COMMUNITY MENTAL HEALTH CARE IN MEXICO: A LOOK AT THE STATE OF JALISCO, MEXICO

Background: Access to mental health care is a worldwide public health challenge. In Mexico an unacceptably high percentage of the population with mental disorders does not receive the necessary treatment, which is mainly due to the lack of access to mental health care. The community mental health care model was created and has been implemented to improve this situation. In order to properly plan and implement this model a precise situational diagnosis of the mental health care network is required, thus this is a first approach to evaluate the community mental health networks in the state of Jalisco. Methods: Two components from the EvaRedCom–TMS instrument were used including a general description and accessibility of the community mental health care network. A geographic and economic accessibility evaluation was carried out for the different regions of the state ranging from scattered rural to urban communities using information gathered from health institutions, telephone interviews and computer applications. Results: Jalisco’s community mental health network includes a total of 31 centers and 0.64 mental health workers for every 10,000 inhabitants >15 years of age. The mean transportation cost required to access mental health care was 16.25 USD. The time needed to reach the closest mental health center in 7 of the 13 analyzed regions was more than 30 minutes and the mean time required to reach a prolonged stay center was 172.7 minutes with transportation cost of 22.3 USD. Some marginalized regions in the state have a mean 114 minutes required to reach the closest mental health care center and 386 minutes to reach a prolonged stay center. Conclusions: This first approach to evaluate the mental health networks in Mexico showed that there are multiple barriers to access its care including an unfavorable number of human resources, long distances and high costs. The identification of Jalisco’s mental health network deficiencies is the first step towards establishing a properly planned community mental health care model within the country.


Introduction
Access to mental health care is a worldwide public health challenge (1). In Latin America and the Caribbean, it is estimated that the treatment gap -which refers to the percentage of people who suffer from a disease or disorder and those that do not receive the necessary treatment -is very high. In Mexico, 87.4% of people with a mild mental disorder, 77.9% of those with moderate disorders and 76.2% of those with severe mental disorders, such as schizophrenia or bipolar disorder, do not receive treatment (2). The deficiencies in access to mental health care in Mexico are fundamentally due to the lack of services and inequity in the distribution of community and outpatient mental health resources within the country (3).
Most people with mental disorders have to overcome several obstacles to access psychological and/or psychiatric care (4). Some of the main barriers to access mental health care are social stigma and discrimination, comorbidity of mental disorders and non communicable diseases (5) as well as the presence of additional mental disorders (dual pathology) (6).
Other obstacles are the lack of trained personnel in health centers, but also the lack of financial resources for the transportation to the nearest health center (7). Regarding the number of specialized human resources, in Mexico, the rate of psychiatrists is 3.71 and 2.23 psychiatric nurses per 100,000 inhabitants (8), while the recommended rate of psychiatrists is 5.0 per 100,000 inhabitants (9,10). In addition, the distribution of specialized mental health personnel is uneven throughout the country, with a higher concentration in large cities and very few or almost none in rural areas and marginal states of the country (11). Other indicators, such as the travel distances required to access a mental health center or the difficulties in obtaining and maintaining pharmacological treatment, are not registered in our country (12). Regarding the economic barrier, a recent study in South Africa identified that the cost of transfers for the general population to access a psychiatric consultation was 13.3 dollars (USD), without taking into account the cost associated to consultation and prescribed drugs (13).
These barriers in access to health gave rise to the community mental health care model, which has inspired reform processes to ensure mental health care even in the most remote territories, thus improving accessibility to care as a new paradigm (14). The main objective of the community mental health caremodel is to promote social reintegration, strengthening outpatient treatments for people with severe mental disorders -such as schizophreniaand preventing hospitalizations in psychiatric hospitals (15). In Latin America, the process of transition to community mental health carehas been uneven among countries (16). This model includes the development of outpatient clinics, day hospitals, rehabilitation centers and sheltered homes (17) and has proven to be cost effective since it improves the distribution of health resources, has a greater geographical scope to provide specialized pharmacological treatment and allows the inclusion of psychosocial interventions such as individual and family psychoeducation (Tristiana et al., 2018).
For this paradigm to be properly implemented, a precise situational diagnosis is required to allow the development of improved strategies in public mental health, recognizing the obstacles and deficiencies in the quality of care received by patients (17). Therefore, the need for tools to evaluate and establish a situational diagnosis in mental health services becomes essential. In this sense, there are different instruments for the evaluation of community mental health networks, such as the Description and Evaluation of Services and Directories in Europe for Long-Term Care (DESDE-LTC) designed for the description and evaluation of health services for people with disabilities, being currently one of the most complete models (18). A second instrument is the EvaRedCom-TMS, which was created in Chile to make a rapid evaluation of community mental health services in low and mid-income countries (17). Its application is based on data that is easy to collect, such as access to care with distances, times and costs, along with information regarding resources and other specific indicators that are useful for the Assessment Instrument for Mental Health Systems (WHO-AIMS). Due to the fact that the EvaRedCom-TMS instrument is faster to apply and assesses the accessibility (geographic and economic) to existing mental health services (19), we decided to use this instrument to describe the community mental health networks in the state of Jalisco.
To our knowledge, this is the first approach of this kind for the evaluation of community mental health networks in the state of Jalisco and takes relevance by providing information in order to establish public mental health strategies to improve access and mental health services through the adequate allocation of human resources and planning for the location of community mental health centers (15).

