or lacks three or more of these factors, while moderate poverty includes those lacking two factors.

[2] Specifically, the General Law for Equality among Women and Men (Ley General para la Igualdad entre Mujeres y Hombres), a National Norm for Labour Equality and No Discrimination (Norma Mexicana NMX-R-025-SCFI-2015 en Igualdad Laboral y No Discriminación) generated as a collaboration between INMUJERES, the Labour and Social Prevision Secretariat (STPS), and the National Center for the Prevention of all Discrimination (CONAPRED), and a General Law for a Life Free of Violence for Women (Ley General de Acceso de las Mujeres a una Vida Libre de Violencia). Within the federal administration, mainstreaming of gender issues and gender equality has been the focus of many efforts in the last presidential terms.

References:

CONEVAL. (2018). Diez años de medición de pobreza multidimensional en México: avances y desafíos en política social. https://www.coneval.org.mx/Medicion/MP/Paginas/Pobreza-2018.aspx

Gutiérrez, J. P., García-Saisó, S., Dolci, G. F., & Ávila, M. H. (2014). Effective access to health care in Mexico. BMC Health Services Research, 14(1). https://doi.org/10.1186/1472-6963-14-186

INMUJERES. (2016). Brecha salarial de género en México. http://www.imf-formacion.com/blog/corporativo/igualdad-2/brecha-salarial-de-genero/

Lambert F, & Park H. (2019). Income Inequality and Government Transfers in Mexico.

Mexico has a long history and constant hazard of large earthquakes and volcanic eruptions. Volcán de Colima, south of Guadalajara, erupted in 1994, and El Chichón, in southern Mexico in 1983. Although dormant for decades, Popocatépetl and Iztaccíhuatl occasionally send out smoke clearly visible in Mexico City and ashes that sometimes reach the city. Popocatépetl showed renewed activity in 1995 and 1996, forcing the evacuation of several nearby villages and led to concern about the effect that a large-scale eruption might have on the heavily populated region nearby. Popocatépetl’s activity and all related concerns continue to date (Abeldaño Zúñiga & González Villoria, 2018).

In addition, the country registers more than 90 earthquakes every year with intensity of 4 degrees or higher on the Richter scale and has had major earthquakes over the past decades. Most recently, in September 1985, an earthquake measuring 8.0 on the Richter scale and centred in the subduction zone off Acapulco, killed more than 4,000 people in Mexico City, more than 300 kilometres away. The same region was rocked in September 2017 by a magnitude 8.1 earthquake that killed nearly 100 people and damaged thousands of buildings. A more damaging 7.1 earthquake in central Mexico later that month left more than 400 dead, including at least 228 in Mexico City.

It is estimated that 90% of natural disasters are hydro-meteorological and affect mainly the southeast of the country. Finally, there is an average of 23 hurricanes with winds of more than 63 km/h between the months of May and November. Of these, on average, 14 hurricanes occur in the Pacific Ocean and 9 in the Gulf of Mexico and the Caribbean Sea (United Nations Office for Outer Space Affairs, 2015). According to the United Nations, Mexico is classified amongst the top 30 countries worldwide exposed to three or more natural disasters of multiple magnitudes per year (United Nations Office for Outer Space Affairs, 2015).

Mexico has a National Civil Protection Program 2008-2012 that promotes a multi-institutional coordination, in the area of civil protection in order to protect the life, the environment and the patrimony of society. Thus, in an emergency, the first authority that has knowledge should provide immediate assistance and inform the specialised civil protection authorities. The hierarchical order goes from municipal authorities to the state ones and, finally, the federal ones. The municipal authority is the first specialised instance, and if its response capacity is overcome, then it must resort to the state authority, and so on, until it reaches the federal authorities.

In addition, the DN-III Plan organised by the Navy and Armed Forces, is in charge of organising and mobilising relocations (shelters, safe houses) for hurricane watch and of conducting recovery and reconstruction actions in case of disasters or damages after these events. Finally, the federal government operates a Natural Disaster Fund and the delivery of support to the population (Gobierno de México, 2008), but there are not any policies/plans for people living with dementia and other disabilities in case of emergencies.

References:

Abeldaño Zúñiga, R. A., & González Villoria, A. M. (2018). Desastres en México de 1900 a 2016: patrones de ocurrencia, población afectada y daños económicos. Revista Panamericana de Salud Pública, 42, 1–8. https://doi.org/10.26633/rpsp.2018.55

Gobierno de México. (2008). Programa Nacional de Protección Civil 2008-2012. Diario Oficial de La Federación. http://dof.gob.mx/nota_detalle_popup.php?codigo=5060600

United Nations Office for Outer Space Affairs. (2015). The Force of Nature in Mexico, as seen from space. http://www.unoosa.org/oosa/en/informationfor/articles/the-force-of-nature-in-mexico–as-seen-from-space.html

Unemployment slightly decreased in the immediate years previous to the year 2018 when it was estimated that 60% of the economically active population were employed (formal, informal and self-employed). Within total working age population, women’s participation, while increasing, still lags compared to men and to women in other Latin American countries, with 43.6% of total women 15 years and older reported in the labour force compared to 77.7% of men[1] (STPS, 2019).

Informal employment[2] amounts to approximately 57% of total working population. However, out of 100 Mexican pesos generated in the country, 77 come from formal employment and 23 from the informal economy (INEGI, n.d.-a). In relation to the group of people employed in the informal sector (16.0 million in 2018), 14.9% were self-employed in agriculture (no income/pay, no benefits), 14.6% worked in paid domestic services, but with no social security benefits, 9.3% worked without pay, and the remaining 61.2% were wage earners but without social security benefits (INEGI, n.d.-b; 2020).

The working status of older adults in Mexico is relevant. According to the National Employment and Occupation Survey, in 2018, 34.1% of adults 60 years and older were employed, and of these, 49.6% were self-employed (INEGI, 2018a).

[1]  Tasa Neta de Participación por Sexo: (PEA/PET en porcentaje)

[2] For statistics purposes the National Institute of Geography and Statistics, INEGI defines informal employment as that is those not affiliated to a social security institution granting health and employment benefits granted within social security insurance.

References:

INEGI. (2018a). Estadísticas a propósito del día internacional de las personas de edad (Adultos mayores). Datos nacionales. https://www.inegi.org.mx/contenidos/saladeprensa/aproposito/2018/edad2018_nal.pdf

INEGI. (2020). Estadísticas a propósito del día del trabajo. Datos nacionales. Comunicado de prensa núm. 166/20; 29 de abril de 2020. https://www.inegi.org.mx/contenidos/saladeprensa/aproposito/2020/trabajoNal.pdf

INEGI. (n.d.-a). Características educativas de la población. Retrieved March 16, 2022, from https://www.inegi.org.mx/temas/educacion/

INEGI. (n.d.-b). Directorio Estadístico Nacional de Unidades Económicas. DENUE. Retrieved March 16, 2020, from https://www.inegi.org.mx/app/mapa/denue/

STPS. (2019). Informaciòn laboral.

The educational system in Mexico is shared between central and regional authorities. Each of the 32 federal entities (31 states and Mexico City) operates their own education services and administrative norms that have not guaranteed equal success in the implementation of recent policy reforms or granted increased quality of education (Education Policy Outlook – OECD, n.d.). The National Union of Education Workers[1], with leaders in each state, has a strong lobby power and plays an important role in defining primary education policy issues, while most decisions in lower secondary education are taken by the central or state governments. Expenditure on education institutions as a percentage of GDP (for all educational levels combined) is above the OECD average, with a higher share of private funding than the OECD average (OECD, 2013). Mexico made upper secondary education compulsory in 2012 (aiming for universal coverage by 2022), extending compulsory education from early childhood and education and care (ECEC) starting at age 4-5 to around age 15.

According to the OECD’s Programme for International Student Assessment, PISA, Mexico is among the few countries with improvements in both equity and quality of education. Although its performance remains below the OECD average in mathematics, science, and reading, Mexico has achieved improvements in mathematics and reading, but remains unchanged with respect to their performance in science across assessment cycles. However, grade repetition is high, and there is a gap with other OECD countries in upper secondary and tertiary attainment, enrolment, graduation, and performance (OECD, 2013).

Literacy in Mexico is defined as those 15 years and older who cannot read or write a short message. Literacy rates among the population 15 years and older in 2015 was 95.3 with slight difference between men (96.2) and women (94.6). Among adults aged 65 years and older, gender differences are larger with rates of 84.5 and 77.4 for men and women, respectively (80.7 total) (UNESCO, n.d.). In addition, by 2015, large differences prevail among states with respect to their total literacy with rates of 84 in more deprived states such as Oaxaca and Chiapas and Mexico City and 98 in the State of Mexico and Mexico City (INEGI, n.d.-b).

[1] Sindicato Nacional de Trabajadores de la Educación, SNTE.

References:

Education Policy Outlook – OECD. (n.d.). Retrieved February 20, 2019, from http://www.oecd.org/education/policy-outlook/

INEGI. (n.d.-b). Directorio Estadístico Nacional de Unidades Económicas. DENUE. Retrieved March 16, 2020, from https://www.inegi.org.mx/app/mapa/denue/

OECD. (2013). Education Policy Outlook Mexico. http://www.oecd.org/education/policy-outlook/

UNESCO. (n.d.). Education and Literacy data by country. Retrieved March 16, 2021, from http://uis.unesco.org/en/country/mx

Brief Overview of social protection schemes implemented by the government

As in most countries in Latin America, social policies, also referred to as social protection or social assistance programmes in Mexico, have been designed as mechanisms to address poverty and among these, non-contributory pensions, and conditional cash transfers (CCT) represent the largest programs now in place. Some programs have aimed at universalisation combining a mix of contributory benefits with cash transfers for poor families, targeting older people and children but also having an indirect impact on reducing gender, race, and urban/rural gaps (Fleury, 2017).

In Mexico, the main CCT program is called Prospera (formerly known as Progresa). The programme was created in 1997 to support human development. It is based on target groups, such as young children, women, older adults, and is means-tested by poverty and size of locality. Another large social protection initiative was the establishment of a fully publicly financed health insurance in 2004, the Seguro Popular. The programme was created as an effort to increase health insurance coverage among those not covered by social security institutions (see details in Part 2). The third largest social protection scheme currently in place is the Universal Pension, introduced in 2014. The Universal Pension programme is an age-based non-contributory pension for older adults, who do not receive a contributory pension from a social security institution. In 2019, reforms to the program established a bi-monthly payment of $2,500 Mexican pesos, equivalent to $130 USD, for individuals 65 years and older in rural areas and those 68 years old in urban areas. Currently, older adults in Mexico rely mostly on state or federal non-contributory pension benefits, which are significantly smaller than social security benefits (Aguila et al., 2011).

On the other hand, social security, and comprehensive benefits such as maternity leave, day-care centres for pre-school aged children, disability and old age pensions and health care are funded through a three-party mechanism where the formal employee, employer, and the government contribute. These are only available for those employed in the formal market. This includes private sector workers and the self-employed. Similarly, three-party mechanisms are in place for federal and state level public servants as well as state companies such as the oil company PEMEX (Angel et al., 2017). It is estimated that only one-half of those employed, work in the formal sector, leaving a large proportion of the population, particularly older adults, unprotected and not receiving any social security benefits (Bravo et al., 2015).

While the implementation of these schemes in Latin America has in a way improved social inclusion and contributed to poverty reduction, experts have noted how universal coverage in fragmented systems does not equal a universal welfare state that entitles rights. They note that it is distinct from rights-based policies and may preserve stratification, paternalism, discretionary selections, and insecurity (Fleury, 2017).

Brief overview of social protection schemes[1] implemented by development partners or international donors.

Currently there are no schemes or programs implemented by international development partners, but there has been active participation by some organisations in fundamental public social protection and development programmes through technical and financial advice as well as different lending mechanisms. For example, the World Bank has provided important support for different social protection programs including the original Education and the Health and Nutrition program PROGRESA, now called PROSPERA. The World Bank supports a total of 18 active projects in Mexico (Banco Mundial, 2019).

[1] NB: Social protection schemes can include: direct welfare programmes (conditional and unconditional cash transfers, disability grants, old-age grants, dependency grants, school feeding programmes, food aid, state pensions), which may or may not focus on targeting vulnerable groups.

References:

Aguila, E., Diaz, C., Fu, M. M., Kapteyn, A., & Pierson, A. (2011). Living Longer in Mexico. https://www.rand.org/pubs/monographs/MG1179.html

Angel, J., Vega, W., López-Ortega, M. (2017). Aging in Mexico: Population Trends and Emerging Issues, The Gerontologist, Volume 57, (2), 153–162, https://doi.org/10.1093/geront/gnw136

Banco Mundial. (2019). México: proyectos.

Bravo J. Lai N. M. S. Donehower G. , & Mejia-Guevara I. (2015). Ageing and retirement security: United States of America and Mexico. In W. E.Vega K. S.Markides J. L.Angel, & F. M.Torres Gil (Eds.), Challenges of Latino aging in the Americas (pp. 77–89). New York, NY: Springer Science.

Fleury, S. (2017). O Estado de Bem-estar Social na América Latina : reforma , inovação e fadiga. Cadernos de Saúde Pública, 33(7).

The Mexican Constitution, signed on 5 February 1917, establishes that Mexico is a Federal, Democratic, Representative Republic, constituted by 31 states and a Federal District, in a Federation, but free and sovereign in their internal regime. In 2018, the Federal District legally changed its status to an autonomous entity now defined as Mexico City.

The Government is constituted by three powers: Executive, Legislative, and Judiciary. The Executive power rests with the President who is elected for 6-year periods. Historically there was no re-election of public officials in Mexico at any level until a Political-Electoral Reform in 2014 permitted re-elections within the Legislative branch for Deputies, Senators, and municipal heads (mayor). The Legislative power resides with Congress, which is constituted by a bi-cameral system. The Chamber of Deputies is integrated by 500 Federal Deputies and is elected every three years. The Senate is integrated by 128 members and is elected every six years. Finally, the Judiciary branch is headed by the Supreme Court of Justice of the Nation as well as a number of federal and state-level courts of justice.

Moreover, within the World Bank’s Worldwide Governance Indicators (WGI) project, Mexico’s classification in the Political Stability and Absence of Violence/Terrorism measure[1] of governance was -0.65 (the measure ranges from approximately -2.5 (weak) to 2.5 (strong) governance performance) showing a weak overall governance and a low ranking of 23.33 in comparison to all other countries (The World Bank, 2019).

[1] The indicator measures perceptions of the likelihood of political instability and/or politically-motivated violence, including terrorism.

References:

The World Bank. (2019). Mexico Data. https://data.worldbank.org/country/mexico

Pre-Columbian Mexico dates to about 8000 BC and was home to many advanced Mesoamerican civilisations such as the Olmec, Toltec, Teotihuacan, Zapotec, and Maya which preceded the Aztec empire, conquered in 1519–1521 by the Spanish. Spain ruled Mexico as part of the viceroyalty of New Spain for the next 300 years until Sept. 16, 1810, representing the first uprising of the country, and which led to independence from Spain in 1821.

The post-independence period was tumultuous, characterised by economic inequality and many contrasting political changes. The Mexican American War (1846–1848) led to a territorial cession of the extant northern territories to the United States. In the 19th century there were several armed conflicts such as The Pastry War, the Franco-Mexican War, a civil war, two empires, and the Porfiriato, named after President Porfirio Díaz who remained in power for almost 30 years (1876 to 1911). The year 1910 saw the beginning of the Mexican Revolution in 1910, which lasted 7 years and gave way to the enactment of the 1917 Constitution and the emergence of the country’s current political system as a federal, democratic republic which is currently maintained.

The last presidential elections were celebrated in July 2018 with Andres Manuel Lopez Obrador, from the Morena party, winning the elections by overwhelming majority. In this electoral period, there were elections for all Congress members and elections for state Governor in 8 states. The next presidential elections will be held in the year 2024.

According to the Corruption Perceptions Index 2018, an index that measures perceived levels of public sector corruption according to experts and business people, Mexico ranked poorly, among the lowest rankings with a rank of 138 (out of 180) and a score of 28 / 100 (where 0 is highly corrupt and 100 reflects no corruption). It is estimated that 1 in 3 persons in Latin America had paid bribes in that same year (Transparency International, 2018).

References:

Transparency international. (2018). Corruption perceptions index. https://www.transparency.org/en/cpi/2018

The Health System in Mexico has been highly fragmented since its creation and health services and users are divided according to the health institution that provides the coverage. There are three main providers: social security institutions, public services offered by the Ministry of Health, and the private sector. These providers offer different benefit and service packages, working independently and in parallel to each other. In addition, they have separate financing mechanisms and rely on different sources of funding (Dantés et al., 2011; OECD, 2016b).

As mentioned above, social protection in Mexico is composed of a fragmented framework of programs and institutions. Social security, available to those employed in the formal market, is further divided into a number of institutions that provide services to workers from different sectors. The Mexican Institute of Social Security (IMSS) covers those employed in the private formal sector, while federal and state level employees are covered by the Institute of Social Security and Services for State Employees scheme (ISSSTE). In addition, other institutions cover people employed in specific sectors such as the national oil company PEMEX and the Armed Forces (military and naval). Social security institutions extend their benefits, in addition to affiliated workers, to their spouses, children, and parents (Gutierrez et al., 2015; Dantés et al., 2011).

The Seguro Popular (Popular Health Insurance) is an income-based health care insurance publicly funded and administered by the Ministry of Health that aims at providing coverage to all those who are not insured by any of the social security institutions, including people who are self-employed, working in the informal sector, unemployed and others who are not participating in formal employment (such as homemakers) (Gutierrez et al., 2015). In 2015 the Seguro Popular provided health insurance to 53.5 million Mexicans, close to 50% of the total population, through services provided by the Ministry of Health. Another 9.2% of the population were covered by the IMSS, 7.7% by ISSSTE, and 1.2% by PEMEX and the Armed Forces social institutions.

References:

Dantés, O. G., Sesma, S., Becerril, V. M., Knaul, F. M., Arreola, H., & Frenk, J. (2011). Sistema de salud de México. Salud Pública de México, 53 Suppl 2(1), s220–s232. https://www.redalyc.org/pdf/106/10619779017.pdf

Gutierrez, L. M., Medina-Campos, R. H., & Lopez-Ortega, M. (2015). Present State of Elder Care in Mexico. In W. Vega, J. Angel, K. Markides, & F. Torres-Gil (Eds.), Challenges of Latino Aging in the Americas (pp. 379–392). Springer International Publishing.

OECD. (2016b). OECD Reviews of Health Systems: Mexico. In OECD Publishing (Ed.), OECD Reviews of Health Systems (OECD Reviews of Health Systems). OECD Publishing. https://doi.org/10.1787/f7b8c403-ja

23.1% of the population used private sector services, 40.1% public services provided by the Ministry of Health, and 36.8% used services provided by social security institutions (OECD, 2017a). Health services in the public (MoH) and social security sectors (i.e. IMSS, ISSSTE, Armed Forces, etc.) are similarly organised.

