Research Directorate, Immigration and Refugee Board of Canada

1. Availability of Health Care and Mental Health Services in Mexico
1.1 Public and Private Health Providers

According to sources, hospital care in Mexico is provided by both public and private institutions (González Block, et al. 2020, 138; Türkiye 2019, 6). A report by Miguel Á González Block et al. on Mexico's health system published by the North American Observatory on Health Systems and Policies (NAO) [1] and the European Observatory on Health Systems and Policies [2] states that public health institutions focus on acute care needs, particularly for lower-income individuals, while the private sector provides advanced care and "better-quality" services to those who are well-off (González Block, et al. 2020, 138). The same source notes, citing data from Mexico's General Directorate of Health Information (Dirección General de Información en Salud, DGIS), that

Mexico has a total of 4341 hospitals, of which 30% (1381) correspond to the public sector and are generally larger than private hospitals, which total 2960 (68%) … . Out of all public sector hospitals, 61% cater to the non-insured and 39% for the insured. Hospitals are distributed mostly in urban areas, while only 46 hospitals (3.3%) are located in rural areas. (González Block, et al. 2020, 102)

The same source further notes that

a total of 123 465 [hospital beds] were registered for 2018 in both the public and the private sectors … giving a density of 1.0 beds per 1000 inhabitants. The public sector operates 76% of beds, with federal and state ministries of health having the largest number of beds, with 39 807, while [the Mexican Institute of Social Security (Instituto Mexicano del Seguro Social, IMSS)] has 33 361. Between 2013 and 2018, total beds increased by only 0.6%, which is not sufficient to keep up with population growth. (González Block, et al. 2020, 104)

According to sources, Mexico's health care system is "fragmented" (Columbia University 21 Jan. 2022; Martinez, et al. May 2017, 497). The same sources report that the system is divided into three streams: services funded by social security for the employed population, private-sector services, and services funded by government social programs for individuals not covered by social security (Columbia University 21 Jan. 2022; Martinez, et al. May 2017, 497). According to sources, employees working for the federal government receive health coverage from Mexico's Institute for Social Services and Security for State Workers (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE) (Columbia University 21 Jan. 2022; Türkiye 2019, 6). Data for 2020 from Mexico's National Institute of Statistics, Geography and Informatics (Instituto Nacional de Estadística, Geografía e Informática, INEGI) [3] indicates that 8.8 percent of Mexico's population was [translation] "entitled" to benefits through ISSSTE (Mexico 2020). Sources indicate that employees in the private sector can receive coverage from the IMSS (Türkiye 2019, 6; Columbia University 21 Jan. 2022), which is funded by contributions from the federal government, private employers and their employees (Columbia University 21 Jan. 2022). Sources indicate that the IMSS provides coverage to "over 57 million" private-sector employees (Columbia University 21 Jan. 2022) or 51 percent of the population (Mexico 2020).

Bertelsmann Stiftung's Transformation Index (BTI) 2022, which "assesses the transformation toward democracy and a market economy as well as the quality of governance in 137 countries" and covers the period from February 2019 to January 2021, states that the Mexican government established the Seguro Popular public health insurance program in 2005, "to provide health care to members of the population not covered by any other system" (Bertelsmann Stiftung 2022, 2, 24). Sources indicate that the Seguro Popular program was replaced by the Institute of Health for Wellbeing (Instituto de Salud para el Bienestar, INSABI) program (Bertelsmann Stiftung 2022, 31; Columbia University 21 Jan. 2022) in 2020 (Columbia University 21 Jan. 2022). The 2020 INEGI data indicates that 35.5 percent of the population is [translation] "entitled" to benefits through Seguro Popular public health insurance or the INSABI (Mexico 2020). The BTI 2022 states that when INSABI was introduced there was not a "significant" increase in the budget and the creation of a new system right before the COVID-19 pandemic "contributed to very poor management of the health crisis" (Bertelsmann Stiftung 2022, 24). The same source further notes that INSABI "still lacks clear guidelines" (Bertelsmann Stiftung 2022, 31).

