Ventanillas de Salud GOVERNING DOCUMENT Information, Counseling and Referrals to Health Services in the United States for Mexicans and their Families
Salomón Chertorivski Woldenberg Secretary of Health in Mexico Pablo Kuri Morales Deputy Secretary of Health Prevention and Promotion Germán Fajardo Dolci Deputy Secretary of Integration and Development of the Health Sector Miguel Limón García Head of the Coordinating Unit of Social Correlation and Participation Hilda Dávila Chávez Director General of International Relations Jorge Humberto Hernández Luna Advisor to the Secretary of Health Eduardo Jaramillo Navarrate Advisor to the Secretary of Health Gudelia Rangel Gómez Coordinator of Integral Strategy for Health of the Immigrant First edition: October 2012 Copyright Secretariat of Health Lieja Nº 7, colonia Juárez, delegación Cuauhtémoc, C. P. 06600, México, D. F. IMPRESO EN MÉXICO / PRINTED IN MEXICO
Ventanillas de Salud GOVERNING DOCUMENT Information, Counseling and Referrals to Health Services in the United States for Mexicans and their Families
Index FOREWORD... 9 BACKGROUND... 13 Organization of the Programa de Acción Específico 2007-2012. Salud del Migrante... 15 Mission... 15 Vision... 15 General Purpose... 16 Specific Objectives... 16 Ventanillas de Salud... 17 Description of the Ventanillas de Salud program... 18 Mission... 21 Vision... 21 Essential Functions... 21 Health Information...23 Impact of the Ventanillas de Salud Program...24 INITIATIVES FOR STRENGTHENING THE PROGRAM... 33 Second Generation of Ventanillas de Salud Project...33 Call Center in Collaboration with National Alliance for Hispanic Health (NAHH), United States...36 Seguro Popular for Families of Mexican Immigrants... 37 Advertising Strategies...38 Mobile Ventanillas de Salud...40 Community Clinics...42 Establishment of the Advisory Board of the Ventanillas de Salud Federal Program... 47 Binational Health Week...49 Research Program on Migration and Health (Pimsa by its Spanish accronym)... 52 CHALLENGES AND OPPORTUNITIES OF THE PROGRAM... 53 VENTANILLAS DE SALUD PROGRAM LEGACY... 55 BIBLIOGRAPHY... 57
Foreword If there is one area in which the enormous complexity of globalization and interdependence is manifested, it is in the health field. The emergence of pandemics, combined with the growing phenomenon of migration, has made health a topic that requires inter-sector and global answers. Within the new global architecture, which has a wide variety of governmental and non-governmental organizations, it is necessary to strengthen the capacity for innovation with new patterns of international cooperation in public health that meet the challenges of the global agenda. Migration and health are a critical dimension of the referred process in which the Mexican government has taken significant actions through innovative public policies in order to improve the living conditions of Mexicans abroad. We have worked in a coordinated manner with the Secretariat of Foreign Relations and the Mexican Embassy in the United States of America in building a strong network of 50 Ventanillas de Salud (health modules), one in each Consulate, which supports health promotion, prevention and care of the Mexican immigrant community in the United States. The Ventanillas de Salud program represents an innovative collaboration design which is co-financed with resources of the Mexican Federal Government, involving the Consulates in the United States and local health service providers and community clinics that are focused on immigrant assistance. Around the Ventanillas de Salud network operates a set of more than 500 public and private U.S. agencies, which through local partnerships perform actions to improve the health of Mexicans residing in the United States of America. The program has become the main promoter of health prevention and promotion in the United States, in order to guarantee the constitutional right to health for all Mexicans, regardless of the country where they live. The Ventanillas de Salud are located within all the Mexican Consulates, which are visited daily by thousands of people, many of them lacking 9
Foreword social security (including health services) due to their immigration status and the work activities that most of them perform (construction, agriculture and manufacturing), which are statistically among the most hazardous to health. During periods of formalities at the Consulates, the Ventanillas de Salud offer Mexican families services such as tests to measure blood pressure and glucose, analysis of HIV / AIDS, screening for breast cancer, provision of certain vaccines, or if necessary, the referral to Community Health Centers in the United States, regardless the immigration status of the recipients. The information and assistance provided through the Ventanillas de Salud are focused on the higher incidence diseases of the Mexican population in the United States, which are non-communicable diseases caused by risk factors such as