References:

OECD. (2017a). Estudios Económicos de la OCDE México (OCDE Publishing, Ed.). OCDE Publishing. https://www.oecd.org/eco/surveys/mexico-2017-OECD-Estudios-economicos-de-la-ocde-vision-general.pdf

Mexico does not have a universal-access National Health System. The health system is highly fragmented among different institutions that provide services depending on affiliation. For those formally employed, social security and health services are provided by two institutions, the Mexican Social Security Institute (IMSS) for those in the private sector, and the Institute for Social Security and Services for State Employees (ISSSTE) for those employed in the national or state-level public sector. In addition, the Ministry of Health provides health services for those who are employed in the informal sector or those who did not accrue enough time in formal employment to be eligible to services at IMSS or ISSSTE.

Within all these sub-systems, services are organised and accessed within a gate-keeping system where people have access to primary care clinics with general or family doctors (equivalent to GPs) as the first point of contact. They conduct first assessments, diagnoses, and treatment and, when necessary, refer patients to specialist physicians, laboratory or diagnostic tests, and major procedures such as hospitalisation or treatments that are provided within a hospital setting.

All private services can be accessed at the point of service, irrespective of service needed such as diagnosis/care of specialist physicians, diagnostic tests, or hospitalisation. These services have to be paid directly to the provider through out-of-pocket payments or insurance policies where insurance companies cover the costs or reimburse the patient, depending on the plan they contracted.

All public (MoH) and social security institutions are based on a reference system (gatekeeping), where primary care units –usually named family medicine clinics—are the main point of access and where care is provided by primary care physicians. When needed, they refer patients to any laboratory or diagnostic tests.

In the private sector, access is mostly through specialist doctors, responding to a specific need –either from previous diagnosis or expected need. Since a change in legislation in the year 2001, a segment of the private sector that has significantly increased is the use of pharmacists who provide “health orientation” by General Practitioners (medico general) and have profited from the parallel sale of medications (Gutierrez et al., 2014).

References:

Gutiérrez, J. P., García-Saisó, S., Dolci, G. F., & Ávila, M. H. (2014). Effective access to health care in Mexico. BMC Health Services Research, 14(1). https://doi.org/10.1186/1472-6963-14-186

Yes, within the public system (MoH and social security institutions), gatekeeper systems are in place (primary care, secondary, high specialisation), but not in the private sector.

Social protection in health is granted to all Mexicans as a right by the fourth article of the Constitution. However, different issues make access unequal and undermine the achievement of universal coverage that the Mexican government strives for. Among these issues is the absence of a universal national health system, access to health service (and social security) based on employment and insurance status, as well as unequal social and economic development throughout the states that results in differences in the development of the infrastructure and human resources available. Thus, unequal access and quality of care between urban and rural areas, northern and southern states, and between those covered by social security, public and private sector insurance schemes are observed (OECD, 2017a).

Program-based health care also has meant that health care provision focuses on some illnesses, age groups or conditions (pregnancy and birth, diabetes, hypertension, reproductive health), leaving some age groups, such as older adults, and conditions such as AD and other dementias, underserved. As such, those who access the private sector could get a consultation with a geriatrician or dementia specialist any time, while referrals to these specialists in the public sector are practically inexistent given the low number of public posts of these within the public sector.

References:

OECD. (2017a). Estudios Económicos de la OCDE México (OCDE Publishing, Ed.). OCDE Publishing. https://www.oecd.org/eco/surveys/mexico-2017-OECD-Estudios-economicos-de-la-ocde-vision-general.pdf

Each of the subsystems that form the health system in Mexico is financed differently. The IMSS and ISSSTE, the two main social security institutions for those in formal employment in the private and public sectors respectively, are financed based on a three-party funding scheme with fees provided by the employer, the employee, and the government; whereas public services provided by the MoH are funded entirely through general taxes. In addition, other institutions have their own health services and social security benefit schemes and financing such as the Navy and the Army (Armed Forces), and public companies such as PEMEX.

According to INEGI, 17.3% of total population in 2015 was not covered by health insurance (INEGI, 2015a). People who are not affiliated to any social security institution (IMSS, ISSSTE, etc.) or public insurance mechanism (Seguro Popular) by law could access MoH services. However, it is frequent that only in the case of acute problems (heart attack) or accidents they would access these and most likely solve minor issues within the private sector, such as consultations within pharmacies in the private sector or private sector physicians, which can be found in most places, but this doesn’t necessarily equal optimal and quality care.

References:

INEGI. (2015a). Encuesta Intercensal 2015 Estados Unidos Mexicanos. Instituto Nacional de Estadística y Geografía, 1, 85–90.

One of the main campaign promises was to end the fragmented nature of the health system and work towards a single universal health system. As of January 2020, the government eliminated the 2003 health reform (Seguro Popular) from national laws and government agencies with the objective of generating a sole, centralised health system with integrated public financing and delivery, while reducing private participation. To this end, President Lopez Obrador (referred to by his initials, AMLO) created the Institute of Health and Wellbeing, INSABI (Instituto de Salud para el Bienestar), but to date (July 2020), no real changes have been implemented. A first study of the proposed reform notes large challenges, many that should have been overseen before implementation, and summarises their findings in five lessons: “First, undoing past reforms is much easier than implementing a new system. Second, the AMLO government’s restructuring emerged more from broad ethical principles than detailed technical analyses, with limited plans for evaluation. Third, the overarching values of the AMLO government reflect a pro-statist and anti-market bias, swimming against the global flow of health policy trends to include the private sector in reforming health systems. Fourth, the experiences in Mexico show that path dependence does not always work as expected in policy reform. Finally, the debate of Seguro Popular versus INSABI shows the influence of personality politics and polarization” (Reich, 2020).

References:

Reich, M. R. (2020). Restructuring Health Reform, Mexican Style. Health Systems & Reform, 6(1), e1763114. https://doi.org/10.1080/23288604.2020.1763114

The Ministry of Finance (Secretaria de Hacienda y Credito Publico) is in charge of presenting the Federal Public Budget to the legislative branch for its review and approval.

While each sub-system has a particular process for planning and allocating funds, as with all policies and programmes financed with public funds, the budget process starts in June with the elaboration of the Annual Operation Programmes (Programa Operativo Annual, POA). These plans are presented by sector or Ministry to the Ministry of Finance, which makes the ultimate decisions on how funds are allocated. This gets integrated into the Federal Budget (Presupuesto de Egresos de la Federación, PEF) initiative that then goes to Congress for final approval. According to the Budget and Expenditure Legislation, the Federal Budget initiative has to be submitted no later than September 8 of each year to the Chamber of Deputies, which has the exclusive power to approve it no later than November 15 and then be published in the Official Gazette of the Federation no later than 20 calendar days after its approval (Ley Federal de Presupuesto y Responsabilidad Hacendaria).

Each institution sets their priorities. Financing is negotiated with the Ministry of Finance.

In Mexico, health budgets are dispersed at the state level through state-level representations of each health or social security institution. The Ministry of Health has a State Health Minister in each state who oversees the priorities, negotiates part of the budget, plans, and implements the local development of priority health programmes and is also responsible for their correct implementation. As state level budgets are based on target populations, programmes and priority strategies, budgets are allocated and dispersed according to these definitions. For some Federal programmes, the budget comes directly form the Ministry of Finance through targeted budgets, specific Operation Regulations (Reglas de Operación) which include evaluation indicators.

Please refer to 02.02.05.01.

While the market for private health insurance has increased in the past decade and more multinational insurance companies have entered the market, the last available estimate from the OECD is 4% of total population purchasing private health care insurance (OECD, n.d.).

References:

OECD. (n.d.). Health data. Retrieved March 16, 2020, from https://data.oecd.org/healthres/health-spending.htm

Yes, the National Insurance and Bonds Commission, a decentralised entity of the Ministry of Health, regulates the companies regarding the operation and administration of these services. The Federal Commission for the Protection against Health Risks (Comision Federal para la Protección contra Riesgos Sanitarios, COFEPRIS), regulates all health-related issues in all private institutions from board certification of medical doctors to malpractice in hospitals, health clinics, etc. COFEPRIS also regulates these matters within public (Ministry of Health) and Social Security institutions.

A consequence of low levels of government health spending, is the relevant participation of the private market. Most of this privately purchased health care is paid through out-of-pocket transactions, as private insurance makes up a very small segment of the market (approximately 4% of total health expenditures). Mexico has the highest out-of-pocket share of total health care spending among OECD countries: out-of-pocket health spending (paid directly by patients) in 2017 reached 40.4% of total spending (OECD, n.d.; OECD, 2016b).

Despite slightly decreasing from 55% in 2005, out-of-pocket health spending (paid directly by patients) in Mexico in 2017 still amounted to 40.4% of total spending. As a result, the high burden of out-of-pocket spending continues to create financial barriers to health care access, particularly for the low-income population. In this same year, government/compulsory health spending represented 51.6% of total health expenditures, while the remaining 8% corresponded to health expenditures by the voluntary sector (NGOs and private corporations) (OECD, n.d.)

References:

OECD. (n.d.). Health data. Retrieved March 16, 2020, from https://data.oecd.org/healthres/health-spending.htm

OECD. (2016b). OECD Reviews of Health Systems: Mexico. In OECD Publishing (Ed.), OECD Reviews of Health Systems (OECD Reviews of Health Systems). OECD Publishing. https://doi.org/10.1787/f7b8c403-ja

While remittances played an important role in supporting families in many localities throughout the country given the large migration to the U.S. through decades, their use has been primarily spent in basic subsistence items such as food and clothing.

Mexico is the fourth largest remittance recipient in the world, and the rise in technology based financial services that make sending money much easier, using banks, mobile devices, stores, etc., have facilitated this. In 2015 it received nearly $25 billion in remittances, just behind India ($72 billion), China ($62 billion), and the Philippines ($30 billion). Most of these resources come from Mexican migrants living in the U.S. which represent 95.6% of Mexico’s remittances (Consejo Nacional de Población et al, 2018).

According to the study, based on different data sources, the main uses of remittances sent by Mexicans are buying clothes and groceries, followed in much less percentages by education, settling debts, health services, and buying, renovating, or building homes (CONAPO & Fundación BBVA Bancomer, 2018).

References:

CONAPO, & Fundación BBVA Bancomer. (2018). Anuario de Migración y Remesas México 2018. https://www.bbvaresearch.com/wp-content/uploads/2018/09/1809_AnuarioMigracionRemesas_2018.pdf

Consejo Nacional de Población, Fundación BBVA Bancomer y BBVA Research (2018). Anuario de Migración y Remesas. México 2018. CONAPO-Fundación BBVA Bancomer-BBVA Research. 1ra edición, México, pp.184.

No, at the moment there are no significant donations from outside the country to support the healthcare system.

The supply of health workers in Mexico has increased over the past decade, but remains low by OECD standards, in particular the number of nurses. The lack of health workforce puts a lot of pressure on the healthcare system and it endangers its potential to provide quality services. In addition, scarce data is published in Mexico about the state of medical specialists in order to inform the design of policies for training and management of human resources for health.

The only official statistics available show a rate of 2.4 medical doctors and 2.9 nurses per 1 000 inhabitants in Mexico for the year 2017 (DGIS, 2017). These figures are similar to those reported by the OECD (OECD Health Statistics, n.d., accessed 22 June 2019).

In 2017, it was estimated that there was a total of 147,910 specialist physicians in Mexico, for a total population of 123.5 million, a rate of 119 specialist per 100 000 population. Of this total, 69% had current specialty certification and showed a highly unequal distribution among the country with 54% of the total concentrated in Mexico City and in the States of Mexico, Jalisco, and Nuevo León. On average, there were 1.7 male specialists per female specialist physicians (Heinze-Martin et al., 2018). On the other hand, there were 16,895 family physicians^[1] or 14 per 100,000 population in 2017 (Heinze-Martin et al., 2018) and 36,184 general practitioners in 2015 or 29 per 100,000 population (DGIS, 2017).

Regarding specialities more relevant to all forms of dementia, there were 422 Geriatricians, 1,345 Neurologists (adult and paediatric), 2992 Cardiologists (adult and paediatric) and 4,429 Psychiatrists in the whole country in 2017. It was estimated that there were 3.25 Geriatricians per 100,000 individuals aged 60 years and older, 3.4 Psychiatrists and 2.2 Cardiologists per 100,000 individuals (Heinze-Martin et al., 2018).

While the General Direction of Health Information, DGIS (Dirección General de Información en Salud) at the Ministry of Health reports data on other professional personnel in their official statistics on human resources, these only cover chemists, biologists, pharmacologists, nutritionists, psychologists, and social workers. Other professions such as occupational therapists and community health workers are not defined currently as part of the public and social security health care institutions’ professional health workers.

[1] Family medicine is also a specialisation in Mexico obtained after the general physician/practitioner diploma.

References:

DGIS. (2017). Recursos en salud.

Heinze-Martin, G., Olmedo-Canchola, V. H., Bazán-Miranda, G., Bernard-Fuentes, N. A., & Guízar-Sánchez, D. P. (2018). Medical specialists in Mexico. Gaceta Medica de Mexico, 154(3), 342–351. https://doi.org/10.24875/GMM.18003770

OECD. (n.d.). Health Statistics. https://www.oecd.org/health/health-statistics.htm

Besides the lack of workforce, the geographical distribution of physicians in Mexico is unequal, as rural localities have a significantly lower density of health professionals overall. While physician density in Mexico City and other large metropolitan areas is elevated, other, less densely populated localities have deficits in health workers and consequently, enormous variations in health care use and health indicators. In addition, more specialised units such as secondary and tertiary hospitals tend to concentrate higher density of health professionals compared to primary care units (Lucio-García et al., 2017, Nigenda et al., 2016).

References:

Lucio-García, C. A., Recaman, A. L., Arredondo, A., Lucio-García, C. A., Recaman, A. L., & Arredondo, A. (2018). Evidencias sobre la inequidad en la distribución de recursos humanos en salud. Horizonte Sanitario, 17(1), 77–82. https://doi.org/10.19136/hs.a17n1.1984

Nigenda, G., Alcalde-Rabanal, J., González-Robledo, L. M., Serván-Mori, E., García-Saiso, S., & Lozano, R. (2016). Eficiencia de los recursos humanos en salud: Una aproximación a su análisis en México. Salud Publica de Mexico, 58(5), 533–542. https://doi.org/10.21149/spm.v58i5.8243

While Mexico City is still the major point of attraction for medical students and specialty medical doctors, other major cities and metropolitan areas follow as large migration pull factors. However, other health professionals such as nurses, have not followed these patterns as they usually work in the same state where they receive their professional education.

Professional migration between Mexico and the United States has historically been present within both countries. However, few studies have documented this migration by type of profession or occupation, besides that of non-professional agricultural migration. With respect to health professionals, migration of nurses has been scarcely documented (Arroyo-de Cordero & Jiménez-Sánchez, 2005). Moreover, migration of medical professionals from Mexico to other countries (U.S. and Europe mostly) has been defined as highly difficult or problematic due to regulatory terms and differences in skills and language barriers that make it difficult to practice elsewhere. For example, a news report stated that out of approximately 19,000 nurses that present exams each year looking for placement in their state hospitals, less than 100 are from Mexico (Nájar, n.d.).

In addition, given current anti-immigration policies in place in the U.S., the reduction in total number of formal work permit and visas (work-visa bans) as well as more restrictions to those issued (such as being required to pay for health care) could hinder the increase of migration of health professionals in the near future.

References:

Arroyo-de Cordero, G. & Jiménez-Sánchez, J. (2005). Repercusiones de la escasez versus migración de enfermeras como fenómeno global. Rev Enferm IMSS, 13(1), 33–40.

Nájar, A. (n.d.). Enfermeras: las mexicanas más cotizadas en EE.UU. BBC Mundo.

In Mexico, strategies for dependent or disabled people are practically inexistent. The country does not have a publicly funded long-term care system at national level nor specific public services that provide care for people with loss of functional ability/capacity (disabled); and, as it will be described below, Mexico only offers very few day-centre services for older adults.

Regarding care legislation, there are no specific laws that guarantee the right to receive care, regardless of the age group or condition for which care is needed, or that give the health and social security system responsibility to provide them. Thus, there is a clear lack of public programs at the national/federal level that aim at providing care services for those with care needs, nor for their carers. On the other hand, strategies have been developed to address aging and disability that seek to influence the well-being of these population groups, encourage their participation, and maintain or recover their independence, but without intending to guarantee or provide care to these groups of the population.

While at national level no long-term care system is in place, there are different working groups collaborating towards the generation of a National Care System. Two main groups are working together, one led by the National Institute for Women (INMUJERES) focused mainly on a gender equity perspective. A second one within the health system is led by the General Health Council, CSG (Consejo de Salubridad General) at the Ministry of Health and the National Institute of Geriatrics (INGER) and focuses on attending care needs of people with disabilities and their carers. The work led by INMUJERES has recently focused on generating an analysis of care needs whilst targeting three groups: infants, people with disabilities, and older adults. Their aim is to raise awareness on the need to establish care as a right in local legislations as well as to identify current public programmes where new strategies could be included to generate a National Care System^[1]. On the other hand, in some forums (but still not in official communications), other institutions like the Social Security Institute IMSS, have presented their efforts towards generating care services for their affiliates, particularly older adults and people with disabilities.

After slightly more than a year of meetings with representatives from all the institutions/sub-systems that form the National Health System within the CSG-INGER collaboration, an agreement was achieved at the national level to define, design, and implement long-term care health policies within the National Health System and health and social security institutions. This agreement was published in the National Official Gazette^[2] in August 2018.

At the moment, both groups are joining efforts and exploring future pathways to generate one system where the health and social development work together. In 2016, Mexico City, changed its administrative status from a Federal District to a Federal Entity (state) at the local level. This changes its legal and administrative rights and obligations within the Federal Republic.

As part of these changes, Mexico City has now its own stale-level approved Constitution^[3] since 2017.  This represents the first to include the right to care in the country (Article 9, Item B). As for now, the specific policies and programmes that will be implemented are in the planning stage and will constitute the first universal (within the City) and publicly funded programs to support those who need care and their carers.

At the moment, there are only two strategies, one at the Mexican Institute of Social Security (IMSS) and one from Mexico City’s Health Secretariat that provide domiciliary services for people with functional disabilities. First, the IMSS Chronic Patient Care Program which began in 1990, aims at providing follow-up medical care after hospital discharge and/or palliative care for patients in terminal stages (Espinel-Bermúdez et al., 2011). According to the IMSS’ reports, the main conditions treated are chronic degenerative diseases and their sequelae, such as cerebral vascular type, chronic obstructive pulmonary disease (COPD), heart failure, chronic kidney failure, Alzheimer’s disease, and terminal cancer conditions.

