Health Policy OPEN 5 (2023) 100100

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Health Policy OPEN

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Health-care policies during the COVID-19 pandemic in Mexico: A

continuous case of heterogeneous, reactive, and unequal response
Daniela Bautista-Reyes a, 1, Jimena Werner-Sunderland b, 1, Alondra Coral Aragón-Gama c,
José Roberto Cabral Duran d, Karla Daniela Contreras Medina e, Manuel Urbina-Fuentes f,
Elysse Bautista-González d, *
a
Independent
b
Latinxs Against AMR, Mexico
c
Laboratorio de equidad en salud, Fundación Mexicana para la Salud (FUNSALUD), Tlalpan, Mexico
d
University College London, UK
e
Universidad Anáhuac, Mexico
f
Investigación en salud y demografía (INSAD), Mexico City, Mexico

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The pandemic in Mexico underlined pre-existing health-care system inequalities. Within the first six
Vaccines months of the COVID-19 pandemic, 154 health policies across health institutions were found to be uncoordinated
Health policy and heterogeneous, leading to health inequalities in access and potential health outcomes.
Health inequalities
Data & methods: Using a rapid qualitative research methodology, data was collected using purposive sampling of
COVID-19 pandemic
institutional policies published for public access on the official websites of the four public health institutions in
Mexico
Mexico from June 16th, 2020 to October 30th, 2021. This policy review used archival analysis to understand the
differences in health-care policies during the COVID-19 pandemic in Mexico. These policies were classified under
the RREAL framework and as a continuation of our first publication.
Results: During this study, categories of public health response and vaccination dominated the policies enacted.
The SSA was the main author of publications. There seems to be a more unified policy response. However, health
inequalities persist.
Conclusions: The Mexican government continued to be reactive to the increase in cases or the arrival of new
variants, rather than preventative. Research and development of policies need to work together in soaring cases
like COVID-19 to work more effectively against the economic and epidemiological burden of a pandemic. It is
suggested that this “vaccination” should be included in the RREAL classification. Other sectors (i.e. the ministry
of foreign affairs) should be considered relevant players in the future management of a pandemic.

1. Background homogeneously faced several challenges during the first 6 months of the
pandemic. For example, case-confirmation algorithms were published
The pandemic in Mexico underlined pre-existing health-care system uncoordinatedly by different institutions; information was being upda­
inequalities. In fact, within the first 6 months of the COVID-19 ted constantly (i.e. new treatments, triage) through different websites,
pandemic, 4154 health policies across health institutions were found however, practitioners were not being able to keep up with the number
to be uncoordinated and heterogeneous, leading to health inequalities in of updates; there were multiple ways of filling out a death certificate;
access and potential health outcomes [1]. established health services activities were suspended; hospitals had
Regardless of the inequalities, Mexico’s health system insufficient staff, infrastructure, and supplies and thus increasing the

* Corresponding author.
E-mail addresses: [email protected] (D. Bautista-Reyes), [email protected] (J. Werner-Sunderland), [email protected] (A.C. Aragón-
Gama), [email protected] (J.R.C. Duran), [email protected] (K.D.C. Medina), [email protected] (M. Urbina-Fuentes), elysse.
[email protected] (E. Bautista-González).
1
NOTE. Daniela Bautista-Reyes and Jimena Werner-Sunderland contribute equally to the development of the present paper, considering both as first authors.

https://doi.org/10.1016/j.hpopen.2023.100100
Received 14 February 2023; Received in revised form 19 May 2023; Accepted 3 July 2023
Available online 2 August 2023
2590-2296/© 2023 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
D. Bautista-Reyes et al. Health Policy OPEN 5 (2023) 100100