obesity, which is present among our fellow citizens due mainly to severe metabolic changes produced by changes in diet and lifestyle. For critical cases, the program provides referral, according to their condition, to federal health centers in Mexico City or hospitals within Mexico in order to provide the required medical care as quickly as possible. Likewise, the Ventanillas de Salud have implemented prevention programs and psychological counseling to strengthen protection factors against the use of drugs among school age young people in populations with high migration rate as in destination cities in the USA. Furthermore, the Ventanillas de Salud include an electronic platform to provide immigrants the possibility of pre-affiliation to the Seguro Popular (Public Health Insurance) from wherever they are, as well as to seek that family members who remain in Mexico may receive health services in their place of origin. Thanks to these services, an in situ empowerment of Mexican communities in the United States is being achieved, where local priorities are defined in each city, responding flexibly to their specific needs. The main purpose is to broaden the knowledge of preventive health that Mexican families have on both sides of the border and to promote its timely and effective use. The broad participation of agencies has consolidated a strong network of preventive health for our communities abroad, which has allowed a growing assistance coverage, which has been enriched with mobile Ventanillas de Salud, allowing to bring health services closer to agricultural workers in distant places. The Ventanillas de Salud are evidence of shared responsibility that the Mexican Government undertakes to seek the welfare of immigrants in 10
Information, Counseling and Referrals to Health Services in the United States for Mexicans and their Families the United States. Much remains to be done. Mexico and the United States need to follow up and work further with the innovative and effective programs that have been implemented, such as the Ventanillas de Salud; and mainly they need to join bilateral efforts to continue guaranteeing the right to health for their population. The establishment of a pilot program of second generation: Ventanillas Second Generation, aims in this direction. This program, among other innovative actions, seeks the participation of Mexican entity governments where migration originates. This publication tells the story of the Ventanillas de Salud. It also raises the challenge ahead for the institutionalization of this assistance model with imagination and commitment, with the purpose of helping to raise the quality of life of our fellow citizens living abroad, extending the generous arms of the Mexican government and its associates in the United States of America. It considers the positive externalities of our actions for the society of that country as a whole. Salomón Chertorivski Woldenberg Secretary of Health 11
Background The constant flow of Mexicans to the United States and the growing volume of illegal immigrants highlight the vulnerability to which they are exposed in the neighboring country. Extreme weather conditions and public safety can become potential hazards affecting the health situation of immigrants. Sometimes, the journey without legal documents to the north of the continent could become a permanent risk, more than an opportunity, due to the conditions to which immigrants are exposed to all the way from their departure point of origin to their destination in the United States. Such conditions may affect their health, which is a priority for the full development of the physical, social and cultural potential of the immigrant and his family, risking specific factors identifiable to public health. According to the population census of the United States for 2008, the Mexican-origin population had the highest percentage (34.6%) of uninsured people living in the U.S. (U.S. Census Bureau, 2008). It stands out that almost half (48.3%) of the people of Mexican origin and 61% of those born in Mexico in the most productive age group (18 to 64 years old) reported that they had no health insurance. Insurance and service access is limited even among the group of children under 18. For example, in the health needs survey conducted at the Mexican Consulate General in Los Angeles, in 2004 (Secretariat of Foreign Relations, 2004), it stands out that 49% Mexican children born in the United States had no health insurance, even when the State of California had a free insurance coverage program for low-income children between 0-18 years. This figure clearly reflects the underutilization of health services among these families. The target population of this program is formed by those Mexicans living in the United States and their families. In 2010, there were about 31.8 million people of Mexican origin in the United States. The potential scope of the Ventanillas is very significant, since the consular network serves an average of 1 500 000 people annually through its 50 Ventanillas de Salud and through two Ventanillas de Salud in the United States. 13