Secondly, in Mexico City, the program ‘The Doctor in your House’ (Medico en tu Casa), has been in place since 2016. The main goal of the program is to provide ambulatory care by multidisciplinary staff, to all vulnerable individuals who, due to their disease condition or disability, cannot attend medical services. However, under the new federal government administration, this program is being modified and its specific attributions and scope is still unknown.

The absence of a public long-term care system, of a national level regulation agency and the lack of a national mandatory registry of institutions in Mexico has generated an absence of precise information on the total number of public or private permanent and temporary care institutions available in the country. As a result, in order to gather information on such institutions, there are few sources that can be consulted; however, data can be over or underestimated. Some of these sources are described below within the public and private services subheadings in items 03.01.03 and 03.01.04.

[1] http://aga.funcionpublica.gob.mx/aga/Home/Documento?doc=2.1%20RENAC.pdf

[2] Diario Oficial de la Federación ACUERDO por el que se establecen las acciones para el diseño e implementación de la política pública en salud para el otorgamiento de cuidados a largo plazo por las instituciones públicas del Sistema Nacional de Salud, published on 2 August 2018. [https://www.dof.gob.mx/nota_detalle.php?codigo=5533729&fecha=02/08/2018 ]

[3] Constitución Política de la Ciudad de México, p. Article 9, Item B. Right to care: Every person has the right to the care that sustains his life and gives him the elements material and symbolic to live in society throughout his life. The authorities will establish a care system that provides public services universal, accessible, relevant, sufficient and quality and develop policies public. The system will give priority attention to people in situation of dependency due to illness, disability, life cycle, especially childhood and old age and those who, in an unpaid way, are in charge of their care.

References:

Espinel-Bermúdez M.C., Sánchez-García, S., Juárez-Cedillo, T., García-González, J.J., Viveros-Pérez, A., & García-Peña C. (2011). Impacto de un programa de atención domiciliaria al enfermo crónico en ancianos: calidad de vida y reingresos hospitalarios. Salud Publica Mex , 53, 17–25. https://www.redalyc.org/pdf/106/10619407004.pdf

There are some permanent LTC residences (care homes) for older people in the country. However, given that there is no single and mandatory public registry, except for a few publicly funded institutions, there is high uncertainty about the total number of institutions, the type of services they offer, their cost and the number of people who use them, as well as the quality of the services they provide and their impact on the well-being and quality of life of its residents. Some of the institutions are managed by public institutions and civil society organisations and there are also some homes ran by for profit organizations.

With respect to public services, in Mexico, it is important to note the differences between national-level public services (funded and provided by central budget and government) and those provided and financed at the local level, by the state or other municipal authorities.

Public institutions

With respect to national, centrally funded services, the National Institute for Older Adults (INAPAM), and the National System for the Development of the Family (DIF), both part of the federal level of government, have a total of ten institutions that provide permanent housing for older adults. INAPAM has six permanent housing/residential institutions (four in the Federal District, one in Guanajuato and another in Oaxaca) and DIF has 4 (two in Mexico City, one in the state of Morelos and one in the state of Oaxaca). Regarding the admission to these public institutions, priority is given to people in extreme conditions of vulnerability such as older people in situations of abandonment or without housing. Voluntary admission can be requested and there is usually a waiting list for the few places available. The services are offered at no charge or cost to the resident, and they generally provide accommodation, food, laundry services, cleaning, general medical care and referral to second or third level health services. They also offer support for the basic activities of daily life, as well as for recreational, sports, and cultural activities.

In addition, some municipalities (local public financing) have day centres (recreation mostly) for older adults. However, given the lack of a national level regulation agency and of a national mandatory registry of institutions, no precise information on the total number of public (or private) institutions is available. As a result, in order to gather information on institutions administered at the state level, there are few sources that can be consulted for information, and since different sources have to be consulted, consequently, data can be over or underestimated. The latest data from the National Statistical Directory of Economic Units, DENUE^[1] (Directorio Estadístico Nacional de Unidades Económicas) reports 819 permanent housing institutions for elderly individuals. Of these, 85% are private and not-for profit organisations and only 15% are publicly funded. The number of institutions per state shows important variations, with 6 states (Jalisco, Ciudad de México, Nuevo León, Chihuahua, Guanajuato, Michoacán, San Luis Potosí, Sonora,  and Yucatán) concentrating 64% of all institutions.

[1] The DENUE offers information on the identification, location and economic activity of the economic establishments currently in operation in the national territory and includes a category for “asylums and other residences for the care of the elderly” (INEGI 2011). It is a broad definition that includes permanent institutions and temporary stay institutions such as day centres. In the case of permanent housing institutions, it includes a wide variety of local used terms such as care homes, rest homes, retirement homes, long-stay for seniors, among others. It registers publicly and privately funded institutions as well as civil society organisations. Last access 5 July 2019 https://www.inegi.org.mx/app/mapa/denue/

The evidence suggests that the private long-term care sector is growing. Currently, there are no legal frameworks or mandatory standards of care and evaluation, which means that there is very little information about the types of services provided, their quality, the professions working for them, and their overall impact on the health and wellbeing of the people that live there. Therefore, the actual number of people that use these services and the size of the private sector is unknown, even though it is larger than the public sector.

Private non-profit institutions

Through the 2015 Social Assistance Housing Census, CAAS^[1] (Censo de Alojamientos de Asistencia Social) (INEGI, 2015a), 4,517 permanent housing institutions could be identified. Among these, almost 23% (1,020) are identified as permanent homes or residences for older adults. Regarding the average number of residents per facility, 37% of the total reported an average between 11-20 residents, 23% between 21-40 residents and the remaining 22% reported having between 5-10 residents. Regarding their legal nature, 75% are private non-profit facilities, 8% are public (government funded), 2.3% religious associations, and 2% private for-profit. Most non-profit institutions combine multiple financing sources: user fees (78%), personal donations (56%), private sector donations (32%), donations from faith-based organisations (28%), government funds (38%), and selling products made by the residents (3%).

Most non-profit institutions work under mixed schemes in which they offer free accommodation services for those older people who do not have resources, or a family network that supports them and for those who have some economic capacity. The group consisting of people without resources generally represents most of their residents. For those with economic capacity, recovery fees depend on the available resources of the older person (their relatives can also be charged). Fees are established according to the financial situation of the resident through a socio-economic assessment of the older person and their responsible family members, if there are any.

Private for-profit institutions

There are also private for-profit institutions that offer care to older people. While people become older and very likely disabled during their time in the institution, most have strict admission requirements that up front only admit “independent” older adults with no severe illnesses or disabilities. Their scale, type of services and quality are not documented. The services of private institutions vary in quality and costs. While there are institutions that offer common accommodation services in very small spaces, others offer spacious single rooms with an integrated bathroom. Similarly, non-professional caregivers and auxiliary nursing personnel constitute most of the personnel, with very few licensed nurses being hired. For more specialised and personalised nursing care, some institutions allow the resident or family member to hire external personnel for their care when needed, incurring in an additional cost. In addition, nursing or other specialised care services contracted out (and paid) by family members are sometimes also allowed. Some institutions offer a wide range of additional recreational services and amenities, such as cable television, internet, movies, access to a gym, climate and controlled ventilation or beauty salons.

According to the DENUE, there are 603 private institutions identified as nursing homes and private homes for the care of the elderly. However, there is no additional information to identify if these are private lucrative or non-profit organisations and as a result, the precise number of private for-profit institutions in the country is unknown. Great diversity was found in the total number of private institutions registered in each state of the country (INEGI, n.d.-b).

Private Community Care

There is an increasing market of private day centers and incipient services for care aides at home. However, since no regulatory framework or agency establish care standards, monitor, or evaluate the services which are in place, little information on their number and how they operate is known. There are some at-home personal assistance (not qualified medical care) services provided by private for profit companies. The range of services usually cover from basic personal company services (inside and outside the home), support with activities of daily living such as feeding (but not cooking), bathing, basic nursing activities and physical therapy or rehabilitation. While these services are being offered in Mexico’s largest cities, the costs are very high and only accessible to a very small percentage of those who can benefit from them (López-Ortega & Aranco, 2019). On the other hand, the lack of regulation and standards to overlook these services generates a wide variety with respect to the quality of services provided (including the training and skills of hired personnel), from highly standardised and monitored U.S. franchises operating in Mexico, to agencies/individuals that gather a group of “carers” and act as placement services. While the former use highly professional advertising campaigns, services with the latter are usually known from word of mouth.

Services provided in day centers are usually focused on independent and highly functional individuals. These are mostly social and recreational centers which aim at maintaining the independence and participation of the elderly, mainly providing occupational therapies, crafts, health promotion and information, training in information and communication technologies (ICTs), physical activation, and, in some occasions, general medical and dentist consultations. That is, they focus primarily on functional people and, for the most part, do not consider dependency care as care strategy or model them (López-Ortega & Gutiérrez-Robledo, 2015). Except for around 15 day-centers for people with dementia in the country, no other day care services are in place for older adults (or any other age groups) with disabilities or care dependent.

Finally, while it is common practice for domestic workers (by the day and live-in), to provide care on a needs-basis (infants, young children, older adults, people with disabilities), no information is publicly available on how many and how much of their time is dedicated to care for each of these population groups.

[1] The objective of CAAS was to collect information on the conditions and services offered by public, social and private establishments that house vulnerable populations, along with their characteristics and those of the people who work in these centres (INEGI 2015). It focuses on all types of social assistance institutions, such as care homes and residences for the elderly, but also others as rehabilitation (drug & alcohol) centres, homes for orphans, etc.

References:

INEGI. (2015a). Censo de Alojamientos de Asistencia Social. https://www.inegi.org.mx/programas/caas/2015/

INEGI. (n.d.-b). Directorio Estadístico Nacional de Unidades Económicas. DENUE. Retrieved March 16, 2020, from https://www.inegi.org.mx/app/mapa/denue/

López-Ortega, M., & Aranco N. (2019). Envejecimiento y atención a la dependencia en México. Nota técnica del BID. https://publications.iadb.org/publications/spanish/document/Envejecimiento_y_atención_a_la_dependencia_en_México_es.pdf

López-Ortega, M., & Gutiérrez-Robledo, L. M. (2015). Percepciones y valores en torno a los cuidados de las personas adultas mayores. In L. Gutiérrez Robledo & L. Giraldo (Eds.), Realidades y expectativas frente a la nueva vejez. Encuesta Nacional de Envejecimiento. (pp. 113–133). Instituto de Investigaciones Jurídicas, Universidad Nacional Autónoma de México.

Mexico does not have a public long-term care system. The DIF and INAPAM are the only public institutions that have a total of ten residences for older adults and that are financed through federal budgets assigned to these institutions. Some of the state branches of these institutions are operated by public state-level budgets and will have some temporary services such as day centres, but the exact number is unknown.

Budget for the few public care homes by INAPAM and DIF comes directly from the total budget of these institutions and has to be planned internally by each institution. However, the overall budget of these institutions has to be approved by the Finance Ministry, thus, adjustments may have to be made.

As previously mentioned, while DIF and INAPAM define the budget annually allocated to the few institutions they have, their overall budget has to be approved by the Ministry of Finance.

As with any other public administration agency, as mentioned above. Just as DIF and INAPAM define the budget to be annually allocated to the few LTC institutions they have, they define their priorities for funding.

No. The central/federal offices of these institutions decide how budgets are allocated and dispersed, given that the exact budget they requested, is granted by the Ministry of Finance.

There are no long-term care programs in the federal or local public administrations and, therefore, no budgets are allocated and dispersed for this.

As previously mentioned, there are only two strategies in the country that cover some long-term care services, one at the Mexican Institute of Social Security, IMSS (one of the main social security institutions in Mexico) and one from Mexico City’s Health Secretariat. Both provide domiciliary services for people with functional disabilities.

While some private insurance companies have tried to introduce long-term care insurance policies (importing mainly US insurance schemes), these have not been popular as the market is restricted only to those with the highest income levels and who already would be able to afford 24-hour care through, for example, live-in carers.

No data is available at national level regarding the purchase of long-term care services or the number of people incurring in catastrophic levels of out-of-pocket LTC expenditures within the private market (profit or non-profit). However, some information on unpaid care work and its value is available.

As part of Mexico’s National Accounts, the National Statistics Institute, INEGI generates different Satellite Accounts[1] in order to cover activities that are not part of the core economy but they are linked to it in a highly relevant way. To date, many countries have a parallel system of Satellite Accounts, being environmental accounts, tourism, unpaid household (domestic) work satellite accounts, and satellite accounts on non-profit institutions and voluntary work are some of the most widely estimated.

Mexico currently estimates satellite accounts for unpaid household work, for unpaid health and personal care, a tourism satellite account, among others (INEGI, 2018b). Unpaid health and personal care is estimated on a yearly basis and published as the National Satellite Health Accounts of the Health Sector (Cuenta Satelite del Sector Salud en Mexico, CSSSM), with data from the National Time Use Survey. Data for 2017 (base year 2013) reports that GDP of the health sector is 5.6% of the national GDP. Of this 5.6%, 1.4% represents unpaid health and personal care (performed within the household). Within the health sector GDP, 72.3% corresponds to the economic activities of the sector and 27.7% to unpaid health and personal care work.

In order to take into account the dimension of the role of unpaid personal and health unpaid work performed within the household, it is important to note that the monetary value of household’s contribution to personal health care of other household members (27.7%) represents more than half of what is generated by public sector establishments (39.5%). This is also larger than the contribution of primary care (ambulatory) medical services (17.0%) and is similar to the one generated by all hospital services (20.7%) (INEGI, 2018b).

Figures of unpaid work in health refer to care for people of all ages. However, changes in the population structure due to the aging process are visible. Since among the population reporting motor, cognitive or sensory limitations in the country, 26% of them refers to old age as being the cause of their limitations, it can be expected that a significant percentage of unpaid care is dedicated to care for the elderly.

Results from the 10/66 research group’s INDEP study (The Economic and Social Effects of Care Dependence in Later Life) show that significant health care costs for households with care additionally presented higher likelihood of catastrophic healthcare spending (Guerchet et al., 2018).

[1]According to the European Union, satellite accounts provide a framework linked to the central accounts and which enables attention to be focussed on a certain field or aspect of economic and social life in the context of national accounts; common examples are satellite accounts for the environment, or tourism, or unpaid household work (European system of national and regional accounts (ESA 2010).

References:

Guerchet, M. M., Guerra, M., Huang, Y., Lloyd-Sherlock, P., Sosa, A. L., Uwakwe, R., Acosta, I., Ezeah, P., Gallardo, S., Liu, Z., Mayston, R., de Oca, V. M., Wang, H., & Prince, M. J. (2018). A cohort study of the effects of older adult care dependence upon household economic functioning, in Peru, Mexico and China. PLoS ONE, 13(4). https://doi.org/10.1371/journal.pone.0195567

INEGI. (2018b). INEGI. Datos. https://www.inegi.org.mx/datos/

Similarly, as for health financing, while remittances play an important role in supporting families in many localities throughout the country and they are predominantly provided by the large number of Mexican migrants living in the U.S., the scarce information available shows that these are primarily spent on basic subsistence items such as food and clothing. One of the few studies available on this subject shows that, based on different data sources, the main uses of remittances sent by Mexicans are: buying clothes and groceries. Remittances are used much less frequently to purchase education, health services, settle debts, and for buying, renovating, or building homes (CONAPO & Fundación BBVA Bancomer, 2018).

References:

CONAPO, & Fundación BBVA Bancomer. (2018). Anuario de Migración y Remesas México 2018. https://www.migracionyremesas.org/docs/Anuario_Migracion_y_Remesas_2018.pdf

As previously explained, there are currently two working groups collaborating towards the generation of a National Care System that could potentially lead to the creation of some LTC policies or strategies in the next years. In addition, in recent months (by August 2020) as ministries and federal institutions develop their six-years plans as required at the beginning of each presidential period[1], three institutions have included care-related objectives that may bring changes towards the generation of a National Care System[2], including long-term care.

The first institution to include actions toward supporting those in need of care and their carers was the National Institute for Women, one of the few institutions that has been working towards the generation of a National Care System in previous administrations. With the objective of increasing awareness about all individuals having care needs during the life course, of achieving a fairer distribution of unpaid domestic work and care between women and men, and of modifying intergenerational cultural norms towards gender equality, the 2020-2024 Program establishes the need to develop and implement a national care strategy in which co-responsibility between the State, the private sector, the community, and households prevails.

Specifically, its Priority Strategy 2.3 to increase awareness on the need to recognise, reduce, and redistribute household work and care among the family, the state, the community and the private sector, includes three main actions (2.3.1-2.3.3): a) to encourage actions between the state, families, communities and the private sector that allow positioning Care as a human right and the revaluation and redistribution of care work, as well as promoting equality between women and men; to collaborate with other ministries and public institutions in order to develop a National Care System; and to promote organisational culture actions within the Federal Public Administration that allow balancing work responsibilities with personal care needs.

Second, the Welfare Secretary (previously the Social Development Secretary), in its Welfare Sector Program 2019-2024 (DOF 26/06/2020) (Secretaría de Bienestar, 2020) includes the need to incorporate the Right to Care as part of All Human Rights in Mexico. Specifically, in its Priority Objective 1 to contribute towards guaranteeing a basic set of human rights in an effective and progressive way, starting with those most in need, the document states the urgent need for the National Government to develop and ensure the Right to Care as a social right, with the aim of decreasing discriminatory practices, development and wellbeing inequalities present within the current system of care characterised by the lack of public support to those in need of care and their carers. By establishing the need to include the Right to Care within Mexican legislation, the Program envisions access to care services as a right for all individuals who might need to be cared for during the life course but focusing on particular groups with care dependency such as older adults, people with disabilities and young children.

Within Priority Objective 1, Priority strategy 1.1 defines the need to work towards granting access to care services for girls and boys, for people with disabilities and older adults in order to improve their well-being. The strategy includes three main actions:

1. implementing care services for girls and boys, people with disabilities and older adults;
2. contributing to the coordination and implementation of a National Care System based on the care services of the sector;
3. ensuring early childhood care service for children with and without disabilities, with a human-right and differentiated approach, for mothers, single fathers, or guardians who are looking for a job, studying or working.

The third program that includes strategies or actions that could support LTC, is the Health Sector Program 2020-2024 developed by the Secretary of Health. Priority Objective 2 aims to increase the efficiency, effectiveness, and quality of all processes within the National Health System to provide comprehensive public health and social care. This program also includes a main action to establish specific actions and strategies for the care of carers of people who are ill, and/or have disabilities or special needs, to prevent excessive burden to the carers.

In addition, Priority Objective 5, which aims at improving health protection by prioritising the prevention of health risks through timely and optimal treatment and control of diseases, includes the Priority Strategy 5.1 to improve coverage, equitable access, and quality in health services for the timely diagnosis and treatment of NCDs, and includes three main actions (5.1.8-5.1.10) related to LTC. These are: to efficiently and safely promote palliative care; to ensure quality of life and relief of patients with advanced disease and in terminal phase; to promote support for patients living with NCDs under a comprehensive and multidisciplinary approach that facilitates self-management and the acquisition of skills oriented towards their quality of life; and to establish protocols for the recognition and support of individuals who care for others who are ill, especially those who care for people with disabilities or special needs.