number of policies on temporary hospitals, reconfiguration of hospitals ensuring Personal Protective Equipment (PPE) for staff directly benefits
and other National Institutes, public–private partnerships, shared hos­ health-care workers; whereas modifying the triage for COVID-19 pa­
pital services were enacted as an effort to centralise the response in the tients directly benefits the health-system users). Data were extracted
country (see Appendix A and B). The pandemic forcefully integrated according to each of the categories above and inputted on a spreadsheet.
virtual monitoring, digital prescriptions, and consultations into delivery Lastly, a member of the research team identified the main topics, and the
services; the military was instructed to guard hospital premises, and the data was cross-checked by all members of the research team. The data
private sector was working together to produce alcohol and face masks. that emerged was subsequently organised and classified according to the
Economic stimuli were given to doctors, some shifts were spaced, and conceptual framework mentioned above. The framework became a dy­
mental health became a topic of concern [1]. namic working document modified as new policies emerged and were
From June 1st, 2020, the term “phases” was no longer used, and the constantly added to the analysis. The interpretation of the results was an
“epidemic traffic light” was implemented. It intended to establish the iterative process (see Appendix C).
gradual opening of socio-economic activities in the country according to Throughout this paper, we will refer to “peaks” for the epidemio­
the virus spread and the responsiveness of the Health System [2]. logical points of soaring cases during this analysis, and “intervals” will
Nevertheless, across states, there was a different use of the policy, and as be the periods identified as a combination of the increase of enacted
the pandemic progressed, the criteria were modified, prioritising eco­ policies and the peaks.
nomic and political interests [3].
The fatality rate of the pandemic in Mexico varied throughout time. 3. Results
At the beginning of the pandemic in Mexico (February 2020), there were
16 cases, and by the end of that month, there were already 433 deaths. The team reviewed 2,500 resources between government websites,
By June 2020 (the beginning of the present analysis), there were official publications of public policies, and press releases, but only 154
166,094 cases and 20,579 deaths (12.4 % fatality rate). By the end of the were eligible as policies according to the reference definition [6] and the
analysis (October 2021), there were 110,093 cases and 7,386 deaths defined inclusion criteria for the analysis. PEMEX did not publish any
(6.7 % fatality rate). During the whole period of analysis (June 2020 to new policies; it only reports its epidemiological data weekly and seems
October 2021), there were 3,671,876 cases and 254,619 deaths (6.9 % to be aligned with the SSA. The majority of policies throughout the
fatality rate). The highest peak fatality rate (15.5 %) was in May 2020, pandemic corresponded to the public health response category (39.6 %),
with 103,935 cases and 16,124 deaths, followed by another peak in followed by vaccination policies (24 %) (see Table 1). The definitions
February 2021 (12.5 %), with the lowest rate presented in July 2021 (2 and percentages of each policy category and their subcategories are
%) [4]. detailed in Appendix D and E.
Our previous paper collected data from February 29th to June 15th, Fig. 1 presents an overview of the COVID-19 cases in Mexico and
2020. This study aims to generate a sequential exploratory review [5] of each corresponding peak in parallel to the total enacted policies from
health-care policies published from June 16th, 2020 - to October 30th, June 16th, 2020 to October 30th, 2021. During this study, the time
2021, and identify inequalities among health institutions, exemplified analysed was divided into the following intervals: interval A, from June
by their response during the COVID-19 epidemic in Mexico. 16th to November 30th, 2020; interval B, from December 1st, 2020, to
May 31st, 2021; and interval C, from June 1st to October 30th, 2021
2. Methods [13].
As a result of the natural development of the response to the COVID-
The team based the process of identifying and selecting public pol­ 19 pandemic, specifically during the second half of 2021, policies cor­
icies on the definition proposed by Raúl Velázquez “Public policy is an responding to the vaccination strategy in the country were mainly
integrating process of decisions, actions, inactions, agreements, and identified. Therefore, the Vaccination category was added to the
instruments, carried out by public authorities with the participation of framework previously published by RREAL [12].
individuals and aimed at solving or preventing a situation defined as Data from Fig. 1 shows a mild correlation between enacted policies
problematic” [6]. and peaks of contagion, with a clear peak during Interval B and marked
Using a rapid qualitative research methodology [7], data were decreases as each peak slowed down; however, to further understand the
collected by the research team using purposive sampling of institutional level and relationship between policies and cases, the data is presented
policies published for public access on the official websites of the four in each of the updated eight categories (See Fig. 2 and Appendix F).
public health institutions in Mexico: Instituto Mexicano del Seguro So­ As seen in Fig. 2, each interval presents a different composition of
cial (IMSS), El Instituto de Seguridad y Servicios Sociales para los Tra­ enacted policies classified by the RREAL framework, with the Clinical
bajadores del Estado (ISSSTE), Petróleos Mexicanos (PEMEX) and response and Health-care management being the main categories for
Secretaría de Salud (SSA) [8–11]. The inclusion criteria were: policies at interval A, alongside a lower number of policies for the other categories.
the national level published from June 16th, 2020, to October 30th, Intervals B and C diverge from the initial one, as the total number of
2021. This policy review used archival analysis to understand the dif­ policies and their scope greatly increase. Additionally, from interval B
ferences in health-care policies developed by the four public health in­
stitutions during the second analysis of the COVID-19 pandemic in
Table 1
Mexico (see Appendix C). These policies were classified into eight
Total policy distribution percentage of enacted policy distributions by category.
categories: Public Health Response, Health-care Delivery, Human Re­
sources, Health-System Infrastructure And Supplies, Clinical Response, RREAL Category % (n)
Health-care Management, Epidemiological Surveillance, And Vaccination; Public Health Response 39.6 % (61)
the first seven developed by the Rapid Research Evaluation and Vaccination* 24 % (37)
Appraisal Lab (RREAL) team as a set of categories that could allow the Health-care management 8.4 % (13)
Clinical Response 7.1 % (11)
comparison of COVID-19 response across countries under the same Epidemiological surveillance 6.5 % (10)
framework [12] and as a continuation of our first research analysis [1] Health system infrastructure and supplies 5.8 % (9)
(See Appendix C). Moreover, to further analyse the policies imple­ Human Resources 5.2 % (8)
mented in Mexico, these policies were also classified according to the Health-care delivery 3.2 % (5)
date of publication, the place where they were expected to be enforced, *
Vaccination is not a category included in the current RREAL framework and
the implementers of the policy (i.e. the people who had to read and take was added for this paper. Source: Prepared by the authors based on the data
action on a particular task) and potential beneficiaries (i.e. policies from SSA, IMSS e ISSSTE, 2020–2021, and the RREAL framework, 2020.