Background Overall, the Secretariat of Health proposed the Programa de Acción Específico 2007-2012. Salud del Migrante (Secretariat of Health, 2008), which seeks to promote the health of Mexicans in the United States of America. To implement this program, the following institutional framework, related to legal fundamentals, was considered. In its general sense, it is based in Article 4 of the Constitución Política de los Estados Unidos Mexicanos (Honorable Union Congress, 2012), which states that every person has the right to health protection. Likewise, specifically, Articles 3 and 13 of the Ley General de Salud (Honorable Union Congress, 2010), highlight the obligations of the Secretariat of Health for maintaining the health of Mexicans. In particular, the Reglamento interior de la Secretaría de Salud (Federal Executive, 2011) was considered, including the competencies, objectives and actions for the International Relations Department of the Secretariat and its functions in the work to improve the health of fellow citizens abroad. Another important link that the Programa de Acción Específico 2007-2012. Salud del Migrante (Secretariat of Health, 2008) has, is the Plan Nacional de Desarrollo 2007-2012 (Mexican United States Government, 2007), which establishes national objectives, strategies and priorities that should govern the actions of the current government. Thus, this program is aimed to promote the means to achieve the protection and attainment of immigrants health, for both, those who arrive in Mexico, and national immigrants in the North American region. In consequence, we will have a favorable environment for prevention and health care that allows individual and social development, as well as seizing of opportunities for the benefit of immigrants and their families. Lastly, the Programa Sectorial de Salud 2007-2012 (Prosesa, Spanish acronym) was considered within this international framework. Such program aims to address health needs of Mexican immigrants, primarily in North America and those who enter the country. Its strategy 4.9 points out the implementation of a program for immigrant s health, through which international cooperation regarding health may be seized to help achieve the objectives of the sector. The following are specific actions proposed by Prosesa: Strengthen collaboration and cooperation with the Border Health Commissions Mexico-United States and Mexico-Guatemala on issues of epidemiological surveillance and control. 14
Information, Counseling and Referrals to Health Services in the United States for Mexicans and their Families Strengthen multilateral and bilateral ties to offer and receive international cooperation to fulfill the objectives of Programa Sectorial de Salud 2007-2012. Consolidate the organization and development of the Binational Health Weeks, which have broadened the access of immigrant population to health services in the United States. Promote the affiliation of migrant families to the Seguro Popular through the Ventanillas de Salud within the consulates throughout the United States. Improve the health care that is provided to ill fellow citizens who need to be repatriated. Strengthen Mexico s active participation in major international health organizations, including the World Health Organization (WHO) and the Pan American Health Organization (PAHO). Through these actions, the Migrant Health Program becomes a key element in achieving the goals and complying with the Programa Sectorial de Salud 2007-2012. Organization of the Programa de Acción Específico 2007-2012. Salud del Migrante Mission To protect the health of immigrants and their families in their destination places through the establishment of specific binational collaboration strategies to promote health care in a culturally sensitive manner. Vision Mexican immigrants and their families have timely information on health promotion and disease prevention, and in their communities they have access to quality health services to achieve the full development of their physical, mental and social potential. 15
Background General Purpose To guarantee access to health services and protect the health of immigrants through binational actions in their places of origin, transit and destination. Specific Objectives Coordinate, support and monitor the various health related programs of the federal public administration that are carried out to benefit the Mexican immigrant population. Promote communication strategies and information regarding education and health promotion aimed at the Mexican immigrant population with cultural sensitivity. Promote and strengthen the binational relationship among health care providers in order to increase accessibility to health care of immigrants. Encourage and facilitate the management of binational agreements with governmental and nongovernmental organizations and academic institutions, which have the purpose to promote health and improve the access to and quality of health services aimed at the Mexican immigrant population. Provide medical care and hospital services to ill fellow citizens on both sides of the border. Foster the research related to the health of immigrants. This program includes ten strategies, each with specific lines of action and the following subprograms: 1. Ventanillas de Salud (VDS). 