Non-communicable disease prevention in Mexico: policies, programs and regulations

Abstract

Non-communicable diseases (NCD), such as diabetes and cardiovascular disease, have become a leading cause of the death in Mexico. The federal government has addressed this issue through developing NCD prevention plans, regulations and policies (PRPs) that seek to address social and environmental factors, which was led by the National Institute of Public Health and Ministry of Health in concert with various non-governmental organizations. This review aims to synthesize and summarize national NCD prevention PRPs addressing social and environmental factors passed from 2010 to 2016, and to assess the extent to which these efforts successfully addressed factors contributing to the epidemic. In total nine federal NCD prevention PRPs were identified from a scan that examined executive and legislative PRPs, which identified five documents. A scoping review was conducted for evaluation studies and reports corresponding to these PRPs. The majority of PRPs focused on nutrition, specifically the access and promotion of food. Studies and reports demonstrated that taxation on energy-dense low-nutrient foods and sugar-sweetened beverages were the most effective. Other PRPs had various issues with implementation, mostly related to adherence and resources available. Overall, there lacked evidence of evaluative work on several NCD prevention PRPs, specifically assessing implementation and effectiveness. Additionally, PRPs did not sufficiently address integration of clinical, social, environmental approaches and access to physical activity. While the Mexican federal government has taken the initial steps to address the multifactorial causes of NCD, firm political commitment and investment of significant resources are still needed.

BACKGROUND

In 2015, 71% of all deaths could be attributed to non-communicable diseases (NCDs) in the world (GHDx, 2017). This has become a recent public health crisis in low- and middle-income countries, such as Mexico where ∼80% of all deaths in the same year were due to NCDs (GHDx, 2017). This is a recent development for a middle-income country such as Mexico, which previously focused on malnutrition and is now addressing NCD and underlying factors of NCD such as overweight and obesity (Kroker-Lobos et al., 2014). Mexico has experienced a rise in the prevalence of NCD in recent years; from 2006 to 2016 the national prevalence of diabetes mellitus increased by ∼30.6%, from 7.2 to 9.4% (INSP and SSA, 2016). NCDs caused an estimated 493 000 deaths in 2015; diabetes mellitus and cardiovascular diseases caused almost half of these deaths, 93 800 and 150 000, respectively (WHO, 2016). Overweight and obesity are underlying factors to NCD-related deaths in the country (Barquera et al., 2013a). In 2016, the estimated prevalence of overweight and obesity among adults 20 years or older was 72.5% (INSP and SSA, 2016). This was a significant increase from 2006 when the reported prevalence was 69.7%, and 2000 when it was 61.8% (Barquera et al., 2013b).

Health care costs associated with obesity-related NCDs are projected to reach US$1.2 billion by 2030 and US$1.7 billion by 2050 in Mexico (Rtveladze et al., 2014). It is estimated that from 2008 to 2013, the Mexican Institute of Social Security (IMSS), the private sector employees health care provider, spent US$1.5 billion in direct hospitalization costs related to diabetes mellitus (Salas-Zapata et al., 2016). Long-term effects of obesity-related NCDs have also had significant costs for the government, such chronic kidney disease, which cost the Secretaria de Salud (Ministry of Health) US$8966 per patient annually and IMSS US$9091 (Figueroa-Lara et al., 2016). Overall, health care service providers in Mexico are spending a significant proportion of their health expenditure on the financial burden of NCD. In 2012, SSA and IMSS spent a total of 8 and 25% of total annual health expenditure on NCD, respectively (Figueroa-Lara et al., 2016).

Aware of the enormous costs associated with NCDs and related risk factors, the Mexican government made several attempts to improve prevention efforts in clinical settings. One example is PrevenIMSS, a program developed to increase education, screening and monitoring of NCDs among IMSS recipients (Gutiérrez et al., 2006, 2010). Also in 2008, the federal government created Specialized Medical Units for NCD (UNEMEs EC) in public hospitals and clinics to provide patients with an integrated clinical approach to NCD prevention and improve adherence to detection, education, and treatment (SSA, 2017a). While programs like PrevenIMSS and UNEMEs EC expanded clinically based preventive services, increases in the prevalence of NCD and its associated costs continued to escalate, calling for additional prevention programs, regulations and policies (PRPs). Specifically, the federal government lacked PRPs that addressed contributing social and environmental factors, such as the overwhelming access and exposure to energy-dense nutrient-low foods, lack of spaces/facilities for physical activity and no nutritional standards for federal programs (Barquera et al., 2013a). It was particularly imperative for the legislative and executive branches to address, considering under Article 4 of the Constitution of the United Mexican States, the Ley General de Salud (General Health Law) establishes their responsibility in improving and prolonging the quality of life for every Mexican citizen through PRPs (Parada, 2012; CD, 2013, 2017; SSA, 2017b).

