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CASALUD: an innovative health-care system to control and prevent non-communicable diseases in Mexico
Roberto Tapia-Conyer, Hctor Gallardo-Rincn and Rodrigo Saucedo-Martinez
Perspectives in Public Health published online 27 November 2013
DOI: 10.1177/1757913913511423

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511423
2013
RSH0010.1177/1757913913511423CasaludCasalud

PEER REVIEW

CASALUD: a health-care system to prevent non-communicable diseases

CASALUD: an innovative health-

care system to control and
prevent non-communicable
diseases in Mexico
Authors
Abstract
Roberto Tapia-Conyer
Carlos Slim Health Institute,
Mexico and other Latin American countries are currently facing a dramatic increase in the
Mexico City, Mexico
number of adults suffering from non-communicable diseases (NCDs) such as diabetes,
Hctor Gallardo-Rincn cardiovascular disease (CVD) and chronic kidney disease (CKD), which require prolonged,
Carlos Slim Health Institute, continuous care. This epidemiological shift has created new challenges for health-care
Lago Zurich 245 Torre
Carso Piso 20, Mexico City, systems. Both the World Health Organization (WHO) and the United Nations (UN) have
11529, Mexico recognised the growing human and economic costs of NCDs and outlined an action plan,
Email: hgallardo@salud. recognising that NCDs are preventable, often with common preventable risk factors linked to
carlosslim.org
risky health behaviours. In line with international best practices, Mexico has applied a number
Rodrigo Saucedo- of approaches to tackle these diseases. However, challenges remain for the Mexican health-
Martinez care system, and in planning a strategy for combating and preventing NCDs, it must consider
Carlos Slim Health Institute, how best to integrate these strategies with existing health-care infrastructure. Shifting the
Mexico City, Mexico
paradigm of care in Mexico from a curative, passive approach to a preventive, proactive
model will require an innovative and replicable system that guarantees availability of
medicines and services, strengthens human capital through ongoing professional education,
expands early and continuous access to care through proactive prevention strategies and
Corresponding author: incorporates technological innovations in order to do so. Here, we describe CASALUD: an
Hctor Gallardo-Rincn, as
innovative model in health-care that leverages international best practices and uses
above
innovative technology to deliver NCD care, control and prevention. In addition, we describe
the lessons learned from the initial implementation of the model for its effective use in Mexico,
Keywords
innovation; Latin America; as well as the plans for wider implementation throughout the country, in partnership with the
Mexico; NCDs; non- Mexican Ministry of Health.
communicable diseases;
policy; primary health care;
prevention; public health;
technology INTRODUCTION non-communicable diseases (NCDs), such
Mexico and other Latin American countries are as type 2 diabetes mellitus (DM2), cardiovascular
currently facing a demographic and disease (CVD) and chronic kidney disease
epidemiological shift that has transformed (CKD), which require prolonged, continuous
morbidity and mortality profiles, creating new care.
challenges for the health-care system. The prevalence of NCDs in Mexico has
Widespread improvements in sanitation and increased rapidly in the last 20 years. For
access to clean drinking water, as well as example, the prevalence of DM2 in Mexico in
technological advances, have led to increased life 2012 was 9.1%, compared to 4.0% in 1993
expectancy from birth.1 The resultant ageing of (Figure 1), positioning Mexico as the country with
the population, combined with increasingly the highest prevalence in Latin America.26 A
sedentary lifestyles, has produced a dramatic survey estimated the 2006 prevalence of DM2 at
increase in the number of adults suffering from 14.4%, with almost half of people surveyed not

Copyright Royal Society for Public Health 2013 Perspectives in Public Health 1
SAGE Publications
ISSN 1757-9139 DOI: 10.1177/1757913913511423

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 PEER REVIEW

CASALUD: a health-care system to prevent non-communicable diseases

Figure 1

Rising prevalence of diabetes mellitus and intermediate risk factors in Mexico, 19932012

Data from various surveys.25

Prevalence of diabetes mellitus and its intermediate risk factors pre-obesity, obesity and hypertension has risen dramatically in Mexico in the last 20
years. Numbers show the percentage of the Mexican adult population suffering from these conditions and arrows show the percentage increase
between 1993 and 2012.

aware they had diabetes, suggesting that
the rise in NCDs may be further
compounded by a lack of access to
health-care.7
This shift has also increased the ratio
of morbidity and mortality attributable to
NCDs. In 1975, NCDs accounted for
54.5% of Mexicos mortality rate;
however, by 2000, this had increased to
82.5% of deaths, with the remaining
17.5% associated with transmissible
diseases, injuries, nutritional, maternal
and perinatal causes. The leading
causes of death for both men and
women in Mexico are CVD and DM2,
accounting for 105,144 deaths (17.8%
of total deaths) and 82,964 deaths
(14.0%), respectively.8 It is predicted
that by 2025, NCDs will account for
90% of deaths.8 Expressing the
burden of disease in disability-adjusted
life-years (DALYs), NCDs account for
72% of total disease burden in Mexico,
above the average of upper-middle

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CASALUD: a health-care system to prevent non-communicable diseases

Table 1

Deaths and average prevalence of intermediate risk factors for Latin America and Mexicoa

Indicator Latin Americab Mexico

Total NCD deaths per 100,000 585.4 542.6

Prevalence of pre-obesity in adults aged 20+ years (%) 58.3% 69.1%

Prevalence of obesity in adults aged 20+ years (%) 24.8% 32.8%

Prevalence of raised blood pressure in adults aged 25+ years (%) 39.6% 36.1%
Prevalence of raised blood glucose in adults aged 25+ years (%) 10.8% 14.1%