2. Binational Health Week (SBS). 3. Repatriation of seriously ill fellow citizens. 4. Research Program on Migration and Health (Pimsa, Spanish acronym). 5. Modules for the prevention and health promotion of immigrants in border cities. 6. Seasonal Agricultural Workers Program Mexico-Canada (PTAT). 7. Mexico-United States Border Health Commission (CSFMEU). 16
Information, Counseling and Referrals to Health Services in the United States for Mexicans and their Families Legal Bases Constitución Política de los Estados Unidos Mexicanos (art. 4º) Ley General de Salud (arts. 3 y 13) Reglamento Interior de la Secretaría de Salud Plan Nacional de Desarrollo 2007 2012 Programa Sectorial de Salud 2007 2012 (Prosesa). Strategy 4.9 Programa de Acción Específico 2007 2012. Salud del Migrante Ventanillas de Salud Strategy 7: "Promote and consolidate Ventanillas de Salud for immigrant population" FIGURE 1. Institutional framework for the approach of Ventanillas de Salud Ventanillas de Salud The Ventanillas de Salud materialize strategy 7 of the Programa de Acción Específico 2007-2012. Salud del Migrante (Secretariat of Health, 2008), which seeks to promote and strengthen the health care of the immigrant population. It is also a contribution from the Mexican government to provide prevention services to their fellow citizens in the U.S. The establishment of the Ventanillas de Salud seeks to supply health information and education to Mexican immigrants in the United States, with the purpose of providing and improving access to health services that are available for this population and harmonize the information that both health systems the Mexican and the American have on a same patient. Regarding this strategy, and within the lines of action that are considered in the Programa de Acción Específico 2007-2012. Salud del Migrante (Secretariat of Health, 2008), the following are highlighted: 17
Background 1. Strengthen the strategic program Ventanillas de Salud in coordination with the Institute of Mexicans Abroad of the Secretariat of Foreign Relations. 2. Increase financial resources in order to implement this project in all U.S. Consulates. 3. Monitor and evaluate the proper functioning of Consulates services. 4. Manage and promote the Ventanillas de Salud (VDS) model in all U.S. Consulates. 5. Opening of 25 Ventanillas de Salud in U.S. Consulates. Description of the Ventanillas de Salud program Since 2000, the Mexican government began a series of actions to improve the living conditions of Mexicans abroad. Three years later, through its consular representative in San Diego, California, and as a goodwill initiative, the Ventanillas de Salud program is tested as a center to provide information on health issues. 1 Inauguration of the first Ventanilla de Salud, San Diego, California, 2003. Having the support of the Mexico-United States Border Health Commission (CSFMEU) 2 and the Mexico- United States Health Initiative (currently known as the Health Initiative of the Americas), the University of California and The California Endowment, 3 a subsidy for a pilot phase in the mentioned Consulate was approved. 1 The term Ventanilla de Salud comes from the initial proposal to act as a channel of communication among the immigrant, the health promoter and the Consulate to provide guidance and information on health issues. 2 The Mexico-United States Border Health Commission is a binational agency of the Secretariat of Health committed to improve health on the border, being a meeting point between Health State Officials and personalities from the community and their federal counterparts to share information and create agreements regarding specific public health issues with the United States. The CSFMEU has six regional offices along the Mexico-United States border (http://www.saludfronteriza. org.mx/). 3 The California Endowment is an institution based in Los Angeles that seeks to broaden the access to quality health care for individuals and communities, to promote fundamental improvements in the health status of all Californians. 18
