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Health systems are complex entities. The Mexican health system includes the private and public sectors, and subsystems that target different populations based on corporatist criteria. Lack of unity and its consequences can be better understood using two concepts, segmentation and fragmentation. These reveal mechanisms and strategies that impede progress toward universality and equity in Mexico and other low- and middle-income countries. Segmentation refers to separation of the population by position in the labour market. Fragmentation refers to institutions, and to financial aspects, health care levels, states' systems of care, and organizational models. These elements explain inequitable allocation of resources and packages of health services offered by each institution to its population. Overcoming segmentation will require a shift from employment to citizenship as the basis for eligibility for public health care. Shortcomings of fragmentation can be avoided by establishing a common package of guaranteed benefits. Mexico illustrates how these two concepts characterize a common reality in low- and middle-income countries.

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BACKGROUND: Literature on barriers and facilitators for early detection of Breast Cancer (BC) among indigenous women is very scarce. This study aimed to identify barriers and facilitators for BC early diagnosis as perceived by women of the otomí ethnic group in Mexico. METHODS: We performed an exploratory qualitative study. Data was collected in 2021 through three focus group interviews with 19 otomí women. The interview transcripts were analyzed using the constant comparison method and guided by a conceptual framework that integrates the Social Ecological Model (SEM), the Health Belief Model and the Institute of Medicine's Healthcare Quality Framework. RESULTS: Barriers and facilitators were identified at several levels of the SEM. Among the main barriers reported by the study participants were: beliefs about illness, cancer stigma, cultural gender norms, access barriers to medical care, and mistreatment and discrimination by health care personnel. Our participants perceived as facilitators: information provided by doctors, social support, perceived severity of the disease and perceived benefits of seeking care for breast symptoms. CONCLUSIONS: Healthcare policies need to be responsive to the particular barriers faced by indigenous women in order to improve their participation in early detection and early help-seeking of care for breast symptoms. Measures to prevent and eradicate all forms of discrimination in healthcare are required to improve the quality of healthcare provided and the trust of the indigenous population in healthcare practitioners.

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BACKGROUND: There is an important gap in the literature concerning the level, inequality, and evolution of financial protection for indigenous (IH) and non-indigenous (NIH) households in low- and middle-income countries. This paper offers an assessment of the level, socioeconomic inequality and middle-term trends of catastrophic (CHE), impoverishing (IHE), and excessive (EHE) health expenditures in Mexican IHs and NIHs during the period 2008-2020. METHODS: We conducted a pooled cross-sectional analysis using the last seven waves of the National Household Income and Expenditure Survey (n = 315,829 households). We assessed socioeconomic inequality in CHE, IHE, and EHE by estimating their Wagstaff concentration indices according to indigenous status. We adjusted the CHE, IHE, and EHE by estimating a maximum-likelihood two-stage probit model with robust standard errors. RESULTS: We observed that, during the period analyzed, CHE, IHE, and EHE were concentrated in the poorest IHs. CHE decreased from 5.4% vs. 4.7% in 2008 to 3.4% vs. 2.9% in 2014 in IHs and NIHs, respectively, and converged at 2008 levels towards 2020. IHE remained unchanged from 2008 to 2014 (1.6% for IHs vs. 1.0% for NIHs) and increased by 40% in IHs and NIHs during 2016-2020. EHE plunged in 2014 (4.6% in IHs vs. 3.8% in NIHs), then rose, and remained unchanged during 2016-2020 (6.7% in IHs and 5.6% in NIHs). CONCLUSION: In pursuit of universal health coverage, health authorities should formulate and implement effective financial protection mechanisms to address structural inequalities, especially forms of discrimination including racialization, that vulnerable social groups such as indigenous peoples have systematically faced. Doing so would contribute to closing the persistent ethnic gaps in health.

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The aim of this study was to estimate the prevalence of health needs and use of outpatient services for indigenous (IP) and non-indigenous (NIP) populations aged ≥15 years, and to explore the associated factors and types of need. A cross-sectional study was conducted based on the 2018-19 National Health and Nutrition Survey. The population aged ≥15 years who had health needs and used outpatient services was identified. Logistic models were developed to explore the factors underlying the use of outpatient services. For both populations, being a woman increased the likelihood of using health services, and having health insurance was the most important variable in explaining the use of public health services. Compared to the NIP, a lower proportion of IP reported health needs during the month prior to the survey (12.8% vs. 14.7%); a higher proportion refrained from using outpatient services (19.6% vs. 12.6%); and a slightly higher proportion used public health services (56% vs. 55.4%). For the NIP, older age and belonging to a household that had received cash transfers from a social program, had few members, a high socioeconomic level, and a head with no educational lag, all increased the likelihood of using public health services. It is crucial to implement strategies that both increase the use of public health services by the IP and incorporate health-insurance coverage as a universal right.