Sources indicate that citizens may also access health care services through social programs provided by the government that are reserved for persons not covered by social security (Columbia University 21 Jan. 2022; Martinez, et al. May 2017, 497). According to an article by William Martinez et al., published by the journal Psychiatric Services, a peer-reviewed academic journal on issues related to mental health services delivery published by the American Psychiatric Association (Psychiatric Services n.d.) and based on a qualitative study using "semistructured interviews" with 25 staff at 19 "community-based primary care clinics" in Mexico City, approximately 49 percent of citizens, those not covered by social security, receive care through community-based primary care clinics "and often are the poorest residents of Mexico" (Martinez, et al. 1 May 2017, 497). According to a report published in 2019 by the Turkish Ministry of Trade, the Mexican Ministry of Health has general hospitals in each state that are specifically intended to provide care to uninsured persons, although these are "more resource-constrained" (Türkiye 2019, 6).

1.2 Cost of Health Care and Access

According to a report published in 2019 by Columbia University's Mailman School of Public Health, "high out-of-pocket" expenses are a major barrier to health care access, particularly for low-income individuals (Columbia University 21 Jan. 2022). Similarly, according to the BTI 2022, Mexico's health care system is "underfunded" compared to other countries in Latin America, with 3.3 percent of GDP spent on the health system, resulting in "extremely high out-of-pocket expenditures (about 50%)" (Bertelsmann Stiftung 2022, 24). Without providing further information, the Columbia University report indicates that out-of-pocket costs in Mexico have fallen from 55 percent to 45 percent of health spending (Columbia University 21 Jan. 2022). The BTI 2022 notes that the government "has allocated more resources" to the health system as a result of the COVID-19 pandemic but that "these resources are insufficient" (Bertelsmann Stiftung 2022, 24).

A report by Bertelsmann Stiftung on sustainable governance in Mexico during COVID-19 notes that "Mexico has the lowest rate of hospital beds per 1,000 habitants" among countries in the Organisation for Economic Co-operation and Development (OECD), with 1.5 hospital beds per 1,000 residents (Bertelsmann Stiftung 10 Dec. 2021, 13).

The report by Türkiye's Ministry of Trade, citing the Pan American Health Organization (PAHO), states that Mexico's healthcare system is "relatively unequal" and "many people can only afford basic care" (Türkiye 2019, 8). In contrast, the report by González Block et al. indicates that the main causes of inequality are supply side barriers, such as the lack of health providers close to citizens' homes or the requirement to pay for services (González Block, et al. 2020, 180). The Bertelsmann Stiftung sustainable governance report states that there are "major inequalities" in health care and that private health care is "largely limited" to middle and upper class Mexicans who represent "roughly" 15 percent of the population "but receive about one-third of all hospital beds" (Bertelsmann Stiftung 10 Dec. 2021, 13). Similarly, the article by Martinez et al. indicates that 4 percent of the Mexican population has the financial resources to access private networks of health care providers (Martinez, et al. May 2017, 497).

A 2019 press release by the government of Jalisco State indicates that the Hospital General de Occidente opened Mexico's first sexual health unit focused on sexual rights and health care for transgender individuals (Jalisco 22 July 2019). The same source cites the head of the sexual health unit as indicating that the unit offers services in specialties such as sexology, endocrinology, urology and gynecology, as well as laboratory facilities (Jalisco 22 July 2019).

However, in its 2019 annual report, the Inter-American Commission on Human Rights (IACHR), an autonomous organ of the Organization of American States (OAS) (OAS n.d.), notes the following:

Despite the gains, the [IACHR] took note with concern of the adoption of health laws in Morelos and Nuevo León that allow service providers in the health sector to refuse to provide medical care to LGBTI persons, based on it not being in accord with their thoughts or beliefs. (OAS 2019, para. 166, footnotes omitted)

A report on the periodic review of Mexico by the UN Committee on Elimination of Racial Discrimination notes

reports that medical personnel in public health institutions have been responsible for discrimination and violence against [I]ndigenous women seeking access to sexual and reproductive health services and that in some cases sterilization procedures have been performed without free and informed consent. (UN 19 Sept. 2019, para. 24)

According to 2020 data from the WHO, while the care and treatment of individuals with mental health conditions is covered by the national insurance scheme in Mexico, the "majority" of individuals pay "at least" 20 percent towards the cost of mental health services and psychotropic medicines (UN 15 Apr. 2022, 2).