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D. Bautista-Reyes et al. Health Policy OPEN 5 (2023) 100100

Fig. 1. COVID-19 cases and enacted policy intervals in Mexico, June 2020 - October 2021 Note. As shown in the graphic, each “interval” corresponds to three
periods of time identified as the combination of the increase of enacted policies and the peaks of contagion during this period of analysis: interval A, from June 15 to
November 30, 2020; interval B, from December 1, 2020, to May 31, 2021; and interval C, from June 1 to October 30, 2021(13). Source: Prepared by the authors
based on the data from SSA, IMSS e ISSSTE, 2020–2021.

Notwithstanding the preceding, it is remarkable that the Public health

response category was maintained throughout the analysis period, with
a marked increase during interval B.

3.1. Institutional response

When policies are analysed at an institutional level, responses show

significant differences, SSA published 65.6 % of policies, followed by
IMSS with 20.1 % and ISSSTE with 14.3 %. Fig. 3 shows an overview of
these differences between institutions.
Furthermore, while the category of Health-care management was
mostly dominated by ISSSTE, it was SSA that enacted most of the
Vaccination, Public health response, Human resources, Epidemiological
surveillance, and Clinical response as shown in Fig. 3. In all of these
cases, SSA was in charge of over 65.6 % of enacted policies.

3.2. Public health response

Public Health Response was the category with the most content
during the time frame of this study, with a total of 39.6 % of all enacted
policies (see Table 1). Embedded in Public Health Response were 29.5 %
of the “New Normal” protocols, as well as a majority of Health promo­
tion campaigns (promoting the stay-at-home campaign and social
distancing), mental health, and disease prevention campaigns. Overall,
this category shows a decreasing tendency across the analysis period,
with clear growths in each of the three intervals identified. In this re­
gard, it was mainly the SSA that published most of these policies. These
policies were 68.9 % directed to the general public to be applied, mostly
in the communities, schools, and workplaces, mainly benefitting the
general population. However, specific interest was shown in vulnerable
groups (pregnant women, newborns, and people with chronic diseases),
Fig. 2. Policies enacted by category Source: Prepared by the authors based
as well as a focus on the “New Normal protocol” for children and ado­
on the data from SSA, IMSS e ISSSTE, 2020–2021. lescents inside academic institutions. Also, there were protocols inten­
ded for airports, ports, frontiers checkpoints and hotels, and tourist
destinations. It is remarkable that the policies enacted, specifically for
onwards vaccination policies become the most prominent enacted in­
anti-discriminatory campaigns, anti-violence campaigns, and bioethical
strument, overtaking the rest of the policies. Finally, towards the end of
guidelines with 1.6 % each. The summary of results by category, sub­
interval C, vaccination policies dominate the policy arena.
categories, implementers, and beneficiaries is detailed in Appendix G.