NCD: non-communicable disease; WHO: World Health Organization; BMI: body mass index; pre-obesity: BMI 25 kg/m2; obesity: BMI 30 kg/m2;
raised blood pressure: systolic 140 mmHg and/or diastolic 90 mmHg or on medication; raised blood glucose: fasting glucose 7.0 mmol/L or on
medication.
This table is the authors own work, based on data from the WHO.13 All estimates are age-standardised adjusted estimates, including both sexes.
aConsiders most recent national data for each country at time of compilation.
bLatin American countries include Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba,

Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay,
Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Uruguay and Venezuela (the Americas
region classification used by the WHO, excluding Canada and the United States).

income countries in Latin America
(62.9%).9
The current epidemic of NCDs has
serious economic consequences for
individuals and society. Direct costs
include expenditure on medical
consultations, drugs and treatment of
complications, but there are also indirect
costs such as loss of productivity,
absence from work of patients or carers
and permanent disability. For the Latin
American and Caribbean regions,
diabetes-related health-care costs were
estimated at US$65 billion annually,
which is 2%4% of gross domestic
product (GDP) or 8%15% of national
health-care budgets.10 Data from
Mexico, which considered both direct
and indirect costs, estimated the annual
cost of DM2 in 2011 as US$7.7 billion:
US$3.4 billion direct costs and US$4.3
billion indirect costs.11 Data from the
Mexican Social Security System showed
that all treatment of patients with
diabetes, including complications,
amounted to US$3.84 million per day.
The human and economic costs of
NCDs in Latin America represent a crisis
that must be tackled urgently. In planning
a strategy for combating and preventing
NCDs, we must consider their causes,
consequences and how best to integrate
plans with existing health-care
infrastructure.
Causes and consequences of NCDs
An important point in understanding and
tackling the rise of NCDs is that they are
preventable, and often have common
modifiable risk factors linked to risky
health behaviours. Behaviours such as
tobacco use, physical inactivity,
consumption of an unhealthy diet and
alcohol use can lead to physiological
changes, or intermediate risk factors for
NCDs.12 These intermediate risk factors
include hypertension, pre-obesity or
obesity, hyperglycaemia and
hyperlipidaemia. In Latin America, the
proportion of deaths attributable to
NCDs and the rising regional prevalence
of intermediate risk factors for NCDs are
significant and call for urgent action
(Table 1; Figure 1).
Globally, the leading intermediate risk
factor for deaths attributed to NCDs is
raised blood pressure, accounting for
13% of global mortality, followed by
hyperglycaemia (6%), and pre-obesity
and obesity (5%). Risky health
behaviours such as tobacco use (9%)
and physical inactivity (6%) are also
major contributors to NCD-related
mortality.13,14 Evidence suggests that up
to 80% of premature heart disease,
stroke and DM2 could be prevented
through healthy diet, regular exercise and
avoidance of tobacco use.15 Also,
compared to individuals with a normal
body mass index (BMI) of 18.524.9 kg/
m2, overweight, or pre-obese, individuals
(BMI = 25.029.9 kg/m2) have twice the
risk of developing DM2; obese individuals
(BMI = 30.034.9 kg/m2) have three
times the risk, and morbidly obese
individuals (BMI > 35.0 kg/m2) six times
the risk.16
NCDs and their associated risk factors
have an enormous impact on the
incidence of several inter-related health
conditions, and are themselves
inextricably related. NCDs account for
half of all global disability, including
physical (e.g. blindness and loss of limbs)

