The Effects of Violence on the Provision/Access to Healthcare Services: A Qualitative Analysis of Health Outcomes in Mexico

Background and Purpose: Mexico has lived through prolonged endemic violence caused by organized crime and the war on drugs. This research seeks to learn more about the effects of violence on the provision (and access) to health care services and any impacts on the health of individuals. While some research has explored the effects of exposure to violence on early life health, the effects of violence on the provision and access to health services remains largely unexplored. Quantitative inquiry alone is insufficient in studying this phenomenon because it’s difficult to isolate causal relationships between disruptions to provision of health care services and individual health outcomes. Qualitative fieldwork invaluably informs how mechanisms of service delivery and health are affected by violence. This paper fills a gap by examining the accounts of health service providers that have had direct or indirect exposure to violence in their work environments and communities.

Methods: Fifty three semi-structured ethnographic interviews were conducted with physicians (56% of sample), mental health providers (10%) and social workers (5%) located in three states of Mexico selected for their high incidence of violence, as well as key informants (29%) located in Mexico City to provide a policy context of the health system. The sample is predominantly male (68%). This study used snowball sampling through local public health agencies and recruitment was through telephone or email.

Interviews focused on participant’s perceptions of how violence affects their ability to provide services or the community to access them, focusing on perceptions of direct or indirect effects of violence on the health of their patients and communities. Field notes, observations and recordings were transcribed, and coded thematically using ATLAS.ti qualitative software, framework analysis was used to interpret key themes and findings.

Findings: Data analysis reveals health provider related effects embodied in a shortage of specialists in various fields ranging from surgery to traumatology in all three states. Violence also affects service provision through reductions in the hours of operation of primary healthcare centers, additionally affecting service provision through the limiting or cancelling of certain services such as scheduled surgery, vaccination campaigns, and home-care visits.

Mental health care is severely underprovided, coupled with a marked shortage of psychologists and social workers it renders mental health care to be severely underprovided and under measured in the Mexican healthcare system. People adapt to contexts of violence and tend to go out less and are inhibited from leading healthier lifestyles.

Conclusions and Implications: Findings reveal that specialty physicians will gravitate away from regions that are violent, despite efforts of public health agencies to offer higher compensation as an incentive to attract specialists. Service providers also give accounts of how they are able to adapt service delivery, for example through the use of Skype enabled TeleMedicine that connects primary care physicians and patients outside of large urban areas with specialists. This study underscores the importance of understanding how violence affects service delivery and the need for improving preventive efforts that may be applicable in other contexts or geographic regions.