Information, Counseling and Referrals to Health Services in the United States for Mexicans and their Families The County of San Diego supports the program by providing basic health education and conducting health prevention and promotion activities for Mexican immigrants in order to provide them with timely information regarding health, and access to basic quality services to Measuring blood pressure to a user of Ventanillas de Salud. achieve the full development of their physical, mental and social potential (Secretariat of Health, 2008). Ventanillas de Salud is a Mexican government program developed Immunizations services at Ventanillas de Salud. by the Secretariat of Health and the Secretariat of Foreign Relations and implemented by the 50 Mexican Consulates in the United States and local health organizations. It provides reliable information regarding health prevention, counseling and referrals to health services that are available and accessible in the community. It was also designed to improve physical and mental health of Mexicans who live in the United States and to improve their access to primary and preventive health services and health insurance coverage, and guarantee culturally sensitive services to decrease the use of emergency services. After a two-year development, two evaluation studies and an adaptation process of the pilot phase, the Mexican government initiated the expansion of this model to other Consulates. In 2004, the Mexican government provided seed money to keep and open modules in other Mexican Consulates in the United States. Each year, the Mexican government provides the program with about two million dollars in cash contributions and approximately one million dollars of in-kind contributions. This resource is in turn matched at different levels by local organizations, foundations and sponsors of each Ventanilla de Salud. The Ventanillas de Salud program has had an extraordinary acceptance and growth since its pilot phase began in the Mexican Consulates in San 19
Background Inauguration of Ventanilla de Salud number 50, San Bernardino, California, 2011. Diego and Los Angeles. Currently, 50 Ventanillas de Salud have been officially opened and are operating. This service is available throughout the whole Mexican consular network in the United States. This coverage, in addition to the culturally sensitive nature, the confidence environment that Mexican Consulates inspire to fellow citizens, and the link among several organizations and two countries, make this program an excellent vehicle for the promotion, health prevention and disease control SOURCE: http://ventanillas.org/index.php/es/. FIGURE 2. Geographic location of the Ventanillas de Salud throughout the U.S. 20
Information, Counseling and Referrals to Health Services in the United States for Mexicans and their Families in a binational level, including Mexico and the United States. The location of the Ventanillas de Salud throughout the country is shown in figure 2. Mission Improve access to primary and preventive health services, increase public insurance coverage, and promote a preventive health culture of Mexicans living in the United States and their families through information, education, counseling and quality referrals, in a safe and friendly environment, by creating local and binational collaborations between the U.S. and Mexico. Vision Improve the physical and mental health of Mexicans living in the United States by increasing access to primary and preventive services, public insurance coverage, the supply and quality of culturally sensitive services, reducing the use of emergency services and establishing the ventanillas network as a reliable and sustainable home-based program that provides information, education and referral on health issues. Essential Functions Issue health prevention and promotion programs. Promote access of migrants to Community Health Centers in the United States through a network of 6 500 medical units. Dissemination and pre-affiliation to Seguro Popular for migrants and their families. Provide Mexicans in the United States the ability to affiliate their family members and themselves to Seguro Popular, from their place of residence, in order to receive health services in national territory. Health services diffusion session in the United States. 21
Background Reduce drug consumption among school age young people both in populations with high migration rates as well as in destination cities in the United States, reinforcing protection issues to prevent the use of drugs, considering the cultural aspects common in Mexican families. Issue information about the services offered by Community Health Centers. Promoting access to healt services through community centers in the United States, Los Angeles, California, 2011. Take action in specific areas, including issues related to migration and health, as well as in areas of research and academic exchange. Give follow-up to patients with serious health problems until they recover. Establish a preventive program in elementary and secondary level schools, targeting potential immigrants. Implement an early psychological intervention program in existing care centers in border crossing cities. Implement a preventive and psychological counseling program in order to strengthen protective factors associated with the use of drugs. The content of this program are sensitive to Mexican culture and families through networks, associations and clubs of Mexicans in the United States. Young Volunteers Program for the creation of a healthy Latino community. Mobile Ventanilla de Salud, Kansas City, 2012. Direct seriously ill patients, according to their disease, to federal health centers in Mexico City or state hospitals in order to provide them with the required medical care as quickly as possible. 22