Description of the state and its health regions
Mexico is divided into five mesoregions made up of several federative entities. The State of Jalisco is located in the central-western region with a territorial extension of 78,599km² (map 1). It contains the second largest Metropolitan area in the country: the Metropolitan Area of Guadalajara (ZMG, for its acronym in Spanish).
Jalisco is made up of 125 municipalities, which in turn comprise 13 geographic and health regions (map 2). Each health region has a main municipality or city and several municipalities, as shown in table 1.
The state has a population of 8,256,000 inhabitants, of which 6,057,265 are people over 15 years of age. Because the state's mental health system is aimed at the population over 15 years old, this study considers this population as the object of study. not have any CISAME, even in states with a greater geographic extension than Jalisco.

Instrument description
For this study, we have taken two components from the EvaRedCom instrument: • A general description of the community care network including the institutions that make up the network, the human resources of each institution and the number of hours available to provide care.
• The accessibility to the community care network which includes information on geographic accessibility, that is, travel times to mental health services and economic accessibility corresponding to the cost of theround-trip to the mental health care center, expressed in dollars (19.90$, value as of December 2019).

Source of information
The general description of the community care network was obtained through the health centers databases, which depends on the State Health Secretariat. The main health center of each municipality was taken as reference and starting point for the analysis of geographic and economic accessibility.
Through direct contact with health institutions, information was requested regarding the number of human resources in mental health (a rate was calculated per 10,000 inhabitants with >15 years of age) and the hours available for clinical care per week (7.5 hours per day and 37.5 hours per week for each professional).

Geographic and economic accessibility evaluation
The geographic and economic accessibility evaluation was carried out under three methodologies: A (from region one to nine), B (region 10 and 13) and C (region 11 and 12), which are explained below: Geographic accessibility: this section refers to the time it takes a user to get to the nearest mental health service center, or one with a higher level of care, from anywhere in the state, both by public transport (bus) and private transport (car). The information was collected through telephone interviews, data provided by health institutions and computer tools such as Google Maps, Waze and Rome2rio. The route from one point to another (from a health center to a mental health service) was introduced between 8 and 13hrs, obtaining an arithmetic mean of the three computer tools, the result is expressed in minutes.  Regarding time in minutes and costs in dollars that are required to travel, whether by public or private transport, from the head of municipality to the nearest mental health institution and to the CAISAME-EB hospital and the CAISAME-EP hospital, the following weighted means were obtained (Table 3, Map 3 and Map 4).  USD, with prices going as low as 2.5 USD and as high as 9.5 USD.
Regarding access to a psychiatric hospital (CAISAME-EP), when hospitalization is needed, It is important to highlight that obtaining the information provided here was a challenge. The search for the appropriate methodology due to the demographic, geographical and cultural differences of the various municipalities of the state, and limited cooperation coupled with long bureaucratic processes for obtaining information made this a monumental task. The limited previous research carried out in the region, the deficiency in the statistical records, and the segmentation of the Mexican health system were also important barriers to overcome while carrying out the study.
As previously noted, EvaRedCom is an instrument designed to have a rapid evaluation of community mental health services, which is why the main limitation of this work is the precision of the estimates, especially those of geographic accessibility. For the calculation of the route a person takes to reach specialized mental health services, the main health center in each municipality was used as a starting point. Therefore, there is an underestimation for all the rural and more remote areas, in which people must make previous trips to get to these centers, generating longer times and additional transportation costs. However, previous studies (17) have found that this approximation reflects good variability and that the most remote areas (with greater problems of geographic and economic accessibility) exemplify the contrast with urban areas, thus, fulfilling the function to provide needed information to make good, informed decisions regarding community service allocation.

Conclusions
The results obtained show that, despite the fact that Jalisco is one of the states with the largest mental health infrastructure in Mexico, there are still multiple barriers to access its care, identified by the unfavorable number of human resources, distances and costs. This first approach to the evaluation of mental health networks in Mexico allows us to recognize the current situation and consider the factors that must be taken into account for the extension of the community mental health care model in the country, through evidence-based management that allows improving the access to mental health services through proper allocation of human resources and planning for the location of community mental health centers.