Addressing social and environmental factors

The growing threat of NCDs led the Ministry of Health, under the executive branch, in coordination with National Institute of Public Health (INSP), international health policy experts, and non-governmental organizations, to create the National Agreement for Healthy Nutrition (ANSA) in 2010, a strategic plan to address social and environmental factors of NCDs (Barquera et al., 2013a; Latnovic and Rodriguez Cabrera, 2013). This agreement was also part of their international commitments to address the growing global pandemic (Barquera et al., 2013a; Latnovic and Rodriguez Cabrera, 2013). One such international commitment specifically calls for the reduction of premature deaths due to NCDs by 33% by the year 2030, which is under goal three of the United Nations Sustainable Development Goals (United Nations Development Programme, 2017).

ANSA was created to address childhood overweight and obesity, and among adults to prevent the development of NCDs, specifically targeting social and environmental factors linked to both nutrition and physical activity (SSA, 2010). The PRPs proposed included: increasing accessibility to healthy foods by establishing nutritional standards in schools and federal programs; improving readability of nutrition labels; decreasing access to energy-dense low-nutrient foods and sugar-sweetened beverages through taxes; and building new physical activity facilities (Basu et al., 2013). The subsequent National Strategy for the Prevention and Control of Overweight, Obesity, and Diabetes (ENPCSOD) was President Peña Nieto’s (2012–18) response to the Mexican NCD crisis and a means to address many issues related to prevention and control of overweight and obesity. Many nutrition-focused PRPs first proposed by ANSA under the Calderon administration (2006–12) were subsequently modified and adopted by ENPCSOD (SSA, 2013a).

The enactment of ANSA was the catalyst for a number of PRPs designed to influence environmental and social factors related to NCD prevention and related risk factors. Given these efforts, there is value in understanding both the scope and effectiveness of NCD prevention PRPs at the federal level after the release of ANSA. In order to monitor efforts, the present study aims seek to: (i) scan legislative and executive PRPs targeting social and environmental factors contributing to NCD; (ii) conduct a scoping review on evaluative studies and reports corresponding to identified PRPs. This study will help provide a concise source of information regarding NCD prevention efforts for other low- and middle-income countries seeking to address the epidemic.

METHODS

Aim I: Scan legislative and executive PRPs targeting social and environmental factors contributing to NCD.

Step 1: Scanning federal PRPs. Cox’s (Cox, 2014) plan for conducting a chronic disease policy scan was utilized and adapted for a Mexican context. We reviewed the federal initiatives, legislation, and scanned government websites (i.e. el Diario Oficial de la Federación, Ministry of Health, Ministry of the Interior, Senate and Chamber of Deputies). We confirmed and supplemented this information with conversations and resources from four chronic disease expert partners, who have extensive experience working in Mexican policy evaluation and research at the federal level.

Step 2: Identifying PRPs. All PRPs proposed post-ANSA had to meet the following criteria: (i) focused on the federal level and influencing the entire population; (ii) aimed specifically at preventing NCD and related risk factors; (iii) did not exclusively focus efforts on traditional clinical settings, and addressed environmental and social factors such as changing access to healthy foods through regulations, prohibiting certain foods from public spaces etc.; (iv) used clear language that targeted a specific sector, environment or institution and provided regulatory support, ample resources, and/or financial incentives in promoting behaviors for NCD prevention. Programs that exclusively provided health information (i.e. printed materials) were not included due to the lack of active strategies.

Objective II: Conduct a scoping review on evaluative studies and reports corresponding to identified PRPs.