[1] Planning and budgeting within Mexico’s Public Administration is based on a National Planning System, which is structured under the guidelines of the Planning Law and with the active participation of public, social and private sectors. This system is reflected in a National Development Plan that, every six years, is presented to Congress by the President for its revision and approval where appropriate, usually within the first six months of each new administration. Once the National Development Plan is published, all Ministries and Decentralised Federal Institutes have to develop and publish their National Plans for the period. These plans define the priority objectives and main actions they will implement throughout the period and which must be aligned with the National Development Plan.

[2] The National Care System would include three main groups/care needs: early childhood care; older adults and people with disabilities and therefore would go beyond LTC for those with care dependency and their carers, by including nurseries, child care, extended hour schools, etc.

References:

Secretaría de Bienestar. (2020). Programa Sectorial derivado del Plan Nacional de Desarrollo 2019-2024. Programa Sectorial de Bienestar. https://www.gob.mx/bienestar/documentos/programa-sectorial-de-bienestar

In terms of people working in long-term institutions for older adults (under any modality: home care, old people homes/residences, etc.), the Social Assistance Housing Census CAAS survey identified 14,582 people working in the 1,020 long-term care institutions for older adults. Of these, 86% were employed and 14% worked without payment or as volunteers. The majority were women, representing 78% of the paid workers and 63% of the unpaid workers or volunteers.

The CAAS survey also asked about different characteristics of the employment performed and if the staff was certified in different skills/competencies expected by type of activities performed. Based on these specifications, the CAAS reports that 97% of the personnel working in permanent residences for older adults do not have adequate certification of competencies in the area in which they work. Moreover, there are other individuals (mostly paid informal workers) working in services such as day centres, home care aides, domestic workers that form part of the LTC workforce, but there is no data available on their number, their labour conditions, etc.

While there is no formal public long-term care system in Mexico, some government institutions are working towards creating different standard competencies of care. For example, the National Institute of Geriatrics is currently working with other health and higher education institutions to develop and implement standards of care and aptitudes (skills—competencies) in cognitive stimulation for older adults for health care professionals and older adult care standard and aptitudes for social workers within the health care system. However, while these could be mandatory and applicable to all health care institutions, they would not be alike for (temporary and permanent) long-term care services since there is no agency or regulation that requires them to do so.

As mentioned at the beginning of Part 3., Mexico does not have a mandatory national registry of long-term care institutions, mandatory standards of care, including human resources, and no professional care/caregiver bodies exist.

No data available.

No data available.

Mexico does not have a LTC system and therefore no human resources or labour force that is registered/accredited nor their working conditions are regulated. However, there is a growing market for paid informal workers, with diverse training and competences, from specialised nurses employed to carry out very specific care activities, to domestic workers that perform personal care or supervision as part of their overall tasks.

While no studies of working conditions of care workers have been carried out, a recent report by the Ministry of Labour and Social Security (El Trabajo Doméstico En México: La Gran Deuda Social., 2016) on the conditions of domestic workers showed that 98% are not affiliated to any health care services and work 32 hours per week on average. In addition, 76% reported no affiliation to a social security institutions and therefore, have no labour related benefits such as disability or old age pension, maternity leave, paid vacation, etc. Regarding their payment, domestic workers earn less than 50% of the average salary.

References:

El trabajo doméstico en México: La gran deuda social. (2016).

Information on the support of voluntary work in health care provision (all areas/population groups) has been collected as part of the National Health Satellite Accounts generated by the national statistics institute INEGI. For the year 2017, voluntary care in health represented 1.2% of the total GDP of the health sector. Volunteer work is mostly performed in non-profit organisations at the community level, and individuals are usually not employed/contracted and/or paid. On the other hand, the 2015 Social Assistance Housing Census, CAAS, showed that of the total staff working at the interviewed long-term care institutions, 14% worked without payment as volunteers.

In Mexico, ageing has been recently considered a relevant issue, and therefore it has been positioning within the public agenda in the past two decades. However, there is still no Ministry that oversees clinical or social aspects of dementia. As a consequence, to date, there are no national policies or programmes for dementia, and there are no strategies that aim at diagnosing, monitoring, or providing treatment and behavioural management options for people with dementia and/or their carers.

There are currently no specific programs for Dementia, or Ministries with the mandate to oversee all dementia-related issues. When people do seek care for cognitive or behavioural complications (likely not identifying possible dementia) they do so through health services. In this context, no specialised services are available and thus, people accessing health services in any of the available institutions, are subject to the existence/availability of other specialist services (geriatrics, neurology, psychiatry) where they could be referred to and probably get some diagnosis. However, there are no standardised treatment protocols in place covering all health and social security institutions, and there are also no specific social care programmes for people with dementia or their carers.

There are no specific programmes for dementia. Within health system institutions, AD and dementia are seen mostly as mental health issues and, therefore, would be seen within these departments or services.

No, there is not.

In 2011, the National Institute of Geriatrics (INGer) was instructed by the Minister of Health to create an action plan on AD and other dementias and with this, INGER brought together the efforts of different researchers, National Institutes, and NGOs going back at least 20 years into the planning and publication of the National Plan in 2012. Some of the main stakeholders participating in the design and publication of the Plan were the Mexican Alzheimer’s Federation, FEDMA, the National Institute of Neurology and Neurosurgery, the National Institute of Public Health, and the National Institute of Elderly People, INAPAM. The main objective of the National Plan is: “To promote the well-being of people with Alzheimer’s disease and related diseases, and their families, by strengthening the response of the Mexican Health System, in synergy with all responsible institutions”. It is a plan that aims at setting out a strategy to achieve awareness of the problem, de-stigmatise AD and dementia, promote adequate care of older adults with dementia and to generate actions to prevent the disease. Specifically, in the population of older adults with dementia, it aims to: decrease comorbidities, increase functionality, decrease behavioural problems, prevent accidents, improve quality of life, and decrease caregiver stress (Gutiérrez-Robledo & Arrieta-Cruz, 2014).

References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

To date, the Plan has not been updated.

So far, the plan has remained at the proposal level, no progress has been made in its implementation, and no resources have been allocated to it.

The plan only indicates strategies and lines of action. However, there are some strategies that comply with the WHO and PAHO recommendations for action plans on dementia, which are mentioned in the Position Statement and Report of the National Institute of Geriatrics (INGER) and the National Academy of Medicine (Academia Nacional de Medicina de México, 2017), such as these:

• Development of evidence-based data created through the compilation of available national evidence on the epidemiology and burden of dementia, based on information from the Mexican Health & Aging Study (Wong et al., 2017), The 10/66 Dementia Research Group study (Prina et al., 2017), and the 2012 National Health and Nutrition Survey (Romero-Martínez et al., 2013).
• Development of education programs for health professionals in primary care, such as the Alzheimer’s and dementias courses for health professionals, by the National Institute of Geriatrics.
• Generate and disseminate information and materials for primary carers.
• Specialised trainings in cognitive aging and dementias at the National Institute of Neurology and Neurosurgery, the specialty in Geriatric Neurology taught at the National Institute of Medical Sciences and Nutrition, and the course in Psycho-geriatrics taught at the National Institute of Psychiatry.
• Clinical practice guidelines, two clinical practice guidelines for dementia from Secretary of Health, one for Alzheimer’s disease and one for Vascular dementia, with the aim of contributing to increase the quality and effectiveness of medical dementia care.

References:

Academia Nacional de Medicina de México. (2017). La Enfermedad de Alzheimer y otras demencias como problema nacional de salud. Documento de postura (L. Robledo, Maria. Peña, Paloma. Rojas, & A. Martinez, Eds.; 1a edición). Intersistemas. https://www.anmm.org.mx/publicaciones/ultimas_publicaciones/ANM-ALZHEIMER.pdf

Prina, A. M., Acosta, D., Acosta, I., Guerra, M., Huang, Y., Jotheeswaran, A. T., Jimenez-Velazquez, I. Z., Liu, Z., Llibre Rodriguez, J. J., Salas, A., Sosa, A. L., Williams, J. D., & Prince, M. (2017). Cohort Profile: The 10/66 study. International Journal of Epidemiology, 46(2), 406–406i. https://doi.org/10.1093/ije/dyw056

Romero-Martínez, M., Shamah-Levy, T., Franco-Núñez, A., Villalpando, S., Cuevas-Nasu, L., Pablo Gutiérrez, J., & Rivera-Dommarco, J. (2013). Encuesta nacional de salud y nutrición 2012: diseño y cobertura. [National Health and Nutrition Survey 2012: design and coverage]. Salud Publica Mex, 55(2), S332-S340 (in Spanish). https://doi.org/10.21149/spm.v55s2.5132

Wong, R., Michaels-Obregon, A., & Palloni, A. (2017). Cohort Profile: The Mexican Health and Aging Study (MHAS). International Journal of Epidemiology, 46(2), e2. https://doi.org/10.1093/ije/dyu263

The central objective of the Alzheimer’s Action Plan and other dementias is to promote the well-being of people with Alzheimer’s disease and related diseases and their families by strengthening the response of the Mexican Health System, in synergy with all responsible institutions. The main strategies of the Plan are (Gutiérrez-Robledo & Arrieta-Cruz, 2014):

• To prevent and promote mental health through public policy that considers mental health from a life-course perspective, that is, it considers preventing risk factors known as diabetes and hypertension while promoting active and healthy aging.
• To improve access to health services at all levels of care with a multidisciplinary approach, encompassing not only the hospital setting but also the community setting; through a long-term care perspective, including the establishment and maintenance of day centres for the care of older adults with dementia in their early stages.
• To identify and diagnose older adults with dementia in a timely manner through a comprehensive, multidisciplinary evaluation that reduces the impact of disability and dependency by training health professionals who are at the first level of care and the appropriate use of current screening instruments.
• To increase the number of personnel trained to treat people with dementia through permanent and constantly updated training programmes, from an inclusive perspective, considering that the care of the elderly person with dementia implies a multidisciplinary team.
• To raise society’s awareness of the importance of dementia as a public health problem in order to prevent abuse and discrimination of older adults with dementia and to recognise the importance of formal and informal carers.
• To increase research, from all areas of knowledge involved in the phenomenon, emphasising applied research studies, favouring the link between different institutions and scientific groups.
• To continuously evaluate the impact of each of the proposed actions through the development of indicators.
• To provide long-term care in the later stages of the disease.

References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

There was no direct participation of people living with dementia. However, there was participation of civil organisations focused on the care of people with dementia.

The plan has not been fully operationalised.

No resources have been allocated towards the implementation of specific activities included in the Plan. The actions that have been carried out have been financed directly by the institutions and civil society organisations.

The Plan does not include consequences or penalties of non-implementation. With respect to the protection of older people’s rights or other human rights, there are different institutions that are in charge of granting these or pursuing those who violate them, such as the Mexico City Specialized Agency for the Care of Older Adults Victims of Family Violence and the National Human Rights Commission or the country’s Ombudsman institution. However, there are no specific provisions for people with dementia within these structures or programs.

In Mexico, the National Development Plan (NDP) is the guiding document of the Federal Government in which they describe the national objectives, strategies, and priorities of the integral and sustainable development of the country. It is prepared during the first semester of the six-year term of each federal government and its validity ends with the corresponding constitutional period.

Given that a large proportion live in poverty and without access to social protection system, the National Development Program PND 2019-2024 includes a program for the Welfare of Older Persons, which is based on providing economic support (US $66.61 by month) to women and men over 68 years. However, to date, neither National Health Sector Programs nor National Old Age Health Care Programs have included dementia. Therefore, at the federal level, the issue of dementia is not placed within the national policy.

While Mexico has not yet ratified its adherence, the Inter-American Convention for the Rights of Older Adults includes in its article 19 ‘Rights to Health’ the promotion of the development of specialised integrated social and health care services for older adults with dependency-generating illnesses, including chronic degenerative diseases, Alzheimer’s disease, and other dementias (Organization of American States, 2015).

While ageing issues and older adults have gained importance and have been positioned at the national level as priorities, no specific government sector or Secretariat is responsible for dementia and there are no specific programs for dementia diagnosis and care.

In the previous government administrations, some institutions or programmes included several related activities within their aims to support older adults, for example:

• National Gerontology Program 2016-2018 (National Institute for the Elderly, INAPAM) (INAPAM, 2016): which focuses on the implementation of public policies to support the wellbeing of older adults.
• Program to Support Aging 2013-2018 (Programa de Atención al Envejecimiento) (National Centre for Disease Control and Prevention Programs, CENAPRECE): where the first objective was to establish a culture of living healthy, with a gender perspective among older adults, care for chronic diseases and mental health coverage including the detection and diagnosis of memory alterations. However, we found no data about their degree of implementation nor to inform if these were implemented.
• Specific Mental Health Action Programme 2013-2018 mentions the need for timely detection of mental or behavioural disorders in adults and older adults.
• Specific Action Programme Psychiatric care 2013-2018 indicates the need to contribute to the deinstitutionalisation of mental health patients with severe cognitive impairment and abandonment.
• Specific Action Programme Research for Health 2013-2018 only describes the issue of ageing, putting into context the population pyramid that points at ageing and non-communicable diseases.

References:

INAPAM. (2016). Programa Nacional Gerontólogico 2016-2018.

Organization of American States, O. (2015). Inter-American Convention on Protecting the Human Rights of Older Persons (A-70). http://www.oas.org/en/sla/dil/inter_american_treaties_A-70_human_rights_older_persons_signatories.asp

The National Ageing Program of Attention 2013-2018 developed by the CENAPRECE predominantly focused on the screening of alterations of memory problems with the application of the Mini-mental (Folstein et al., 1975). The indicator of compliance was the coverage of mental health in the detection of alterations of memory (numerator: total number of detections carried out through the Mini-mental / denominator: population of 60 years and more) by 100. The information was planned to be captured by the National Health Information System (Sistema Nacional de Información en Salud) at the Ministry of Health. However, no official estimates for this indicator have been reported so far.

References:

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. https://doi.org/10.1016/0022-3956(75)90026-6

No, there are not.

Not applicable.

The Alzheimer’s and other dementias Action Plan (Gutiérrez-Robledo & Arrieta-Cruz, 2014) is in line with a human rights-based approach.

References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

The Alzheimer’s and other dementias Action Plan (Gutiérrez-Robledo & Arrieta-Cruz, 2014) includes multisectoral collaboration and it considers the participation of public health agencies, civil society, and industry.

References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

Although it does not mention universal health coverage, it does describe the need to improve access to quality services, with timely diagnosis and treatment, as well as long-term care in the later stages of the disease.

References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

Although not openly mentioned, the plan appears to refer to Goal 3 which refers to ensuring healthy lives and promote well-being for all at all ages.

People with dementia are recognised in the following lines of action (Gutiérrez-Robledo & Arrieta-Cruz, 2014):

1. Educational programs on the rights of people at the end of life, including topics such as testaments and advance directives.
2. Legal, social, and financial assistance to prevent abuse, violence, or neglect in the care of the person with dementia.
3. Financial support, especially for people with limited economic resources.

The family of the person with dementia is recognised in the following lines of action:

1. To develop a model of training, evaluation, and care for primary caregivers and family members.
2. To promote family guidance for better care and management of their family members affected by dementia.
3. To create programs and training for family members and health personnel in palliative care.
4. To establish facilities for the family primary caregiver.
5. To develop psychological and spiritual support programs.
6. To subsidise or low-cost programmes for funeral and purchase of essential medicines in palliative care at home (e.g., for pain control).
7. To create respite care units for primary caregivers.

References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

The plan considers the need to promote the fight against discrimination in all spheres, as well as to inform vulnerable older adults about their rights, and mechanisms for access to services in case they become victims of mistreatment or discrimination, as well as to provide legal, social, and financial assistance to prevent abuse, violence or negligence in the care of the person with dementia.

The dedicatory of the plan presents a recommendation for a humanistic, compassionate, person-centred, and quality-of-care approach; however, this concept is not developed throughout the full text.

An active role of the people with dementia is not mentioned in the plan.

There’s no special emphasis on it.

It is not specifically mentioned in the document.

There is a specific strategy focusing on ensuring access to quality services, and it is centred on the following lines of action:

1. The availability of human, material, and financial resources in accordance with the number of dementia patients at the three levels of health care.
2. To improve the quality of geriatric, neurological and psychiatric care to achieve comprehensive medical management in advanced stages of the disease.
3. To strengthen care at the community and family level with a comprehensive ambulatory, non-hospital vision for long-term care of dementia patients through specific rehabilitation programs.
4. To establish, grow, maintain, and regulate day centres as an alternative for the comprehensive management of patients with dementia in the early stages of the disease.
5. To destine the third level of attention to the study and management of difficult cases for an adequate differential and final diagnosis.

The health and long-term care workforce is represented in the National Plan through two strategies, the first one aims at training adequate and specific human resources through the following lines of action:

1. To increase the number of specialists to provide care for dementia patients, in accordance with the needs of the country.
2. To implement permanent training programs to update health professionals and non-professional personnel.
3. To include topics on aging during undergraduate and graduate training for all health professionals, with emphasis on dementia.
4. To promote human resource training strategies, taking advantage of new information technologies and inter-institutional collaboration.
5. To create scholarships for the training of non-medical health professionals specialised in the care of the elderly with dementia.
6. To promote family guidance for better care and management of family members affected by dementia.

The second strategy is aimed specifically at long-term care in the last stages of the disease, focussing on the need for programs or services for comprehensive palliative care at home.

There is no description of key actors or the definition of their roles.

It emphasises the need for an integrated care model involving all levels of the national health system, as well as the development of a training, evaluation and care model for primary caregivers and family members. On the other hand, the document aims at generating an inter-institutional network for the updating and feedback of personnel dedicated to the care of the person with dementia.

It outlines the interface with other aspects of care with regards to the prevention and promotion of mental health with a life-course perspective. This involves considering known risk factors, and encouraging active and healthy ageing, which could help preventing, or at least delaying, the onset of dementia and other conditions.

No potential barriers to access are described.

Although it is not directly mentioned, the plan not only refers to equity through awareness raising, but it also aims to emphasise that dementia is a public health problem that can affect anyone, and that generates profound changes in the lives of those who live with it. This includes promoting the fight against discrimination, informing people about their rights and services available to them, should they become victims of abuse or discrimination, recognising the role of caregivers as partners, and incorporating civil organisations to broaden the dissemination.

Three lines of action are developed around prevention and risk reduction:

1. Considering dementia as a relevant public health problem.
2. Strengthen preventive campaigns against diabetes, obesity, hypertension, and physical inactivity to reduce risk factors associated with dementia.
3. Promote mental health care at all stages of human development.

A continuous evaluation is proposed through the creation of an advisory group to evaluate the relevance and sustainability of the proposed actions, the mechanisms to execute them, and the generation of evaluation tools to measure the impact of the implemented actions. However, although there is institutional leadership, the group has not been officially formed.

