South Korea - International Children's Heart Fund

	International Children's Heart Fund
	Mexico 2004, 2006, 2007
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On Location - Mexico - November 2006

Mexico is a vibrant country of 106.2 million people (figure 1) (1). This democratic country has made significant progress over the past 50 years. The economy continues to grow with an annual GDP of 2.7%. The Health Development Index (HDI) is a composite of adult literacy (92.2%), average years of schooling, income level, and life expectancy (2). The HDI of Mexico in 2006 is 81.4 (>80 is high; 50-79 is medium; and <50 is low). The life expectancy is 73.7 years for males and 78.6 for females. The health care budget is 6.2% of GDP (USA is >14% of GDP). Health care coverage is uneven with approximately 40% of the entire population receiving care from the federal social security system, local state support, and major corporate coverage, e.g. the state owned PEMEX oil corporation. There is little private insurance, with out of pocket payment rounding out the financial support. The northern part of the country is better served than the central and southern regions. The new Popular Health Insurance (Seguro Popular) is an attempt to alleviate the imbalance in health care access and delivery (3) over the past six years. This program has given gradual health care protection for a variety of services to over 50 million Mexicans.

A more detailed history of the national health system dates back to 1943 with the establishment of the Ministry of Health and the Mexican Institute for Social Security (Instituto Mexicano del Seguro Social, IMSS) (4). In 1959, the Institute of Social Security and services for Civil Servants (ISSTE) was formed to cover public – sector workers and their families. These two systems covered public and private employed workers, with the uninsured sector being able to access state and federal health – service facilities, but paying a user fee, especially for supplies (e.g. open-heart disposables; valves, grafts, etc – amounting to about $2,000-2,500 per patient). As of 2000, the IMSS accounted for 40% of the population, the ISSTE an additional 7%, and private insurance 3-4%. This was the basis for establishment of the Seguro Popular. The horizontal component or coverage is designed to provide coverage for the uninsured (roughly 12 million families by 2010, at an average of 1.7 million families/year). Vertical coverage is designed to cover explicit intervention priorities. This means coverage of high-priority health conditions, like AIDS, childhood cancers, cervical cancer, and cataract surgery. Cardiac surgery is not one of the initial high priority conditions.

Against this background, Cardiac surgery has grown slowly, but progressively over the past 15 years (figure 2 ). Few Mexican cardiothoracic surgeons have received formal training in the USA in either accredited residency programs, or non-accredited one or two year fellowship programs. There has been little interaction between USA CT surgeons, centers, NGO’s or foundations with Mexican CT surgery programs. At present there are four formal CT surgery residency programs in Mexico. The program is eight years duration following medical school, with 4 years general surgery and 4 years CT surgery. There is a formal board and credentialing process. Approximately 15 residents / year are trained. There is one major society – the Mexican Society of Cardiac Surgery – which meets annually. There is no formal CT surgery dedicated journal. At the present time there are at least 41 identified centers performing cardiac surgery. There are less than 200 Mexican CT surgeons, with fewer than 100 doing the majority of cases. Approximately 7,000 cases are done annually with an approximate one third coronary, one third valve and one third congenital cases. Coronary artery disease continues to rise with increased urban lifestyle and diet changes (figure 3 ). The largest centers include the social security hospitals in Monterrey, Mexico City, and Guadalajara. The National Center of Cardiology in Mexico City is a major center both in caseload, training, and research.

In 2004, a short trip was made to Mexico City, and Monterrey. A tour of the National Cardiology Center in Mexico City was conducted. An interview was conducted with Dr. Rodolfo Barragan Garcia (tercar95@prodigy.net.mx) who gave a very candid overview of cardiac surgery in Mexico. His major concern was the imbalance in the number of cardiac surgery centers with resultant poor access for the major part of the population. In Monterrey, over 60% of the population had coverage from the Social Security System, whereas 10-20% are indigent and have no financial help.

A subsequent recent visit to Monterrey was taken in November, 2006. The primary purpose was to update the given statistics and spend two weeks working with Dr Felipe Rendon (drfrendon@yahoo,com.mx) and his CT surgery staff at the University Hospital (figure 4 ). This is the only Mexican medical school with an associated university hospital. They serve primarily the indigent, uninsured patient population. Less than 200 open heart operations are done there per year. The Social Security hospital (IHSS) in Monterrey is the largest center in Mexico, with over 1,200 open heart procedures performed per year (figure 6 ). The Chief of pediatric cardiac surgery Dr. Humberto Rodrigez-Saldana(humberto.rodriguezs@hotmail.com), (figure 5, figure 6 ) has established a voluntary humanitarian program in Chiapas, in cooperation with ADANEC, a non-profit organization devoted to developing and assisting cardiac surgery in underserved areas of Mexico. Contact Rosa Alicia Ramirez de Zepeda (adanec@prodigy.net.mx) for more details re. this voluntary project.

There are a few notable examples of USA cooperation with Mexico. Dr. J. Mark Morales (Jmarkmorales@aol.com), a pediatric cardiac surgeon from Corpus Christi, Texas has developed a voluntary humanitarian program in Satillo, Mexico, near Monterrey. With assistance from Dr. Carlos Xavier Lopez Uribe (carlosxlopez@gmail.com) , a pediatric cardiac surgeon from the Social Security center in Monterrey, they have performed over 170 cardiac surgery operations on poor children from that area. Another example is the cooperative effort at Texas Heart Institute. Dr. Charles Frazer, a pediatric cardiac surgeon, has hosted surgeons, and cardiac surgery team members from the Monterrey Social Security hospital to come to Houston for short periods of observational training.

The Rotary Gift of Life program from Boston, MA, coordinated by Barry Friedman (bfriedman@copleycontrols.com) ,has been active in recent years in bringing selected complex children to Boston Children’s Hospital for complex pediatric cardiac surgery.

There is certainly a desire and willingness on the part of the Mexican cardiac surgery community to develop and foster co-operative projects with their USA counterparts. For more detailed information and contacts, please contact A. Thomas Pezzella MD , e-mail (tpezzella@hotmail.com).

References

1. The World Fact Book. Prepared by C.I.A. Barnes and Noble, New York 2006; p. 395-398.

2. The Economist-Pocket World in Figures – 2007; p. 178-179.

3. Frenk, J. Bridging the Divide: global lessons from evidence based health policy in Mexico. Lancet 2006; 368: 954-961.

4. Frenk, J., Gonzalez-Pier, E., Gomez-Dantes, O, Lezana, MA., Knaul, FM. Health System Reform in Mexico – Comprehensive reform to improve health system performance in Mexico. Lancet 2006; 368: 1524-34.