Defragmenting the Health Care System in Mexico: Universal Access for Obstetric Emergencies

Introduction

Methods

We conducted an observational and descriptive cross-sectional study in order to analyze the Agreement strategy within different scenarios. The objective was to verify whether Mexico was in a position to offer five EmOC facilities, at least one comprehensive, per 500,000 inhabitants, as recommended by the UN, the UNFPA and the UNICEF.¹³ The scenarios included Agreement facilities accredited for providing EmOC services (a distinction awarded exclusively to hospitals in the Agreement) and public/private facilities providing EmOC services independently of the Agreement and, hence, without the relevant accreditation. In regard to the private sector, we considered only facilities endorsed by the National System for the Certification of Medical Care Establishments (“Certification”).¹⁴

Certification is a MoH distinction awarded to secondary-care facilities that meet a set of standards for care quality and the safety of patients. Requirements relate to infrastructure, care processes and inputs. Certification is voluntary and applicable to public and private hospitals that request and merit this recognition. Because it guarantees quality, our analysis of private-sector facilities included only certified hospitals. Accreditation, on the other hand, was established by the MoH as a mandatory condition for its facilities when the Seguro Popular public insurance scheme was created. Certification and accreditation standards and requirements are comparable. When the Agreement was launched, the MoH devised an accreditation certificate for EmOC facilities. Agreement participants, which are all administered by the IMSS, the ISSSTE and the MoH, are required to undergo the accreditation process.

Results

In 2013, a total of 1,366 facilities offered secondary- care services in the Mexican public health sector, 1,141 of which were equipped with the necessary infrastructure and resources to support vaginal births, cesarean sections and OEs. The 466 facilities participating in the Agreement (MoH,2013) represented merely 41% of the public health care facilities with available EmOC infrastructure and resources. The remaining 675 facilities operating outside of the Agreement provided basic and comprehensive EmOC services without the relevant accreditation.

Table 1 illustrates the four scenarios developed to compare EmOC service availability in Mexico at the national and state levels with the international recommendations. Column A presents the ideal number of facilities; columns B, E, H and K, the actual numbers of facilities; columns C, F, I and L, the deficit in facilities reflected as percentages; and finally, columns D, G, J and M, the deficit in facilities reflected as numbers.

Discussion

The General Agreement on Inter-Institutional Collaboration for Emergency Obstetric Health Care (referred to as the Agreement in this article) was conceived as a strategy for reducing maternal morbidity and mortality in Mexico. Since its inception, it has spearheaded the functional integration of the national health care system.¹⁵ This notwithstanding, however, our results demonstrate that its impact on emergency obstetric care (EmOC) has been insignificant.

As many as 750,000 obstetric emergencies (OEs) occur annually in Mexico. For every 10 pregnant women, 3.44 experience an OE during pregnancy, childbirth or the postpartum period, whether or not they have complied with adequate antenatal control measures or are subject to predisposing risk factors. It is important to note that EmOC services provided under the Agreement offer women the opportunity to be treated at facilities other than the ones they normally use under their health insurance plan. This means that they can choose any hospital in the network of Agreement facilities either on their own or by inter-institutional referral. However, utilization of Agreement facilities has been virtually null, with EmOC interventions representing less than 1% of the national total.

The Agreement can be depicted as a public policy that has failed to achieve its anticipated results, namely a substantial reduction in maternal mortality and an increase in EmOC services for mothers and their newborns. A negligible portion of the population and health care providers actually utilizes it as an instrument for enhancing access to care. This can be explained partly by the fact that potential users are unaware of its existence. Several authors^16,17 have reported that insurance affiliates who would certainly reap the benefits of Agreement comprehensive services are not referred to its participating facilities because they simply are unaware of this possibility. It has also been documented that even though health personnel are fully empowered to rely on Agreement facilities as an option for their patients, they prefer to use their own service networks.