The actions in the plan are being led by national health institutes as well as by civil associations.

Although progress has been made, no monitoring mechanisms have been established.

They are not mentioned.

They are not mentioned.

All areas are generally fulfilled.

It raises the need to consider dementia as a public health problem, integrating civil society, private institutions, and industry in the fight against dementia, against discrimination, and to promote mobilisation.

It points to the need to strengthen prevention campaigns against diabetes, obesity, hypertension, and physical inactivity, in order to reduce risk factors associated with dementia.

It points out the need for timely diagnosis and treatment, as well as for strengthening care at the community and family level, with a comprehensive outpatient, non-hospital vision for the long-term care of patients with dementia, through specific rehabilitation programs.

It points out the need for qualified and specialised personnel, organised in multidisciplinary teams with the participation of specialists, rehabilitators, caregivers, and family members.

It emphasises that the recognition and support to professional and family caregivers is vital to maintain quality care of patients.

It mentions the need to develop new sources of information for the construction of a permanent epidemiological surveillance system to monitor dementia cases in Mexico as well as the generation of evaluation tools to measure the impact of the implemented actions.

Encouraging national research (basic, clinical, epidemiological, and social) on this disease is essential to generate new knowledge to promote better management of the disease to optimise the quality of life of family members and people with dementia.

In Mexico, so far, there are no specific laws on dementia. However, there is the Law on the Rights of Older Persons (Congreso General de los Estados Unidos Mexicanos, 2002), which is based on the principles of autonomy and fulfillment, participation, equity, co-responsibility, and preferential attention. It also aims at  guaranteeing the rights of integrity, dignity and preference, legal certainty, protection of health, alimentation and family, education, employment and economic capacities, social assistance, participation, popular denunciation, access to services. However, it does not mention dementia specifically.

References:

Congreso General de los Estados Unidos Mexicanos. (2002). Ley de los Derechos de las Personas Adultas Mayores. Diario Oficial de La Federación, 38, 38–52. http://www.diputados.gob.mx/LeyesBiblio/ref/ldpam/LDPAM_orig_25jun02.pdf

Although there are no specific laws on dementia, other laws have an indirect impact.

In eleven states in Mexico (Aguascalientes, Chihuahua, Coahuila, Colima, Mexico City, Mexico state, Guerrero, Hidalgo, Michoacan, Nayarit, and San Luis Potosí), there are advance directive laws that allow people to freely and consciously decide how they want to be medically treated if they face a terminal illness or an accident. For this reason, people who wish to make the request, must present themselves before notaries to express in advance how to be treated if they find themselves in that position. Regulation regarding advance directives include power of attorney regulated by the Federal Civil Code[1] established as a legal and judiciary condition for those individuals who do not have the capacity to make decisions on their own because of a mental disorder, illness, or due to impairment as a consequence of substance abuses and who are consequently limited as to their integrity and ability to make decisions and take care of themselves, and therefore need to appoint a legal representative (guardian and curator) who must attend to their legal life. Thus, patients with chronic, progressive, and degenerative and/or dementia such as Cerebral Vascular Disease, Huntington’s disease, and Alzheimer’s disease, fall into this category.

The guardian is the person who will be in charge of the guardianship of a person or their material goods, and the curator will be the one who will supervise the fulfillment of the obligations of the guardian. Healthcare power of attorney trials, take place in a family court in most of the country, for which the advice of gerontologists, geriatricians and neuro-geriatricians are recommended. In fourteen states in Mexico, Do Not Resuscitate Orders (DNR) are established through a law and its regulation[2] so that all individuals with intact capabilities can decide if they want to be submitted or not to means, treatments or medical procedures that aim to prolong their life when the person is at the end of life, aiming to protect their dignity, and favouring palliative care and end of life care. The emphasis is on accompanying the patient during this stage of his life, not prolonging or shortening his life, but respecting the natural moment of death. It is a document that will be used at the moment a doctor has diagnosed an advanced stage disease.

[1] CÓDIGO CIVIL FEDERAL. Nuevo Código publicado en el Diario Oficial de la Federación en cuatro partes los días 26 de mayo, 14 de julio, 3 y 31 de agosto de 1928. TEXTO VIGENTE: Última reforma publicada DOF 03-06-2019; http://www.diputados.gob.mx/LeyesBiblio/pdf/2_030619.pdf

[2] Ley de Voluntad Anticipada para el Distrito Federal, 2008 (https://drive.google.com/file/d/0B0qDlFGzsYQfaHFCQWQ0cXZKRzA/view ) and its Reglamento (https://drive.google.com/file/d/0B0qDlFGzsYQfSEJJV2QyTmMtNjQ/view )

While there are no specific laws in favor of persons with dementia or their caregivers in Mexico, more general laws are aimed at preserving their rights as persons, such as the Federal Law to Prevent and Eliminate Discrimination, and the General Law for the Inclusion of Persons with Disabilities. However, it must be recognised that neither of these two mentions dementia specifically.

There are no specific guidelines for transitioning to community-based services.

There are clinical practice guidelines for the detection and management of elder abuse (CENETEC, 2013; IMSS, 2013). But they do not make any specifications about people living with dementia.

References:

CENETEC. (2013). Detección y Manejo del Maltrato en el Adulto Mayor. www.cenetec.salud.gob.mx

IMSS. (2013). Guía de Práctica Clínica GPC. Detección y manejo del maltrato en el adulto mayor.

The Official Mexican Standard 025 (DOF, 2015) for the Provision of Services in Psychiatric Medical Hospital Care Units, indicates a set of Provisions that regulate the treatment and rehabilitation of people with a mental disorder, respecting their human rights and covering two areas: a) Quality specialised medical care, and b) Preservation of the human rights of the user. With respect to this second item, it is stated that people with mental disorders have the right to receive dignified and humane treatment by mental health personnel, they are not to be discriminated against because of their condition, not to be the object of diagnosis or treatment for political, social, racial, religious or other reasons different from or external to the state of their health, they have to be protected against all exploitation, abuse or degrading treatment, and they are not to be subjected to physical restrictions or involuntary confinement.

References:

DOF. (2015). Norma Oficial Mexicana NOM-025-SSA2-2014. Para la prestación de servicios de salud en unidades de atención integral hospitalaria médico-psiquiátrica. http://www.dof.gob.mx/normasOficiales/5805/salud3a11_C/salud3a11_C.html

The Official Mexican Standard on Criteria for the Care of Terminally Ill Patients with Palliative Care 011 (DOF – Diario Oficial de la Federación, 2014), includes support management as part of the continuum in the care of patients in advanced disease, which indicates that the management should follow this order: 1. Curative intention, 2. Symptomatic support, 3. Palliative care, 4. Patient close to death, 5. Agony, and 6. Bereavement.

Although it was issued in 2014, it was not until 2018 that dementia was specifically identified in an annex, where the following recommendations are made:

1. Assessment of functional status
2. Evaluation of comorbid situations and quality of care
3. Limitations: Inability to transfer from one place to another and to dress without assistance, inability to bathe properly, fecal and urinary incontinence, inability to communicate intelligibly
4. Presence of medical complications
5. Comorbid conditions associated with dementia (aspiration pneumonia, decubitus ulcers, pyelonephritis, or lower urinary tract infection, etc.)
6. Difficulty swallowing food or refusing to eat, and in those receiving nasogastric tube feeding, deterioration of nutritional status.

In a general way the norm points out:

1. Areas of attention: Patients must be identified and diagnosed with an advanced disease limiting life by the doctors treating the Health Units
2. Palliative management plan for the patient and his or her family, proposed by the multidisciplinary health team
3. The patient and the family are guided and trained to carry out the role of care, to continue their care in the best family environment and to be able to refer the patient properly to their home.

This service is free in Health Units and home care must be received. However, given the infrastructure of the Mexican health system, it has not been possible to adequately implement this standard.

References:

DOF – Diario Oficial de la Federación. (2014). ACUERDO que modifica el Anexo Único del diverso por el que el Consejo de Salubridad General declara la obligatoriedad de los Esquemas de Manejo Integral de Cuidados Paliativos, así como los procesos señalados en la Guía del Manejo Integral de Cuidados Paliativos. https://www.dof.gob.mx/nota_detalle.php?codigo=5534718&fecha=14/08/2018&print=true

There is no specific legislation related to fighting discrimination against people with dementia.

There is no specific legislation related to fighting discrimination against family carers.

So far, there is no specific law to promote the rights of unpaid family or caregivers of persons with dementia.

Article 9 of the Law on the Rights of Older Persons (DOF – Diario Oficial de la Federación, 2018) states that the family of the older adult must fulfil its social function; therefore, it must look after each. Each family is responsible for providing the necessary satisfiers for their care and integral development, and has the following obligations to them:

1. Granting food,
2. Encourage daily family life, where the elderly person actively participates, and promote at the same time the values that affect their emotional needs, protection and support,
3. Prevent any of its members from committing any act of discrimination, abuse, exploitation, isolation, violence, and legal acts that endanger their person, property, and rights.

References:

DOF – Diario Oficial de la Federación. (2018). Ley de los Derechos de las personas adultas mayores.

Education Policy Outlook – OECD. (n.d.). Retrieved February 20, 2019, from http://www.oecd.org/education/policy-outlook/

For the curatorship/power of attorney obtained to take place, a resolution dictated by a competent authority is needed. A comprehensive assessment of the physical and mental situation of the older adult has to be performed in order to exclude other ailments or temporary conditions such as delirium, where usually there may be an underlying cause, and that once treated, disappear.

Three clinical practice guidelines have been developed in Mexico in relation to dementia and cognitive impairment:

1. Diagnosis and Treatment of Alzheimer’s Disease. Evidence and Recommendations Guide: Clinical Practice Guide. Updated in 2017 (CENETEC, 2017).
2. Clinical Practice Guide Diagnosis and treatment of vascular dementia in adults in the three levels of care, updated in 2017 (Secretaría de Salud, 2017).
3. Guide to Clinical Practice, Diagnosis and Treatment of Cognitive Impairment in the Elderly in the First Level of Care, Mexico, updated in 2012 (Secretaría de Salud, 2012).

References:

CENETEC. (2017). Diagnóstico y Tratamiento de la Enfermedad de Alzheimer. Guía de Evidencias y Recomendaciones: Guía de Práctica Clínica. Guia de Practica Clinica. http://www.cenetec-difusion.com/CMGPC/IMSS-393-10/RR.pdf

Secretaría de Salud. (2012). Guía de Práctica y Tratamiento del Deterioro Cognostivo en el Adulto Mayor en el Primer Nivel de Atención. In CENETEC (Vol. 1).

Secretaría de Salud. (2017). Guía de Práctica Clínica Diagnóstico y Tratamiento de demencia vascular en el adulto en los tres niveles de atención.

The guidelines are developed by the Ministry of Health, through the National Centre of Technological Excellence in Health (CENETEC), which is a government dependence body whose objective is to provide information based on the best available evidence for appropriate decision-making on health technologies in health services in Mexico, through advice, coordination of sectoral efforts and the generation, integration and dissemination of information.

The guidelines are developed, approved, and disseminated by the Ministry of Health, and are supported by the main institutions that are part of the national health system, such as IMSS, ISSSTE, PEMEX, DIF, as well as other health institutions at the national level.

The guidelines describe risk factors, criteria, and methods for diagnosis, as well as the pharmacological and non-pharmacological management of dementia. They present some differences between Alzheimer’s dementia and vascular dementia. There are no guidelines of other types of dementia (for example, frontotemporal).

a) Alzheimer’s disease

Modifiable risk factors are identified: Depression, Physical inactivity, Hypertension, Obesity, Smoking, Low educational attainment, and Diabetes. And the non-modifiable: advanced age, first-degree family history, autosomal dominant gene presence of apolipoprotein allele E4.

b) Vascular dementia

It is mentioned that cardiovascular risk factors contribute to the development of vascular dementia, and these are classified as modifiable and non-modifiable.

Not modifiable: Age, sex, ethnic group (black, Hispanic, and Asian race), family history.

Modifiable: Hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, smoking, obesity, carotid disease, homocysteinaemia.

a) Alzheimer’s disease

Various actions are recommended to improve the accuracy of the diagnosis, such as the following:

1. Obtain a medical and family history of the individual, including a neuropsychiatric history and a history of changes in cognition and behaviour.
2. Review of medications used that could affect cognition
3. Ask family members and others close to you individually for changes in thinking or behaviour.
4. Cognitive tests, neurological exam, and physical tests.
5. Serological and neuroimaging tests (primarily to rule out other causes).

b) Vascular dementia

Patients at high risk for vascular cognitive impairment should be considered those who present the following risk factors: hypertension, age over 65, hyperlipidemia, diabetes mellitus, clinical evidence of cerebral vascular event, findings in neurodiagnostic images of cerebral vascular event and/or leukoencephalopathy, damage to other target organs (eye, kidney, heart), and patients with cognitive or functional changes that are clinically evident or reported during the completion of the clinical history.

General examinations are recommended in patients with suspected dementia, to exclude potentially reversible causes of dementia and for screening for comorbidities. As well as neuroimaging studies for the detection of vascular components.

It is recommended to differentiate between vascular dementia, Alzheimer’s disease or the co-existence of the two entities, using the Hachinski ischemia scale, in order to better identify treatment and prevention.

a) Alzheimer’s disease

Acetylcholinesterase inhibitor (ACE) therapy such as donepezil, rivastigmine and galantamine are described as drug treatment interventions. As well as the evaluation of the response to the global treatment of behavioural and psychological symptoms of dementia.

Non-pharmacological interventions are indicated: Structured Activities, Behavioural Therapy, Environmental Modifications, Social Contact, Sensory Stimulation and Relaxation.

The active participation of the caregiver is essential for the efficacy of non-pharmacological intervention programmes in patients with dementia.

Among the main comorbidities are depression and the recommendation of the use of antidepressants, preferably sertraline and citalopram.

b) Vascular dementia

Treatment for cardiovascular risk factors is recommended to prevent new events (secondary prevention) rather than to improve cognitive function[1].

The pharmacological treatment of behavioural and psychological symptoms of dementia will be used only in the presence of specific syndromes or that impact the patient’s quality of life or safety.

It is recommended that a multidisciplinary team should be formed for the comprehensive care of the patient. The intervention of personnel trained in geriatrics, psychiatry, neurology, nutrition, social work, physical, occupational and language therapy is suggested, depending on the case and institutional capacity. Rehabilitation strategies adapted to the mental and functional limitations, as well as the remaining cognitive skills of the individual, should be implemented and the needs and goals of patients and caregivers identified. Structured exercise programs, as well as recreational activities, are recommended to maintain functionality and mobility; improve quality of life and self-perception of well-being. However, there is no mention of carer support strategies.

[1] The recommendations are: maintain blood pressure less than 150/90 mmHg (in older adults), with diastolic pressure greater than 60-65 mmHg, adequate glycaemic control, lifestyle interventions, physical exercise, smoking cessation and when appropriate, treatment with platelet antiaggregant, statins and antihypertensive therapy.

For the patients with any kind of dementia, it is recommended to assess the progression of cognitive impairment at least every 3 months, given that a wide range of psychological and behavioural manifestations are presented in each patient. Therefore, it is recommended to recognise promptly the needs of the patient and family to refer the corresponding health personnel (geriatrician, neurologist, psychiatrist, neuropsychologist, nutritionist, occupational and physical therapist) to the second and third levels of care within an appropriate time frame.

It is not mentioned in the clinical practice guidelines.

It is not mentioned in the clinical practice guidelines.

It is not mentioned in the clinical practice guidelines.

It is not mentioned in the clinical practice guidelines.

The clinical practice guides are developed mainly in the Ministry of Health, through the National Centre of Technological Excellence in Health (CENETEC). Their updating depends on the identification and evaluation of new evidence, the opinion of experts, as well as the opinion of the team that developed the guide, the perception of users, and the analysis of the context. As there is no defined time to update it, it will rather depend on these points, as well as on the resources, the availability of time, the methodology used, as well as the collaboration of the institutions involved (Secretaría de Salud, 2015a).

References:

Secretaría de Salud. (2015a). Metodología para la integración de Guías de Práctica Clínica en el Sistema Nacional de Salud.

In general terms, it is proposed that the use of clinical practice guidelines should be a national reference to favour clinical and managerial decision-making based on recommendations supported by the best available evidence, aiming to reduce the variability of clinical practice, as well as the use of unnecessary or ineffective interventions, to facilitate the treatment of patients with the maximum benefit, with a lower risk and an acceptable cost (CENETEC, 2016).

References:

CENETEC. (2016). Dirección de integración de Guías de Práctica Clìnica. CENETEC. http://www.cenetec.salud.gob.mx/contenidos/gpc/dir_gpc.html

Mexico has a strong history of use of traditional medicine, based on different needs or services: pregnancy and deliveries, bone-healers, traditional medics. These traditions are a mix of pre-Hispanic indigenous cultures and beliefs, as well as the use of local herbs, remedies, etc., and the practices brought by the Spanish which have been widely documented (Lozoya X & Zolla, 1984). These practices are different between states and regions and their prevalence of use is highly correlated with higher percentage of rural population/localities, some of them presenting a wide diversity of “remedies”. For example, one of the first studies of traditional medicine practices in the State of Chiapas (southeast of the country) documented the use of 206 plants for a huge diversity of ailments and diseases such as stomach ache, burns, cough, wounds, head ache, tuberculosis, diabetes, diuretics, empacho (colloquial for indigestion) or verguenza (literal translation, shame) (Lozoya X & Zolla, 1984). Since these first studies, many more have documented the use of alternative or complementary medicine use in the country. Notwithstanding the fact that most likely some “remedies” are being used to manage or treat symptoms of dementia like memory loss, no information or published studies are identified on the use of these alternative practices to treat or manage dementia.

References:

Lozoya X, & Zolla C. (1984). Medicina Tradicional en México. Boletín de La Oficina Sanitaria Panamericana (OSP), 96(4). https://iris.paho.org/bitstream/handle/10665.2/17007/v96n4p360.pdf?sequence=1&isAllowed=y

As previously mentioned, traditional medicine is widely used. No studies are yet available/published on its particular use for dementia and its related symptoms.

Not yet described.

As mentioned above, there are no national dementia policies and no care coordination mechanisms are in place.

No data is available as no care coordination mechanisms are in place.

No data is available as no care coordination mechanisms are in place.

No data is available as no care coordination mechanisms are in place.

No data is available as no care coordination mechanisms are in place.

No data is available as no care coordination mechanisms are in place.

No data is available as no care coordination mechanisms are in place.

The new government administration is in its first year, when all the national plans and programs are generated. It is hoped that dementia is at least included as a priority in the Specific Action Program: Aging Care 2019-2024.

Not specifically, but it is hoped that it will be included in the Specific Action Program: Aging Care 2019-2024. This will create a directive for the need to generate specific actions and financing.

Not applicable.