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 PEER REVIEW
CASALUD: a health-care system to prevent non-communicable diseases
and mental (e.g. chronic depression)
impairment.17,18 DM2, hypertension and
CVD are all major causes of CKD. Over
5% of people diagnosed with DM2 have
CKD and an estimated 40% of patients
with both type 1 and 2 diabetes will
develop CKD during their lifetime, the
majority within 10 years of diagnosis.19 In
addition, kidney dysfunction is a major
cause of hypertension, which in turn
exacerbates CKD and accelerates its
progression. Currently, hypertension is
the major risk factor for development and
progression of diabetic and non-diabetic
CKD.20 The close relationship between
different NCDs provides an even stronger
case for prevention, early detection,
effective control and treatment and
strategies to provide continuity of care in
order to reduce the burden of NCDs and
their associated conditions.
TACKLING NCDS IN MEXICO:
GLOBAL APPROACHES AND
CHALLENGES
Mexico has acknowledged the growth of
NCDs and their risk factors and has
applied a number of approaches to start
tackling these diseases. However,
challenges remain for the Mexican
health-care system, and further steps are
needed to effectively tackle the rise of
NCDs.
Population-wide strategies have
recently been implemented to tackle the
rising prevalence of pre-obesity and
obesity, through the governments
National Agreement for Nutritional
Health,21 which promotes collaboration
between all government agencies (mainly
the Health and Education Ministries) and
a series of multi-sector interventions
aimed at improving the populations diet
and incentivising physical activity. A mass
communication campaign, 5 steps for
health, was launched as a non-profit,
publicprivate partnership to promote
healthy habits and change risky
behaviours.22 Most recently, the incoming
government plans to integrate all related
interventions in the National Strategy
against Obesity and Diabetes, in an effort
to prioritise the fight against the NCD
epidemic and organise all actions into
one effective public policy instrument
4 Perspectives in Public Health
PPH511423.indd 4
coordinated by the Ministry of Health and
implemented by the states.23
Mexico has also advanced in
extending universal health coverage
through its Seguro Popular health
insurance programme, which has
granted nominal coverage to previously
uninsured populations, funding all
primary health-care interventions, 95% of
second-level care and implementing a
reimbursement fund to cover the most
important tertiary health-care
interventions.24 However, Seguro Popular
does not guarantee full access to
effective health-care, due to inefficiencies
in health-care infrastructure such as
insufficient and irregular supply of
medicines, lack of access to laboratory
tests and insufficient coverage of health
services. To increase real coverage,
Seguro Popular uses a screening
strategy (Consulta Segura)25 that requires
all insured individuals to undergo a
consultation to identify risk factors,
detect NCDs and proceed to treatment.
Social security institutions also offer
programmes aimed at providing
preventive services to their beneficiaries
and incentivise changes in risky
behaviours when diagnosed with an
NCD.26,27
Despite these important efforts,
Mexicos current approach to combating
NCDs is insufficient in that the model still
focuses too heavily on the treatment
rather than the prevention of disease,
and treatment follow-up is often deficient:
w Services are heavily centred in primary
health-care units, but the current
infrastructure cannot cope with the
increasing demand of services. There
are 10,433 primary health-care units;
81% are rural centres and of these,
78% only have one medical room;28
w Despite a slight increase in 2012 as
compared to 2000 and 2006, only
23.7% of the adult population were
screened for DM2, and 28.4% for
hypertension;2
w Treatment follow-up is often passive
and insufficient. For example, although
an estimated 14.4% of the Mexican
adult population has diabetes, half of
them are not aware of their disease.7
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Also, 6 out of 10 patients with
diabetes do not receive a foot
examination during consultation, for 6
out of 10, there is no eye examination,
and only 7.5% of patients received a
HbA1c measurement during the last
year;2
w Strategies to train and update health-
care providers (HCPs) may be
inadequate for primary settings, and
the population typically lacks the
education to demand preventive
services or participate more actively in
the management of NCDs.
Both the World Health Organization
(WHO) and the United Nations (UN) have
recognised the growing threat of NCDs
and outlined an action plan based on
increasing the body of knowledge of
these diseases, recognising that, so far,
the epidemic has been misunderstood
and under-reported.10 The WHOs 2008
2013 Action Plan aims to implement its
Global Strategy for the Prevention and
Control of Non-Communicable
Diseases.12,13 More recently, in 2011, the
UN convened the UN General Assembly
High-level Meeting on the Prevention and
Control of Non-Communicable Diseases,
in order to reinforce the Action Plan as an
international priority and to address barri-
ers to successfully tackling NCDs.10 So
far, the main focus of health-care for
NCDs in many low- and middle-income
countries has been hospital-centred
acute reactive care, an expensive
approach that ignores the health benefits
of preventing and treating these condi-
tions at early stages. To ensure early
detection and timely treatment, NCD
interventions need to be integrated into
primary health-care.13 To achieve the
paradigm shift now required for effective
control of NCDs, the following principles,
based on cost-effectiveness studies and
WHO/UN guidelines, should be met:
1. The health-care system should
prioritise guaranteeing effective
access to primary care;29
2. Primary care should include first
contact care29 implementing a
community outreach strategy as well
as care in primary settings;
22/11/2013 6:31:07 PM

3. Continuity of care is crucial.17,30
Interventions to tackle NCDs must
occur at all stages: promotion of a
healthy lifestyle, and prevention, early
detection, diagnosis, continuous treat-
ment and recommendations, follow-up
and monitoring of diseases. The cost-
effectiveness of these interventions
relies, in most cases, on early screen-
ing, detection of pre-disease stages
and effective treatment;31
4. A trained workforce with appropriate
skills must be sustained;10
5. A reliable supply chain of medicines
and laboratory tests is required across
the continuum of care;10
6. There must be a shift towards collabo-
rative care between patients and
HCPs. This approach empowers
patients with chronic diseases to make
decisions about their care, and pro-
vides them with information and the
means to detect and solve problems
effectively. Such patient responsibility
for self-management and self-monitor-
ing is crucial in tackling risk factors for
NCDs, such as hypertension;32,33
7. Monitoring and surveillance are crucial
strategies and provide an impetus for
action by governments and policy-
makers.10 Three necessary
components of NCD surveillance are
as follows: monitoring exposure to
risk factors; monitoring outcomes,
such as morbidity and disease-
specific mortality; and keeping track
of health-care system responses,
including national capacity to prevent
NCDs through access to health-care,
medicines and human resources;10
8. Technological innovations can be
used to improve access to health
services. Use of technology such as
the Internet and mobile phones is an
accessible and cost-effective tool to
facilitate health-care provision and
also responsible self-care and
management.34 Data for Mexico
indicate that 85.6% of the population
has access to mobile phones and
40.2% have Internet access.35
Shifting the paradigm of care in Mexico,
and in Latin America more broadly, will
require a comprehensive, innovative and
replicable model that effectively
PPH511423.indd 5
PEER REVIEW
CASALUD: a health-care system to prevent non-communicable diseases
incorporates the global principles for the applies systematic risk assessment to
control of NCDs described above. patient screening, identifying people as
healthy, at risk (or pre-disease) or sick.36
Identifying individuals at a pre-disease
CASALUD: A PROPOSED
stage is a recommended practice to
SOLUTION
effectively reduce disease.37,38
CASALUD, derived from casa and salud
Systematic risk assessment comprises
(home and health), offers an innovative
three steps and is implemented by
model that uses technology to deliver
HCPs. Step 1 involves assessment of
NCD prevention and care in line with
pre-obesity, obesity and hypertension via
international best practices. CASALUDs
a questionnaire to detect risk factors,
main objective is to create health rather
and measurement of BMI, waist
than treat disease by providing outreach
circumference and blood pressure. If the
to patients in their homes, promoting
questionnaire identifies five or more risk
changes in health behaviour and provid-
factors, or the patient is diagnosed with
ing effective health services throughout
pre-hypertension, the HCP proceeds to
the continuum of care, from prevention
step 2, which assesses risk for DM2 via
to follow-up.
measurement of blood glucose.
CASALUD is based on four main com-
Individuals identified as pre-diabetic or
ponents, which are summarised in Figure
diabetic, and those identified with pre-
2. Briefly, CASALUD aims to assure ade-
hypertension or hypertension, continue
quate supplies of medicines and labora-
to step 3, which assesses the risk of
tory tests, strengthen human capital
CKD via measurement of serum
through ongoing professional and practi-
creatinine, rate of glomerular filtration
cal education, incorporate proactive pre-
(GFR) and urinary protein. Again,
vention strategies reaching the house-
individuals are classified as healthy, or in
hold and community and expand early
the initial, intermediate or advanced
access to health-care through the strate-
stages of the disease using
gic use of technological innovations. The
internationally recognised criteria (Table
operation of CASALUDs four compo-
2). Finally, depending on the availability of
nents is integrated into existing Mexican
laboratory tests, the HCP can screen for
public health care, adding to (rather than
hypercholesterolaemia, with individuals
fragmenting) the system. All strategies
classified as healthy or positive for the
and solutions are financed by the Carlos
disease.
Slim Health Institute/Foundation and do
MIDO assessment is available in two
not impose any additional implantation
formats: the first is provided by nurses in
costs to the health-care system or, most
primary health-care settings and public
importantly, to its users or beneficiaries.
centres using a MIDO Mobile Module;
Using a structured process to deploy
the second is designed for nurses to
these four components, CASALUD aims
administer in patients homes, using
to strengthen and enhance health-care
Portable MIDO.
delivery, increasing the capacity of ser-
vices and hence improving the efficiency Clinics and public places: MIDO
and the quality of care. The main initia- Mobile Module
tives within these four components are Health professionals can assess NCDs
described below. either at a clinic or in public places,
including supermarkets, community
Incorporate proactive prevention centres and outside schools. MIDO
strategies Mobile Module includes equipment that
MIDO Medicin Integrada para la wirelessly communicates with a USB
Deteccin Oportuna (Integrated modem to measure weight, height, blood
Measurement for Early Detection) pressure, blood glucose and urinary
MIDO, the core innovation for the model, protein. It also includes personalised
aims to move away from the traditional handouts to provide recommendations
dichotomous approach of classifying and treatment options according to the
individuals as sick or healthy and instead level of risk detected for each disease.
Perspectives in Public Health 5
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CASALUD: a health-care system to prevent non-communicable diseases