To better understand why the Agreement strategy is falling so dramatically short of its goals, it is imperative to consider factors other than the relationship between inhabitants and facilities. For instance, the orographic characteristics of the sites where facilities are located may be obstructing the transfer of patients between health units. The case of Chihuahua is a vivid example: if only inhabitants and facilities are factored into the analysis, the state would appear to offer adequate OE coverage. However, this overlooks the fact that many state health facilities are located amidst a rugged mountainous terrain that hinders the transfer of patients. Failure to consider topographical factors was one of the limitations of our study.

In analyzing the availability of EmOC facilities in the United States, Lobis et al. found that, in 2005, 31% of the states lacked the minimum number of EmOC facilities recommended by the UN.¹⁸ Similarly, in 2013, Mexico exhibited a significant gap between available and required facilities. Likewise, our results indicated that the Mexican State Health Services covered all affiliates of the Seguro Popular (replaced in January 2020 by the Health Institute for Wellbeing - INSABI), but provided practically no basic EmOC facilities for stabilizing patients while they reached a comprehensive facility. Finally, according to Lobis, the United States offered a large number of comprehensive EmOC services; however, they were concentrated in urban areas, with rural women facing limited EmOC availability. Moreover, these services were characterized by a high rate of cesarean births owing to fear of lawsuits and to a culture unsupportive of traditional vaginal births.

It is urgent that a much larger number of facilities be incorporated into the Agreement strategy which, launched by the government over a decade ago with the aim of meeting the EmOC demand of Mexican women, yields an exiguous 0.07% of the services required. All facilities within Mexican health care institutions virtually assist all obstetric emergencies without, however, forming part of the EmOC-accredited Agreement network. The purpose of this national, intersectoral pact was to ensure the quality and availability of services needed to meet Mexican public health requirements and to implement the recommendations of the UN Organization 24 hours a day, seven days a week. Being the first strategy charged with providing universal access to EmOC services, it must allow for public and private participation. According to our results, defragmentation –or integration– of the Mexican health care system requires the affiliation of all facilities in the country with EmOC response capacity, including private hospitals. This entails an exhaustive accreditation process, in itself a vehicle for improving the quality of health services. Among other functions, accreditation involves the supervision and regulation of health facilities with a view to ensuring the provision of sufficient and quality health resources (human, material and infrastructural) in the areas dedicated to obstetrical and neonatal care. In like manner, the certification of private facilities ensures their compliance with MoH norms.

EmOC accreditation (exclusive to Agreement facilities) and hospital certification constitute different processes despite their similarities regarding care, infrastructure, input and equipment standards in the delivery of EmOC services. They should therefore be aligned with the view of incorporating additional EmOC facilities that meet the standards of the Agreement.

The incorporation of private-sector services was proposed as a strategy by Mony et al. after analyzing the availability and distribution of all public and private facilities providing EmOC services in southern India. According to their results, private facilities provided 89% of comprehensive and 70% of basic EmOC services in that part of the country.¹⁹ By contrast, our findings in Mexico show that it is the public sector that plays the leading role in the provision of population health services. Among other government efforts in this area, a law was enacted in November 2015 to the effect that EmOC services shall be provided immediately and entirely free of charge to every woman in Mexico. This initiative not only justifies, but also catalyzes, the inclusion and accreditation of institutions and facilities currently operating independently of the Agreement.

Pearson and Shoo assessed the indicator available health care facilities in Kenya, Rwanda, South Sudan and Uganda, all suffering from very high rates of maternal mortality. According to their results, the number of facilities with basic EmOC services was far below the recommended standard, whereas the number of facilities with comprehensive EmOC services was adequate in all the participating countries except South Sudan. They found, however, that comprehensive services were concentrated in urban areas, and assisted less than 8% of all births and 2% of all obstetric complications at the national level.²⁰ Basic facilities are crucial for stabilizing OEs. According to the standards in the manuals for monitoring availability and utilization of obstetric services published by international organizations, achievement of the minimum internationally recommended number of basic EmOC facilities is one of the most promising steps towards abating maternal mortality. Adding such facilities protects women who either seek basic services or need to be stabilized while reaching a comprehensive EmOC facility.