A revision of the National Dementia Plan could be likely developed in the next couple of years.

It might be included as an end-goal of NCD prevention and management.

As previously mentioned, there are two groups working together towards the generation of a National Care System, one led by the National Institute for Women (INMUJERES) and a second one at health system level lead by the General Health Council, CSG (Consejo de Salubridad General) at the Ministry of Health and the National Institute of Geriatrics (INGER). As people with care dependency will be included as a target group, this could be a viable way to include people with dementia who have care needs as a specific target group. In addition, the inclusion of care-specific priorities in the six-year plans of three federal government institutions, opens the door to the establishment of the National Care System and long-term care policies.

No information to indicate this is available.

Ministry of Health, Ministry of Wellbeing, Ministry of Finance, and Social Security Institutions. In terms of care-specific policies, the National Institute for Women also has an important role.

There have been no national level public awareness campaigns, but some National Institutes have issued information and awareness messages and campaigns via their internal publications and social media accounts.

In 2016, the Mayor (Jefe de Gobierno) Miguel Angel Mancera launched a campaign against Alzheimer’s called “My memory CDMX” in collaboration with local Alzheimer’s Associations. As with programs for people with dementia and their carers, most initiatives of public awareness have come from the civil society, mainly, Alzheimer’s and other dementias associations. Since the year 2000, FEDMA and other associations have organised a National Alzheimer’s Congress including both academic sessions and sessions for the general public. The latter ones include information sessions, group activities, training for carers, among other activities.

In more recent years, every September as part of the World’s Alzheimer’s month, different activities have been generated. For example, invitations to different TV and radio programmes (public media) of experts and civil society organizations to talk about some topic related to dementia, whereas diagnosis, treatment options, symptoms to be aware of, etc. Other activities include Dementia Walks organised by FEDMA and the INGER since 2014.

A movement that has quickly progressed is the Dementia Friends Initiative. Since January 2019, the Mexican Alzheimer’s Association, FEDMA, in collaboration with the National Institute of Geriatrics, INGER and the University of Guadalajara in the State of Jalisco, have been developing the initiative’s workshops aiming at changing people’s perceptions of dementia. Currently, the movement is present in 11 (out of 32) States and has trained 5,000 dementia friends.

Currently no other professions or groups (including the listed below) receive training as part of their mandatory training or education curriculum.

Dementia is perceived as part of the normal process of ageing. Memory loss is almost normalised, and this means that little help or formal health care is sought and often, only in the late stages. Lack of knowledge of dementia, its symptoms and causes also cause many people, especially in individuals with low resources and low educational attainment, to attribute what happens as the result of an external factor such as stress, alcohol consumption, sequelae of another illness/being in hospital, and in some cases, of someone “wishing you ill”.

On the other hand, hiding the illness/symptoms to others outside the household (at times even to close family members) or the person with dementia when the dementia is in its advance stages, is a common practice. Moreover, even health professionals sometimes hide the diagnosis to the person and will disclose only to the family members or primary carer.

In accordance with to World Alzheimer Report 2019 on the attitudes towards dementia (ADI, 2019), in Mexico there are varied perceptions according to the profile of the participants, while 7.6% of healthcare practitioners agreed that people with dementia are perceived as dangerous, 41.2% of the general public agreed that people with dementia are perceived as dangerous. Moreover, 73% of them approved that people living with dementia are impulsive and unpredictable (ADI, 2019). This denotes a negative attitude among the general population. However, there is not enough evidence of changing perceptions.

References:

ADI. (2019). World Alzheimer Report 2019: Attitudes to dementia. https://www.alz.co.uk/research/WorldAlzheimerReport2019.pdf

Lack of information means that negative perceptions are present at the individual, family, community, and society levels. While government does not have a negative perception, there is a high proportion of public employers that have these negative perceptions too and this may affect their overall behaviour. While it is evident that negative perceptions exist around dementia, there is only little documented evidence on perceptions of dementia coming from studies. From the few available, it becomes clear that lack of information and high stigma is present (Juárez-Cedillo et al., 2014).

References:

Juárez-Cedillo, T., Jarillo-Soto, E. C., & Rosas-Carrasco, O. (2014). Social representation of dementia and its influence on the search for early care by family member caregivers. American Journal of Alzheimer’s Disease and Other Dementias, 29(4), 344–353. https://doi.org/10.1177/1533317513517041

There is no training covered in question 05.03.

No, the only campaigns mentioned have not been evaluated.

No, currently no specific initiatives to improve the accessibility for people with dementia are in place. However, several laws and regulations around the rights of people with disabilities include granting accessibility to public spaces and buildings, making education and work opportunities available, as well as enhancing mobility (streets).

Mexico does not have a National Program for Dementia, and currently, no strategy is in place to diagnose, monitor, or provide management options for people with dementia.

No data is routinely gathered or monitored.

While not established to monitor people with dementia, a national longitudinal survey, the Mexican Health and Aging Study, MHAS (Wong et al., 2017) and the 10/66 study (Prina et al., 2017) have provided epidemiological data on cognitive impairment and dementia. However, these studies do not monitor these individuals’ condition routinely.

References:

Prina, A. M., Acosta, D., Acosta, I., Guerra, M., Huang, Y., Jotheeswaran, A. T., Jimenez-Velazquez, I. Z., Liu, Z., Llibre Rodriguez, J. J., Salas, A., Sosa, A. L., Williams, J. D., & Prince, M. (2017). Cohort Profile: The 10/66 study. International Journal of Epidemiology, 46(2), 406–406i. https://doi.org/10.1093/ije/dyw056

Wong, R., Michaels-Obregon, A., & Palloni, A. (2017). Cohort Profile: The Mexican Health and Aging Study (MHAS). International Journal of Epidemiology, 46(2), e2. https://doi.org/10.1093/ije/dyu263

Data sets for these studies are publicly available, thus, the estimates on incidence and prevalence of cognitive impairment and dementia can be obtained.

The 10/66 study is representative of rural and urban locations and data can be disaggregated by gender and different socio-economic characteristics. MHAS study data can be disaggregated by gender, urban location, and different socio-economic characteristics.

Since 2003, two national health surveys and two dementia specific surveys have documented the prevalence of dementia and cognitive impairment in Mexico.

1. Mexican Health and Aging Study, MHAS (Encuesta Nacional de Salud y Envejecimiento en México, ENASEM, mhasweb.org).

The initiative is funded by the National Institute of Health and the National Institute of Aging of the United States. This is the first large scale longitudinal study in Mexico with data collected in 2001 (baseline study) with follow-up interviews in 2003, 2012, 2015 and 2018 (Wong et al., 2015). The objective of this longitudinal study is to prospectively evaluate the impact of diseases, functioning and mortality of adults 50 years of age and older (or adults born in 1951 or earlier at the time of the baseline survey), in more and less urban areas of Mexico. In MHAS, the identification of cases of dementia was made using an algorithm based on a cognitive evaluation (performed with a battery of instruments) and another on functional ability. The prevalence of dementia estimated in a report of 2011 was 5.2%, adjusted for age and schooling (Mejía-Arango et al., 2011).

2. National Health and Nutrition Survey ENSANUT 2012 (Encuesta Nacional de Salud y Nutrición, https://ensanut.insp.mx/).

The National Survey of Health and Nutrition (ENSANUT) is a probabilistic, multi-phase survey designed to estimate the prevalence of health conditions, nutrition, and its determinants, in nationally representative samples of children 0 to 11 years of age, adolescents 12 to 19 years old, adults 20 to 59, and older adults (60+ years). It has a representative sample design at the national, state, urban and rural stratum (Romero-Martinez et al., 2013). The module for the evaluation of older adults was first added in 2012 and included a sample of 8,874 adults aged 60 or older. Two instruments were used for dementia diagnosis: a battery to assess cognitive functioning (semantic verbal fluency the Mini-cog) and the evaluation of functional ability. These were used to construct a diagnostic algorithm. People who presented alteration in both cognitive ability and functional ability were considered to have dementia. This resulted in an estimated dementia prevalence of 7.9% for the total of older adults’ sample (Manrique Espinoza et al., 2013). In relation to distribution of dementia across the country, Acosta-Castillo et al., (2017) report the prevalence of dementia by state and level of deprivation, and report adjusted prevalence of dementia (by sex, age and education) of 8.0% at national level, ranging from 3.3% in Querétaro to 12.5% in Jalisco, and from 3.9% in people between 60-69 years and 20.6% in the group aged 80 years or more. The prevalence is similar in some levels of deprivation (around 8.0%), except in those areas with high and very high deprivation (11.1%). They report that of the almost 900,000 people living with dementia in Mexico, more than half have experienced food insecurity and about 200 thousand live in localities with high and very high levels of deprivation. This demonstrates great variability in the prevalence of dementia by state and suggests that many people affected by dementia experience high levels of vulnerability.

3. Dementia Research Group 10/66 study (https://www.alz.co.uk/1066/).

The 10/66 Dementia Research Group research programme was developed to address the dementia prevalence, incidence, and impact across Latin American countries, China and India, using a validated and common methodology in a multi-centric population of adults aged 65 years and over (Prina et al., 2017). Data have been obtained on the prevalence and impact of dementia, and on incidence (phase 2007-2010), which evaluated the incidence of dementia and some associated risk factors, as well as mortality, with a median follow-up of 3 years (Prince et al., 2012). The case identification of dementia is carried out using two algorithms, one that operationalizes the criteria for dementia of the DSM-IV, and another that is developed by the 10/66 group (Prince et al., 2003). A case is considered positive for dementia if either of the two criteria is positive. The prevalence of dementia is of 8.6% in the urban area, compared to 7.4 in the rural area. However, the standardised prevalence (95% CI) using the 10/66 algorithm is 7.4% (5.9-8.9) in Mexico in urban areas, and 7.3% (5.7-8.9) in rural areas. The standardised prevalence according to DSM-IV criteria is 3.2% (2.2-4.2) in Mexico urban, and 2.4% (1.2-3.6) (Llibre et al., 2008).

4. Survey of the Metropolitan Area of Guadalajara.

In 2014, a cross-sectional study was conducted on a population aged 60 years or above, living in the state of Jalisco (in the Western region of the country). A total of 1,142 people participated. Participants were selected through multiple probability random sampling and door-to-door interviewing. All participants were evaluated for their cognitive function, emotional state, and physical performance. Cognitive function, depression and functional disability were assessed using the Mini-Mental State Examination (Folstein et al., 1975), the geriatric depression scale and the Katz index, respectively. The diagnosis of dementia was made according to the DSM-IV criteria. The prevalence of dementia was 9.5% (63.35% of women and 36.7% of men) (Velázquez-Brizuela et al., 2014).

Table 11 shows prevalence data of dementia. Variations may be due to the use of different classifications, forms and extensions of cognitive assessments and assessment of limitations in functionality. For example, while ENSANUT and MHAS/ENASEM only assess dementia with cognition and loss of function (assessed through altered activities of daily living); in 1066 DSM-IV criteria are operationalised and the algorithm is tested against these criteria, not only against the sum of cognitive impairment and loss of functionality. 

Table 11. Population studies, prevalence data of dementia.

References:

Acosta-Castillo, G. I., Sosa-Ortiz, A. L., Manrique Espinoza, B. S., Salinas Rodriguez, A., & Juárez, M. de los Á. L. (2017). Prevalence of Dementia By State and Level of Marginalization in Mexico. Alzheimer’s & Dementia, 13(7), P512. https://doi.org/10.1016/j.jalz.2017.06.583

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. https://doi.org/10.1016/0022-3956(75)90026-6

Llibre, J., Ferri, C. P., Acosta, D., Guerra, M., Huang, Y., Jacob, K. S., Krishnamoorthy, E. S., Salas, A., Sosa, A. L., Acosta, I., Dewey, M. E., Gaona, C., Jotheeswaran, A. T., Li, S., Rodriguez, D., Rodriguez, G., Kumar, P. S., Valhuerdi, A., & Prince, M. (2008). Prevalence of dementia in Latin America, India, and China: a population-based cross-sectional survey. The Lancet, 372(9637), 464–474. https://doi.org/10.1016/S0140-6736(08)61002-8

Manrique Espinoza, B., Salinas Rodríguez, A., Moreno Tamayo, K. M., Acosta Castillo, I., Sosa Ortiz, A. L., Gutiérrez Robledo, L. M., & Téllez Rojo, M. M. (2013). Health conditions and functional status of older adults in Mexico. Condiciones de salud y estado funcional de los adultos mayores en México. Salud Pública de México, 55(1), 323–331. https://doi.org/10.21149/spm.v55s2.5131

Mejía-Arango, S., Gutierrez, L. M., Minthon, L., Londos, E., Jo, L., Bostro, F., Larraya, F. P., Grasso, L., & Marí, G. (2011). Prevalence and Incidence Rates of Dementia and Cognitive Impairment No Dementia in the Mexican Population. International Journal of Geriatric Psychiatry, 23(7), 713–719. https://doi.org/10.1177/0898264311421199

Prina, A. M., Acosta, D., Acosta, I., Guerra, M., Huang, Y., Jotheeswaran, A. T., Jimenez-Velazquez, I. Z., Liu, Z., Llibre Rodriguez, J. J., Salas, A., Sosa, A. L., Williams, J. D., & Prince, M. (2017). Cohort Profile: The 10/66 study. International Journal of Epidemiology, 46(2), 406–406i. https://doi.org/10.1093/ije/dyw056

Prince, M., Acosta, D., Chiu, H., Scazufca, M., & Varghese, M. (2003). Dementia diagnosis in developing countries: a cross-cultural validation study. Lancet (London, England), 361(9361), 909–917. https://doi.org/10.1016/S0140-6736(03)12772-9

Prince, M., Acosta, D., Ferri, C. P., Guerra, M., Huang, Y., Rodriguez, J. J. L., Salas, A., Sosa, A. L., Williams, J. D., Dewey, M. E., Acosta, I., Jotheeswaran, A. T., & Liu, Z. (2012). Dementia incidence and mortality in middle-income countries, and associations with indicators of cognitive reserve: A 10/66 Dementia Research Group population-based cohort study. The Lancet, 380(9836), 50–58. https://doi.org/10.1016/S0140-6736(12)60399-7

Romero-Martínez, M., Shamah-Levy, T., Franco-Núñez, A., Villalpando, S., Cuevas-Nasu, L., Pablo Gutiérrez, J., & Rivera-Dommarco, J. (2013). Encuesta nacional de salud y nutrición 2012: diseño y cobertura. [National Health and Nutrition Survey 2012: design and coverage]. Salud Publica Mex, 55(2), S332-S340 (in Spanish). https://doi.org/10.21149/spm.v55s2.5132

Velázquez-Brizuela, I., Ortiz, G., Ventura-Castro, L., Árias-Merino, E., Pachecho-Moisés, F., & MA, M.-Islas. (2014). Prevalence of Dementia, Emotional State and Physical Performance among Older Adults in the Metropolitan Area of Guadalajara, Jalisco, Mexico. Current Gerontology and Geriatrics Research, 2014, 1–8. https://doi.org/10.1155/2014/387528

Wong, R., Michaels-Obregón, A., Palloni, A., Miguel Gutiérrez-Robledo, L., González-González, C., López-Ortega, M., María Téllez-Rojo, M., Mendoza-Alvarado, L. R., & Ts, L. (2015). Progression of aging in Mexico: the Mexican Health and Aging Study (MHAS) 2012 HHS Public Access. In Salud Publica Mex. https://researchexperts.utmb.edu/en/publications/progression-of-aging-in-mexico-the-mexican-health-and-aging-study

This information is not available.

Of the 10 leading causes of DALYs in Mexico’s older population, seven conditions are age-related, namely diabetes mellitus, ischemic heart disease, chronic kidney disease, and other organ diseases, Alzheimer’s disease and other dementias, cerebrovascular diseases, and chronic obstructive pulmonary disease. Alzheimer’s and other dementias represent the fifth main cause of DALYS (disability-adjusted life-years) in Mexican older persons (Parra-Rodríguez et al., 2019). However, no accurate data is available on the total deaths due to dementia.

References:

Parra-Rodríguez, L., González-Meljem, J. M., Gómez-Dantés, H., Gutiérrez-Robledo, L. M., López-Ortega, M., García-Peña, C., & Medina-Campos, R. H. (2019). The Burden of Disease in Mexican Older Adults: Premature Mortality Challenging a  Limited-Resource Health System. Journal of Aging and Health, 898264319836514. https://doi.org/10.1177/0898264319836514

Even though there is no official data reported at the state level, an analysis with the data derived from ENSANUT (Acosta-Castillo et al., 2017) demonstrates great variability in the prevalence of dementia by state and suggests that numeorous people affected by dementia experience high levels of vulnerability.

References:

Acosta-Castillo, G. I., Sosa-Ortiz, A. L., Manrique Espinoza, B. S., Salinas Rodriguez, A., & Juárez, M. de los Á. L. (2017). Prevalence of Dementia By State and Level of Marginalization in Mexico. Alzheimer’s & Dementia, 13(7), P512. https://doi.org/10.1016/j.jalz.2017.06.583

No available data.

No available data.

According to ENSANUT dementia is more prevalent in women (9.1%) compared to men (6.9%). In MHAS, rate of dementia in women was higher compared to men (3.1 vs 2.1), adjusted by age.

Disaggregated data by ethnic groups is not yet available.

No data is yet available.

No data is yet available.

There are no sufficient studies to prove this. However, as it was previously mentioned, Acosta-Castillo et al. (2017), demonstrate great variability in the prevalence of dementia by state and suggest that numerous people affected by dementia experience high levels of deprivation.

References:

Acosta-Castillo, G. I., Sosa-Ortiz, A. L., Manrique Espinoza, B. S., Salinas Rodriguez, A., & Juárez, M. de los Á. L. (2017). Prevalence of Dementia By State and Level of Marginalization in Mexico. Alzheimer’s & Dementia, 13(7), P512. https://doi.org/10.1016/j.jalz.2017.06.583

There are currently no campaigns, however, Mexico is part of the FINGER study which aims at piloting an intervention to reduce risks of dementia and the results may be available in the near future.

Studies in Mexico have reported diabetes and hypertension as risk factors for dementia (Academia Nacional de Medicina de México, 2017).

References:

Academia Nacional de Medicina de México. (2017). La Enfermedad de Alzheimer y otras demencias como problema nacional de salud. Documento de postura (L. Robledo, Maria. Peña, Paloma. Rojas, & A. Martinez, Eds.; 1a edición). Intersistemas. https://www.anmm.org.mx/publicaciones/ultimas_publicaciones/ANM-ALZHEIMER.pdf

Educational status has been reported as the main preventable risk factor in studies in México (Academia Nacional de Medicina de México, 2017).

References:

Academia Nacional de Medicina de México. (2017). La Enfermedad de Alzheimer y otras demencias como problema nacional de salud. Documento de postura (L. Robledo, Maria. Peña, Paloma. Rojas, & A. Martinez, Eds.; 1a edición). Intersistemas. https://www.anmm.org.mx/publicaciones/ultimas_publicaciones/ANM-ALZHEIMER.pdf

In 2015, last educational level obtained by individuals 15 years and older show that 15% report completed primary level (INEGI, 2015b).