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3.5. Health-care delivery

This group represented just 3.2 % of the whole universe analysed. 60

% of these were published in interval B; during interval A there were no
enacted policies. 40 % focused on Prioritisation of care, followed by
Homecare, Informing death of family members, and Medical guidance
(via phone), with 20 % each. These policies were directed to Health-care
professionals and the General public, to be applied in the community
and inside the Hospital, benefiting mainly the General population (see
Appendix G).

3.6. Health system infrastructure and supplies

This category represented 5.8 % of the analysed policies and were

mainly published in intervals A and B, with 44.4 % each. However, when
disaggregated by institution, there is a stark difference between each of
them: ISSSTE implemented 100 % of its policies in interval A; SSA made
three divided into intervals A and B, and IMSS three policies in intervals
B and C. These policies were addressed for implementation by the
General public, Health-care providers, and Health-care professionals,
mainly inside hospitals; to benefit mostly the general population and
COVID-19 patients.

3.7. Human resources

This group represented 5.2 % of the whole universe and over 50 % of

them were enacted by the SSA, with 50 % of their publications published
in Interval C. Almost all of them were directed to public-health pro­
fessionals (62.5 %), the General public (25 %), and the rest to Health-
care providers at a hospital setting level. Relevant subcategories corre­
spond to Economic and other stimuli for COVID-19 staff (62.5 %
together); and Mental health programs (25 %); to benefit mostly Health-
Fig. 3. Policy responses by health institution Note. Just one of the included care professionals (see Appendix G). These policies were focused on
policies was signed by ISSSTE and IMSS. Nevertheless, for this analysis was both economic incentives and periods off for health professionals within
included as a part of ISSSTE which was the main author. Source: Prepared by hospitals. It is remarkable the inclusion of policies on psychological
the authors based on the data from SSA, IMSS e ISSSTE, 2020–2021. support required after long working hours during the pandemic and the
high emotional impact that health professionals experienced daily.
3.3. Vaccination
3.8. Health-care management
At the start of interval B, policies related to vaccination began to
surge. Representing 24 % of all policies enacted (13.6 % and 10.4 % for Only 8.4 % of all the analysed policies were classified as Health-care
intervals B and C, respectively) (Table 1 and Fig. 1). They included 37.8 management. Most of them were published by ISSSTE (53.8 %) in the A
% of Immunisation Guidelines, 27 % of Vaccination rollout guidelines, and B intervals. They mainly described the reopening or reactivation of
16.2 % of Vaccination promotion campaigns, 10.8 % of Early or limited programs (30.7 %); other labour issues, Infection prevention and con­
approval of vaccines, and the rest of Vaccination resources allocation. trol, and Awareness and consent of data usage, with 15.4 % each; and
In contrast to Public Health Response, most of these policies were the 23.1 % divided equally between Approval of screening tests, Family
directed to Health-care professionals and the general public; to be Support, and Response team management. They mainly targeted the
applied in the community and hospital facilities. These policies were general public, to be applied in hospitals, benefiting the general popu­
aimed to benefit the general population 89.2 %, followed by vulnerable lation, followed by Health-care professionals and vulnerable citizens
groups 8.1 % and Health-care professionals 2.7 % (see Appendix G). (see Appendix G).

3.4. Clinical response 3.9. Epidemiological surveillance

The Clinical Response category represented 7.1 % of the policies This category concentrated most of the policies in interval B (50 %)
enacted and remained fairly constant throughout the observation representing 6.5 %. Going further into the subcategories, 50 % of the
period. However, in July 2020 and January, August, and October 2021, policies used Case confirmation algorithms, and 30 % of these include
there was an increase in these policies that correlated to the increasing the subcategory COVID-19 research process and, the rest for the Defi­
COVID-19 cases. Most of these policies were designed to be imple­ nition of the vulnerable population and guidelines for epidemiological
mented by Health-care professionals (63.6 %); Health-care providers, surveillance, to be implemented mainly by Health-care professionals
and the general public (18.2 % each); inside hospital facilities, and and Health-care providers in hospital settings, benefiting mostly the
having as main beneficiaries, COVID-19 patients (54.5 %), the general general population (see Appendix G).
population (36.4 %) and to a lesser extent pregnant women and new­
borns (see Appendix G). It is noteworthy that only one policy (ISSSTE) 4. Discussion
was aimed at indigenous communities.
The published health policies and even the communication notes
issued by the analysed institutions, decrease and increase in association