1.3 Impact of Violence on Access to Health Care Services

According to a 2022 report by the International Committee of the Red Cross (ICRC) on the humanitarian situation in Mexico, "[h]igh levels" of violence in "various parts" of Mexico have impacted access to health care services (ICRC 16 Mar. 2022, 20; SHCC May 2021, 1). Sources report that health care workers [and patients (ICRC 2020, 7)] have been killed (SHCC May 2021, 3; ICRC 2020, 7) or "attacked" (Amnesty International 13 July 2020, 38). According to the ICRC's 2020 annual report on Mexico, patients have also been abducted from hospitals, ambulances have been blocked, and health care workers have faced "abuse," "extortion" and "abduct[ion]" (ICRC 2020, 7). The same source indicates that there are certain "high-risk areas" in Mexico where health care workers will not travel, which results in a lack of access to consistent community-based health care for residents (ICRC 2020, 7).

According to a 2021 report by the Safeguarding Health in Conflict Coalition (SHCC), a coalition of over 40 organizations "working to protect health workers and services threatened by war or civil unrest," the SHCC documented "16 incidents of violence or obstruction of health care in Mexico in 2020," with 7 health care workers killed, and notes that violence by criminal organizations is rising throughout Mexico, particularly in the Guerrero region (SHCC May 2021, 3, 16).

According to a report by Amnesty International, citing data from the Mexican Ministry of Interior, as of 28 April 2020, there were "at least" 47 cases of "aggressions" against health care workers in 22 states, of which 70 percent were directed at women (Amnesty International 13 July 2020, 38). A New York Times article reports that there have been "at least" 21 "viciou[s] attacks" against nurses resulting from a perception of health workers as "vectors of [COVID-19] contagion"; victims included a nurse in Culiacán, in Sinaloa, who reported being "drenched with chlorine while walking along the street" and a nurse in Mérida, on the Yucatán Peninsula, who reported being "hit with an egg" thrown by a passing motorcyclist "(The New York Times 27 Apr. 2020).

1.4 Access to Mental Health Services

Sources report that the provisions of Mexico's General Health Law (Ley General de Salud) regarding mental health were updated (Animal Político 2 Aug. 2022; Milenio 19 May 2022) in May 2022 (Milenio 19 May 2022). Milenio, a Spanish-language national newspaper in Mexico, reports that the reforms aim to shift mental health care from a hospitalization-based model to a community-based one, adding that the new legislation requires primary and secondary medical facilities to have mental health services and staff (Milenio 19 May 2022). Animal Político, a Mexico-based online news source (Animal Político n.d.), similarly indicates that authorities are working to implement a new formula for mental health care that makes services [translation] "available in the community in order to avoid involuntary hospitalization[s]" (Animal Político 2 Aug. 2022). The same source notes that the government has undertaken a [translation] "massive" project to train primary care providers, such as nurses, social workers and general practitioners, in response to the "exponential" growth in mental health issues "in recent years" (Animal Político 2 Aug. 2022).

The General Health Act, last amended 16 May 2022, provides the following:

Article 73 Bis.- The public institutions of the National Health System shall provide access to mental health care services for the consumption of psychoactive substances and addictions in compliance with the following principles:

1. Proximity to the place of residence of the population using mental health services and those with psychoactive substance use concerns and addictions;
2. Respect for the dignity and human rights of people, with a focus on gender, equity, intersectionality, and interculturality, emphasizing the prevention, early detection, and promotion of mental health, including actions focused on the prevention of disorders caused by the consumption of psychoactive substances and addictions;
3. Promote and develop measures for mental health awareness, the eradication of stigmas and stereotypes, and improved awareness throughout society and among healthcare professionals in order to reduce all types of discrimination of populations that require the use of mental health services, as well as of people with psychoactive substance abuse challenges and addictions;
4. Harm reduction of the various risk factors experienced by the population using mental health services and those with psychoactive substance abuse challenges and addictions;
5. Priority attention will be given to populations in vulnerable situations such as children, adolescents, women, the elderly, people with disabilities, Indigenous people, Afro-Mexicans, people living on the streets and in poverty, migrants, victims of violence, and people discriminated against because of their sexual orientation or gender identity;
6. Primary healthcare as the main foundation on which community mental health and addictions care is based, within the framework of the healthcare model;
7. Ongoing access and comprehensive interdisciplinary care required by the population using mental health services and people with psychoactive substance abuse challenges and addictions
8. Involvement of family members and mutual aid organizations for care.

