Background

In the post-revolutionary years of the 1920s, the demographic profile of Mexico was characterised by high birth rates with concomitant high death rates. However, from 1950s to 1960s onwards, a dramatic decline in child and maternal mortality rates occurred without any significant change in fertility rate. This lead to an astonishingly high population growth rate of 3.4 percent then. This demographic pattern was supported by pro-natalist population laws, and also the prohibition of use and promotion of fertility regulating agents by the sanitary code. The profound impact of the demographic explosion upon the economy and development of the country and the recognition of gender legal equality were the basis upon which the Federal Government formulated a new population policy as part of a national strategy.

In 1974, the Political Constitution of Mexico was amended, and family planning (FP) was considered a basic human right for all Mexicans. This initiative, a true milestone in the Mexican population history, set the stage for issuing a new population law. Accordingly, the Mexican government officially launched the new population programme with strong political and concrete commitments. The main objective of the population programme was to reduce the population growth rate through the decrease of total fertility rates (TFR) with a parallel effort to decrease child and maternal mortality rates.

It must be stressed that before the implementation of the new population programme, a number of activities had been undertaken by bio-medical and social research centres as well as by non-governmental organisations. Mexico was the birthplace of the birth control pill; indeed, in October 1951, the first non-natural steroid molecule with progestational and contraceptive effects (noretistherone) was synthesized in Mexico City. Relevant contributions of Mexican scientists those days lead to a number of new developments in contraceptive research. NGOs were pioneers in providing FP services throughout the country.

In 1977, a National Coordination for the Family Planning Programme was established and since then the Federal Government took over the responsibility of providing, free of charge, FP services in the public sector. In the subsequent 20 years (1974-1994) the prevalence of modern contraceptive use among women in reproductive age significantly increased. In the 1970s only 30 percent of Mexican couples were using a contraceptive method, and by the end of 1994 the contraceptive use was well above 64 percent. As a result of effective actions of the programme, particularly related with information and service delivery, the TFR declined from 6 children per woman in the 1970s to 3 in 1994. In addition to its demographic impact, the FP programme had a profound beneficial effect on the total health status of the population. There was a significant fall in the infant mortality rate, which was 52 per 1,000 registered newborns (r.n.) in 1976, while in 1994 this rate was reduced to 17 per 1,000 r.n. Maternal mortality also showed a considerable decline during this period. In 1976, there was 110.0 maternal deaths per 100,000 r.n., whereas in 1994 the maternal mortality rate was 48.5 per 100,000 r.n.

The Mexican Family Planning Programme in its first 20 years

• Improved of the overall health of the people;
• Decreased the population growth rate; and
• Increased the life expectancy of 60.7 years in 1970 to 72.6 in 1994.

The Paradigm Shift:
From Family Planning to Reproductive Health

Immediately after the Cairo ICPD, 1994, the Federal Government of Mexico decided to adopt the holistic vision of reproductive health (RH), moving from the traditional concepts of maternal child health/family planning (MCH/FP) to a more integral and comprehensive RH programme. Early in 1995 the president of the country, Dr. Ernesto Zedillo, introduced this new concept into the National Developmental Plan of the Federal Government for the period 1995-2000, clearly indicating the strong political support to the implementation of the ICPD-Programme of Action (POA). President Zedillo stated that reproductive health, together with nutrition and disease prevention are the health axis for nation development. Thereafter, the Minister of Health, Dr. Juan Ramon de la Fuente implemented the Reform of the Health Sector including the establishment of a National Programme of Reproductive Health as one of the main component of this process. The immediate actions taken to institutionalise the reproductive health programme included the creation of an Inter-institutional Group on Reproductive Health with wide inter-sectoral representation within the Ministry of Health of the Directorate of Reproductive Health, and the elaboration of a comprehensive POA for the period 1995-2000.

The strong political will of the Federal Government of Mexico played a crucial role in the implementation of the programme at the national level, considering the ICPD-POA as a breakthrough in the world history of population and health. The incorporation of innovative issues into the health scenario such as gender perspective, male responsibility, sexual and reproductive rights and sexual and reproductive health for adolescents with priority focus on rural disadvantaged communities and undeserved populations, allowed the elaboration of a working agenda, centred on family health and welfare.