The scoping review was conducted from January 2017 to May 2017, and was guided by Arksey and O’Malley (Arksey and O’Malley, 2005) framework and other published work (Welsh et al., 2015; Vliet-Brown et al., 2017) taking the following steps:

Step 1: Communicating with partners. Identified PRPs were discussed with chronic disease expert partners involved in policy to identify sources of evaluative work. Mexican experts recommended specific databases, including PubMed and Google Scholar. Internal evaluative memos or reports by government institutions were inaccessible or not available.

Step 2: Scoping review of policy evaluation studies and reports. A scoping search was conducted for articles, grant/government reports and other grey literature (dissertations, organizational memos etc.) utilizing selected general terms, such as: chronic disease* OR non-communicable disease*); AND Mexico; AND (national polic* OR polic*). The databases used were PAIS Index, PubMed, ScienceDirect, PyschINFO, PRISMA, Web of Science, and Google Scholar.

Step 3: Initial Search. The search included the following requirements: published in English or Spanish; published in 2010 or after; provided a summary or abstract about the article; addressed a Mexican context. Additionally to ensure rigor, we excluded studies if they derived from sources such as news reports or magazines. The searches yielded the following results: PAIS Index (191); PubMed (135); ScienceDirect (2244); PsychINFO (62); PRISMA (50); Web of Science (90); Google Scholar (4070).

Step 4: Examining articles. Of these 6842 articles, we excluded those that did not contain all of the following: (i) referred to evaluating a PRPs that focused on NCD prevention; (ii) summary of the PRP being evaluated; (iii) description of evaluation objective and process. Only 48 articles contained all three components, however the overwhelming majority of these articles were focused on evaluating clinical practices or insurance programs, and not PRPs focused on NCD prevention.

Step 5: Articles evaluating the PRP. Five studies (one being a report) met the criteria as evaluating one of the federal PRPs. These results were then reviewed and discussed with Mexican experts (Figure 1).

Fig. 1:

Summary of scoping review.

RESULTS

Overview

We identified nine PRPs approved after 2010 that addressed environmental and social factors related to NCD and risk factors, and five evaluation studies. In Table 1, the PRPs are provided with their corresponding year passed, principle objective(s), summary of actions, the sector being targeted by the policy and corresponding evaluation.

Table 1:

NCD prevention PRPs and corresponding evaluations

Year	Policy/initiative	Objective(s)	Summary of actions	Target sector/institution	Evaluation
2010	ANSA (SSA, 2010)
2010	National Commission for the Prevention and Control of Non-communicable Diseases (CONACRO) (DOF, 2010)	Creation of a body charged with the permanent coordination on matters related to the prevention and control of NCD and its risk factors among the general population.	To support in establishing inter-institutional mechanisms for the prevention and control of chronic diseases through developing instruments to support prevention programs, increasing and improving communication tools for collaboration, and creating a registry of NCD for evaluation of medical treatments.	Health care providers; Research institutions
2011	Nutritional Support for Workers Law (CD, 2011)	Promote and regulate a useful nutrition table as a resource that benefit workers, with the purpose of improving their nutrition, in order to prevent illnesses related to a deficient diet and protect the workplace.	Supports private companies in providing healthy food options within the workplace by providing models for healthy eating and promotion, and tax incentives for companies following the optional law.	Private industry
2013	ENPCSOD (SSA, 2013a)
2013	Sugar-Sweetened Beverage and Processed Food Tax (CD, 2013)	Decrease consumption to processed foods and beverages that do not meet nutritional standards.	Implements a tax of 10% for sugar-sweetened beverages (or approximately MX$ 1 per liter), and an 8% tax for nonessential foods with an energy density of ≥275 calories per 100 g. Delegates these funds for improving health of the general population, and increasing access to potable water in schools.	Private industry	Colchero et al. (Colchero et al., 2017) (sugar-sweetened beverage tax)Batis et al. (Batis et al., 2016) (processed food tax)
2014	Nutrition Labeling System (DOF, 2014a)	Provide nutritional labels on packaged products in a manner that allows consumers to easily comprehend and observe when making purchases.	Require the clear presentation of the following nutrients in the front-of-packaging: saturated fats, other fats, total sugars, sodium and calories (energy), with whole numerical values, and daily percentage.	Private industry	Carriedo et al. (Carriedo et al., 2015)
2014	Regulation of Food and Beverage Advertisements to Children through Media (DOF, 2014b)	Limit exposure of unhealthy food and beverage media advertisements to children.	Require foods and beverages advertised during children television programming and in movies theaters to following various nutritional standards related to calories, sodium, saturated fats and total sugars.	Private industry	Rincón-Gallardo Patiño et al. (Rincón-Gallardo Patiño et al., 2016)
2014	Nutritional Guidelines for Food Sold in Schools (DOF, 2014c)	Establishes general guidelines for the distribution of foods and beverages prepared and given in schools.	Requires nutritional guidelines set by the government to be implemented and reinforced in schools within the national education system, in order to regulate the types of foods being sold to children: increasing access to fruits and vegetables, whole grains, legumes and healthy beverages.	Public schools	Monterrosa et al. (Monterrosa et al., 2015)
2014	Mexican Observatory of Non-communicable Diseases (OMENT) (DOF, 2014d)	Support in the evaluation and measurement of the impact the public policies implemented by the ENPCSOD.	Provide recommendations for institutions on the implementation, evaluation and measurement of ENPCSOD-related policies; create working groups to support OMENT on its objective, and effectively disseminate information in order to promote problem solving.	Health care providers; Research institutions
2015	Regulation of food and beverage advertisements to children in schools (DOF, 2015)	Limit exposure of unhealthy food and beverage advertisements to children in schools.	Prohibits advertisement of food and beverages in schools that do not meet nutritional standards set by the federal government.	Public schools
2016	Comprehensive Guidelines for the Strategy on Food Assistance (SSA, 2016a)	Contribute to food security of population served by food programs through the implementation of nutrition tables, food guides, ensuring the quality and production of food.	The implementation of four specific programs: school breakfast program, food assistance to vulnerable populations under 5 years of age, food assistance to vulnerable populations, and food assistance for families in need.	Government