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with the number of cases. Many of the policies examined were mainly information more easily.
updates to the initial ones, highlighting the follow-up given with those Public response policies focused on strategies to mitigate contagion
previously issued by the SSA. Hence, results continue to show a reactive and the return of the country’s economic activity through the epide­
rather than a preventative health system. Throughout the different miological traffic light. However, each sovereign state determined and
COVID-19 waves, policies quickly emerged trying to solve the incoming implemented its own traffic light. In addition, this resource was not
COVID-19 difficulties. After the third wave of the epidemic contagion in planned at the beginning of the vaccination strategy and was centralised
Mexico (which started on June 15th, 2021) [14], a decrease in the and implemented officially from interval C onwards.
number of cases was expected. Nonetheless, there were three additional Only one policy was identified that addressed the indigenous com­
peaks of contagion, plus six different variants [15]. munities in the category of “Public Health Response’’, enacted by
Contrary to the cases of countries like Italy or Spain, Mexico had the ISSSTE, which sought preventive care for this population after fifteen
rare benefit of foresight, as it became evident there was a global months (Feb 27th - May 14th, 2021), since the first case of COVID-19
pandemic. In this regard, data shows how the Mexican government was detected in Mexico [19,20].
wasted vital weeks, which led to a reactive crisis response approach that Surprisingly, 4.8 % of policies related to Anti-discriminatory cam­
took institutions off guard. It was not until the first initial peak that paigns, Anti-violence campaigns, and Bioethical guidelines. This reflects
clinical response policies started to be enacted in force. It is natural for a wider approach needed to guide the response to the pandemic, one
reactive policymaking to be present in a crisis, however, the lack of that involves the psychological aspects of the Health-care workers and
scenario planning led to the number of policy spikes observed for many the population. As Tena Suck et Gaitán Rossi explained there is still a
categories. This, in turn, reduces the effectiveness of some policies, as wide gap between the needs of mental health programs and the focal­
staff have little time to understand and embed the policy before further ization and finance of those [21].
changes are needed; this is consistent with the findings of Romeu- Only 11.1 % of the “Health system infrastructure and supplies”
Labayen et al. [16]. Policymaking continued to show a similar pattern, policies (5.8 % in total) were published in interval C, which may be
even when it came to vaccination policies, which mirrored interval C. related to the decrease in hospitalizations and vaccination campaigns.
Vaccination policy likely acted as a response mechanism to the ongoing As seen previously [1], as COVID-19 cases increased, policies for addi­
peak of cases. Fig. 2 and Appendix F show that the current public health tional resource allocation (i.e. medical oxygen) were enacted, playing a
strategies seem not to be making an impact in slowing down the spread reactive rather than a preventive role. For example, policies related to
of the disease as the cases continue increasing; they have been seen as the reconfiguration of hospitals increased 30 days after the COVID-19
the vaccination strategy, a disarranged and chaotic implementation peak.
without the engagement of the population. In this sense, it is important Unlike other countries, the Ministry of Foreign Affairs (SRE, by its
to emphasise interval B, where there was the greatest accumulation of acronym in Spanish) in Mexico was in charge of the procurement process
public policies issued by the institutions analysed. These policies of vaccines from other countries; its involvement was due to the United
focused on contention campaigns, especially at the beginning of 2021, States-Mexico-Canada commercial and economic agreement (T-MEC)
just after the holidays. that catalogued the vaccines as tradable goods [22–29]. The SSA then
At the institutional level, it was the SSA that published the largest was involved in a think tank with the leaders of other Health Institutions
