Authors: Juan Manuel Guzman, MD Elva Garcı´a Salazar, MD
Health Policy
Affiliations: From the International Society of Physical and Rehabilitation Medicine (ISPRM); and Mexican Society of Physical Medicine and Rehabilitation (PM&R) (JMG, EGS).
Correspondence: All correspondence and requests for reprints should be addressed to: Juan Manuel Guzman, MD, International Society of Physical and Rehabilitation Medicine.
ANALYSIS
Disability and Rehabilitation in Mexico ABSTRACT Guzman JM, Salazar EG: Disability and rehabilitation in Mexico. Am J Phys Med Rehabil 2014;93(Suppl):S36YS38.
Disclosures: Juan Manuel Guzman, MD, is the president of the 8th World Congress of ISPRM and honorary president of the Mexican Society of PM&R. Elva Garcı´a Salazar, MD, is secretary of the 8th World Congress of ISPRM and past president of the Mexican Society of PM&R. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9301(Suppl)-S36/0 American Journal of Physical Medicine & Rehabilitation Copyright * 2013 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000019
Recent disability-related data are available from the 13th National Census of Population and Housing, which was performed in 2010. Disability assessment followed the recommendations of the Washington Group on Disability Statistics and identified 5,739,270 (5.1%) persons with disability, 51.1% of whom were women. Almost 60% of all persons 85 yrs or older reported disabilities. Policies and legislation endorse the rights of persons with disabilities. However, little is known about the real-life situation of persons with disabilities in Mexico as well as the met and unmet needs for rehabilitation. Rehabilitation services in Mexico are mainly organized by the Mexican Institute of Social Security. Because of the increasing need for rehabilitation, an innovative model of small first-level rehabilitation services has been designed and successfully implemented. This model has increased the capacity of rehabilitation services by 60% since 2003. Key Words:
Rehabilitation, Persons with Disability, Epidemiology, Policy
BURDEN OF DISABILITY The first representative and meaningful disability data in Mexico were obtained by the 12th National Census of Population and Housing in 2000. Disability assessment was based on the International Classification of Impairments, Disabilities, and Handicaps and indicated a prevalence of severe disability of 1.8% of the total Mexican population. Almost half of the persons with disability reported physical impairments (45.3%), and nearly one-third had sensory impairments. Major causes of disability were chronic degenerative diseases and congenital malformations. These disability data were updated in 2003 by the National Survey of Evaluation of Performance. This survey revealed that approximately 9% of the total Mexican population had a disability at the time. From these results, it was estimated that the total number of persons with disability in the country was approximately 9.7 million. The most recent data are available from the 13th National Census of Population and Housing, which was performed in 2010 and included a total population of 111,960,139 people.1 The assessment of disability followed the recommendations of the Washington Group on Disability Statistics2 and incorporated difficulties in six functional domains including seeing, hearing, mobility, cognition, self-care, and communication. The 2010 census identified 5,739,270 (5.1%) persons with disability, 51.1% of whom were women. Although aging of
S36
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 1, (Suppl) January 2014 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the Mexican population has been noted, the Mexican population is still relatively young, with a median age of 26 yrs; 29.3% were younger than 15 yrs. On the other hand, persons with disability are a predominately old population, and almost 60% of all persons 85 yrs or older reported at least one difficulty. A total of 16.4% of the population with disability reported two or more limitations, whereas 58.3% had physical impairments, 27.2% had difficulties in seeing, and 12.1% had difficulties in hearing.