The major health challenge that Mexico faced in 1995 was the large population that had no access to information and health services. It was estimated that nearly 10 million Mexicans residing in remote, marginal, low-density population areas were in this situation. To bridge this inequity, an effective process of decentralisation by operating the public health services and their corresponding budgets at the provincial state and municipality levels was implemented.

To incorporate the Cairo ICPD message into a National Plan of Action, the Mexican Inter-institutional Group on Reproductive Health together with the government and NGOs including public health institutions, and academic institutions took the initiative in 1995 to articulate the National Programme of Reproductive Health and Family Planning. The group had a number of consultations with national and international experts, United Nations agencies and women's advocate groups on this matter. The programme which contain a situational analysis on RH that highlight the national concerns and also a programme of action including relevant strategies to achieve specific goals on implementation and the impact by the year 2000 was published in the National Official Gazette. Three major areas of RH were identified as family planning, peri-natal health and women's health. The gender perspective was included in each programme component.

In addition to the ICPD recommendations, the objectives and goals of the National Programme of Reproductive Health and Family Planning are in line with the recommendations established by the National Developmental Plan, the Reform of the Health Sector, the National Population Programme and the National Woman's Programme. The new programme on reproductive health had high acceptability by both the health care providers and the clients. Nevertheless, there were some criticisms about its implementation from certain sectors, especially from groups with traditional views on demographic targets and concerns, thus the naming of the programme as Reproductive Health and Family Planning. Soon after the programme was implemented, opposition disappeared and the concept of RH permeated into all segments of society.

Creating an Organisational Structure for the National Reproductive Health Programme

The Directorate of Reproductive Health, under the Ministry of Health was set up in December 1994 to implement RH programmes. The former MCH/FP Directorate was integrated into the new system and the Women's health programme which was previously in the preventive medicine section is also placed in this new system. The organisation's initial task was to establish the national and provincial RH groups and building-up collaborative bridges between the public, social and private sectors. Their responsibilities include: defining reproductive health policies including that of family planning; establishing a national comprehensive plan of action; setting standards, norms and technical guidelines for service delivery, training, supervision and evaluation; coordinating mission oriented/operations research; and implementing new strategies into the programme. As a start, advocacy activity to promote the vision and mission of reproductive health was carried out, hence a comprehensive programme of social and educative communication was designed together with a multimedia package of promotional and didactic materials.

The adoption of the RH programme coincided with the decentralisation by the Ministry of Health of health services. The Directorate of Reproductive Health assisted and trained senior health officers at the provincial state level in managerial leadership to enable them to redesign organisational structures to deliver RH services at each given level. Thereafter, all actions addressing RH concerns at the regional and local levels were made after taking into consideration the decentralisation process, underlining that the operation of RH service is the responsibility of provincial health authorities.

Programme Component

The Directorate has five programme components and these are:

• Family Planning - contraceptives, adolescent sexual and RH education and services, STDs and infertility prevention and management and programme strategies development for specific target groups.
• Peri-natal Health - norms, standards and guidelines for ante-natal and peri-natal care, training of health care providers in rural areas, introduction of innovative strategies to promote safe motherhood to reduce maternal and peri-natal mortality and management of induced abortions.
• Women's Health - screening, prevention and control of cervical and breast cancers, menopause services, incorporation of gender perspective and actions against domestic violence into programmes.
• Programme Management - Information management system (MIS) including logistics and programme evaluation at the national level.
• Programme Administration Ð resource mobilisation, budget planning and allocation and human resource management.

Inter-institutional Group in Reproductive Health

The National Inter-institutional Group in Reproductive Health formed by the Federal Government in February 1995 undertook to formulate a national framework for the implementation of RH programmes. The Group that was formed by 12 government agencies and seven NGOs provide an inter-sectoral NGOs vision to establish national policies, implement the plan of action and set standards and guidelines, and follow up activities.

The Inter-institutional Group had in the organisation all health institutions of the government sector involved in RH matters and national NGOs that were pioneers in the field of FP, population and RH. The Group's responsibility is to coordinate the implementation, monitoring and evaluation of the national programme, including IEC activities, introduction of new strategies and social mobilisation. Recently, the Group was actively involved in the preparation of the National Report for the Cairo+5 Conference. The Group meets regularly to deliberate on issues relating to the implementation of programme and make recommendations for improvement or introduce new strategies.