Gabrysch et al. have proposed an alternative approach for measuring the minimum number of facilities required by the population. They suggest tallying births rather than inhabitants, assuring that, in so doing, the demand for EmOC facilities would rise as much as tenfold. The authors hold that current policy on skilled assistance should be revised to include all births,²¹ given that all are subject to unpredictable complications that may require immediate OE support.²² On the other hand, Campbell (2006) suggests that childbirth services should be provided at highly specialized hospitals offering comprehensive EmOC services, thus limiting the role of basic EmOC facilities.²³ In Mexico, both basic and comprehensive EmOC services are provided exclusively at secondary-care facilities, thus limiting the OE functions of primary-care facilities, most of which even lack the means for transporting referral patients to installations with the required response capacity.

Our findings indicate that the IMSS and State Health Services supply the majority of EmOC services in Mexico. According to the 2015 Intercensal Survey, 49.9% of the Mexican population was served by the Seguro Popular (administered by the State Health Services). However, our study shows that no EmOC facilities from the State Health Services and only a few from other public institutions are included in the Agreement. Furthermore, we found that all facilities with available EmOC infrastructure in Mexico support OEs, whether or not they are accredited for that function and operate as part of the Agreement. The quality of services in unaccredited facilities is unknown, however, because, as mentioned previously, quality norms are defined by the MoH accreditation and certification processes.

The Observatory of Maternal Mortality in Mexico has documented that, aside from the Agreement, a wide range of local initiatives have been undertaken to develop collaborative health services for OEs and other health interventions. It has also found that MoH executives themselves are unaware of exactly how many such legal instruments have been concluded. It is important to note that health service providers favor local agreements because fees are established and paid at a higher rate than under the Agreement. Furthermore, return on expenditure is negotiated directly between participating institutions in a shorter period (timing of reimbursements among Agreement participants can take as long as six months). These conditions render local arrangements more attractive to service providers.

In 2009, the UNICEF published The State of the World's Children report with a focus on maternal and neonatal health. A call to action among all member states, this document provides guidelines for supervising programs and formulating policies aimed at improving the distribution of EmOC facilities and other relevant health indicators in this area.²⁴ The report reiterates the recommendations of experts from the Mailman School of Public Health at Columbia University (1991 and 1992), subsequently appropriated by international organizations as the Guidelines for monitoring availability and use of obstetric services. Since the release of their last version in 2009, these Guidelines have provided a valuable tool for analyzing and supervising EmOC services at the national level.²⁵

Conclusion and Implications for Translation

This study indicates that the Mexican health care system is far from providing universal access to adequate EmOC services, primarily because accreditation has been limited to a few facilities notwithstanding the capacity of many others to respond to OEs. The Agreement strategy simply echoes the fragmentation of the health system by excluding primary-care, highly specialized and private-sector facilities from its network. Primary- and tertiary-care facilities must participate in the provision of basic and comprehensive EmOC services, respectively, if Mexico is to reach the UN international standard. This would ensure the required amount and quality of care, inputs, infrastructure and resources to meet the needs of women in Mexico. Moreover, service continuity depends on primary- and tertiary-care providers bringing EmOC services more closely into line with the needs of mothers and their newborns through coherent and interlinked interventions. It is imperative to formally institute a service model capable of ensuring comprehensive EmOC services through continuous networking among all institutional and care levels.

The Agreement would undoubtedly reach its potential as a catalyst for universal EmOC access were its field of action not confined to such a small number of facilities covering only the 0.07% of women with obstetric complications who are referred to its facilities by health service providers. The insufficient accreditation of facilities with EmOC response capacity and the high demand for OE services highlight the urgency of opening the accreditation process to all facilities routinely delivering such services in the national health care system. This would ensure the required amount and quality of resources to meet the needs of women in Mexico. The limited participation of facilities and institutions in the Agreement network hampers the achievement of full institutional coverage and impedes the reinforcement of infrastructure already available for the supply of EmOC services.