References:

INEGI. (2015b). Encuesta Intercensal 2015 Estados Unidos Mexicanos. Instituto Nacional de Estadística y Geografía, 1, 85–90. http://internet.contenidos.inegi.org.mx/contenidos/Productos/prod_serv/contenidos/espanol/bvinegi/productos/nueva_estruc/702825078966.pdf

In 2015, 24% completed secondary school, 22% completed high school[1] (3 years between secondary and undergraduate education), 19% completed graduate/undergraduate education (university, technical colleges, etc.), 6% reported no formal education, and the remaining (14%) reported uncompleted primary or secondary school (some years attended but not graduated/finished) (INEGI, 2015b). On average, population 15 years and older in Mexico have 9.2 years of schooling, which would be equivalent to completing secondary education school and 93.6% of this same age group knows how to read and write (literacy).

[1] Starting in 2018, public compulsory education in Mexico comprises preschool (3 years, starting at age 3), primary education (6 years) and secondary education (3 years). For those 15 years and older at the time of the Inter-Census, compulsory education was comprised of primary (6 years) and secondary (3 years) education.

References:

INEGI. (2015b). Encuesta Intercensal 2015 Estados Unidos Mexicanos. Instituto Nacional de Estadística y Geografía, 1, 85–90. http://internet.contenidos.inegi.org.mx/contenidos/Productos/prod_serv/contenidos/espanol/bvinegi/productos/nueva_estruc/702825078966.pdf

Please refer to Table 12 under part 06.02.13.11.

Please refer to Table 12 under part 06.02.13.11.

Disability data from the 2010 Census (INEGI, 2010b) estimates that a total of 4,527,784 individuals (4% of the total population) live with some physical or mental limitation[1]. Of this total, 498,640 report difficulty to hear even when using a hearing aid or are deaf. Regarding older adults, data from the National Health and Nutrition Survey 2012 (Gutiérrez-Robledo et al., 2012) show that 11.3% of individuals 60 years and older report hearing limitations even when using a hearing aid or are deaf. Among those, 4.9% are aged 60-69, 11.8% are 70-79 years old and 31.4% are 80 years of age and older.

[1] Since 2000 INEGi is part of the Washington Group on Disability and includes in its Census and many national surveys the Groups’ questions on disability. The term used in the Census is “limitacion con/para…” “Limitation with or to do…”

References:

Gutiérrez-Robledo, L. M., Téllez-Rojo, M. M., Espinoza-Manrique, B., Castillo-Acosta, I., López-Ortega, M., Rodríguez-Salinas, A., & Ortiz-Sosa, A. L. (2012). Evidencia para la política pública en salud. Discapacidad y dependencia en adultos mayores mexicanos : un curso sano para una vejez plena. https://ensanut.insp.mx/encuestas/ensanut2012/doctos/analiticos/DiscapacidAdultMayor.pdf

INEGI. (2010b). Principales resultados del Censo de Población y Vivienda 2010. In Principales resultados del Censo de Población y Vivienda 2010. (Vol. 1).

Please refer to Table 12 under part 06.02.13.11.

Data from the ENSANUT 2012 survey (Instituto Nacional de Salud Pública, 2012), taking a cut-off point of 7≥9 of the Center of Epidemiological Studies of Depression Scale (CES–D) (Radloff, 1977), shows that the prevalence of clinically significant depressive symptoms is estimated at 22.7% (95% CI 16.5-28.9) of women and 8.3% (95% CI 3.3-13.2) of men. Looking at these data by age group, it shows that 14.7% (95% CI 10.3-19.1) adults aged 20-59 years, and 26.8% (95% CI 15.2-38.4%) adults aged 60 years and older experience clinically significant symptoms of depression (Salinas-Rodríguez et al., 2013).

References:

Instituto Nacional de Salud Pública. (2012). Encuesta Nacional de Salud y Nutrición 2012. Resultados nacionales. https://ensanut.insp.mx/encuestas/ensanut2012/doctos/informes/ENSANUT2012ResultadosNacionales.pdf

Radloff, L. S. (1977). The CES-D Scale. Applied Psychological Measurement, 1(3), 385–401. https://doi.org/10.1177/014662167700100306

Salinas-Rodríguez, A., En, M. C., Manrique-Espinoza, B., En, D. C., Acosta-Castillo, I., Ma Téllez-Rojo, M., Franco-Núñez, A., Miguel Gutiérrez-Robledo, L., En, D. C., & Luisa Sosa-Ortiz, A. (2013). Validación de un punto de corte para la Escala de Depresión del Centro de Estudios Epidemiológicos, versión abreviada (CESD-7). Salud Pública de México, 55(3), 267–274. http://saludpublica.mx/index.php/spm/article/viewFile/7209/9386

While it is widely acknowledged that the Mexican population in general is not very physically active, not much data is available to confirm this. Since 2013, INEGI started to collect data through the Sport and Physical Activity Module[1] (MOPRADEF) and in 2017 it was approved as a key indicator in the design and evaluation of public policies and is now part of INEGI’s National Catalogue of Indicators. The latest report from MOPRADEF in 2017 (INEGI, 2018c) shows that only 42.4% of population 18 years and older practices some sport in their spare time or is physically active[2], showing a slight decrease since 2013 (45.4%) when data was first gathered. Men reported being more active (49.8%) than women (36.0%) and as age increases, people reported being less physically active.

[1] Módulo de Práctica Deportiva y Ejercicio Físico MOPRADEF; http://www.beta.inegi.org.mx/proyectos/enchogares/modulos/mopradef/default.html

[2] Sufficient physical-sport activity was defined as practicing some sport or physical activity at least three times a week, accumulating at least 75 minutes of vigorous or 150 minutes of moderate intensity per week.

References:

INEGI. (2018c). Módulo de Práctica Deportiva y Ejercicio Físico. https://www.inegi.org.mx/contenidos/programas/mopradef/doc/resultados_mopradef_nov_2018.pdf

Please refer to Table 12 below under part 06.02.13.11.

According to data reported by the OECD (OECD, 2016a), the number of litres of alcohol consumed per capita by individuals 15 years and older in Mexico was 4.0 in 2014 and 4.4 in 2016.

References:

OECD. (2016a). OECD iLibrary | Alcohol consumption. https://www.oecd-ilibrary.org/social-issues-migration-health/alcohol-consumption/indicator/english_e6895909-en

Please refer to Table 12 below.

Table 12. Prevalence of risk factors in adults 20 years of age or older, by sex and age groups. Mexico

Source: ENSANUT, 2012 (Instituto Nacional de Salud Pública, 2012). *Percentage of population aged 20 and over who smoke

**Has been intoxicated with alcohol at least once in the past month.

References:

Instituto Nacional de Salud Pública. (2012). Encuesta Nacional de Salud y Nutrición 2012. Resultados nacionales. https://ensanut.insp.mx/encuestas/ensanut2012/doctos/informes/ENSANUT2012ResultadosNacionales.pdf

Mexico does not have a Dementia Care system in place at the moment and, therefore, there is no typical path for diagnostic assessment. Additionally, given the lack of knowledge and high stigma, usually people with “possible” dementia and/or their family members only seek services when advanced symptoms are present. Social security institutions in the largest metropolitan areas can refer people with suspected cognitive impairment or visibly advanced symptoms of some type of dementia to a specialist for further evaluation and some diagnostic tests. However, entry access will depend on the availability of specialists, such as psychiatrists, geriatricians, or neurologist who, as described in part 2, are scarce. Therefore, a large percentage of people remain undiagnosed. Furthermore, the few public institutions that have Memory or Dementia care services (such as the National Institute of Neurology in Mexico City), are the only places that can conduct rigorous evaluations and diagnostic assessments, as they have the human and technological resources available. Unfortunately, they can only oversee a very small number of those in need. Very few memory clinics are in place and only few third level public hospitals include specialists that are trained to diagnose and provide treatment and management for dementia.

No data is available on this. In addition to the problems stated in 07.01.01., Mexico does not have a national registry in place at the moment, and therefore, no aggregated data exist.

No data is available.

No data is available. However, as specialist doctors are scarce and those available work in the main metropolitan areas, we would expect smaller cities and rural areas to have even less people with access to a diagnostic assessment.

Mexico does not have a long-term care system and, therefore, these services are not available within this context. Regarding health system services, there are no specific areas responsible for coordinating care. Hence, no specific care strategies or programs for people with dementia are currently in place.

Mexico does not have dedicated services supporting people with dementia.

There are no established links for dementia care, as no dementia diagnosis and management programs are in place. Given that health and social security institutions work using gatekeeping mechanisms where general practitioners or family doctors see all individuals first and then decide to send them to secondary or tertiary level services. This means that in some cases individuals will be referred to specialists if they are available, as very few positions of dementia specialists exist in health and social security institutions.

As previously stated, no links specific to dementia diagnosis and management are in place.

No related protocols or policies are in place.

As there are no public dementia care strategies in place, there is a large proportion of individuals who incur in large out-of-pocket payments by going to private services from the moment they experience memory concerns, and for the whole of their diagnosis, treatment and care. There is no data available on the size of out-pocket payments.

Mexico does not have a publicly funded national long-term care system. However, care is being provided in different ways. First, unpaid informal care by family members is the main source of care and in some cases, especially when economic resources are available with the support of domestic paid workers. To our knowledge, there are only 4 long-term care (care homes) private institutions in the country that are focused exclusively on people with dementia. While (for-profit and non-profit) private care homes usually have as their main requirement for entry that the older adult is “functional and independent”, those who develop dementia will usually remain under their care, while others will make them return to the care of a family member. As a result, most older people with dementia, while receiving care in LTC institutions, will receive sub-standard care or care that is not optimal as the majority of managers and carers are not trained, nor the institutions equipped to provide dementia care and management.

Using unit costs for other conditions and international estimates when local unit costs were not available, the ADI World Report 2016 (Prince et al., 2016) costing estimates of the pathway of dementia care in Mexico show that the costs of the task-shifted pathways are relatively low compared to overall healthcare spending, and puts the cost of the pathway in 2015, per diagnosed person in Mexico at $39 USD (or $3.90 per person with dementia). This likely reveals that specialised services are not available and that little is done and performed in primary care where resources are not available or are lower than in the secondary or tertiary care level. For example, this is reflected in the salaries for general practitioners compared to the specialists’ ones.

References:

Prince, M., Comas-Herrera, A., Knapp, M., Guerchet, M., & Karagiannidou, M. (2016). World Alzheimer Report 2016 Improving healthcare for people living with dementia. Coverage, Quality and costs now and in the future. In Alzheimer’s Disease International (ADI).

No, currently there are no available community based public health and long-term care services in place, including care services to support people with dementia.

Not as part of any public health or social security institutions. Most people with a diagnosis obtains it from private services/specialists.

Not as part of public or social security services and no information is available from any private (profit or non-profit) services that offer these services. Some specialists could offer these, but no information is available publicly that we could document.

Not applicable.

Not applicable.

In Mexico, the inclusion within the Federal Legislation, of palliative care for individuals with terminal conditions took place in 2009, specifying the need to attend the care of those individuals “with illnesses that have no cure and are in an irreversible condition of health deterioration”, but people with dementia are not included as a specific group. However, very little advances have been made and public services for palliative care are almost inexistent. No private services offering support for palliative care could be identified and only two non-profit organisations in the country were identified providing these support services for any individual/illness.

None are available.

No public services are available. While some community-based day centres are available for people with dementia, these services are offered in the private sector. Currently, FEDMA has knowledge of 9 day-centres for people with dementia and around 50 support groups in the country. These services are provided at the state level by the institutions affiliated to FEDMA.

These services are provided by the private sector.

No information available.

No mechanisms alike are available.

Unpaid carers are not recognised or registered as part of any service, whether they are caring for someone with dementia, with any other chronic disease or disability.

No information is provided/available.

Management and care of people with dementia in most institutions is not specialised dementia care and little is known about (staff are not trained in) Social-Psychosocial interventions. Some exceptions of few day centres will have cognitive stimulation activities, but more specialised social-psychosocial interventions are not commonly available.

The few community-based services available are private sector services and little information is available on the type of services they provide, the profile or characteristics of their service users, etc. Therefore, regional diversity or differences are hard to establish. However, given that most associations are located in the state capitals or major cities, at least urban/rural large/small city differences in access (as with most health and social services) are present.

No public or private specialised dementia care home services are available.

As explained in Part 3, since 2016, Mexico City has operated the program ‘The Doctor in your House’ (‘Medico en tu Casa’). The goal of the program is to provide primary care for vulnerable population who, due to their disease conditions or disabilities, cannot attend medical services, with the help of a multidisciplinary team at home. However, under the new federal government administration, this program is being modified and its specific attributions and scope are still unknown. Mexico does not have a publicly funded national long-term care system; however, care is being provided in different ways. First, unpaid informal care at home, provided by family members, is the main source of care and in some cases, when economic resources are available, with support from domestic paid workers.

Care home services in general are available through private services for those who can afford them and through 10 public institutions that provide services for those who are destitute or have no family members to take care of them. This leaves a possible large group of older adults with no access to long-term care services.

There are several NGOs in Mexico. The main organisation is the National Alzheimer Federation, FEDMA (Federación Mexicana de Alzheimer). FEDMA groups 20 associations from different states of the country.

FEDMA has a national office and works with its state-level affiliated associations.

The majority are volunteers who receive no payment. As with care homes, most of the services they offer are provided by volunteers (self-contact) or student volunteers who carry out these activities as part of their professional practices (for example, psychology, social work, nursing).

Currently FEDMA has a help line providing general information and orientation services. All its state-level affiliates offer diverse services such as day care, carer training and general information on dementia and care recommendations for carers. At national level there are currently 21 associations that are part of FEDMA. Most of them provide support group sessions, general information on dementia and care for people with dementia. Support groups are usually quite diverse depending on who delivers them: geriatricians, nurse, occupational therapist, psychologist, among others.

No.

Yes. FEDMA was involved in the process of development and publication of the National Alzheimer Plan.

As previously mentioned, most services are provided locally by NGOs. There is no systematic information gathered to assess variability or detailed characteristics of their services, but, in general, services are available in state capitals and larger cities. Out of the 32 States, 19 currently have a dementia/Alzheimer’s association. They all have support groups, but only 6 have day centres, and there are 9 day centres, of which 4 are located in Mexico City.

While some services such as support groups are mostly free of charge or they may ask for small fees or “recovery” costs, all-day care centres charge a fee as well as care homes given that they are private and they make up most of their income to be then used for carers salaries, meals, etc., provided by them.

No systematic data is gathered, and therefore this is unknown. A first survey of carers was developed in 2018 by the National Association of Dementia Specialists with the aim of generating a profile (quantitative survey) of carers in the country. The survey was sent locally to all associations and to specialists in the private sector so they could distribute and gather the data within their participants/patients. However, no publications of their results are available.

Mexico does not have a LTC system in place and, therefore, there is no data available on specific LTC workforce categories. As stated in part 2, there are still low numbers of specialist doctors, most are neurologists, psychiatrist or geriatrician who see/treat individuals with any illness/disease, not exclusively dementia. In terms of medical doctors, in the country, it was estimated that there were a total of 147,910 specialist physicians in Mexico, for a total population of 123.5 million in the year 2017 (Heinze-Martin et al., 2018), and 36,184 general practitioners in 2015 or 29 per 100,000 population (DGIS, 2017). This represents a rate of 119 specialist physicians per 100 000 population. Of this total, 69% had specialty certification and showed a highly unequal distribution among the country with 54% of all specialists concentrated in Mexico City and in the States of Mexico, Jalisco, and Nuevo León. On average, there were 1.7 male specialists per female specialist physician. Among specialities relevant to all forms of Dementia, there were 422 Geriatricians, 1,345 Neurologists (adult and paediatric), 2992 Cardiologists (adult and paediatric) and 4,429 Psychiatrists in the whole country in 2017. It was estimated that there were 3.25 Geriatricians per 100,000 individuals 60 years and older, 3.4 Psychiatrists and 2.2 Cardiologists per 100,000 individuals (Heinze-Martin et al., 2018).

References:

DGIS. (2017). Recursos en salud.

Heinze-Martin, G., Olmedo-Canchola, V. H., Bazán-Miranda, G., Bernard-Fuentes, N. A., & Guízar-Sánchez, D. P. (2018). Medical specialists in Mexico. Gaceta Medica de Mexico, 154(3), 342–351. https://doi.org/10.24875/GMM.18003770

No rate has been estimated on the number of Neurologists.

Among specialities relevant to all forms of Dementia, there were 422 Geriatricians and 4,429 Psychiatrists in the whole country in 2017. It was estimated that there were 3.25 Geriatricians and 3.4 Psychiatrists per 100,000 individuals 60 years and older (Heinze-Martin et al., 2018).

References:

Heinze-Martin, G., Olmedo-Canchola, V. H., Bazán-Miranda, G., Bernard-Fuentes, N. A., & Guízar-Sánchez, D. P. (2018). Medical specialists in Mexico. Gaceta Medica de Mexico, 154(3), 342–351. https://doi.org/10.24875/GMM.18003770

Not included.

Psychiatrists, neurologists but briefly.

May be very briefly included in revising stages of psychosocial ailments.

Not included.

Not included.

Not included.

Not included.

No specific training programmes for these workers are available, nor posts in health or long-term care institutions.

No specific training programmes for these workers are available, nor posts in health or long-term care institutions.

No training programmes are available or made specifically for untrained paid workers such as domestic workers; however, they could pay/register, for example, for the training course at the National Institute of Geriatrics. However, it is unlikely that employers would do this, or that these workers would search for this option as they generally have very low educational attainment and would not seek further training. But this is only from experience, as no studies or data are available.

No data is available.

So far, to our knowledge (including FEDMA), there are only four residential LTC facilities specialised in people with dementia available in the country, two in Mexico City, one in the state of Morelos, and one in the state of Querétaro.

As noted above, while (for-profit and non-profit) private care homes usually have as their main requirement for entry that the older adult is “functional and independent”, those who develop dementia will usually remain under their care, while others will have to return to the care of a family member. As a result, most older people with dementia in receiving care in LTC institutions will receive sub-standard care or care that is not optimal as most of the managers and carers are not trained, nor the institutions are equipped to provide dementia care and management.

Not available.

No publicly funded day centres specialised in people with dementia are available. The only centres available belong to the private sector, both profit and not-for-profit. There is no data available to document if people with dementia attend non-specialised day centres; however, it is highly unlikely as these cater and require that older adults attending the centre are “functional and independent”.

There is no data available on community-based self-organised social centres in the country. Thus, their number, location, and area/population of focus is not known.