The Inter-institutional Group on Reproductive Health is in charge of the overall coordination of the programme. The Public Health Institutions of the Ministry of Health is responsible for the surveillance of national policies, set norms, standards and formulate technical guidelines as well as for the provision of information and services to the public. The National Population Council coordinates the National Population Policies, evaluates the programmes and provides social education and communication. The Ministry of Public Education addresses RH issues through their formal and non-formal education programmes. The National Institute for Indigenous Affairs is a major partner on RH actions for the indigenous communities, especially in communicating IEC messages in the indigenous languages. The National Women's Programme has been instrumental over the last years for the incorporation of gender perspective, Women's health advocacy and the promotion of sexual and reproductive rights. Most, if not all, government agencies, which are members of the group, have changed their organisational structure to include the term reproductive health in their agenda through multi-discipline and inter-sectoral coordination. Civil society is represented in the group by seven NGOs which had contributed splendidly in their own areas, adopting the holistic vision of RH. MEXFAM, with its national network of service units, was a pioneer in the area of family planning in Mexico with outstanding work on sexual education, sexual health for adolescents, IEC and most recently in Women's health. FEMAP has a large network throughout the country providing information and services in RH. CORA's major contributions have been in the area of sexual and reproductive health for adolescents with innovative programmes for the management of pregnancy in teenagers. The Committee for the Promotion of Safe Motherhood, established five years ago, is an NGO whose main objective is to reduce maternal morbidity and mortality. Catholics for the Right to Decide has been one of the NGOs promoting Women's sexual and reproductive rights as well as Women's empowerment.

The Inter-institutional Group keeps strong collaborative links with a number of other NGOs, including Women's advocate groups, which are deeply involved in the task of adoption of the Cairo ICPD agenda. The Mexican Federation of Obstetricians and Gynaecologists as well as a number of academic scientific and research organisations have also played important roles as technical consultants for the Inter-institutional Group. Special mention must be made on the collaborative agreements established between the government and the private sector.

Experience of the New Organisational Arrangements

The move to institutionalisation of RH programmes, in line with the recommendations made at ICPD-POA, set the tone for the legislation change process. A number of modification in the structure and rules of the Ministry of Health is required. In addition to the clauses regarding structures, new government bodies need to be included, for example, the National Women's Programme which was established in March 1996. To ensure that the provision of medical services, including that of RH, comply with the official norms, standards and technical guidelines, the National Commission for Medical Complaints was set up by Presidential Degree in June 1996.

The creation of the new organisational structure, including the formation of the federal and provincial inter-institutional groups, played a key role in the successful implementation of RH programme within a relatively short period of time. The Inter-institutional Group, which linked government agencies, academic institutions and civil society as partners, has made possible the paradigm shift and programme institutionalisation.

Creating a Societal Consensus on Reproductive Health

The challenge faced at the beginning of programme was that of promoting and disseminating the Cairo ICPD message among health service providers, clients and society. The Inter-institutional Group launched a comprehensive multimedia advocacy campaign aimed at creating awareness on the basis of the new culture of RH. The first step was to design an institutional-corporate image for identification of the new programme. A RH logo was produced with a contemporary design indicating that the programme agenda addresses family health, gender equity and the people's right to a free decision about the number and spacing of their children. The IEC campaigns undertaken by each member institution of the group have used a variety of strategies, including mass media, graphic and printed materials, outdoor advertisements, itinerant exhibits, telephone hotlines and face-to-face communication to advocate the message.

IEC campaigns are carried out via radio and television spots and educational programmes; through national and provincial newspapers; journals, magazines, special feature articles/editorials and interviews with health personnel. Promotional materials are carefully designed and after consultations with target audience and focal groups. These materials are pre-tested in specific settlements before distributions for public consumption. These are displayed and made available at the service units of the health institutions.

Recently, the National Board of Radio and Television industry has signed a memorandum of understanding with the Ministry of Health to strengthen the health campaigns with focus on RH. To reinforce the RH institutional image, two jingles were produced and are being incorporated into all radio and TV spots.

Since their inception, the campaigns have used external advertisements in the metropolitan areas of large cities; RH messages are displayed on billboards, electronic screens, and public transportation vehicles and underground/bus stations. Another innovative strategy has been the use of designed graffiti to promote RH services. Under the initiative of public health institutions, NGOs and the National Population Council, several telephone hotlines are operating, providing information and assistance in specific components of RH.