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Health is a human right that everyone should be able to exercise. Yet health systems segmentation and fragmentation are a major challenge to advancing universal health coverage (UHC) and achieving health equity. Between 2019 and 2020, Mexico launched a profound restructuration of its health system claiming its aim was to attain UHC, free healthcare services and drugs and to combat corruption. We analyse the implications of the modifications of the Mexican Constitution and the dismantling of the Seguro Popular de Salud (Popular Health Insurance) in relation to segmentation. We argue that, instead of advancing towards UHC and equality, these changes reinforce inequalities and that transforming health systems must respect human rights.

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This article examines the coverage in the continuum of antenatal-postnatal care for vulnerable women in Mexico according to indigenous status and assesses the influence of public health insurance strategies on the evolution of coverage over the last 25 years. We studied a total of 19 613 567 Mexican women, aged 12-54 years at last birth, based on a pooled cross-sectional analysis of data from the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics. After describing sociodemographic characteristics and maternal-health coverage by indigenous status, we constructed a pooled fixed-effects and interaction multivariable regression model to assess the influence of the Seguro Popular programme on continuum of care. We estimated adjusted continuum of care coverage between 1994 and 2018 according to Seguro Popular affiliation and indigenous status. Prior to the Seguro Popular programme, crude coverage in the continuum of care for non-indigenous women stood at 14.5% [95% confidence interval (CI): 13.2-15.8%] or 11 percentage points higher than for indigenous women. During the last period of the programme, it rose to 46.5% [95% CI: 45.6-47.5%] and 34.1% [95% CI: 30.7-37.4%], respectively. Our regression analysis corroborated findings that, on average, indigenous women faced lower odds of benefiting from continuum of care [adjusted odds ratio (aOR) = 0.48, 95% CI: 0.40-0.57] than did their non-indigenous counterparts. It also revealed that coverage for indigenous women without Seguro Popular affiliation was 26.7% [95% CI: 23.3-30.1%] or 12 percentage points lower than for those with Seguro Popular affiliation (38.6%, 95% CI: 35.7-41.4%). Our regression results confirmed that the latter benefited from higher odds of continuum of care (aOR = 1.67, 95% CI: 1.36-2.26). Gaps between those of indigenous and non-indigenous status have persisted, but the Seguro Popular clearly contributed to reducing the coverage gaps between these two groups of women. Strategies yielding better outcomes are required to improve the structural conditions of indigenous populations.

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Resumen: Objetivo: Presentar los resultados de una intervención pedagógica para mejorar la calidad en el trato que brindan los prestadores de servicios de salud en regiones indígenas. Material y métodos: Se diseñó una metodología didáctica con enfoque crítico-constructivista dirigida a personal de salud que atiende a población indígena en cinco entidades de México. Resultados: Entre 09/2016 a 01/2020 se capacitó a 1 825 trabajadores de la salud que deconstruyeron las creencias que determinan prácticas de discriminación y maltrato durante la atención a la salud de los usuarios indígenas. La intervención logró un aprendizaje significativo transformador de las valoraciones y prácticas sociales, con propuestas para evitar cualquier forma de maltrato y garantizar el trato digno. Conclusiones: Para la construcción de un sistema de salud universal y equitativo, es necesario incluir intervenciones que actúen sobre las creencias determinantes de las prácticas de discriminación y maltrato en los servicios de salud hacia grupos sociales vulnerables.

Abstract: Objective: Present the results of a pedagogical intervention to improve the quality-responsiveness in healthcare provided by health service providers in indigenous regions. Materials and methods: A didactic methodology with a critical-constructivist approach was designed aimed to health personnel who attend to the indigenous population in five entities of Mexico. Results: Between 09/2016 and 01/2020, 1 825 health workers were trained, who deconstructed the beliefs that determine practices of discrimination and abuse during the health care of indigenous users. The intervention achieved significant transformative learning of social beliefs and practices, with proposals to avoid any form of abuse and guarantee dignified treatment. Conclusions: For the construction of a universal and equitable health system, it is necessary to include interventions that act on the beliefs that determine discrimination and mistreatment practices in health services towards vulnerable social groups.

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