As mentioned in part 3, there is no national registry of LTC facilities and therefore data comes from diverse sources. With respect to non-specialised facilities, a first try at generating a Census of institutions was the 2015 Social Assistance Housing Census, CAAS[1] (INEGI, 2015a), as 4,517 permanent housing institutions were identified. Of these, almost 23% (1,020) are identified as permanent homes or residences for older adults. The average number of residents per facility is 11-20 (37% of the total), followed by 21-40 (23%) and 5-10 (22%). Regarding their legal nature, 75% are private non-profit facilities, 8% are public (government funded), 2.3% are run by religious associations, and 2% are private for-profit. There are no specialised LTC dementia facilities.

[1] The objective of CAAS was to collect information on the conditions and services offered by public, social and private establishments that house vulnerable populations, along with their characteristics and those of the people who work in these centres (INEGI 2015). It focuses on all types of social assistance institutions, such as care homes and residences for the elderly, but also others as rehabilitation (drug & alcohol) centres, homes for orphans, etc.

References:

INEGI. (2015a). Censo de Alojamientos de Asistencia Social. https://www.inegi.org.mx/programas/caas/2015/

No data is available. Even the total exact number of adults or older adults living in residential LTC institutions is not known given the fact that Mexico does not have a compulsory national registry of institutions or its residents.

No, these specific beds are not available.

Only few hospitals have a Geriatrics unit. No data on geriatric-specific beds was found.

While all hospitals are required to track and register the main causes of hospitalisation, most of the times dementia is not stated as a main cause and therefore tend not be registered. This creates a situation where it is likely that dementia-related hospital admissions are considerably underestimated.

Please see previous sections.

No public social or community services available.

To date, we are only aware of one research project carrying out dementia specific interventions. However, some residential LTC facilities, even when not specifically or exclusively designed for people with dementia but older adults in general, try to provide person-centred care.

No, they do not.

According to the Clinical Guidance[1] for Cognitive Impairment, the recommended medicines are cholinesterase inhibitors for management of dementia and antipsychotic medications for the management of challenging behaviours (CENETEC, 2017).

[1] Diagnóstico y Tratamiento de la Demencia Alzheimer. http://www.cenetec.salud.gob.mx/descargas/gpc/CatalogoMaestro/393_IMSS_10_Demencia_Alzheimer/EyR_IMSS_393_10.pdf

References:

CENETEC. (2017). Diagnóstico y Tratamiento de la Enfermedad de Alzheimer. Guía de Evidencias y Recomendaciones: Guía de Práctica Clínica. Guia de Practica Clinica. http://www.cenetec-difusion.com/CMGPC/IMSS-393-10/RR.pdf

Yes, medications are available as generics for memantine (clorhidrato de memantina) and galantamine (bromhidrato de galantamina).

No, and neither for older adults nor people with disabilities in general, except for sporadic give-aways by local-level institutions, but no specific numbers are reported. Usually, they include it as an activity supporting older adults, but no annual or periodic results of what they give out or the number of older adults covered can be identified.

Some programs at local level have provided assistive technology instruments but efforts are isolated; most of the times these are a one-off benefit and not following some continuous programmes.

No, and neither for older adults nor people with disabilities in general.

No. While the Clinical Practice for Alzheimer’s Disease & other Dementias (CENETEC, 2017) recommends cholinesterase inhibitors for managing dementia and the use of antipsychotic medications for challenging behaviour (Haloperidol and second generation medications Quetiapine and Risperidone), for all public and private institutions, a review of the Mexican Social Security Institute IMSS basic catalogue of medicines and of the Ministry of Health’s medication catalogue showed that these medications are not included. This means clinics or hospitals are not obliged to stock them or provide them for free.

References:

CENETEC. (2017). Diagnóstico y Tratamiento de la Enfermedad de Alzheimer. Guía de Evidencias y Recomendaciones: Guía de Práctica Clínica. Guia de Practica Clinica. http://www.cenetec-difusion.com/CMGPC/IMSS-393-10/RR.pdf

At the moment, these are not available at large scale through public health services.

Not within the public and social security services. Technology support services could be available within the private sector, but they are only accessible to very few people.

There was no publicly available information regarding prices within the public health services or social security institutions, as these are not included in the public sector medicine catalogues.

A rapid search of prices among private sector pharmacies (Metropolitan Area of Mexico City), where most people purchase them, given they are not usually covered by health or social security institutions, shows an average price for the main presentations of these four medications as follows:

1. Clorhidrato de donepezilo: a) PEZZIL (torrent): 5mg / 28 tablets: $1,450.- MXN (around $74 USD)  b) Eranz (Pfizer) 5 mg / 28 tablets $2,150.- (around $113.- USD),
2. Bromhidrato de galantamina: a) Reminyl ER (Jannsen-CILAG) 20.508 mg (equivalent to 16 mg of galantamine) / 14 capsules: 14: $1420 MXN (around $70.- USD),
3. Clorhidrato de memantina a) Menural (Apopharma) 10 mg / 28 tablets: $640.- MXN (around $32.- USD), b) Ebixa (Lundbeck) 20 mg / 28 tablets: $1,500.- MXN; c) Akatinol (Merz) 20 mg / 28 tablets: $1650.- MXN ($83.- USD),
4. Rivastigmina: Exelon patches (Novartis) 9.5 mg / 24 hours / 30 patches: $2,900.- MXN ($145.- USD).

Some pharmacies offer a discount of 5% for older adults if they are registered with INAPAM, the national older adults’ institute. In addition, some private insurance companies have agreements with pharmacies and so they offer discount for some medicines of 10% on average.

Just as presented in Part 7, most care for older adults and people with disability, including people with dementia, are provided by unpaid informal carers, but no data on the total numbers is available.

No data is available since no disaggregated data on carers, whom they care for, and the type/intensity of care provided, has been gathered.

No data available as no disaggregated data on carers, whom they care for, and the type/intensity of care provided has been gathered.

Mexico is a country with a long tradition of internal migration and migration to and from the U.S. These migration patterns have left many localities with scarcity of young adults who could be informal carers, but to date, no studies that document this with sound data are available.

No data available as no disaggregated data on carers, whom they care for, and the type/intensity of care provided has been gathered.

No data available as no disaggregated data on carers, whom they care for, and the type/intensity of care provided has been gathered.

No support (monetary, in-kind, services, etc.) is available for family/unpaid carers.

None is available for family/unpaid carers.

None is available for family/unpaid carers.

Very few basic programs for family/unpaid carers are available. Most recent data (2017) showed there are only two training programmes at national level for carers of people with chronic diseases or disabilities (López-Ortega & Aranco, 2019), and one for carers of people with dementia provided by the National Institute of Geriatrics. The course “Person-centred care for people with dementia” is an online course for general public, in this way people can know and establish different care practices for people with dementia, using a person-centred approach.

References:

López-Ortega, M., & Aranco N. (2019). Envejecimiento y atención a la dependencia en México. Nota técnica del BID. https://publications.iadb.org/publications/spanish/document/Envejecimiento_y_atención_a_la_dependencia_en_México_es.pdf

Cultural norms towards care for older adults, children, and people with disabilities are still strong, with a large proportion of individuals stating that the family should have the main responsibility for caring. However, economic and social changes in the last years make these expectations increasingly difficult to meet (López-Ortega & Gutiérrez-Robledo, 2015). In a context with practically no publicly funded support for carers available nationally, especially for those caring for older adults and people with disabilities, families/unpaid carers provide the largest proportion of care in the country. Strong gender roles imply that within families, most care is taken up by women. In addition, women frequently take up most of other domestic activities (cleaning, washing, etc.) and increasingly, try to obtain some reconciliation between all these household responsibilities and their own individual development through education and work outside the household (Barrios Márquez AY & Barrios Márquez, 2016; Pedrero Nieto, 2004). As a result of the demographic transition and often perceived as a last-resource option, an increasing number of men have been observed to provide care for their spouses (Giraldo-Rodríguez et al., 2019; Nance et al., 2018).

References:

Barrios Márquez AY, & Barrios Márquez, O. (2016). Participación femenina en el mercado laboral de México al primer trimestre de 2016. Economía Actual, 9(3), 41–45.

Giraldo-Rodríguez, L., Guevara-Jaramillo, N., Agudelo-Botero, M., Mino-León, D., & López-Ortega, M. (2019). Qualitative exploration of the experiences of informal care-givers for dependent older adults in Mexico City. Ageing and Society, 39(11), 2377–2396. https://doi.org/10.1017/S0144686X18000478

López-Ortega, M., & Gutiérrez-Robledo, L. M. (2015). Percepciones y valores en torno a los cuidados de las personas adultas mayores. In L. Gutiérrez Robledo & L. Giraldo (Eds.), Realidades y expectativas frente a la nueva vejez. Encuesta Nacional de Envejecimiento. (pp. 113–133). Instituto de Investigaciones Jurídicas, Universidad Nacional Autónoma de México.

Nance, D. C., Rivero May, M. I., Flores Padilla, L., Moreno Nava, M., & Deyta Pantoja, A. L. (2018). Faith, Work, and Reciprocity: Listening to Mexican Men Caregivers of Elderly Family Members. American Journal of Men’s Health, 12(6), 1985–1993. https://doi.org/10.1177/1557988316657049

Pedrero Nieto, M. (2004). Género, trabajo doméstico y extradoméstico en México. Una estimación del valor económico del trabajo doméstico. In Estudios Demográficos y Urbanos (Vol. 19, pp. 413–446). https://www.redalyc.org/pdf/312/31205605.pdf

We have identified one peer-reviewed study on the burden carers of people with dementia experience (Rosas-Carrasco et al., 2014). As in other studies on informal care in Mexico, they found that providing care for someone with dementia has a negative impact by increasing risk of burden. Results showed that variables relating to the person with dementia have a greater impact on caregiver burden than caregiver-associated variables. Specifically, dysexecutive syndrome (disruption of executive function, closely related to frontal lobe damage, encompasses cognitive, emotional, and behavioural symptoms), sleep disorders and low educational attainment in the person with dementia were associated to a higher level of caregiver burden, while for the carers, the only factor that showed a higher risk or burden was for those with higher depressive symptoms.

References:

Rosas-Carrasco, O., Guerra-Silla, M. G., Torres-Arreola, L. P., García-Peña, C., Escamilla-Jiménez C.I, & González-González, C. (2014). Caregiver burden of Mexican dementia patients: The role of dysexecutive syndrome, sleep disorders, schooling and caregiver depression. Geriatrics & Gerontology International, 14(1), 146–152. https://doi.org/10.1111/ggi.12072

No specific information is available.

No information is available.

No information is available.

No there are no employment policies in place for them.

No specific data was presented, as it is not available.

Training is the only support available at the moment. The main providers are two social security institutions (ISSSTE and IMSS) and the National Institute of Geriatrics (INGER).

No data available.

There is one program at the Federal level of government that supports people with disabilities called the Pension Program for the Welfare of People with Disabilities. However, potential beneficiaries are only children and adolescents as well as young people (0 to 29 years old) who have permanent disabilities, and for indigenous population with disabilities from 0 to 64 years old. Since 2016, following the initiatives in most of the states, the federal government established a universal old age pension. Eligibility sets minimum age of 68 years (65 years if living in indigenous municipalities) and who do not receive any public or private sector old age pension or any similar program from their state of residence.

Mexico does not have any policies that protect employment or support workers in case they are fired, etc.

Mexico does not have any policies that support carers.

Mexican labour legislation does not include care leave as a benefit, no programs are in place.

Mexican social security legislation (covering social security institutions IMSS, ISSSTE, and other federal and state level institutions) includes disability, work related accidents pensions, but does not contemplate any credited contributions in case of unemployment, illness, etc.

Mexican Income and Taxation legislation does not contemplate tax allowances (understood as exemptions that reduce how much income tax an employer deducts from an employee). Employer taxation is fixed given different income gaps and the only deductions in place are at the individual (employee) level, given different fiscal regimes.

There are no universal tax rebates in place in Mexico; however, some local governments have special tax rebate programs for older adults. For example, Mexico City has a 30% reduction in property tax (paid yearly) for pensioners and older adults (60 years and older).

No universal transportation discount programs are in place in Mexico. However, older adults can register in the National Institute for Older Adults and get a wide variety of discounts (amount and type) with public and private institutions that have collaboration agreements with INAPAM[1]. Thus, they could get specific transportation fares/discounts (airlines, coaches) if agreements are in place. On the other hand, there are some states/localities that offer transportation benefits, for example, Mexico City where older adults do not have to pay for public transportation (buses, underground, etc.).

[1] INAPAM publishes a directory of all the services/institutions they have established agreements with in their webpage. Information is presented by categories of discounts: food, legal and accounting consultancy, education, culture, recreation, and sports; property tax and water services; health; transport; dress and home. For each category, there is a downloadable directory with information by state. Available at: https://www.gob.mx/inapam/acciones-y-programas/beneficios-test

Mexico does not have any policies to support this.

Mexico does not have government policies or programmes to support dementia research. With the objective of raising awareness on the need to increase research on dementia, ideally allocating public funds for this, the National Action Plan on Alzheimer’s and other Dementias includes a specific strategy (#6) that states the need to (Gutiérrez-Robledo & Arrieta-Cruz, 2014). The lines of action of Strategy 6 are:

1. Include research on ageing, with emphasis on applied research studies to improve the treatment of dementia, as a priority within the demands of Health Sector Research Funds.
2. Promote inter-institutional links with national and international scientific groups dedicated to research/work on dementia.
3. Increase and strengthen research on dementia through collaborations among different scientific groups in Mexico that integrate the National Thematic Network: Ageing, Health and Social Development (part of the National Council of Science and Technology’s Thematic Networks Fund).
4. Promote a public health research basis on aging by academic and scientific institutions, with particular emphasis on the subject of dementia.
5. Develop new information and data sources for the generation of a permanent epidemiological surveillance system to closely monitor cases of dementia in the country.
6. Establish an inter-institutional collaboration network for the molecular, clinical, and imaging diagnosis of dementias at national level.

References:

Gutiérrez-Robledo, L., & Arrieta-Cruz, I. (2014). Plan de Acción Alzheimer y otras demencias, México 2014. http://diariote.mx/docs/plan_alzheimer_WEB.pdf

The government has not been allocating money for dementia research. However, there are research groups in health institutions and universities, mainly. In addition, federal and state level institutions, including the National Institute of Health, public hospitals, etc. can plan, budget, and allocate funds for research in any topic related to their mission, and as such, they could allocate funds to dementia research if they chose to. An overview of dementia research in Mexico shows that it has been increasing in recent years, mainly focused on clinical and intervention aspects, following those of an epidemiological nature, evaluation of informal care and the impact of the caregiver. However, there is little research on the effectiveness of interventions, the impact of dementia, as well as on other areas such as attitudes and stigma.

No, people with dementia are not involved in research. While some studies (clinical and population) on dementia have been developed in Mexico, to our knowledge, none of these have involved people living with dementia in the development of their projects. However, with the STRiDE project, we aim to include them in different activities such as part of our advisory group.

At national level, there are calls from the National Council for Science and Technology (CONACYT) aimed at health issues, if the priority is mental health or aging. In addition, several National Institutes of Health have international agreements, for example the institute of neurology has partnerships with Wellcome Trust, European Research Council, Medical Research Council (UK), Alzheimer’s Association, and FEDMA. The National Institute of Public Health (INSP) and the National Institute of Geriatrics (INGer) have collaborated with the Mexican Health and Aging Study (MHAS).

At least three National Institutes of Health include in their Research and/or Clinical Departments researchers that have dementia as one of their main lines of research (National Institute of Geriatrics, National Institute of Neurology and Neurosciences and the National Institute of Nutrition and Medical Sciences). For example, Sara Torres Castro, researcher at the National Institute of Geriatrics has received a grant from the British Academy/Newton Fund to develop the ‘PROCUIDA-Dementia’ study; a feasibility study investigating an optimised person-centred intervention to reduce antipsychotic medication and improve the quality of life of older people living in care homes (ISRCTN 16463016); the National Institute of Neurology and Neurosciences has been part of the 10/66 dementia project since its onset and is currently collaborating in the FINGERS project. The Institutes, in collaboration with the National Academy of Medicine and different universities have collaborated in publishing three books[1], one position statement together with the National Academy of Medicine, one with the Autonomous University of San Luis Potosí (UASLP) and one with the Alzheimer’s Iberoamerica association.

[1] La Enfermedad de Alzheimer y otras demencias como problema nacional de salud (https://www.anmm.org.mx/publicaciones/ultimas_publicaciones/ANM-ALZHEIMER.pdf); El Alzheimer en Iberoamérica (https://alzheimeriberoamerica.org/wp-content/uploads/media/uploads/regular_files/el-alzheimer-en-iberoamerica.pdf ); Demencias. Una visión panorámica (http://www.cdi.salud.gob.mx/descargas/publicaciones-inger/Demencia.pdf ).

To our knowledge, the few initiatives for capacity building come from international institutions/initiatives such as the Global Brain Health Institute’s training program; specific calls for international projects like the Newton Fund, or through large projects that include this as one of its components such as the 10/66 and the STRiDE projects.

None for this specific purpose. No national registry of people with dementia, no dementia care policies are in place, and no performance indicators.

Currently, performance of the Health System, in general, is measured by process indicators (number of vaccines, births, deaths). No impact indicators related to dementia are available. Epidemiological evidence available comes from research projects, or national level surveys (for health in general and dementia in particular), not from monitoring systems. There is urgent need to generate research on the social and economic determinants and impacts of dementia, and that this information is made available to decision-makers. There is also need of greater involvement of decision-makers in the research process.

The national dementia plan has not been followed up, nor have resources been designated for its implementation. There is a lack of inter-sector coordination/collaboration. Dementia and mental health are not recognised as public health priorities. No public information campaigns are in place. There is lack of awareness. Lack of certification and regulation of informal care workers and lack of a regulatory body that oversees their performance and working conditions, are key issues.

There is no national system of care. No specific public dementia-care services are in place at national level. Few specialised memory clinics and only few third level hospitals that have specialists that are trained to diagnose and offer treatment/management for dementia, are in place. There is no specific support for carers (training, respite services, income benefits). There is also lack of coordination among services and stewardship.

There are no routine monitoring systems. There is lack of research and data on the role of unpaid family care, paid informal workers, including the number of carers for people with dementia, the type of activities they do, the time spent in them and the costs of caring for someone with dementia. There is little support for dementia research, especially on the social and economic determinants and impact. Few dementia-specific calls for projects have existed periodically during the last 10 years and three National Institutes of Health have included researchers what have dementia as one of their main lines of research (National Institute of Geriatrics, National Institute of Neurology and Neurosciences and the National Institute of Nutrition and Medical Sciences). Research projects and results are almost never used as input for the development of policies or as information underlying political decision-making. As specified in Part 10, three relevant books on dementia have been published recently. At the moment, one of the main priorities is to focus on policy briefs that can translate current knowledge for use by decision-makers in policy and planning. Perceptions and expectations of carers regarding their needs for support are crucial. Finally, there is need for costing and economic evaluation studies (in general and dementia specific).