From the nine federal PRPs: four targeted private industry in some capacity, two were designated to care providers and research institutions, two increased regulations in public schools, and one was aimed at a social assistance program. PRPs addressing private industry overwhelmingly aimed to increase regulation on access and exposure to unhealthy foods; two focused on advertising and two on the accessibility to energy-dense low-nutrient foods/sugar-sweetened beverages. Public schools had regulations implemented related to advertisements and types of foods sold on campus. Additionally, the federal government encouraged increased collaboration by healthcare providers and research institutions under two separate programs, and social welfare assistance was given regulatory nutrition standards to implement. No NCD prevention PRPs could be identified that specifically and proactively targeted physical activity at a federal level with set criteria.

Only five published articles described the evaluation of any component of the nine federal NCD prevention PRPs. These five articles evaluated the following NCD prevention PRP components: advertisements to children on television; implementation of national guidelines in schools; sugar-sweetened beverage tax; low-nutrient energy-dense food (i.e. junk food) tax; front-of-package (FOP) labeling system (Carriedo et al., 2015; Monterrosa et al., 2015; Batis et al., 2016; Rincón-Gallardo Patiño et al., 2016; Colchero et al., 2017).

Focus on nutrition

Government efforts primarily on curbing access to energy-dense low-nutrient foods and changing social norms around promotion of certain foods through PRPs. Implementation of policies varied as indicated by evaluations surrounding PRPs.

As noted in Rincón-Gallardo Patiño et al. (Rincón-Gallardo Patiño et al., 2016), advertisement regulation has not been fully enforced on television, failing to safeguard children from being exposed to energy-dense low-nutrient food advertisements since its implementation in 2014. According to the regulatory law, the Federal Commission for the Protection against Sanitary Risk is tasked with ensuring all foods advertised during child programming must meet established nutritional standards (DOF, 2014b). The evaluative study found during child programming—foods with the highest calories and sugar content were advertised, and more than 60% of foods advertised overall did not meet the nutritional standards (DOF, 2014b; Rincón-Gallardo Patiño et al., 2016). The study clearly demonstrates a lack of compliance with the regulation among both food and media companies, but also a failure by the federal government to effectively implement standards. However it is important to recognize that internationally, several countries (such as the UK, Canada and Australia) have also had problems with regulating the private sector or having them self-regulate in meeting similar standards (Buse et al., 2017). Both approaches have had major issues with administering control and conflicts of interest (Buse et al., 2017).