Information, Counseling and Referrals to Health Services in the United States for Mexicans and their Families Health Information Priority issues on which information is delivered to the fellow citizens, are closely related to the disease profile of those who move to the north of the continent. These are: Substance abuse (alcohol / drug addiction). Arthritis / rheumatism. Asthma / allergies. Cancer Prenatal care. Diabetes. Heart disease. Sexually transmitted diseases (HIV / AIDS, other). High blood pressure. Influenza. Nutrition and physical activity Obesity / metabolic syndrome / cholesterol Family planning Back and neck problems Women s health. Dental health Mental health (depression / anxiety / stress). Occupational health (prevention of work accidents). Smoking. Tuberculosis. Ulcer / gastritis. Domestic violence. Visual health. Promoting and doing an HIV screening. Promoting healthy habits for chronic diseases prevention. Meeting for the presentation of services offered by Ventanillas de Salud and challenges that they face. Denver, Colorado, 2012. 23
Background Impact of the Ventanillas de Salud Program The following data is intended to highlight the impact that the Ventanillas de Salud program has had among compatriots living in the U.S. The source of information used in this section corresponds to that contained in the Indicators Report of the Ventanillas de Salud Program, which presents average data of 40 Ventanillas de Salud modules between July 2011 and September 2012. The total population covered in the reference period was 903 919 persons. Its should be mentioned that the population covered by each of the available Ventanillas de Salud is different according to the size of population and the consulate. According to a diagnosis made between 2010 and 2011 by Consultant Knowledge is Power, 40.4% of the VDS attended on average more than 200 people a week. 19% of the VDS attended weekly between 50 and 100 users, and another 19% between 100 and 150 people. Only three VDS serve on average 150 to 200 people. The total number of 3 108 379 services was distributed as follows: - 68% focused on guidance and counseling on specific topics on health issues that are priorities for the Latino population living in the U.S., such as diabetes mellitus, obesity, high blood pressure, some determinants of risk for chronic diseases such as eating habits, sedentary lifestyle, HIV / AIDS and sexually transmitted infections, mental health, addictions, women s health, access to health services: references, health insurance, etc. (see graphic 1). - Likewise, 16%, helped for an early detection of diseases such as diabetes mellitus, obesity, high blood pressure, cholesterol, HIV / AIDS and sexually transmitted infections (see graphic 1). - Of those treated, 9% were referred to health services in the United States (see graphic 1). - Another 6% were treated in mobile consulates where they received guidance, detection or reference to some kind of health service (see graphic 1). 24
Information, Counseling and Referrals to Health Services in the United States for Mexicans and their Families - The remaining 1% received other services such as vaccines or affiliation to some health insurance in the United States (see graphic 1). GRAPHIC 1. Number of Users Treated in Ventanillas de Salud by type of Service Received 2,300,000 2,200,000 2,100,000 2,103,101 2,000,000 1,900,000 1,800,000 1,700,000 1,600,000 1,500,000 Population served 1,400,000 1,300,000 1,200,000 1,100,000 1,000,000 900,000 903,919 Population served Total counseling sessions / departments Total detections 800,000 700,000 Total vaccines applied 600,000 500,000 488,484 Total referrals for health services in the U.S. 400,000 300,000 200,000 100,000 0 25,542 287,484 12,697 191,071 Total people enrolled in health insurance in the U.S. Total mobile or outpatient services SOURCE: Indicators Report of the Ventanillas de Salud Program. Period from July, 2011 to September, 2012. Number of Ventanillas per period: 35 July-August 2011, 39 October to December 2011, 48 January-March 2012, 50 April-June 2012 and 52 July-September 2012. TABLE 1. Prevalence of the leading causes of morbidity in the migrant population treated at the Health Windows Program. July 2011 and September 2012 Test Type Measurements Performed Positive tests High levels Prevalence (percentage) Measurement of glucose in blood 64 435 9 736 15 Obesity and overweight 41 967 15 312 36 Arterial hypertension 84 171 17 043 20 Cholesterol 15 078 3 667 24 Heart diseases 19 584 4 286 22 HIV / AIDS 8 522 95 1.1 STI 2 443 49 2 Tuberculosis 282 9 3 25