Figure 2

Design principles of CASALUD

The authors hold the copyright for this figure.

Table 2

Systematic risk evaluation by MIDO

Healthy Pre-disease Sick

Obesity39 BMI = 18.5024.99 kg/m2 BMI = 25.0029.99 kg/m2 BMI 30.00 kg/m2

Hypertension40 BP = 120129/8084 mmHg BP = 130139/8589 mmHg BP 140/90 mmHg

Diabetes41 FPG < 100 mg/dL; RPG < 200 FPG = 100125 mg/dL FPG 126 mg/dL;
mg/dL
RPG 200 mg/dL
Kidney disease42 Stage 0: GFR 90 mL/min/ Stage 2: GFR = 6089 mL/ Stage 4: GFR = 1529 mL/min/
1.73 m2 without markers min/1.73 m2 1.73 m2
Stage 1: GFR 90 mL/min/ Stage 3: GFR = 3059 mL/ Stage 5: GFR < 15 mL/min/1.73 m2
1.73 m2 with markers min/1.73 m2

BMI: body mass index; BP: blood pressure; FPG: fasting plasma glucose; GFR: glomerular filtration rate; RPG: random plasma glucose; WHO: World
Health Organization; KDIGO: Kidney Disease: Improving Global Outcomes.
Individuals are assessed for obesity, hypertension, diabetes and kidney disease, and classified as being healthy, pre-disease or sick. Classification is
based on norms and recommendations set by the WHO, International Diabetes Federation, American Diabetes Association, KDIGO guidelines and
National Clinical Practice Protocols.