An evaluation of the policy to curb advertisements of unhealthy foods and regulate their availability in schools was not found. Prior to implementation of the policy, a qualitative assessment on nutritional guidelines for public school was conducted through a national feedback collection process from multiple stakeholders (parents, citizen, academics, food industry) prior to implementation. Stakeholders had varying perspectives; on the one hand, most actors perceiving the policy as necessary to curb the obesity epidemic, particularly among children (Monterrosa et al., 2015). On the other hand, the food industry voiced concerns over lack of multilevel approaches, and placing an unfair amount of responsibility on their contributing role (Monterrosa et al., 2015). Clearly there was a tension between the majority of actors and the food industry prior to implementation, which could have contributed to an ineffective implementation of the program. Unfortunately, the evaluation for the public schools’ nutrition guidelines has to yet to be published.

Similarly related to food access, the sugar-sweetened beverage tax was aimed at curbing the consumption of beverages such as soda, juices and sports drinks among the Mexican population. This policy approach gained international attention and, perhaps for this reason, was more rigorously evaluated than other policy efforts (i.e. nutritional guidelines in schools, television advertisement regulations etc.). Evaluation demonstrates that the policy is effective when looking at the national consumption of sugar-sweetened beverages, from 2014 to 2015 there was over a 15% decrease in consumption (Colchero et al., 2017). The second tax on processed food or energy-dense nutrient-poor foods also influenced consumption. In 2014, there was an estimated 5.1% decrease in consumption when compared to the pre-tax era (Batis et al., 2016). These trends indicated that implementing these imposed taxes are effective in curbing Mexican consumption of unhealthy foods and beverages, and their effective implementation is evident in the results. This is particularly important and a priority considering the easy access to junk food and sugar-sweetened beverages; areas in the country are even labeled as ‘food swamps’ because of the overwhelming access (Bridle-Fitzpatrick, 2015).

The availability and visibility of nutritional information on processed foods packaging is related to both healthy food access and promotion. The government utilized an FOP labeling system allowing consumers to read with ease pertinent information (Carriedo et al., 2015). Many consumers found this FOP labeling system favorable in understanding nutrition contents of products (Carriedo et al., 2015). Currently, data related to the acceptability of FOP by Mexican consumers and how it may be influencing their health behaviors or purchases is being processed (Carriedo et al., 2015). However, initial stakeholder reports suggest consumers question the reliability of information on nutrition labels (Carriedo et al., 2015). Therefore, it is important to note many consumers may find the information helpful, but in certain circumstances may not actually trust the information. As a result, this may not influence their behavior when making decisions on food purchases. Overall while strong nutrition-related PRPs addressing social and environmental factors exist in terms of changing access and expose to energy-dense nutrient-poor foods, there continues to be major issues concerning effective implementation, funding and adherence (Table 2).

Table 2:

Summary of results

Article	PRP	Methods	Major findings
Rincón-Gallardo Patiño et al. (Rincón-Gallardo Patiño et al., 2016)	Regulation of Food and Beverage Advertisements to Children through Media (DOF, 2014b)	600 h recording from four major public broadcasting channels and categorizing advertisements over 5 months	Investigators found during child programming 60% of foods advertised overall did not meet the nutritional standards. This was due to a lack of compliance with the regulation among both food and media companies, but also a failure by the federal government to effectively implement standards.
Monterrosa et al. (Monterrosa et al., 2015)	Nutritional Guidelines for Food Sold in Schools (DOF, 2014c)	Qualitative analysis of 857 responses collected nationwide by the federal government prior to regulatory implementation	Most actors perceived the policy as necessary to curb the childhood obesity epidemic. The food industry voiced concerns over a lack of multilevel approaches, and placing an unfair amount of responsibility on their contributing role. There was a tension between the majority of actors and the food industry prior to implementation, as many centered their response on the role of processed foods and sugar-sweetened beverages.
Colchero et al. (Colchero et al., 2017)	Sugar-Sweetened Beverage Tax (CD, 2013)	Observational study from 6645 household on changes in beverage purchases in post-tax years	Evaluation efforts demonstrated that the policy is effective when looking at the national consumption of sugar-sweetened beverages, from 2014 to 2015 there was over a 15% decrease in consumption (−5.5 in 2014; −9.7 in 2015). Investigators observed the largest decreases among the lowest socioeconomic group.
Batis et al. (Batis et al., 2016)	Processed Food Tax (CD, 2013)	Observational study from 6248 households on packaged food purchases during first year of tax implementation	In 2014, there was an estimated 5.1% decrease in consumption of processed foods when compared to the pre-tax era. Among low socioeconomic households purchases of processed foods decreased 10.2% on average. Investigators found it essential for future studies to focus on overall energy intake, dietary quality and food purchase patterns.
Carriedo et al. (Carriedo et al., 2015)	Nutrition Labeling System (DOF, 2014a)	Qualitative study consisting of 12 focus groups among various stakeholders on new regulation	Consumers found FOP labeling system simple and understandable for comprehending nutritional contents of products. Initial stakeholder reports suggest consumers question the reliability of information on nutrition labels. Given these findings, investigators doubt the actually influence FOP labeling currently has or will have on health behaviors and food purchases. Investigators collected additional qualitative and quantitative data with plans to publish in the future.