WHAT HAS BEEN DONE? Policies and Legislation In the last few years, many disability-related laws and regulations have been passed and implemented.3 The BGeneral Law for the Incorporation of the People with Disability[ (June 10, 2005) mandates that the state has to promote, protect, and ensure the full enjoyment of human rights for persons with disabilities and their full inclusion in society including respect and equality of opportunities. The law also guarantees the inclusion of people with disabilities in all areas of the society. Another important national law is the BFederal Law to Anticipate and to Eliminate the Discrimination.[ It aims to eliminate all forms of discrimination against any person as well as to promote the equality of opportunities and treatment. In addition, official Mexican norms and regulations guarantee accessibility to buildings and services, for example, by the BNOM-197-SSA1-2000[ and the BTechnical Complementary Norm for the Architectural Project.[ These support the inclusion of persons with disabilities, for example, by the establishment of a certification for professionals who translate the Mexican Language of Signs to Spanish and vice versa, and enable access to rehabilitation services and social assistance including the BNOM-173-SSA1-1998[ and the BNOM-EM-001-SSA3-2010.[
Human Resources During the 1960s, the Mexican Institute of Rehabilitation, a nongovernmental facility, established the first formal training course for specialists in physical medicine and rehabilitation (PM&R) and simultaneously started the School of Physical and Occupational Therapy, along with a prosthetics and orthotics laboratory. In 1965, the Mexican Institute of Social Security (MSSS) opened its first postgraduate training program in rehabilitation. In 1972, the School of Medicine of the National Autonomous University of Mexico approved a curriculum for PM&R. This program was gradually expanded to other facilities. Currently, seven institutions educate www.ajpmr.com
and train PM&R specialists, and 70 physiatrists are finishing their residency program every year. After finishing the residency program, residents have the option of completing one of several postgraduate programs of 1 or 2 yrs of duration. They can also complete studies for a master’s degree or a doctor of philosophy degree in health sciences.
Service Delivery Rehabilitation in Mexico started at the end of the 19th century, when the National School for the Blind and Visually Impaired was established. In 1905, Mexico’s General Hospital opened the first Mexican PM&R department. Nowadays, the most important provider of rehabilitation is the MSSS. The MSSN runs 164 services around the country and provides integrated medical care to more than 50 million inhabitants. All members insured by the MSSS are entitled to receive rehabilitation services as part of their health benefits. Individuals who are injured at work are entitled to orthotic and prosthetic devices necessary for their return to work. Return to a job within the same company is highly encouraged, if possible. An increased life span and a reduction in mortality have resulted in an increasing number of people living beyond the age of 70 yrs. Currently in Mexico, there are 3.8 million people in this age group, with a projected growth of 3.8% per year. Accordingly, disabilities caused by degenerative and chronic diseases are also expected to increase. As the industrialization of the country expands and city dwelling increases, there are more traffic- and work-related accidents, with many and diverse forms of disability that require increased quality of care in a cost-effective manner. In response to these challenges, the MSSS initiated the implementation of first-level rehabilitation services. The conceptual model implemented by these units was developed by the authors of this article. The authors defined first-level rehabilitation service as services that have a physiatrist who takes care of the persons with disabilities and leads, organizes, coordinates, and supervises service delivery. These services must include physicians for medical evaluations, clinical areas of electrotherapy, and a well equipped gymnasium for therapeutic exercise. Each unit consists of one physiatrist, four physical therapists, one social worker, and one nurse. Currently, in Mexico, there are 46 such integrated units of care in operation. These have increased the capacity of rehabilitation services by 60% (Table 1). In Mexico, the Health Ministry provides care to those not covered by the Social Security system. To Disability and Rehabilitation in Mexico
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S37
TABLE 1 Number of rehabilitation services on the third, the second, and the first level in the years 2003 and 2013 Level Third Level Type of Service Numbers Subtotal Total
2003 2013 2003 2013 2003 2013
Second Level
Specialized PM&R Units
Medical Centers
Regional Hospitals
General Hospitals
Family Medicine Units
4 4
14 14
0 14
86 86
0 46 0 46
18 18
86 100 104 164
provide services to this group of the population, the BPopular Insurance[ was established. This government insurance program includes coverage for rehabilitation services. Most of these services are located within the National Institute of Rehabilitation and the rehabilitation services of the National Institute of Pediatrics, the Institute for Respiratory Disorders, and the Hospital for Children. There are other institutions, such as the Army and the Navy, which also have rehabilitation services in specific areas of the country. The Health System for State Employees has one specialized rehabilitation unit and 18 rehabilitation services in general hospitals around the country. Finally, the National System for the Integrated Development of the Family has 104 centers and 1444 Basic Rehabilitation Units providing services to adults and children with disabling conditions. These services are community based and distributed across the country. Finally, institutions in the private sector in rehabilitation can be seen throughout Mexico. For example, the Teleton company has made an impact in the healthcare industry of the country with the establishment of 20 centers for pediatric rehabilitation distributed throughout several states of the Republic of Mexico.