Article 73 Ter.- In order to combat stereotypes or other widely disseminated, oversimplified, and often mistaken ideas or images about the population requiring mental health and addiction support services, the mental health authorities and service providers shall carry out:

1. Training programs for mental health professionals, teachers, and educational authorities;
2. Dissemination of social media campaigns using clear language, accessible formats, and with linguistic relevance across different media, both conventional and other platforms, aimed at the general population to emphasize the dignity and human rights as well as a respectful image of people requiring mental health and addiction services, with confidentiality protection and the right to not identify oneself as a person with psychosocial disabilities;
3. Educational programs on mental health with a human rights and gender perspective for families, schools, and workplaces; and
4. Programs in mass media using clear language, accessible formats, and with linguistic relevance.

Article 74.- In order to ensure access and continuous care for mental health and addictions, outpatient primary care establishments and psychiatric services shall be available in general hospitals, specialized regional hospitals, and national health institutes.

Likewise, in order to eliminate the psychiatric asylum model, no more psychiatric-specific hospitals should be built, and the current psychiatric hospitals should be progressively converted into outpatient centres or general hospitals within the overall health services network.

Article 74 Bis.- The Ministry of Health, in following a human rights approach, shall explicitly prioritize interventions in mental health and addictions that ensure access to prevention and care actions in this area.

Article 74 Ter.- The population using mental health services shall have the following rights:

1. The right to the best available mental health care that includes an intercultural perspective, linguistic relevance, and gender perspectives, which includes treatment without discrimination and with respect for the dignity of every patient, in facilities throughout the National Health System network;
2. The right to decision support mechanisms and advance directives on informed consent;
3. he right to informed consent by the person who will receive the treatment;
4. The right not to be subjected to measures of isolation, coercive restraint, or any other practice that constitutes cruel, inhuman or degrading treatment and, where appropriate, be subjected to crisis mitigation measures;
5. The right to a comprehensive and interdisciplinary diagnosis and treatment based on an individually prescribed plan with clinical history, periodically reviewed and modified according to the patient’s development, which ensures respect for their dignity as a human person and their human rights;
6. The right not to be subjected to irreversible treatments or treatments that modify the integrity of the person;
7. The right to be treated and cared for in their community or as close as possible to the place where their family or friends live;
8. The right to confidentiality of health information;
9. The right to access and availability of mental health and addiction services, and
10. The rights stipulated in national legislation and binding international treaties and conventions to which Mexico is a party.

Article 75.- The hospitalization of those using mental health services and persons with challenges around the consumption of psychoactive substances and addictions shall be used as a last therapeutic resort, and shall meet the aforementioned ethical and social principles, respect for human rights, the dignity of the person, as well as the requirements determined by the Ministry of Health and other applicable legal provisions.

Hospitalization may only be carried out on a voluntary basis and when it provides greater therapeutic benefits for the person than the other possible interventions; it shall only be carried out for the time that it is strictly necessary and at the General or Pediatric Hospital closest to the patient's home.

Under no circumstances shall hospitalization be carried out or prolonged, if it is intended to solve familial, social, labour, housing, or patient care problems.

In the case of children or adolescents, community alternatives will be favoured; if there is clinical justification for hospitalization, it shall be carried out in general hospitals or pediatric hospitals, and the opinion of the children or adolescents will be sought and recorded in the patient’s clinical record. In case of disagreement with hospitalization, the institution, together with the mother, father, or guardian, shall evaluate other alternatives of care.

Article 75 Bis.- All treatment and hospitalization of those in need of mental health services and persons with challenges related to psychoactive substances abuse and addictions shall be given prior informed consent.

Providers of public or private mental health services are obliged to communicate to the person, in an accessible, timely manner and in understandable language, truthful and complete information, including the objectives, benefits, possible risks, and alternatives of a given treatment, to ensure that the services are provided on the basis of free and informed consent. Once the information has been entirely understood through the necessary means and supports, the population using mental health services has the right to accept or refuse them.

The individual facing mental and substance abuse challenges and addictions has the right to consent or refuse permission for any treatment or hospitalization, so all patients should be presumed to have the capacity to comprehend, and every effort should be made to allow a person to voluntarily accept treatment or hospitalization.