Even though the campaigns are designed to have nation-wide coverage, there are special IEC activities for specific population groups. Itinerant exhibits, providing information and services at the colleges and university campuses have had an effective impact on the adolescent population. Culturally accepted and appropriate graphic and printed materials are specially designed for rural population, considering the plural cultural, ethnic and social patterns of the country. Promotional materials for indigenous communities are printed or recorded in major indigenous languages and broadcasted through the indigenous radio network.

In 1995, the Inter-institutional Group decided to celebrate October as the Month of Reproductive Health, an initiative that promote service programmes intensively in the whole country. Since then, each year the member institutions of the group undertake a number of activities in support of this initiative.

Programmes include concerts, conferences, symposia, parades, graphic design contests and special radio and TV broadcasts. The Directorate of Reproductive Health produces commemorative posters and special promotional printed materials, while the service units provide in-house and community services through mobile units. In 1998 a record number of Papanicolaou smears were taken in a campaign to detect cervical cancer in its early stage. Since 1996, the Mexican Post Service issues annual commemorative RH stamps to address issues of FP, adolescent reproductive health and safe motherhood.

The IEC strategy includes also the production of didactic materials to be used in training workshops and seminars for health operative personnel. These materials contain information on the holistic concept of RH and components as well as recent advances in contraception, STDs, peri-natal care and Women's health. These are in the form of handbooks, learning packages, audio-visuals and more recently CD-ROMs. Special multimedia materials have been developed to train provincial trainers to locally multiply the process in a "cascade" fashion.

Last but not least, the Ministry of Health of Mexico and the Inter-institutional Group has implemented a South-to-South cooperation programme with other countries within the Latin American region to share in experiences in the implementation of the ICPD-POA. Over the last three years, 214 governmental and NGOs health officers from 14 Latin American countries have actively participated in this horizontal technical collaborative programme. One of the important outputs of the South-to-South initiative was the production of a six-videotape collection, describing the Mexican experience in institutionalising the RH programme. The videos provided information on national policies, managerial aspects of the programme, IEC activities, FP, peri-natal care, and RH for adolescents. The tapes have been already distributed to participants, and they are also being widely used. Throughout this initiative, a Latin American benchmarking process has been established.

New Programme Outcomes

The lessons learnt and the experience acquired through the first four years of implementation have resulted in the formulation of new programmes, strategies and instruments, all of them jointly developed by member institutions and adopted by public, social and private sectors of the country.

National Women's Health Carnet

Gazetted in March 1998, the National Women's Health Carnet is an innovative instrument to strengthen the promotion of Women's health programmes and the Women's health self care. The carnet collects information and data on Women's health, with special focus on contraceptive use, peri-natal health, cervical and breasts cancers and hormone replacement therapy. The carnet is provided free of charge to all women of reproductive age and about 23 million carnets were distributed to 32 provincial states in 1998.

Baby and Mother Friendly Hospital

Back in 1991, WHO and United Nations Children's Fund (UNICEF) launched a worldwide strategy to rescue the culture and practice of breastfeeding: the Baby Friendly Hospital initiative. This strategy had transformed Mexico to become more comprehensive in RH programmes, the most relevant aspect is the overall improvement of service delivery quality in peri-natal care involving the participation of both the health personnel and the community. Neo-natal care includes immunisations; and prevention of birth defects and control of infectious diseases. Maternity care, on the other hand, include proper ante-natal, delivery and puerperium care with special attention to adolescents; post-partum contraception; pre- and post-abortion care that include post-abortion contraception; and screening, prevention and control of cervical and breast cancers. At the moment, 650 health institutions providing obstetrical care have been duly certified as Baby and Mother Friendly Hospitals, and even though initially designed for hospitals, the initiative has been adopted by the first level of medical care. This initiative represents a most convenient managerial strategy to operationalise RH services, integrating peri-natal care, Women's health, FP and sexual and adolescent reproductive health as programme components.

Informed Consent

Informed consent guarantees the client's right for an informed and free decision to accept any form of RH services and is particularly relevant in FP. The service provider must provide counselling over the choice of method, its side effects and its appropriateness. In cases where the decision is to adopt a permanent method, the client must sign an institutional consent form. Informed consent also includes the client's right to discontinue a given method at any time she desires to. All member institutions of the group have distributed promotional materials for clients and health personnel are given training on informed consent.