CONCLUSIONS Persons with disabilities and their rights have more attention during the last decade, and the level of
S38
Guzman and Salazar
First Level
awareness of disability-related issues has also significantly increased. This has led to a number of laws and regulations that protect the rights of persons with disabilities and ensure equality of access to most areas of social and public life. These laws include the principle of inclusion and nondiscrimination. However, little is known about the real-life situation of persons with disabilities in Mexico. Rehabilitation services in Mexico are mainly organized by the MSSS. Because of the increasing need for rehabilitation, an innovative model of rehabilitation services has been designed and implemented in addition to common hospital-based rehabilitation services. Furthermore, community-based rehabilitation services are available. These developments show the growing efforts in the field of rehabilitation services. However, more detailed data about needs and unmet needs are missing.
REFERENCES 1. Instituto Nacional de Estadı´stica y Geografı´a: Principales Resultados del Censo de Poblacio´n y Vivienda 2010. 2011 2. Madans JH, Loeb ME, Altman BM: Measuring disability and monitoring the UN Convention on the Rights of Persons with Disabilities: The work of the Washington Group on Disability Statistics. BMC Public Health 2011;11(suppl 4):S4 3. Instituto Mexicano del Seguro Social: Libro Blanco 2006Y2012. Mexico City, Mexico: Instituto Mexicano del Seguro Social, 2013
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 1, (Suppl) January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Health Policy
Affiliations: From the International Society of Physical and Rehabilitation Medicine (ISPRM); and Mexican Society of Physical Medicine and Rehabilitation (PM&R) (JMG, EGS).
Correspondence: All correspondence and requests for reprints should be addressed to: Juan Manuel Guzman, MD, International Society of Physical and Rehabilitation Medicine.
ANALYSIS
Disability and Rehabilitation in Mexico ABSTRACT Guzman JM, Salazar EG: Disability and rehabilitation in Mexico. Am J Phys Med Rehabil 2014;93(Suppl):S36YS38.
Disclosures: Juan Manuel Guzman, MD, is the president of the 8th World Congress of ISPRM and honorary president of the Mexican Society of PM&R. Elva Garcı´a Salazar, MD, is secretary of the 8th World Congress of ISPRM and past president of the Mexican Society of PM&R. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9301(Suppl)-S36/0 American Journal of Physical Medicine & Rehabilitation Copyright * 2013 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000019
Recent disability-related data are available from the 13th National Census of Population and Housing, which was performed in 2010. Disability assessment followed the recommendations of the Washington Group on Disability Statistics and identified 5,739,270 (5.1%) persons with disability, 51.1% of whom were women. Almost 60% of all persons 85 yrs or older reported disabilities. Policies and legislation endorse the rights of persons with disabilities. However, little is known about the real-life situation of persons with disabilities in Mexico as well as the met and unmet needs for rehabilitation. Rehabilitation services in Mexico are mainly organized by the Mexican Institute of Social Security. Because of the increasing need for rehabilitation, an innovative model of small first-level rehabilitation services has been designed and successfully implemented. This model has increased the capacity of rehabilitation services by 60% since 2003. Key Words:
Rehabilitation, Persons with Disability, Epidemiology, Policy
