Closing Attention Gap for NCDs After COVID-19

For over two years, the burden of the COVID-19 pandemic has increasingly disrupted traditional health priorities and altered the criteria for public health prioritization. This has proved harmful to the prevention, diagnosis and treatment of many diseases, which threatens long-term outcomes, warn experts.

Mexico’s National Health Plan 2019-2024 is based on five large objectives: universal, free and effective access to healthcare, continuous improvement, capacity and quality of the National Health System, epidemiological surveillance and sexual and reproductive health, as well as health for well-being. The latter is focused on Mexico’s serious public health problem of obesity and related non-communicable diseases (NCD), which are already a pandemic that affects both individual and population health, directly impacting the country's productivity and economy.

The national health plan identifies chronic non-communicable diseases (CNCD), in particular cancer and cardio-metabolic diseases, such as cardiovascular disease, high blood pressure and Type 2 diabetes, as the main challenge for the health system in the country, both due to their magnitude, the great impact on premature mortality and quality of life and the costs of treatment for the disease and its complications. “One of the main risk factors that explain the increase in these chronic diseases is the accelerated growth that Mexico has presented in the prevalence of overweight and obesity,” says the national health plan.

According to the Ministry of Health, there are four determinant causes for Mexico’s high prevalence of chronic diseases. The first one is the limited and inequitable access to health services, which impacts mostly those in conditions of vulnerability, discrimination or marginalization. The second one is related to the prevalence of unhealthy lifestyles, while the third one relates to high levels of multidimensional poverty and the aging of the Mexican population. “Although it is not a cause, it is a determinant that puts pressure on the protection and prevention of diseases,” says the ministry. The fourth cause is the predominance of medical care over prevention and health promotion.

Access to health services was severely impacted by the COVID-19 pandemic. The main findings by the World Health Organization (WHO) show that in 2020, non-COVID-19 health services were partially or totally interrupted in many countries. More than half (53 percent) of the countries surveyed by the organization had partially or fully discontinued hypertension treatment services, treatments for diabetes and related complications (49 percent), cancer treatment services (42 percent) and cardiovascular emergencies (31 percent).

In 94 percent of the surveyed countries, staff from ministries of health working on NCDs were partially or fully redeployed to support the COVID-19 response. As the pandemic advanced, 58 percent of the surveyed countries switched to telemedicine (advice by telephone or electronic means) for face-to-face consultations. In low-income countries, the rate was 42 percent. Triage has also been used extensively to determine priorities in two-thirds of reporting countries.

A study by BMJ Global Health used health data of January 2019 to December 2020 from IMSS, which provides health services to 65 million Mexicans, to determine the disruption in essential health services in Mexico during COVID-19. The analysis included nine indicators of service use and three outcome indicators for reproductive, maternal and child health and non-communicable disease services. Results of the study found that across nine health services, an estimated 8.74 million patient visits were lost in Mexico. This included breast and cervical cancer screenings (79 percent and 68 percent, respectively), and over half of the diabetes, hypertension and prenatal care consultations. In terms of patient outcomes, the proportion of patients with diabetes and hypertension with controlled conditions declined by 22 percent and 17 percent, respectively.

“During the pandemic, the conversion of hospitals to 100 percent COVID-19 care was a mistake. There are many diseases that require continuous care and around 16 million Mexicans chose not to go to their medical appointments. In public health, risks must be communicated in an understandable, correct and brief way to patients. The stay-at-home policy confused many people. Staying home impacted the health decisions of many families,” explained Carolina Gómez, Public Health Consultant.

Regarding prevalence of unhealthy lifestyles, a case study by Universidad de las Americas Puebla found that from its national surveyed population, 44.4 percent of the female population and 47.1 percent of the male population felt that their diet had been affected due to confinement, finding an increase in the consumption of sweets and desserts in 39 percent of men and 51.6 percent of women. On the other hand, participants indicated an increase in the consumption of sugary drinks and junk food by around 30 percent.

Of the people surveyed, 81.9 percent do not consume tobacco and 11.53 percent increased their consumption. Physical activity was a common activity for 62.5 percent of people before confinement, with 6.6 percent of these people decreasing their activity. Regarding sleep, 35.2 percent stated that their sleep pattern has changed for the better, while 57 percent said that they wake up at night.

