In this blog, Zlatko Nikoloski and Elias Mossialos et al discuss the link between health system inputs and amenable mortality in Mexico between 2000 and 2015. The findings suggest significant heterogeneity in levels of amenable mortality across different states and a negative association between the density of general practitioners and amenable mortality. This blog is based on their publication: The impact of primary health care and specialist physician supply on amenable mortality in Mexico (2000–2015): Panel data analysis using system-Generalized Method of Moments.
Mexico has been on the forefront of universal healthcare coverage. Since 2003, the country has gradually introduced the so-called Seguro Popular (SP) – a public health insurance scheme for uninsured people. In concert with the introduction of SP, the Mexican government steadily increased its investment in the public health care system from 2.6% of the Gross Domestic Product (GDP) in 2004, to 3.2% of GDP in 2014. The increased public spending was coupled with improvements in the health infrastructure, with the construction of 2,284 outpatient clinics and 262 community, general, and specialised hospitals between 2001 and 2006. In addition, the government invested in human resources for health, thus increasing the density of medical staff by roughly 30 percent.
The first part of the SP (i.e. providing health insurance coverage to the previously uninsured population) has received significant attention; however the second part, which is tied to the expansion of the health infrastructure and how it translates into improved health outcomes, remains less studied. After all, improving health outcomes should be the target when evaluating any health systems reform, or health systems performance more broadly.
There are a few methodological concepts in use, when analysing health systems performance, with avoidable mortality being one of them. The concept of avoidable mortality was first coined by Rutstein et al. as an alternative measure of quality of health care and was based on the notion that if everything goes well in the medical system, deaths due to certain conditions should not occur. Over the years, when studying the concept of avoidable mortality, researchers started to distinguish between ‘amenable’ deaths (i.e. deaths due to conditions amenable to medical interventions) and ‘preventable’ deaths (i.e. deaths due to conditions that can be prevented by system-wide health policies). In other words, a death can be considered as amenable if it could have been avoided through optimal quality health care.
Against this background, a new research paper published in Social Science and Medicine aims to shed more light on the concept of amenable mortality in Mexico, while also exploring sub-national variation during the period of 2000-2015. The authors rely on the widely used definition of amenable mortality which has been previously been applied in the context of both, high- and middle-income countries. Moreover, the paper goes a step further by also explaining the link between health system inputs and amenable mortality.
Understanding mortality trends and non-communicable diseases
According to the paper, overall, the age standardised amenable mortality rate in the country dropped from 136.0 per 100,000 population in 2000 to 124.1 per 100,000 population in 2015 – a 9% decrease. This reduction seems somewhat modest when compared to a double-digit reduction in amenable mortality across European members of the Organisation for Economic Co-operation and Development (OECD) – a club of mostly high income countries. Similarly, and in the wider Latin American context, a study in Brazil, using municipality level data, has found a double-digit reduction in amenable mortality in the first decade of the 21st century (although, admittedly, the study only uses a fraction of the total number of municipalities in the country).
This, slower than expected rate in reduction of the amenable mortality in Mexico, is a result of the amenable definition that is used in the study as well as the Mexican reality on the ground. The definition of amenable mortality used in this paper predominantly consists of non-communicable diseases, whose mortality has been either decreasing slowly or increasing (as in the case of diabetes). For example, during the study period, mortality rate due to cardiovascular conditions in Mexico dropped by 6%, while mortality rate due to diabetes increased by 22%. This dynamic in mortality trends due to certain non-communicable diseases overshadows some of the gains achieved in the reduction of mortality due to perinatal conditions or tuberculosis.
Overall, by 2015, non-communicable diseases (NCDs), including cardiovascular conditions, tumours, and diabetes accounted for more than 60% of amenable deaths in Mexico. According to the paper, cardiovascular diseases such as ischaemic heart disease accounted for approximately 44% of amenable deaths; malignant neoplasms were the second largest contributor, accounting for 13% of all amenable deaths, while premature deaths due to diabetes accounted for 6% of amenable mortality (up from 4% in 2000).
The high contribution of NCDs in the overall amenable mortality also explains the significant heterogeneity across states and the robust North-South divide as suggested by this research paper. The amenable mortality was highest in northern states, mostly due to higher mortality resulting from diabetes and cardiovascular diseases. There is a mushrooming evidence which suggests that the northern and central states of Mexico had the highest rates of obesity, diabetes, and mortality from ischaemic heart disease.
The findings of the study on rising deaths due to diabetes are particularly daunting. Official data suggests that the prevalence of diabetes at national level has witnessed a steady rise from 7.5% in 2000 to 12.6% in 2013. Importantly, mortality due to diabetes has increased despite the continuing policy efforts of the national authorities such as the National Action Plan for Diabetes (2001–2006) which led to the creation of “Grupos de Mutua Ayuda” in each state to provide education, metabolic control, and adherence to treatment, for people with diabetes. The more recent National Plan for Diabetes (2007–2012) – including mass media campaigns for self-care, active screening and care campaigns – has not translated into a sufficient reduction of increased risk for mortality associated with obesity. As in the rest of the higher middle-income countries, rising income, sedentary lifestyle and poor diet have been put forth as potential explanations for increasing Mexican waistlines.
The link between primary health care and amenable mortality
However, there is some hope. Based on a panel dataset comprising data for all 32 states over the period 2000-2015 and employing system-Generalized Method of Moments (system-GMM), the results of the paper show a significant and negative link between primary health care (measured using the density of GPs as a proxy) and amenable mortality. This finding echoes previous research findings on the impact of primary health on amenable mortality in a cross-country European setting, Germany and the United States. More importantly, in light of contribution of certain NCDs in the overall amenable mortality in Mexico, this finding confirms the notion that the single best medicine for NCDs (and in particular type-2 diabetes) would be greater investment in primary health care.
As such, the paper recommends increasing investment in primary healthcare. While there has been some progress over the years, Mexico can do better. Currently, not all Mexican citizens register with a primary care doctor and primary care has not been developed as a distinct medical specialty. Furthermore, Mexico has only 2.2 practising physicians per 1,000 population, and although this is comparable to the density of physicians in Brazil (2.1), it is much lower than that of Argentina (3.9). More resources and better training could increase physician availability and access in disadvantaged areas and reduce dependence on the hospital sector, thus contributing to further reductions in amenable mortality.
The views expressed in this post are those of the author and in no way reflect those of the Global Health Initiative blog or the London School of Economics and Political Science.