Adolescent Reproductive Health

The adolescent population in Mexico has doubled over the last 25 years which in turn has increased the demand for services on sexual and RH for adolescents. Although the incidence of adolescent pregnancy is declining because of programme interventions, there is still a large number of births from mothers below 20 years of age. In addition, the number of reported cases of AIDS in individuals between 25 and 34 years has significantly increased, indicating that the HIV infection occurred during adolescence, and there is also an increase in substance abuse, including tobacco, alcohol and drugs. To counteract the spread of these health problems and habits, the health institutions with the cooperation of the civil society and the private sector have implemented a nation-wide programme on sexual and RH for adolescents on the prevention of : unwanted pregnancies; abortion; STDs including HIV and AIDS; alcohol and drug addiction and care of pregnancy in teenagers. Information and services are available in all health service units with a number of specialised referral centres.

Prevention and Control of Cervical Cancer

Cervical cancer is one of the major causes of mortality among Mexican women, age 25 years and above. A special programme for the prevention and control of cervical cancer was officially launched by the Minister of Health involving the active participation of all member institutions of the group. New strategies and a new official norm were formulated and intensive training provided to health personnel of the cytology laboratories, dysplasia clinics and oncology centres. An IEC campaign with the support of private TV and industries has been launched. There has been a significant increase in the number of cervical smears taken within the last six months, with a simultaneous increase of early detection of pre-malignant and malignant cervical lesions, indicating that the programme has been successfully implemented. The goal of the programme is to achieve 70 percent of early detection coverage.

Resource Mobilisation and Sustainability

To achieve the objective of universal access to basic health service, including that of RH, the government of Mexico has implemented the Programme of Extension of Coverage, an inter-sectoral programme on the improvement of health education and nutrition and the provision of Basic Package of Health Services. These services are particularly needed for populations living in marginalised zones without access to health care services. The Basic Package comprises 13 essential health interventions that include health promotion, family planning, peri-natal care and Women's health. The impact of this initiative is borne out by the fact that in less than four years, 8 out of 10 million Mexicans now have access to health services.

A network of informatics to meet evaluation and policy needs has been established, with special attention to the development of health indicators and selection. Gender-disaggregated quantitative and qualitative databases have been developed in all health institutions. Mission-oriented research activities on RH are coordinated by the government with the academic community and NGOs under the support of international agencies, donors and the private sector. The government has allocated a large budget to strengthen the RH programme, improving financial sustainability through integration of health services. The international community has played an important role by providing expert technical assistance and catalytic financial support for the strengthening of specific research and introduction of new strategies. The private sector has been committed to support the national programme on RH, both in financial terms and social mobilisation.

NGO Sustainability

The NGOs involved in RH activities have had the support of the international community; however, over the last few years, they have experienced significant budgetary cuts. Several strategies including recovery fees from services, establishment of Board of Trustees and trust funds, among others, have allowed them to maintain the role they have played in the implementation of the ICPD-POA. Joint Government-NGO projects have secured international support, whereas the federal and provincial state governments have provided support to several NGO programmes.

Conclusion

The ICPD-POA, agreed upon by the international community, including Mexico in 1994, endorsed a new strategy on sustainable development that focussed on meeting the needs of the individuals in matters of health. Hence, the Government of Mexico has implemented a National Programme on Reproductive Health, incorporating the recommendations of the Cairo ICPD, giving particular attention to sexual and reproductive rights of the population, particularly those of women and girls. The strong political will, the appropriate legislation changes and the collaborative bridges established between government, civil society and private sector have been the key factors for the permeation of the new holistic concept on reproductive health and the institutionalisation of the programme. Although in the first years after its inception, the programme has achieved significant advances, there is still a lot more to do in order to fully develop a holistic mission on RH. Major national concerns and weaknesses of the programme have been identified and current efforts are directed towards achieving the objective of Reproductive Health for All Mexicans in the 21st Century. At the end of the millennium, Mexico still requires technical and financial assistance from the international community in order to reach its ambitious health goals. Needless to say, Mexico will continue sharing its experience on RH with other countries of the developing world.