BURDEN OF DISABILITY The first representative and meaningful disability data in Mexico were obtained by the 12th National Census of Population and Housing in 2000. Disability assessment was based on the International Classification of Impairments, Disabilities, and Handicaps and indicated a prevalence of severe disability of 1.8% of the total Mexican population. Almost half of the persons with disability reported physical impairments (45.3%), and nearly one-third had sensory impairments. Major causes of disability were chronic degenerative diseases and congenital malformations. These disability data were updated in 2003 by the National Survey of Evaluation of Performance. This survey revealed that approximately 9% of the total Mexican population had a disability at the time. From these results, it was estimated that the total number of persons with disability in the country was approximately 9.7 million. The most recent data are available from the 13th National Census of Population and Housing, which was performed in 2010 and included a total population of 111,960,139 people.1 The assessment of disability followed the recommendations of the Washington Group on Disability Statistics2 and incorporated difficulties in six functional domains including seeing, hearing, mobility, cognition, self-care, and communication. The 2010 census identified 5,739,270 (5.1%) persons with disability, 51.1% of whom were women. Although aging of
S36
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 1, (Suppl) January 2014 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the Mexican population has been noted, the Mexican population is still relatively young, with a median age of 26 yrs; 29.3% were younger than 15 yrs. On the other hand, persons with disability are a predominately old population, and almost 60% of all persons 85 yrs or older reported at least one difficulty. A total of 16.4% of the population with disability reported two or more limitations, whereas 58.3% had physical impairments, 27.2% had difficulties in seeing, and 12.1% had difficulties in hearing.
WHAT HAS BEEN DONE? Policies and Legislation In the last few years, many disability-related laws and regulations have been passed and implemented.3 The BGeneral Law for the Incorporation of the People with Disability[ (June 10, 2005) mandates that the state has to promote, protect, and ensure the full enjoyment of human rights for persons with disabilities and their full inclusion in society including respect and equality of opportunities. The law also guarantees the inclusion of people with disabilities in all areas of the society. Another important national law is the BFederal Law to Anticipate and to Eliminate the Discrimination.[ It aims to eliminate all forms of discrimination against any person as well as to promote the equality of opportunities and treatment. In addition, official Mexican norms and regulations guarantee accessibility to buildings and services, for example, by the BNOM-197-SSA1-2000[ and the BTechnical Complementary Norm for the Architectural Project.[ These support the inclusion of persons with disabilities, for example, by the establishment of a certification for professionals who translate the Mexican Language of Signs to Spanish and vice versa, and enable access to rehabilitation services and social assistance including the BNOM-173-SSA1-1998[ and the BNOM-EM-001-SSA3-2010.[
Human Resources During the 1960s, the Mexican Institute of Rehabilitation, a nongovernmental facility, established the first formal training course for specialists in physical medicine and rehabilitation (PM&R) and simultaneously started the School of Physical and Occupational Therapy, along with a prosthetics and orthotics laboratory. In 1965, the Mexican Institute of Social Security (MSSS) opened its first postgraduate training program in rehabilitation. In 1972, the School of Medicine of the National Autonomous University of Mexico approved a curriculum for PM&R. This program was gradually expanded to other facilities. Currently, seven institutions educate www.ajpmr.com
and train PM&R specialists, and 70 physiatrists are finishing their residency program every year. After finishing the residency program, residents have the option of completing one of several postgraduate programs of 1 or 2 yrs of duration. They can also complete studies for a master’s degree or a doctor of philosophy degree in health sciences.