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Household and community outreach:
Portable MIDO
Community HCPs can assess diabetes,
hypertension and their preceding
conditions in the community or
household using Portable MIDO, an all-
in-one system with a blood pressure
meter and glucometer connected to a
mobile phone via Bluetooth. Personalised
recommendations, aimed at preventing
NCDs, are given depending on the
patients level of risk. HCPs can refer any
patients found to have an NCD to a clinic
to confirm the diagnosis and start
treatment immediately.
For both MIDO Mobile Module and
Portable MIDO, measurements of weight,
height, blood pressure and blood
glucose are transmitted wirelessly via
Bluetooth to a laptop or a mobile phone,
where the SI-MIDO information system
sends the data to a cloud storage
provider and performs analysis to provide
HCPs with up-to-date information to
support them in evidence-based
decision-making.
MIDO allows for mass screening,
thereby increasing early access to
primary health-care services. Treatment
through a personalised set of
recommendations encourages informed
decision-making and patient
responsibility for their own health. MIDO
is a cost-effective strategy, costing less
than US$4 per person, with assessment
taking less than 5 minutes.
For MIDO to be effective, the patient
must have tools to support them in
taking responsibility for their own health,
post-screening. CASALUD has therefore
developed two innovative solutions
implemented via mobile phone and the
Internet: ViveSano, an application for
managing wellness and a healthy
lifestyle, and Diabediario, an application
for people living with DM2.
Strategic use of technological
innovations
Wellness and lifestyle: ViveSano
ViveSano is a low-cost application
focused on preventing cardiovascular
risk and unhealthy lifestyles. Its objective
PPH511423.indd 7
CASALUD: a health-care system to prevent non-communicable diseases
is to teach individuals to understand their
health, self-monitor and interpret their
own results, adapting their lifestyle to
prevent NCDs. Individuals identified by
MIDO to be at risk of developing an NCD
use ViveSano to capture base health
indicators: age, weight, height, tobacco
usage, blood pressure, cholesterol level
and glucose level. The tool offers criteria
to self-assess the level of risk as high,
medium or low (e.g. high risk: BMI > 30
kg/m2, medium risk: BMI = 2530 kg/m2,
low risk: BMI < 25 kg/m2). The tool then
offers personalised recommendations for
disease prevention based on the level of
risk detected. Individuals also transmit
this information to the cloud storage
provider, where the results sync with
SI-MIDO to provide continuous
assessment. ViveSano also shares data
with the patients doctor, allowing him to
define the best strategies to either
prevent the appearance of the disease or
control it in the early stages to prevent
complications.
Disease management for people living
with DM2: Diabediario
Diabediario (diabetes diary)43 is an
application that focuses on the
empowerment of patients already
diagnosed and living with diabetes. Its
main objective is to improve their
compliance with treatment, thereby
helping them achieve effective control of
the disease, averting complications and
improving quality of life significantly.
People with diabetes can access per-
sonalised monitoring protocols, including
reminders for taking medicines or attend-
ing doctors appointments, an educa-
tional platform to learn more about the
disease, and an application to self-
assess risk and health status. In addition,
individuals can register their glucose,
blood pressure, weight and various labo-
ratory tests, and Diabediario will immedi-
ately provide feedback based on the
results. Information on health indicators
is stored securely and can be monitored
by the individual through a webpage indi-
cating their level of risk and giving rec-
ommendations on when to seek medical
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attention. Finally, users receive personal-
ised educational messages.
Strengthen human capital
Center for Education in Health Online
Primary health-care units must cope with
demand for increasingly complex ser-
vices, where patients no longer seek
medical treatment to cure a disease, but
rather require a holistic, multidisciplinary
approach towards improving their health
and lifestyle. HCPs must embrace new
theories and public health evidence that
consider changes in health demograph-
ics and epidemiology. To do so, they
must have up-to-date information about
treatments and be able to use this
knowledge in daily practice. The
CASALUD model relies on the Center for
Education in Health, a pioneering online
educational platform developed by the
Carlos Slim Health Institute (ICSS) that
incorporates global best practices in
health education to support health-care
services in strengthening the skills and
competencies of HCPs.44 The centre
provides Free Online Courses for the
Universal Strengthening of Health
Professionals (FOCUS), to assess both
theoretical and clinical case-based learn-
ing with academic endorsement from
national universities.
To strengthen human capital for the
prevention, diagnosis and management
of NCDs, the Center for Education in
Health offers a diploma programme
called Diploma on Prevention and
Integral Attention of NCDs, awarded by
the National Academy of Medicine and
the National Normative Committee of
General Medicine. The diploma focuses
on providing up-to-date and practical
information and education on how to
treat NCDs, including prevention, early
detection and treatment of obesity, DM2,
hypertension, CKD and hyperlipidaemia.
The diploma is available at anytime, any-
where with an Internet connection, and is
divided into video lessons. Before com-
mencing the diploma, all professionals are
subject to a pre-evaluation that indicates
the most appropriate level and any lessons
that will be of particular use to them.
Perspectives in Public Health 7
22/11/2013 6:31:07 PM
 PEER REVIEW
CASALUD: a health-care system to prevent non-communicable diseases
Table 3
Classification of individuals (not previously diagnosed) using MIDO criteria
Number of
individuals
Disease screened
Diabetes 24,985
Hypertension 24,985
Data from the SI-MIDO system. Data were collected from a total of 24,985 individuals, screened at 12 Mexico City subway stations using a MIDO
Module. Despite having received no previous diagnosis, the majority of individuals were classified as pre-disease or sick on evaluations for diabetes
and hypertension.
Digital Portfolio
The Digital Portfolio is aimed at HCPs to
support them in adequately preventing,
diagnosing and treating people living with
NCDs using simplified tools and support
documents.45 It comprises a set of
applications, including health calculators
to estimate BMI, cardiovascular risk and
other health risks, a digital library with
information on national health guidelines,
flashcards to be used with patients
during consultations and a Drug Index
describing over-the-counter medicines,
generic drugs and specialised drugs. The
Digital Portfolio is focused on NCDs as
well as prevention strategies targeted by
age group. This technology facilitates the
continuous education and
professionalisation of HCPs.
Assure availability of adequate
supplies
Finally, CASALUD has designed the
following technological application to
improve the logistics and efficiency of the
medical supply chain, allowing HCPs to
provide quality care across the health-
care system.
Stock measurement mobile phone
application
In rural and suburban areas where clinics
are usually small and difficult to access, it
is crucial to have systems that monitor
the clinics efficiency and ensure that
quality of care (as compared to urban
8 Perspectives in Public Health
PPH511423.indd 8
Individuals
previously
diagnosed Healthy
N % N %
4,847 19.4% 8,795
9,344 37.4% 3,673
clinics) is maintained at a low cost. ICSS
has developed a mobile phone
application that can operate from a low-
cost SIM card. The application allows
HCPs to report current stock levels and
any stock depletions; patients can also
report any prescribed medicines not
provided, creating real accountability.
CASALUD IN MEXICO: INITIAL
DATA AND PLANS FOR
EXPANSION
MIDO
Up to November 2012, CASALUD has
established partnerships with 7 out of 32
state governments to deploy the model in
a total of 28 primary health-care units,
reaching almost 1 million users, of whom
400,000 live with an NCD. In Mexico City,
MIDO has been incorporated in a pio-
neering initiative to provide screening in
12 of the citys subway stations and to
date, has screened 24,985 individuals
(Table 3). When tested for DM2, 80.6% of
individuals had not previously been diag-
nosed with the disease; however, 14.6%
of this group were classified as pre-dia-
betic and 30.8% classified as sick.
Similarly, when tested for hypertension,
62.6% of individuals screened had not
previously been diagnosed; however,
28.5% of this group were classified as in
the pre-disease stage and 19.4% as sick.
The extent of undiagnosed disease
demonstrated by the subway testing
initiative can only add to the potential
Downloaded from rsh.sagepub.com at DIRSA/TABASCO on April 25, 2014
Individuals with no previous diagnosis
Pre-disease Sick
N % N %
35.2% 3,648 14.6% 7,695 30.8%
14.7% 7,121 28.5% 4,847 19.4%
burden of NCDs and associated
morbidities. According to national data,
only 24.5% of diabetic patients have an
adequate metabolic control, while only
25.4% of patients with hypertension have
adequate control of their disease.2 These
baseline estimates on disease diagnosis
and control imply that there is an
enormous window of opportunity for a
model such as CASALUD. We anticipate
that, although increased early screening
will at first increase the number of people
diagnosed with these conditions, early
treatment through a combination of
strategies such as ViveSano and
Diabediario and more efficient provision
of health services will lead to reductions
in NCDs within the decade. This has
already been demonstrated in other
countries, such as Finland, in which the
Finnish Diabetes Prevention Study
reported a 43% reduction in the risk of
developing diabetes for the intervention
group compared to the control after a
median of 7 years.46 Evidence from
subgroup analyses of the Action to
Control Cardiovascular Risk in Type 2
Diabetes (ACCORD), Action in Diabetes
and Vascular disease: PreterAx and
DiamicroN Controlled Evaluation
(ADVANCE) and VA Diabetes Trial (VADT)
trials has also shown that tight glycaemic
control early in DM2 reduced CVD risk
within a median 5 years of follow-up.4749
In partnership with the Mexican
Ministry of Health, and within the context
22/11/2013 6:31:07 PM