number of policies highlighting the central role of the federal govern­ to generate the prioritisation strategy. Mexico was the first Latin
ment in health policymaking. In this regard, IMSS and ISSSTE seemed to American country to access vaccines. Nevertheless, the implementation
be following the leading role of SSA. Compared to the results in our first proved to be challenging due to centralization, geography, and the po­
publication (analysis period from February 29th to June 15th, 2020), litical aspects that guided the policy [25,30–40]. The regulatory insti­
the IMSS published most of its policies [1]. This is likely due to the fact tution COFEPRIS approved the vaccines arriving in the country, some of
that Mexico started off the pandemic with a new executive arm of the them (CanSino, Sputnik) without published data on their efficacy and
SSA (for the uninsured population that replaced “Seguro Popular (SP)”): safety [28,29] and even accepting to buy vaccines from the USA that
the Instituto de Salud para el Bienestar (INSABI). The replacement were, at that moment, questioned on their safety [29,41]. Also,
started in January 2019 [17]; thus, the government was still working on COFEPRIS was forced to change its structure, now being part of the
the administrative and procedural guidelines for the INSABI when the Subsecretary of Prevention and no longer being a decentralised orga­
first COVID-19 case in the country was announced (Wuhan, December nisation, which might have affected the perceived neutrality of the
2019 vs Mexico, February 2020). Nevertheless, the Sub-secretary of institution [41].
Health Promotion and Prevention (SPSS, by its Spanish acronym), part As in many other countries during the pandemic [42–44], in Mexico,
of the SSA and MoH, was the governance leader in the emergency there were limited resources and an increasing number of cases and
response, rather than the main Office of the Ministry of Health [18]. deaths. This led the government to prioritise vaccination [45,46]. The
As is shown in Fig. 3, during interval A, there was the least number of vaccination strategy was thought of and discussed by several multidis­
policies enacted by the analysed institutions, taking the lead from in­ ciplinary working groups and presented to the National Vaccine Tech­
terval B onwards. Nevertheless, other governmental units and subunits nical Committee, then published in January 2021 by the Mexican
developed and communicated agreements (primarily focused on the Government [47–49] (See Appendix H). Worldwide there was a
public health recommendations for the “New Normal protocol”), mostly shortage of vaccines, creating a complex environment to roll out a
in the same period (and during interval C); those agreements were issued vaccination strategy due to the uncertainty of vaccine delivery [50].
(mostly during interval A and C), by the Official Journal of the Feder­ Moreover, as a result of the T-MEC [22–25] vaccine deployment change
ation (DOF, by its Spanish acronym), and signed by the leaders of such [51–53], the SRE became a key player in the negotiations of COVID-19
institutions. However, according to the inclusion criteria, those DOF vaccine procurement and as such, a new player in the policy spectrum in
documents were not incorporated in the final analysis since they were Mexico, outside of the health sector responsibility.
not prepared by any of the health institutions analysed. Throughout the vaccination deployment, priority was given to poor,
Although few policies related to “Clinical Response” were published rural communities and staff working in the education sector. However,
in this updated analysis, when reviewed individually, there continued to the scientific community recommended starting vaccination in dense
be no clear chronology to identify the latest update. Some were repeti­ urban areas where transmission rates were highest [32,33,54]. In some
tive and therefore confusing to health professionals. Furthermore, unlike cases, vulnerable populations were vaccinated before health personnel
our first publication (which reflects the first six months of the had had their first dose [55]. As a result, this led to several protests and
pandemic), all the information was centralised into two websites social uprisings that were caught in the national and world press media
[10,19], allowing health professionals and others access official [34–39]. Moreover, despite the risk, the private health system was not