Article 75 Ter.- If they anticipate requiring health care services in the future, individuals have the right to make a request in advance in which they may determine the actions they wish to be taken in their treatment, or their refusal to receive treatment. This request in advance will set, if applicable, the form, scope, duration, and guidelines of such support, as well as the time or circumstances in which their designation of future support will be effective. At any time, a person may revoke the content of any previously adopted request in advance. (Mexico 1984)

According to the article by Martinez et al., "[d]espite the high prevalence" of mental health conditions in Mexico, there are "minimal" mental health services available and "large gaps" treatment (Martinez, et al. May 2017, 497). Similarly, another report by researchers in Mexico, published in the International Journal of Mental Health Systems (IJMHS), a peer-reviewed journal published by Springer Nature which covers mental health research (IJMHS n.d.), indicates that there are "deficiencies" in access to mental health services in Mexico due to a lack of services and an unequal distribution of outpatient and community mental health resources (Carmona-Huerta, et al. 11 Jan. 2021, 2). The same source, citing data obtained from research published in 2018, states that "87.4% of people with a mild mental disorder, 77.9% of those with moderate disorders and 76.2% of those with severe mental disorders, such as schizophrenia or bipolar disorder, do not receive treatment" (Carmona-Huerta, et al. 11 Jan. 2021, 1–2).

González Block et al. note that many patients with mental health disorders covered by Seguro Popular [4] "still struggled with difficulties in the referral process and the confirmation of the validation of payments" (González Block, et al. 2020, 154).

The WHO indicates that in 2020, 1.8 percent of Mexico's health expenditure was on mental health, with 62.7 percent of that spending going towards psychiatric hospitals (UN 15 Apr. 2022, 1). According to an article by Beatriz Reyes-Foster, an associate professor of anthropology at the University of Central Florida who researches mental health in Yucatán, and Whitney L. Duncan, an associate professor of anthropology at the University of North Colorado who researches global mental health, "[o]nly" 2 percent of the overall public health budget is devoted to mental health, with 80 percent of that amount going toward funding psychiatric hospitals (Reyes-Foster and Duncan 27 Aug. 2020, 283, 288).

The information in the following tables on the availability of mental health facilities and care was provided by the WHO:

Inpatient Mental Health Facilities

	Total facilities
Mental hospitals	40
Psychiatric units in general hospitals	52
Community residential facilities	7
Inpatient facilities specifically for children	1

Outpatient Mental Health Facilities

	Total facilities
Outpatient facilities attached to a hospital	412
Community-based/non-hospital facilities	400
Other outpatient facilities (e.g., mental health day care or treatment facility)	7
Facilities specifically for children and adolescents	785

Inpatient Mental Health Care

	Beds per 100,000 inhabitants	Annual admissions per 100,000 inhabitants
Mental hospital	2.80	24.60
General hospital psychiatric unit	0.20	2.47
Community residential	0.13	2.46
Child and adolescent specific	0.21	2.23

Outpatient Mental Health Care

	Visits per 100,000 inhabitants in the previous year
Number of visits by service users to mental health outpatient facilities attached to a hospital	944.88
Number of visits by service users to community-based/non-hospital mental health outpatient facilities	431.83
Number of visits by service users to other outpatient facilities	77.10
Number of visits made by service users to outpatient facilities specifically for children and adolescents	860.97

(UN 15 Apr. 2022, 2)

The WHO also notes that 414 community-based mental health facilities exist, at a ratio of 0.32 per 100,000 inhabitants (UN 15 Apr. 2022, 2).

Reyes-Foster and Duncan note that "Mexico's psychiatric services have always been concentrated in large urban centers" (Reyes-Foster and Duncan 27 Aug. 2020, 285). Similarly, Carmona-Huerta et al. indicate that the distribution of specialized mental health personnel is "uneven" throughout Mexico and that there is a higher concentration in large cities, with "very few or almost none" in rural areas (Carmona-Huerta, et al. 11 Jan. 2021, 2).

The information in the following two tables regarding the mental health workforce was provided by the WHO:

	Total number (government and non-government)	Number per 100,000 inhabitants
Psychiatrists	1,996	1.56
Mental health nurses	6,198	4.86
Psychologists	7,469	5.85
Social workers	1,741	1.36
Other specialized mental health workers (e.g., occupational therapists)	1,338	1.05
Total mental health professionals	18,742	14.69

	Total number (government and non-government)	Number per 100,000 inhabitants
Child and/or adolescent psychiatrists	176	0.39
Total mental health workers in child and adolescent mental health services	1,542	3.46

(UN 15 Apr. 2022, 2)

González Block et al. state that Mexico has "insufficient mental health human resources" (González Block, et al. 2020, 155).