The study observed that people reported eating all the time during confinement, a practice they did not have before the pandemic, “which shows that these two factors can directly contribute to the increase in overweight and obesity in the country,” states the study.

Multidimensional poverty has also worsened following the pandemic. An additional 3.8 million Mexicans fell into poverty in 2020 compared to 2018, largely because of the COVID-19 pandemic, according to National Council for the Evaluation of Social Development Policy (CONEVAL). The poor made up 43.9 percent of the population compared to 41.9 percent in 2018, found CONEVAL. “About 2.1 of the 3.8 million newly poor fell into extreme poverty, defined as being unable to meet their basic needs for food, clothing and shelter. There are 10.8 million Mexicans, about 8.5 percent of the population, in extreme poverty,” said the Council.

The situation has been further complicated by rising inflation rates. As of July of 2022, inflation stands at 7.4 percent, but is likely to raise to 8 percent and reach 9 percent by the end of the year, according to Banxico.

The fourth cause is the predominance of medical care over prevention and health promotion which, according to the Ministry of Health, would ideally be achieved through an improvement in coverage, equitable access and quality in health services for the diagnosis and treatment of NCD, with an emphasis in primary care, under the principles of non-discrimination, dignified treatment and inclusion.

Universal Health Coverage (UHC) means ensuring quality health services for all who need these, without putting their economic situation at risk, according to WHO. To achieve this objective, it is necessary to consider three dimensions: affiliation, services and spending. Yet, according to the Center for Economic and Budget Research (CIEP), Mexico does not have UHC in any of the three dimensions.

Figures indicate that the State Health Services (SESAs) are the ones with the least economic, physical and human resources for healthcare provision against social security services like IMSS and ISSSTE, said CIEP. “At the national level, 30.6 percent of the population, 38.8 million people, reported not being affiliated with any health subsystem in 2020, this represents an increase of 16.4 million people compared to 2018. The population affiliated to INSABI decreased by 18.7 million people during that same period,” stated the Center.

As for services, Mexico has 1.1 beds per 1,000 inhabitants against 4.8 beds which is the OECD average. For the ministry of health’s state services, the CIEP found that the rate stands between 0.2 and 0.9 beds per 1,000 inhabitants. The number of doctors per 1,000 habitants is also lagging against the OECD average, with the rate in Mexico being 2.0 against the 3.3 OECD base. This range varies from 0.47 to 1.49 doctors per 1,000 inhabitants, said CIEP for ministry of health state services. Finally, the average number of male and female nurses in the country per 1,000 inhabitants is 2.4, while the OECD average is 9.1.

Regarding expenditure, federal resources increased by 16.7 percent in 2020 compared to 2019, while state resources increased by 34.6 percent. Nevertheless, there is a public budget gap to move toward universal health coverage, states CIEP. “At the national level and for all health subsystems, the budget gap reaches 3 percent of the GDP, of which the SESAs require at least an increase in their resources of 1.1 percent of GDP. At the subnational level, the budget gap ranges from 0.4-7.2 percent of state GDP. As a percentage of the budget that the states allocate to health, that ranges from 29.7-153.4 percent,” said the Center.

The complexity of these issues calls for structural changes that would take years to achieve. “However, a technology-based strategy can help. For example, telemedicine would allow doctors to provide primary care without being next to the patient, making the provision of care more uniform,” explained David Kershenobich, Former Director General, Salvador Zubirán National Institute of Health Sciences and Nutrition (INCMNSZ).

According to Kershenobich, this telemedicine-based strategy would foment the homogenization of health services in an equitable way, which requires a referral and counter-referral system where patients know when, where and how they are going to be treated. “These services can actively regularize the provision of care in Mexico and record information about the country's epidemiology, fostering clinical and basic research,” he said.

A study on cancer by the American Health Foundation also recommended health systems to first map the new problems afflicting patients to then advocate for public policies and specific support programs for such new problems, allocating sufficient resources to the expenditure of such diseases, integrating a gender perspective, ensuring continuity of supplies and programs provision, implementing communication and awareness programs, fomenting local research and embracing tech for constant and remote attention.