of the National Strategy against Obesity
and Diabetes, 13 states will start
implementing the CASALUD model in 67
health units, covering a total population
of 601,423 and requiring participation of
1,697 health professionals. The main
goal is to achieve screening of the whole
target population within the time frame of
3 years, as well as to increase effective
disease control for those diagnosed with
diabetes by at least 50%.50
Diabediario
Diabediario has been tested in a
controlled trial in Salud Xalapa,
comparing use of Diabediario, with or
without a glucometer, against a control
group. The results of this trial to test the
impact of the application and blood
glucose self-monitoring in the
metabolic control of diabetic patients are
being analysed, and will be reported
elsewhere.
The evaluation of Diabediario included
a qualitative analysis of the utility and the
usefulness of the solution as a
component of public health services.
Among the main results are:
w Diabediario and the glucometer do
not work to generate awareness but
to raise it in those patients who
accept their disease, helping them to
gain control over the disease;
w Patients who do not accept their
disease change their behaviour, since
they feel pressure to do so given the
support received through the Project.
These patients require a more robust
support network, including their
family peers and the doctor;
w Diabediario and the glucometer,
when used together, enable the
patient to monitor himself or herself,
increasing awareness of glycaemic
control.
Following the evaluation of Diabediario in
Xalapa, an updated version will be
delivered as part of the CASALUD model
through the National Strategy against
Obesity and Diabetes with the Ministry of
Health.
PPH511423.indd 9
CASALUD: a health-care system to prevent non-communicable diseases
ViveSano
This solution was tested in 2009 and
2010; the full results of the test, which
identified real-world patient needs, will be
published elsewhere. An updated version
will be delivered as part of the CASALUD
model through the National Strategy
against Obesity and Diabetes with the
Ministry of Health. Ultimately, the aim is
for both ViveSano and Diabediario to be
used by the whole target population.50
Center for Education in Health
Diploma
Uptake of the diploma has been moni-
tored following its launch. In 2011, a total
of 931 health professionals took the
diploma around 75% of all health pro-
fessionals participating in the CASALUD
model. Of this total, 731 professionals
graduated (78.3%). During 2012, the
diploma was taken by those health pro-
fessionals within the 28 health units in
the 7 states participating in the model
who had not previously taken the
diploma, so as to ensure a minimum of
90% of health workers trained. Therefore,
an additional 111 health professionals
took the diploma, of which 73 profes-
sionals graduated successfully (71.2%).
Among the total 810 diploma
graduates, 142 professionals (17.5%)
took the Essential Level aimed at social
workers and health promoters, 211
professionals (26%) took the Intermediate
Diploma for general and auxiliary nurses,
and finally, 457 professionals (56.4%)
graduated from the Advanced Diploma
for General Practitioners. This increased
training in prevention, early detection and
treatment of chronic diseases will help
address the need identified in the
Mexican health system.24 The expanded
implementation of CASALUD across 13
states aims to ensure that 90% of all
participating health professionals actually
achieve the diploma.50
Digital Portfolio
The Digital Portfolio is used in the 28
health-care units where the CASALUD
model has been implemented. After its
initial deployment, a qualitative
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PEER REVIEW
assessment of the utility and the
usefulness of the solution was made
using focus groups (full details of which
will be published elsewhere).
Refinements to the tool to improve user-
friendliness following the assessment
included adding a pharmacological
dictionary, medical calculators and
search tools. The latest version will be
implemented in the 13 states
participating through the National
Strategy against Obesity and Diabetes
with the Ministry of Health.50
Stock measurement mobile phone
application
This solution will be implemented for the
first time in the 13 states through the
National Strategy against Obesity and
Diabetes with the Ministry of Health. It
aims to contribute to achieving the
strategys goal of complete supply of all
drugs at least 90% of the time.50
Lessons learned from the initial
implementation of CASALUD
Important challenges have been faced
and lessons have been learned during
the deployment of the CASALUD model.
The main conclusions are as follows:
w Any solution or application must be
deployed systematically, with clear
definitions of leaders that can be
accountable, and with clear
milestones;
w The appropriate deployment of the
model is subject to the leadership of
the health personnel of the clinics.
Therefore, it is crucial to have a
robust social marketing strategy in
the clinic to engage the health
workers in the adoption of the
solutions (gain their buy-in);
w The solutions must be implemented
within the whole NCDs model. High
technology use is not equal to high
impact unless it is deployed within a
structured health-care model;
The CASALUD model began as a model
to improve health services from the
health perspective only. Nonetheless, the
Perspectives in Public Health 9
22/11/2013 6:31:07 PM
 PEER REVIEW
CASALUD: a health-care system to prevent non-communicable diseases
model has now embraced a very
ambitious agenda to shift the current
managerial model, so as to improve the
efficiency and the effectiveness of health-
care provision.
CONCLUSION
Prevalence, morbidity and mortality of
NCDs are rising rapidly in Latin America
and represent a crisis that must be
tackled urgently. Mexico has
acknowledged that a radical change of
health-care paradigm is required to
reflect this epidemiological shift; health
care must now move towards a
proactive, preventive model incorporating
community outreach rather than the
References
1. Consejo Nacional de Poblacin (CONAPO). La
situacion demografica de Mexico, 2011 [The
Demographic Situation in Mexico, 2011].
Mexico, D. F., Mexico: Consejo Nacional de
Poblacin, 2011.
2. Gutirrez J, Rivera-Dommarco J, Shamah-Levy
T et al. Encuesta Nacional de Salud y Nutricin
2012: Resultados Nacionales [National Survey