Emphasis on collaboration within NCD prevention

Efforts to approach NCD prevention and surveillance in a collaborative manner are the proposed objectives of two PRPs. This has led to the creation of the National Commission for the Prevention and Control of Non-communicable Diseases (CONACRO) and Mexican Observatory of Non-communicable Diseases (OMENT). However, when searching CONACRO, we found limited information regarding the work of the commission or strides made by the commission in recent years. Most of the information on CONACRO related exclusively to its creation and objectives set for by the government in preventing NCD. It is important to note the Calderon administration created CONACRO, thus its advancement may have been curtailed by executive change in office. OMENT, established under the subsequent Peña Nieto administration, has a website displaying on-going work and resources for institutions working towards NCD prevention and control (OMENT, 2017a). The limited information regarding the current work surrounding NCD prevention and control is mainly composed of a few research studies done in Mexico and globally (OMENT, 2017a). It does provide examples of educational materials available for prevention and control efforts, particularly focused on individual lifestyle changes for the general population (OMENT, 2017b). However, OMENT may also suffer from conflicts of interest, the advisory council’s most influential representatives are from the food and beverage industry, and exclude major national health institutes and consumer groups instrumental in the creation of ANSA (UK Health Forum, 2018).

DISCUSSION

The PRPs of the past 6 years are an approach to NCD prevention that can help better address the rising prevalence of NCDs in Mexico. We aimed to create a concise source of information surrounding these efforts through a PRP scan for both legislative and execute branches, and sought to provide a scoping review of corresponding published evaluation studies and reports. Many low- and middle-income countries are facing similar challenges to Mexico’s in NCD prevention and control, and effective PRPs are becoming the most only viable option to address this pandemic (Miranda et al., 2008). Mexico offers an example of the benefits of collaboratively working on national health agreements that seek to address underlying social and environmental factors related to NCDs, but also demonstrates myriad issues that can occur with policy implementation. Two policy efforts, the tax sugar-sweetened beverage and the tax on energy-dense nutrient-low food taxes were the only PRPs for which we were able to find documentation of both implementation and outcomes. While several countries have successfully implemented similar taxes, the usage of these revenues in funding NCD prevention and control is central to addressing the epidemic (Mytton et al., 2012), which in the case of Mexico is not clearly known.

While the nutrition of the Mexican people was repeatedly addressed through these PRPs, we documented several deficiencies. Firstly, no PRP promoted the integration of clinical, social, environmental approaches to jointly address NCD prevention among the Mexican population. Secondly, physical activity was rarely mentioned, nor given strong concrete resources. It should be noted that in order to promote physical activity, the government would have to address underlying issues such as safety and security; environmental pollution; need for infrastructure; prioritization of pedestrians and cyclists within urban spaces; and other social determinants of health, which has been mentioned by Ministry of Health (SSA, 2014). Finally, identified PRPs required improved reinforcement, monitoring and evaluation techniques to insure implementation and success. For example, the Nutritional Support Law could not be linked to any evidence of implementation or success (CD, 2011).

