Between 2001 and 2006, a national set of quality indicators known as INDICAS (Sistema Nacional de Indicadores de Calidad en Salud) were developed by the Mexican government. The government has implemented many initiatives on the use of quality indicators and their role in performance monitoring.  A key aim of the governments initiatives is to support the use of INDICAS within institutions in Mexico responsible for the provision of health care.

The General Directorate of Quality and Health Education (Dirección General de Calidad y Educación en Salud – DGCES) began a project on the “Evaluation, Design and Implementation of the National System for Quality Care Monitoring”. The project had support from the Inter-American Development Bank. After invitation, NICE International successfully submitted a proposal to provide technical support on the project.

The NICE International work programme aims to support the DGCES in strengthening the existing monitoring system. The programme focuses on the development of a sustainable and robust methodology for indicator development. It builds on the existing strengths of key stakeholder organisations in this area.

 NICE International release report from situational analysis in Mexico

March 2016

NICE International and Prof. Stephen Campbell (University of Manchester) released a Situational Analysis report summarising lessons and recommendations from the early part of the IADB-funded Quality Indicators project. The report details current obstacles in the Mexican health system which have hindered the development of a sustainable and robust methodology for using indicators. Some challenges relate to the Mexican health system being fragmented across separate public insurers, which have provided healthcare, defined quality, and managed health facilities in parallel to one another. Private healthcare providers are also predominant and effectively work independently. However, even when the main institutions in the health system work together and submit data at a national level, these activities are largely not coordinated. For example, while epidemiological data, clinical guidelines, data systems and indicators all exist, there is no coherent system for integrating these.

Read the situational analysis report

Interviews and discussions emphasised that despite excellent capacity and data which can potentially be used for quality improvement, this is hindered by the particular fragmentation of the Mexican healthcare system. There are key elements missing or a lack of integration at present that prevent coherent quality improvement in health care and lead to duplication and waste of resources and data. It is not known how far indicator sets developed by different public institutions overlap, making comparison across different sub-systems impossible in most cases. There is also no national system for using quality indicators to track quality of care and give feedback to providers, particularly due to the lack of electronic health records and unique patient data. For these reasons, many of the recommendations in this report focus on improving coordination between the main institutions.

The report details a set of phased recommendations to the Ministry of Health/Government of Mexico over the next five years, which were discussed in an earlier form with stakeholders in December 2015. The immediate, medium- and long-term recommendations cover five mutually reinforcing areas:

• political will and policy
• prioritisation of topics for indicator development
• commitments and investment to introduce a unique patient identifier
• communication and monitoring of a core national indicator set
• data collection and analysis on core indicator set

This report was agreed by Mexico’s Ministry of Health to be a publicly available resource. It was submitted by NICE International in January 2016, and was finalised and disseminated following a consultation period with the main institutions NICE met during previous visits.

NICE International visit Mexico with academic partner for Quality Indicator project

November 2015

At the end of November 2015, NICE International team members visited Mexico City with Professor Stephen Campbell (University of Manchester), the academic partner on the IDB-funded Quality Indicator project. The purpose of the trip was to present key recommendations from a draft situational analysis report and to discuss the capabilities and institutional arrangements for using quality indicators, following on from the initial visit in September 2015. The final report recommendations will tie into the Total Quality Model (Modelo de Gestión de Calidad) developed by the Ministry of Health.

Prof. Campbell, Francis Ruiz and Laura Morris attended meetings with the DGCES (the department of Mexico’s Ministry of Health leading on the quality project) and representatives from the following Mexican agencies:

• Instituto Mexicano del Seguro Social (IMSS)
• Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE)
• Comision Nacional de Proteccion Social en Salud (CNPSS/Seguro Popular)
• Centro Nacional de Excelencia Tecnologica en Salud (CENETEC)
• Consejo General de Salud (CGS) (inter-agency body)
• Comité Nacional por la Calidad en Salud (inter-agency body)

Key themes identified during the discussions included the need for organisational coordination, the need for Unique Patient Identifiers (and previous unsuccessful attempts to introduce these in Mexico) and the need for the processes for indicator development to include a nationally relevant prioritisation method.

During the visit, the team also attended a meeting of the inter-agency National Committee for Health Care Quality and delivered an interactive workshop for policy-makers and technicians about the development and use of quality indicators. This workshop focussed on core principles of quality measurement and the development, testing and implementation of indicators, with reference to international literature and case studies. Examples of successful and relevant indicator schemes included the UK Quality and Outcomes Framework (QOF) and the Thai QOF.