Carmona-Huerta et al. indicate that according to the WHO, the recommended rate of psychiatrists is 5.0 per 100,000 inhabitants (Carmona-Huerta, et al. 11 Jan. 2021, 2). Corroborating information could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.

2. Mexico City

Reyes-Foster and Duncan indicate that "over" 40 percent of Mexico's psychiatrists are located in Mexico City (Reyes-Foster and Duncan 27 Aug. 2020, 285). According to the report by González Block et al., Mexico City has 177 total public hospital beds per 100,000 inhabitants, compared with the national average of 74 beds per 100,000 (González Block, et al. 2020, 106). The Turkish Ministry of Trade indicates that in 2017, according to the OECD, Mexico City had 2.4 beds per 1,000 inhabitants, while the national average was 1.4 beds per 1,000 inhabitants (Türkiye 2019, 4).

A report by the Ministry of Health (Secretaría de Salud) of the government of Mexico City indicates that there are 392 medical units in the city, including 260 primary care units and 32 hospitals (Mexico City [2021], 15).

The information in the following table was provided in the 2021 update to the ISSSTE's Unified Directory of Medical Units (Catálogo Único de Unidades Médicas), a document detailing health care facilities and services in Mexico:

Medical Units by Neighbourhood in Mexico City

	Primary Care	Secondary Care	Tertiary Care	Total
North (Norte)	36	6	1	43
East (Oriente)	7	2	1	10
West (Poniente)	11	3	0	14
South (Sur)	18	5	2	25
Total	72	16	4	92

(Mexico [2021], 9, 19, 33)

In the study conducted by Martinez et al., health care workers interviewed reported shortages of both staff and necessary medications, and according to interviewees in the same study, medical personnel are overworked and "lac[k] the time necessary to adequately evaluate and treat physical ailments"; as a result, staff "believed that they would not have the time to adequately detect mental health issues" (Martinez, et al. 1 May 2017, 499). Corroborating information could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.

3. Yucatán (Mérida)

According to the ISSSTE health unit directory update, Yucatán State has 17 health care units: 14 for primary care, 2 for secondary care, and 1 for tertiary care [5] (Mexico [2021], 143).

The information in the following paragraph was provided by Reyes-Foster and Duncan:

Yucatán has two community mental health centres that are "both located in large urban settings and largely inaccessible to rural residents." According to a psychiatrist working at Mérida's Hospital Psiquiátrico Yucatán, "the greatest obstacle to mental health coverage is organizational not financial" noting that mental health services are "unevenly distributed" with community-based psychiatric services "concentrated" in cities such as Mérida and Valladolid. The same psychiatrist indicated that while they continued to provide outpatient psychiatric care in person during the COVID-19 pandemic, "all" staff psychologists shifted to providing telephone therapy through the "state mental health phone bank" (Reyes-Foster and Duncan 27 Aug. 2020, 286, 287). Corroborating information could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.

4. Jalisco (Guadalajara)

According to the ISSSTE health unit directory update, Jalisco State has 88 health care units: 84 for primary care, 3 for secondary, and 1 for tertiary (Mexico [2021], 78).

Carmona-Huerta et al. indicate that the community mental health network in Jalisco has a total of 31 centres with services for mental health care, and includes the following:

• 13 modules of mental health care in charge of the Ministry of Health,
• 8 Comprehensive Mental Health Centres (Centros Integrales de Salud Mental, CISAME),
• 5 community hospitals,
• 3 general hospitals
• 2 psychiatric hospitals
  
  • The Short-Stay Comprehensive Mental Health Care Centre (Centro de Atención Integral en Salud Mental de Estancia Breve, CAISAME-EB)
  • The Long-Stay Comprehensive Mental Health Care Centre (Centro de Atención Integral en Salud Mental de Estancia Prolongada, CAISAME-EP) (Carmona-Huerta, et al. 11 Jan. 2021, 6).

