Article Text

Advances and challenges on the path toward the SDGs: subnational inequalities in Mexico, 1990–2017
  1. Juan Pablo Gutierrez1,
  2. Marcela Agudelo-Botero1,
  3. Sebastian Garcia-Saiso1,
  4. Carolina Zepeda-Tena1,
  5. Claudio Alberto Davila-Cervantes2,
  6. Maria Cecilia Gonzalez-Robledo3,
  7. Nancy Fullman4,
  8. Christian Razo4,
  9. Bernardo Hernández-Prado4,
  10. Gabriel Martínez5,
  11. Simón Barquera6,
  12. Rafael Lozano4
  1. 1Center for Policy, Population & Health Research, Universidad Nacional Autónoma de México, Coyoacan, Mexico
  2. 2Departamento de Población y Desarrollo, Facultad Latinoamericana de Ciencias Sociales Mexico, Mexico DF, Mexico
  3. 3Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública, Cuernavaca, Mexico
  4. 4Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
  5. 5Departamento Académico de Economía, ITAM, Alvaro Obregon, Mexico
  6. 6National Institute of Public Health, Cuernavaca, Mexico
  1. Correspondence to Dr Rafael Lozano; rlozano{at}


Background The sustainable development goals (SDGs) have generated momentum for global health, aligning efforts from governments and international organisations toward a set of goals that are expected to reflect improvements in life conditions across the globe. Mexico has huge social inequalities that can affect access to quality care and health outcomes. The objective of this study is to analyse inequalities among Mexico’s 32 states on the health-related SDG indicators (HRSDGIs) from 1990 to 2017.

Methods These analyses rely on the estimation of HRSDGIs as part of the Global Burden of Disease study 2017. We estimated the concentration index for 40+3 HRSDGI stratified by Socio-demographic Index and marginalisation index, and then for indicators where inequalities were identified, we ran decomposition analyses using structural variables such as gross domestic product per capita, poverty and health expenditure.

Findings Mexico has made progress on most HRSDGIs, but current trends in improvement do not appear to fast enough to meet 2030 targets. Out of 43 HRSDGIs, we identified evidence of inequality between Mexico’s states for 30 indicators; of those, 23 HRSDGIs were unequal distributed affecting states with lower development and seven affecting states with higher development. The decomposition analysis indicates that social determinants of health are major drivers of HRSDGI inequalities in Mexico.

Interpretation Modifying current trends for HRSDGIs will require subnational-level and national-level policy action, of which should be informed by the latest available data and monitoring on the health-related SDGs. The SDGs’ overarching objective of leaving no-one behind should be prioritised not only for individuals but also for communities and other subnational levels.

  • health policy
  • public health

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  • Handling editor Eduardo Gómez

  • Twitter @gutierrezjp

  • Contributors JPG, MA-B, SG-S, CZ-T, CAD-C, MCG-R and RL conceived the study. JPG designed and implemented the inequalities analysis. MA-B and CAD-C implemented the trend analysis. JPG, MA-B, SG-S, CZ-T, CAD-C, MCG-R, NF and RL drafted the manuscript. All authors discussed the results and contributed to the final manuscript.

  • Funding This study was funded by Bill and Melinda Gates Foundation.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. Data used for these analyses are available at the Institute for Health Metrics and Evaluation GBD Project website

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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