Future directions: potential solutions to deficiencies

Two programs had the potential to address identified deficiencies from our study, but did not fit within the inclusion criteria of our PRP scan. A health center-based support group (Grupo de Ayuda Mutua-GAM) for people living with or at-risk for NCD sponsored by the government health care system currently addresses NCD secondary prevention (SSA, 2016b). The Ministry of Health utilizes the GAMs as part of their standard of care: once individuals are diagnosed and controlled for their NCD in their corresponding clinic, they are then referred to these support groups (SSA, 2016b). GAMs are designed to provide support for patients from health professionals and fellow diabetic patients to self-manage and prevent further health issues (SSA, 2016b). GAMs have sessions where they share experiences and barriers, in addition to engaging in educational activities (SSA, 2016b). Internationally, the support framework for dealing with NCD self-management has been found to be an effective, particularly among underserved and disadvantaged populations (Mills et al., 2017). To optimize its effectiveness GAMs could be integrated into community settings, transforming the groups into agents of change to address NCD social and environmental contributors. This approach could integrate clinical, social and environmental approaches to NCD prevention.

Secondly, the Specific Action Plan for Nutrition and Physical Activity promotes environmental changes to improve access to facilities and spaces within cities, towns and villages (SSA, 2013b). It mainly serves as a plan to continue to prevent overweight and obesity in communities through educating and providing resources for healthy eating and exercise, but while also evaluating those efforts as well (SSA, 2013b). However, this plan lacks financial resources and concrete objectives on how to accomplish these goals, which is the reason for its exclusion in our scan. The plan, with the inclusion of these components, could serve to address the promotion and access to physical activity, as well as needed changes to the built environment.

In terms of evaluation, open-access holistic evaluation is needed surrounding the actual implementation of PRPs, along with how they influence Mexican citizens’ health behavior. The clear exception to this claim would be taxation on nutrient-poor foods and beverages, which has demonstrated success and maintained a holistic evaluative approach. Moving beyond the exclusive use of traditional clinical approaches may complicate prevention efforts given the novel challenges that exist; however, it is necessary to address the complexity behind the rising NCD epidemic. Additional rigorous independent evaluations, using various methodologies must be done to understand the complexity of applications in real-world settings. We recommend that comprehensive evaluations incorporate the following elements:

• Monitoring process implementation of PRPs.

• Assessing reinforcement and effectiveness of PRPs.

• Acceptability by the population.

• Inequities in access to NCD prevention services.

• Structural barriers to implementation (surrounding adherence and resources) and facilitators for acceptability.

• Tailoring necessary for effectiveness, based on indigeneity, culture, language, socioeconomic status, region and gender.

• Perspectives from stakeholders related to PRPs and resources needed to effectively execute.

Limitations

There were limitations to this study. Firstly, it was difficult to trace every aspect of NCD prevention being proposed by a PRP, so our criteria may have excluded potential PRPs. However, our purpose was to focus on major federal PRPs influencing population health. Additionally the government may internally evaluate PRPs without publishing, thus it was difficult to account for all evaluation work done on all PRPs. Finally, it is important to note that while the Mexican federal government is attempting to address NCD prevention, efforts and progress can also be made at state and local levels, which were not accounted for in this paper. However, given the state of the epidemic of NCD and their continued rapid growth, there remains a necessity for effective PRPs.

CONCLUSION

Evaluation efforts can clearly improve PRPs through ongoing monitoring of implementation processes and specifically measuring progress towards desired outcomes. Other countries seeking to implement similar policies should build in evaluations from the outset, and ensure they are explicitly stated and permanently funded. If NCD and related risk factors are not effectively addressed, the pandemic will continue. In 2016, Mexico announced an epidemiological emergency due to the extremely high prevalence and growth of diabetes in the country (SSA, 2016c). It is estimated that 40% of Mexicans living with diabetes remain undiagnosed, only 50% of Mexicans diagnosed with diabetes receive treatment, and 15% of those diagnosed with diabetes remain controlled (Rivera Dommarco, 2016). Government must act by providing more funding to evaluate these PRPs and their implementation, creating spaces for academia, industry and community advocates to discuss evidence-based multilateral solutions, and including all stakeholders in the evaluation process.