Carmona-Huerta et al. state that Jalisco has 8 of the 54 CAISAMEs in Mexico, which makes it the state with the "most" centres in the country (Carmona-Huerta, et al. 11 Jan. 2021, 3). The same source indicates that 23 of the 125 municipalities in Jalisco have "at least" one mental health care centre (18.4 percent of municipalities) (Carmona-Huerta, et al. 11 Jan. 2021, 6). The source further states that the rate of mental health workers in Jalisco is 0.64 for every 10,000 inhabitants over 15 years of age and notes that the rate of mental health workers in Jalisco is "well below the global rate" (Carmona-Huerta, et al. 11 Jan. 2021, 6, 7). Corroborating information could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.

5. Treatment of Persons with Mental Illness and State Protection

Sources indicate that individuals with mental health conditions face stigma (Carmona-Huerta, et al. 11 Jan. 2021, 2; Lagunes-Cordoba, et al. 5 Sept. 2020, 990; Martinez, et al. May 2017, 499) and "discrimination" (Carmona-Huerta, et al. 11 Jan. 2021, 2). An article in the Community Mental Health Journal, a journal of the American Association for Community Psychiatry published by Springer (Springer n.d.), on the perceptions of stigma among mental health service users in Mexico, based on a qualitative study using focus groups and interviews with individuals receiving services from a psychiatric hospital in Mexico City with a total of 47 participants, finds that while participants considered members of society "the main source of stigma," they "also considered psychiatrists to hold stigmatising attitudes towards their patients" (Lagunes-Cordoba, et al. 5 Sept. 2020, 986, 988, 990).

According to sources, persons with disabilities, including mental health disabilities, faced human rights violations and abuse in psychiatric institutions in Mexico (US 30 Mar. 2021, 29, 30; DRI 26 Oct. 2020, 5, 6). The same sources report these abuses of persons with disabilities at institutions included the use of physical and chemical restraints, physical and sexual abuse (DRI 26 Oct. 2020, 5–6; US 30 Mar. 2021, 31) and forced sterilization (DRI 26 Oct. 2020, 5).

The US Department of State's Country Reports on Human Rights Practices for 2020 states that "[i]nstitutionalized persons with disabilities often lacked adequate medical care and rehabilitation services, privacy, and clothing; they often ate, slept, and bathed in unhygienic conditions" (US 30 Mar. 2021, 30). A Human Rights Watch (HRW) report on family violence against individuals with disabilities in Mexico, based on research conducted in 2018 and 2019 including interviews with 24 women and 14 men with disabilities in the states of Oaxaca, Jalisco, Nuevo León, and Mexico City "who had been victims of physical and emotional abuse by family members with whom they live," indicates that women with "real or perceived psychosocial disabilities" were denied access to Mexico's national domestic violence shelters and instead were referred to a psychiatric hospital (HRW 4 June 2020). The same source notes that managers, senior government officials, and advocates who were interviewed by HRW "confirmed that they do not allow women with diagnosed mental health conditions to enter shelters" (HRW 4 June 2020).

A report by Disability Rights International (DRI), an international human rights organization based in Washington, DC and "dedicated to the rights and full participation in society of people with disabilities," on the treatment of children and adults with disabilities in Mexican institutions states that "investigators recorded extensive accounts of physical and sexual abuse" (DRI 26 Oct. 2020, 2, 5). The same source documented the following incidents:

• At an institution in Mexico City, "run by a Catholic order, investigators observed dozens of children and adults held in cages and tied down to beds" (DRI 26 Oct. 2020, 6).
• At a rehabilitation centre in Mexico [City], "nearly all children and adults were restrained with layers of bandages from head to toe for at least an hour a day" (DRI 26 Oct. 2020, 6).
• "In several facilities, dangerous conditions and inappropriate care has led to high death rates. At the El Batan psychiatric facility, for example, authorities report that at least 98 of the approximately 300 people at the facility have died in the last two years" (DRI 26 Oct. 2020, 7).
• "DRI observed the use of physical and/or chemical restraints in 83% of the institutions for people with disabilities [they] visited – much of it for prolonged periods of time" (DRI 26 Oct. 2020, 8).