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D. Bautista-Reyes et al. Health Policy OPEN 5 (2023) 100100

included in the initial vaccination strategy. According to Mexican offi­ respective areas of competence [57]. Additionally, in most cases was
cials, there was a lack of personnel databases in order to plan ahead for really difficult to map the content of the policies, since these policies
the prioritisation of the vaccine for these health professionals [40]. were not always properly published in the official pages, and the in­
formation between the different sources was not always consistent,
5. Conclusions complicating the process of recollection.

The Mexican government continued to be reactive to the increase in CRediT authorship contribution statement
cases or the arrival of new variants, rather than preventative. Hence,
research and development of policies need to work together in soaring Daniela Bautista-Reyes: Conceptualization, Data curation, Formal
cases like COVID-19 in order to work more effectively against the eco­ analysis, Writing – original draft, Writing – review & editing. Jimena
nomic and epidemiological burden of a pandemic. Werner-Sunderland: Conceptualization, Data curation, Formal anal­
Compared to our previous publication, after June 2020 the SSA led ysis, Writing – original draft, Writing – review & editing. Alondra Coral
policies throughout the COVID-19 pandemic. Hence, there seems to be a Aragón-Gama: Data curation, Formal analysis, Project administration,
more unified response across the health sector. However, when laying Validation, Writing – original draft, Writing – review & editing. José
out vaccination, priority is given to specific population groups. In order Roberto Cabral Duran: Writing – review & editing. Karla Daniela
to prevent social discomfort in future pandemics, more discussion on Contreras Medina: . Manuel Urbina-Fuentes: Writing – review &
vaccination layout should be carried out across the world in ethical editing. Elysse Bautista-González: Conceptualization, Data curation,
committees. Funding acquisition, Methodology, Supervision, Writing – review &
Although the number of official websites for COVID-19 information editing.
was reduced, it still wasn’t clear which documents had been updated. A
single website with information to keep health professionals updated on Declaration of Competing Interest
the appropriate literature is still encouraged.
As the COVID-19 pandemic evolved, less importance was given to The authors declare that they have no known competing financial
contact tracing and infrastructure policies; while vaccination became interests or personal relationships that could have appeared to influence
the most prevalent policy. In fact, Vaccination represented 24 % of all the work reported in this paper.
the policies published, during the time of analysis and became the sec­
ond most common category in the case of Mexico. Hence, given the Acknowledgement
importance of the existing content for vaccination research, strategies,
and/or procurement of these supplies, it is suggested that this new We would like to thank FUNSALUD for the financial contribution
category is included in the RREAL classification. towards the research. Additionaly, we would like to thank Citlali
As previously discussed, there was a significant number of policies González-Alvarez, Gunther Hasselkus, Catalina Thompson, and Yani
issued by the DOF, focused on broadcasting agreements related to the Limberopulos for their valuable research assistance.
reactivation or suspension of activities inside governmental institutions
(health-related or not health directly related). Those were not included Source of support/funding
in the final analysis, as were not signed by any of the four health in­
stitutions. This adds to the evidence that leadership during the pandemic Fundación Mexicana para la Salud A.C. (FUNSALUD) financed some
response was unclear; future research lines should analyse the Health of the research, but not the publication itself.
Governance adopted during the preparation and response against SARS-
CoV-2 in the country. Disclosure of relationships and activities (i.e., conflict of interests)
There have been several changes in the Governance of the Mexican
Health System (MHS); in the last four years, the Government decided to Jimena Werner-Sunderland certifies that she has had no privilege on
dismantle the economic instrument called Seguro Popular (which had the acquisition of information, despite having had work affiliation with
more than ten years and several improvement cycles), creating the Eli Lilly (Pharmaceutical Company) as a Medical Scientific Liaison for
INSABI, as the governing body of the MHS (see Appendix A). Never­ the Heart Failure Alliance in Mexico. The Pharmaceutical Company
theless, INSABI didn’t present its norms and regulations and after just doesn’t have any portfolio of vaccines. All the opinions written in this
32 months, on August 31st, 2022, the Government decided to substitute paper are her own and do not necessarily reflect Eli Lilly company’s
it with the founded IMSS-Bienestar [56]. This threw the country into opinion.
chaos and a state of bureaucratic miscommunication, without any ruling Roberto Cabral Duran certifies that he had no privilege in acquiring
organisation to coordinate the health strategies. To be prepared for any information, despite having a work affiliation with a global consulting
other emergency, the Mexican health system should have a united front, firm as a Senior Associate. Roberto does not directly work with any
and other sectors (i.e., the Ministry of Foreign Affairs) should be Pharmaceutical Companies as a part of his business portfolio.
considered relevant players in the future management of a pandemic.
Finally, we firmly believe that this publication in conjunction with
Ethical issues
our first one presents a rapid classification methodology for policies
useful in the health emergencies response [1].
There was no need for the ethics committee to approve this research,
as the policies included in the policy review are publicly available.
5.1. Limitations
Appendix A. Supplementary materials
Limitations to our study include the fact that the Mexican Health
System was under a reformulation some of the official webpages were
Supplementary data to this article can be found online at https://doi.
continually changing; the disorganization of the institutions publishing
org/10.1016/j.hpopen.2023.100100.
policies efficiently. More than that the enacted policies by IMSS and
ISSSTE were not published in the DOF which is the Mexican federal
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