of Health and Nutrition 2012: National Results].
Cuernavaca, Mexico: Instituto Nacional de
Salud Pblica, 2012.
3. Olaiz G, Rojas R, Barquera S, Shamah T,
Aguilar C, Cravioto P, et al. Encuesta Nacional
de Salud 2000: La salud de los adultos
[National Health Survey 2000: Adult Health].
Cuernavaca, Mexico: Instituto Nacional de
Salud Pblica, 2003.
4. Olaiz-Fernndez G, Rivera-Dommarco J,
Shamah-Levy T, Rojas R, Villalpando-
Hernndez S, Hernndez-Avila M, et al.
Encuesta Nacional de Salud y Nutricin 2006
[National Survey of Health and Nutrition 2006].
Cuernavaca, Mexico: Instituto Nacional de
Salud Pblica, 2006.
5. Secretara de Salud DGdE. Encuesta Nacional
de Enfermedades Crnicas [National Survey of
Chronic Diseases]. Mexico, D. F., Mexico:
Secretara de Salud, 1993.
6. International Diabetes Federation. IDF Diabetes
Atlas, 4th edn. Brussels: International Diabetes
Federation, 2012. Available online at: http://
www. idf.org/media/press-materials/diabetes-
data (Last accessed August 2013).
7. Villalpando S, de la Cruz V, Rojas R, Shamah-
Levy T, vila MA, Gaona B, et al. Prevalence
and distribution of type 2 diabetes mellitus in
Mexican adult population: A probabilistic survey.
Salud Pblica de Mxico 2010; 52(Suppl. 1):
S1926.
8. Secretara de Salud, Sistema Nacional de
Informacion en Salud (SINAIS). Bases de datos
en formato estandar [Databases in Standard
Format]. Mexico, D. F., Mexico: Secretara de
Salud. Available online at: http://www.sinais.
salud.gob.mx/basesdedatos/estandar.html
(Last accessed August 2013).
10 Perspectives in Public Health
PPH511423.indd 10
traditional passive, curative, hospital-
centred approach. CASALUD offers a
comprehensive, integrated, sustainable
and innovative health-care model to
assure effective access to continuous
health-care and to combat NCDs.
Through the initiatives described here,
CASALUD delivers solutions to the NCD
crisis facing Mexico based on its four key
design principles and aims to optimise
the existing health-care system and
change the health-care paradigm
effectively. Initial data reinforce the need
to expand access to early health-care
and provide proof of principle for the
successful use of CASALUD. Plans for
expansion of CASALUD throughout
9. World Health Organization (WHO) Global Health
Observatory. Disease and Injury Country
Estimates. Geneva: World Health Organization,
2004.
10. United Nations (UN). Prevention and control of
non-communicable diseases. Report of the
Secretary-General (A/66/83). New York: United
Nations, 19 May 2011.
11. Arredondo A, Zuniga A, Alvarez C. Costos y
consecuencias financieras del cambio en el perfil
epidemiolgico en Mxico [Costs and Financial
Consequences of Change in the Epidemiological
Profile in Mexico] (ed National Institutes of Public
Health). Cuernavaca, Mexico: Instituto Nacional de
Salud Pblica 2012.
12. World Health Organization (WHO). 20082013
Action Plan for the Global Strategy for the
Prevention and Control of Non-communicable
Diseases. Geneva: World Health Organization,
2008.
13. World Health Organization (WHO). Global Status
Report on Non-communicable Diseases. Geneva:
World Health Organization, 2010.
14. World Health Organization (WHO). Preventing
Chronic Diseases: A Vital Investment. Geneva:
World Health Organization, 2005.
15. Strong K, Mathers C, Epping-Jordan J, Beaglehole
R. Preventing chronic disease: A priority for global
health. International Journal of Epidemiology 2006;
35: 4924.
16. Hernndez vila M, Secretara de Salud. Polticas
para la prevencin de la obesidad y las
enfermedades crnicas relacionadas
con la nutricin [Policies for the Prevention of
Obesity and Chronic Diseases Related to
Nutrition]. Mexico, D. F., Mexico: Secretara de
Salud, 2009.
17. Beaglehole R, Bonita R, Alleyne G, Horton R, Li L,
Lincoln P, et al. UN high-level meeting on non-
communicable diseases: Addressing four
questions. The Lancet 2011; 378: 44955.
18. Lee PT, Henderson M, Patel V. A UN summit
on global mental health. The Lancet 2010; 376:
516.
19. Parving HH, Hommel E, Mathiesen E, Skott P,
Edsberg B, Bahnsen M, et al. Prevalence of
Downloaded from rsh.sagepub.com at DIRSA/TABASCO on April 25, 2014
Mexico are underway, providing hope for
combating Mexicos current NCD
epidemic.
ACKNOWLEDGEMENTS
This work was supported by the Carlos
Slim Health Institute, Mexico City, Mexico
(no specific grant was received). The
authors thank Manett Vargas for research
assistance and contribution. Editorial
support was provided by Hazel Urwin of
Interlace Global Communications Ltd and
funded by the Carlos Slim Health Institute.
CONFLICT OF INTEREST
The authors declare that there is no conflict
of interest.
microalbuminuria, arterial hypertension, retinopathy
and neuropathy in patients with insulin dependent
diabetes. British Medical Journal (Clinical Research
Ed.) 1988; 296: 15660.
20. Couser WG, Remuzzi G, Mendis S, Tonelli M.
The contribution of chronic kidney disease to the
global burden of major noncommunicable
diseases. Kidney International 2011; 80:
125870.
21. Secretara de Salud. National Agreement for
Nutritional Health Strategy against Preobesity
and Obesity. Mexico, D. F., Mexico: Secretara de
Salud, 2010.
22. Secretara de Salud. 5 pasos para tu salud [5
Steps for Health]. Mexico, D. F., Mexico:
Secretara de Salud, 2010.
23. Gobierno de la Repblica. Plan Nacional
de Desarrollo 20132018. Mexico, D. F.,
Mexico: Presidencia de la Repblica,
2013.
24. Knaul FM, Gonzalez-Pier E, Gomez-Dantes O,
Garcia-Junco D, Arreola-Ornelas H, Barraza-
Llorens M, et al. The quest for universal health
coverage: Achieving social protection for all in
Mexico. The Lancet 2012; 380: 125979.
25. Comisin Nacional de Proteccin Social en
Salud. Informe de Resultados Primer Semestre
2012 [Report: Results for the First Half of
2012]. Mexico, D. F., Mexico: Secretara de Salud,
2012.
26. Instituto de Seguridad y Servicios Sociales de los
Trabajadores del Estado [Institute of Security and
Social Services for State Workers]. PrevenISSSTE.
Mexico, D. F., Mexico: Instituto de Seguridad y
Servicios Sociales de los Trabajadores del Estado,
2012.
27. Instituto Mexicano del Seguro Social [Mexican
Institute of Social Security]. PREVENIMSS
Programas Integrados de Salud [PREVENIMSS
Integrated Health Programs]. Mexico, D. F.,
Mexico: Instituto Mexicano del Seguro Social.
Available online at: http://revistamedica.imss.gob.
mx/index.php?option=com_multicategories&view=
article&id=1232:programas-integrados-de-
salud-prevenimss&Itemid=640 (Last accessed
August 2013).
22/11/2013 6:31:08 PM