NICE International sees DGCES as a key coordinating body in the development and dissemination of a core set of national indicators that can be used across organisations in Mexico, most of whom are currently developing and using quality indicators separately to one another. The General Directorate of Health Information (DGIS) is also a key Ministry partner gathering and using health and healthcare performance data to inform these indicators, along with CENETEC, CGS and other agencies.

In 2016, NICE International and Prof. Campbell will lead on a unified Methods and Process Manual for indicator development in Mexico. The early phase of this project will continue until summer 2016 and NICE International expects to participate again in the Mexican Quality Forum.

Mexican quality forum

October 2015

The Director of NICE International visited Mexico City at the invitation of the Ministry of Health (MOH) for the annual Quality Forum held over 3 days and attended by just under 3,000 people from across Mexico as well as numerous countries in South America, the USA and Europe and representatives of WHO, PAHO and OECD.

Kalipso Chalkidou gave a plenary on quality standards and their application across the English NHS with a focus on diabetes management. At the fringes of the meeting, Kalipso held meetings with NICE International’s partners at the MOH, the Quality and Education Directorate, to discuss progress with the IADB-funded quality improvement work and also with CENETEC to explore potential opportunities for partnering up in sharing experiences with technology assessment. The discussions were chaired by the undersecretary, Dr Eduardo González Pier and attended by Dr Sebastián García Saisó, as well as Healthcare UK representation, amongst others.

It was agreed that NICE International will continue to work with the Mexican MOH especially under the bilateral UK/Mexico MOU which identifies HTA and quality as key priority areas. We look forward to welcoming the Mexican Minister and her team to London in March 2016.

 NICE International begins a situational analysis as part of Mexico Quality Indicator project

September 2015

NICE International and Prof. Stephen Campbell (University of Manchester) travelled to Mexico to review the current capabilities for developing and implementing quality indicators.

They held talks with representatives from the following key Mexican stakeholders:

• Instituto Mexicano del Seguro Social (IMSS)
• Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE)
• Seguro Popular
• Directorate General of Information
• and DGCES.

The talks highlighted key points to ensure the sustainability and local ownership of effective quality indicators including:

• The need for more collaboration among public sector stakeholders to encourage data sharing.
• The development of evidence-informed guidance to support the creation of indicators.

The Rashtriya Swasthya Bima Yojana (RSBY) is the Government of India health insurance scheme for families below the poverty line (BPL), with over 37 million families currently enrolled. RSBY covers a range of inpatient services and surgical procedures, provided by a network of private and public hospitals and reimbursed on a fee-for-service basis with defined benefits packages (bundle of services) for each procedure or intervention. However, these packages are not determined through a scientific process Healthcare providers and insurers currently lack clear guidance on the most appropriate treatment options for the clinical management of the conditions covered by the scheme. This lack of direction often leads to disagreement about payment and sub-optimal care for patients.

With technical assistance from NICE International (iDSI), RSBY has established a quality programme to provide authoritative and evidence-based clinical guidance for its network hospitals. This is the first time such guidance has been introduced at a national (Central) level in India. The new guidance will serve as a benchmark for regulating the quality of healthcare services received by patients and informing claims reimbursement with potential impact on the millions of citizens covered by RSBY.

Initially seven procedures under the RSBY scheme were selected on the basis of their high volume, high cost, or potential for fraud. For example, hysterectomy was identified as the second most frequent claim, contributing to 3.7% of all RSBY procedures and 10% of its budget. The other six selected procedures related to:

• chronic kidney disease and end-stage renal disease
• uncomplicated gallstone disease
• hernia
• hydrocele
• appendicitis
• pterygium

RSBY established a committee, chaired by the Director General Labor Welfare, to oversee four Expert Groups in gynaecology, nephrology, surgery, and ophthalmology. Each group consists of:

• public and private providers
• specialist and district level clinicians
• public health personnel
• representation from professional bodies
• insurance companies, the World Bank
• RSBY
• NICE International’s India technical adviser.

Each Expert Group is tasked with developing evidence-informed clinical pathways and related tools (including quality standards and audit tools, insurance pre-authorisation checklists, and patient information sheets) for the relevant procedures. NICE International (iDSI) has provided advice on the governance and process of the RSBY quality programme, as well technical assistance throughout the development of the guidance documents. In addition, NICE International facilitated an independent external review of the guidance by UK experts.

This work is expected to set a precedent for the development of authoritative clinical pathways on other healthcare topics, showcasing how the Indian government as a major purchaser and provider of service can leverage improvement in quality of healthcare.