Service Delivery Rehabilitation in Mexico started at the end of the 19th century, when the National School for the Blind and Visually Impaired was established. In 1905, Mexico’s General Hospital opened the first Mexican PM&R department. Nowadays, the most important provider of rehabilitation is the MSSS. The MSSN runs 164 services around the country and provides integrated medical care to more than 50 million inhabitants. All members insured by the MSSS are entitled to receive rehabilitation services as part of their health benefits. Individuals who are injured at work are entitled to orthotic and prosthetic devices necessary for their return to work. Return to a job within the same company is highly encouraged, if possible. An increased life span and a reduction in mortality have resulted in an increasing number of people living beyond the age of 70 yrs. Currently in Mexico, there are 3.8 million people in this age group, with a projected growth of 3.8% per year. Accordingly, disabilities caused by degenerative and chronic diseases are also expected to increase. As the industrialization of the country expands and city dwelling increases, there are more traffic- and work-related accidents, with many and diverse forms of disability that require increased quality of care in a cost-effective manner. In response to these challenges, the MSSS initiated the implementation of first-level rehabilitation services. The conceptual model implemented by these units was developed by the authors of this article. The authors defined first-level rehabilitation service as services that have a physiatrist who takes care of the persons with disabilities and leads, organizes, coordinates, and supervises service delivery. These services must include physicians for medical evaluations, clinical areas of electrotherapy, and a well equipped gymnasium for therapeutic exercise. Each unit consists of one physiatrist, four physical therapists, one social worker, and one nurse. Currently, in Mexico, there are 46 such integrated units of care in operation. These have increased the capacity of rehabilitation services by 60% (Table 1). In Mexico, the Health Ministry provides care to those not covered by the Social Security system. To Disability and Rehabilitation in Mexico
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S37
TABLE 1 Number of rehabilitation services on the third, the second, and the first level in the years 2003 and 2013 Level Third Level Type of Service Numbers Subtotal Total
2003 2013 2003 2013 2003 2013
Second Level
Specialized PM&R Units
Medical Centers
Regional Hospitals
General Hospitals
Family Medicine Units
4 4
14 14
0 14
86 86
0 46 0 46
18 18
86 100 104 164
provide services to this group of the population, the BPopular Insurance[ was established. This government insurance program includes coverage for rehabilitation services. Most of these services are located within the National Institute of Rehabilitation and the rehabilitation services of the National Institute of Pediatrics, the Institute for Respiratory Disorders, and the Hospital for Children. There are other institutions, such as the Army and the Navy, which also have rehabilitation services in specific areas of the country. The Health System for State Employees has one specialized rehabilitation unit and 18 rehabilitation services in general hospitals around the country. Finally, the National System for the Integrated Development of the Family has 104 centers and 1444 Basic Rehabilitation Units providing services to adults and children with disabling conditions. These services are community based and distributed across the country. Finally, institutions in the private sector in rehabilitation can be seen throughout Mexico. For example, the Teleton company has made an impact in the healthcare industry of the country with the establishment of 20 centers for pediatric rehabilitation distributed throughout several states of the Republic of Mexico.
CONCLUSIONS Persons with disabilities and their rights have more attention during the last decade, and the level of
S38
Guzman and Salazar
First Level
awareness of disability-related issues has also significantly increased. This has led to a number of laws and regulations that protect the rights of persons with disabilities and ensure equality of access to most areas of social and public life. These laws include the principle of inclusion and nondiscrimination. However, little is known about the real-life situation of persons with disabilities in Mexico. Rehabilitation services in Mexico are mainly organized by the MSSS. Because of the increasing need for rehabilitation, an innovative model of rehabilitation services has been designed and implemented in addition to common hospital-based rehabilitation services. Furthermore, community-based rehabilitation services are available. These developments show the growing efforts in the field of rehabilitation services. However, more detailed data about needs and unmet needs are missing.
REFERENCES 1. Instituto Nacional de Estadı´stica y Geografı´a: Principales Resultados del Censo de Poblacio´n y Vivienda 2010. 2011 2. Madans JH, Loeb ME, Altman BM: Measuring disability and monitoring the UN Convention on the Rights of Persons with Disabilities: The work of the Washington Group on Disability Statistics. BMC Public Health 2011;11(suppl 4):S4 3. Instituto Mexicano del Seguro Social: Libro Blanco 2006Y2012. Mexico City, Mexico: Instituto Mexicano del Seguro Social, 2013
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 1, (Suppl) January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