The DRI report notes that there are no laws in Mexico limiting the use of restraints and no requirement to document the use of restraints (DRI 26 Oct. 2020, 8). The same source states that there is "a culture of impunity in which abusers are not held accountable and government authorities fail to respond to known human rights violations in institutions" (DRI 26 Oct. 2020, 8). The DRI report further states the following:

Despite well documented abuses, Mexico has not created the human rights oversight and enforcement systems necessary to protect its institutional populations. Indeed, creating policies and programs to respond to abuses has been impossible because the main authorities responsible for operating these services – the national Ministry of Health, the System for Integral Family Development ([Sistema nacional para el desarrollo integral de la familia,] DIF), the Ministry for Social Development [Secretaría de Desarrollo Social], and the National System for the Integral Protection of Children and Adolescent ([Sistema Nacional de Protección de Niñas, Niños y Adolescentes,] SIPINNA) – do not even track the number of people placed within these systems. (DRI 26 Oct. 2020, 8)

HRW reports that a "regressive" draft mental health bill, which would have permitted families, with the approval of a medical expert, to force people with psychosocial disabilities to accept medical treatment or be hospitalized, and to "force kids with so-called 'mental health and behavioral disorders' to be institutionalized," "was put on hold" prior to going before the Senate for a vote (HRW 19 Aug. 2020). The same source indicates that a coalition of human right organizations, including HRW and a number of organizations that advocate for individuals with disabilities in Mexico, campaigned against the bill and the Mexican Senate responded by removing the bill from their agenda and initiating a consultation process with disability rights organizations (HRW 19 Aug. 2020). Further information on the draft mental health bill could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.

This Response was prepared after researching publicly accessible information currently available to the Research Directorate within time constraints. This Response is not, and does not purport to be, conclusive as to the merit of any particular claim for refugee protection. Please find below the list of sources consulted in researching this Information Request.

Notes

[1] The North American Observatory on Health Systems and Policies (NAO) is "a collaborative partnership" of researchers, academic and health organizations, and governments which "promotes evidence-informed health system policy decision-making" in Canada, Mexico, and the US (González Block, et al. 2020, iii).

[2] At the European Observatory on Health Systems and Policies "policy-makers, academics and practitioners" collaborate to "promot[e] evidence-based health policy-making through comprehensive and rigorous analysis of health systems in Europe" (González Block, et al. 2020, iii).

[3] Mexico's National Institute of Statistics, Geography and Informatics (Instituto Nacional de Estadística, Geografía e Informática, INEGI) is the "autonomous public body" responsible for gathering and sharing information on Mexico's population, economy, territory and resources (Mexico n.d.).

[4] Mental health disorders covered by Seguro Popular include "attention deficit disorder with hyperactive component," affective disorders such as depression and bipolar disorder, anxiety disorders, and psychotic disorders such as schizophrenia (González Block, et al. 2020, 154).

[5] The Institute for Social Services and Security for State Workers (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE) classifies medical services into three levels of care as proposed by the WHO—primary, secondary, and tertiary—based on a unit's treatment capacity and structure (Mexico [2021], 19). Primary care refers to preventative and outpatient care, as well as the treatment of common ailments (El Universal 10 Jan. 2020). Secondary care covers [translation] "most" ailments requiring hospitalization or urgent care, as well as "'basic'" surgical procedures (El Universal 10 Jan. 2020). Tertiary care is "specialized [and] more complex"; this category also includes research activities (El Universal 10 Jan. 2020).

References

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Bertelsmann Stiftung. 2022. "Mexico Country Report." Bertelsmann Stiftung's Transformation Index (BTI) 2022. [Accessed 29 Aug. 2022]

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Additional Sources Consulted

Oral sources: Researcher with a school of public health at a university in California.

Internet sites, including: Asociación Psiquiátrica Mexicana; Australia – Department of Foreign Affairs and Trade; Austrian Red Cross – ecoi.net; Center for Strategic and International Studies; Compañeros en Salud; Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz – Salud Mental; Jalisco – Gobierno de Jalisco, Instituto de Información Estadística y Geográfica del Estado de Jalisco; La Jornada; Medical News Today; Mental Health Innovation Network; Mérida – Dirección de Salud y Bienestar Social; Mexico – Instituto Mexicano del Seguro Social, Secretaría de Salud; México Evalúa; Organisation for Economic Co-Operation and Development; Orgullo Loco; Partners in Health; Red Voz Pro Salud Mental; UK – Home Office; UN – Committee on the Rights of Persons with Disabilities, General Assembly, Refworld; Universidad Veracruzana; US – Centers for Disease Control and Prevention; Yo Quiero Yo Puedo; Yucatán – Servicios de Salud de Yucatán.