28. Secretara de Salud, Direccin General de
Informacin en Salud. Subsistema de
Informacin de Equipamiento, Recursos
Humanos e Infraestructura para la Salud
[SINERHIAS Equipment, Human Resources and
Infrastructure for Health]. Mexico, D. F., Mexico:
Secretara de Salud, 2012.
29. World Health Organization (WHO). The World
Health Report: Primary Health Care (Now More
than Ever). Available online at: http://www.who.
int/whr/2008/en/ (Last accessed August 2013).
30. Maher D, Harries AD, Zachariah R, Enarson D. A
global framework for action to improve the
primary care response to chronic non-
communicable diseases: A solution to a
neglected problem. BMC Public Health 2009; 9:
355.
31. Li R, Zhang P, Barker LE, Chowdhury FM,
Zhang X. Cost-effectiveness of interventions to
prevent and control diabetes mellitus: A
systematic review. Diabetes Care 2010; 33:
187294.
32. Bodenheimer T, Lorig K, Holman H, Grumbach
K. Patient self-management of chronic
disease in primary care. JAMA 2002; 288:
246975.
33. Glynn LG, Murphy AW, Smith SM, Schroeder K,
Fahey T. Self-monitoring and other non-
pharmacological interventions to improve the
management of hypertension in primary care: A
systematic review. The British Journal of
General Practice 2010; 60: e47688.
34. Americas Health Insurance Plans (AHIP) Center
for Policy and Research. Innovations in Health
Information Technology. Washington, DC: AHIP
Center for Policy and Research, 2005.
35. Comisin Federal de Telecomunicaciones.
Sistema de Informacin Estadstica de
PPH511423.indd 11
CASALUD: a health-care system to prevent non-communicable diseases
Mercados de Telecomunicaciones [Statistical
Information System of Telecommunications
Markets]. Mexico, D. F., Mexico: Comisin Federal
de Telecomunicaciones, 2012.
36. Carlos Slim Institute of Health. CASALUD. Mexico,
D. F., Mexico: Carlos Slim Institute of Health.
Available online at: http://www.salud.carlosslim.
org/casalud/ (Last accessed August 2013).
37. Sherwin RS, Anderson RM, Buse JB, Chin MH,
Eddy D, Fradkin J, et al. Prevention or delay of
type 2 diabetes. Diabetes Care 2004; 27(Suppl. 1):
S4754.
38. Centers for Disease Control and Prevention.
National Diabetes Prevention Program. Atlanta,
GA: Centers for Disease Control and Prevention.
Available online at: http://www.cdc.gov/diabetes/
prevention/ (Last accessed August 2013).
39. World Health Organization (WHO). BMI
Classification. Geneva: World Health Organization.
Available online at: http://apps.who.int/bmi/index.
jsp?introPage=intro_3.html (Last accessed August
2013).
40. Secretara de Salud. Mexican Official Norm for
Prevention, Diagnosis and Treatment of
Hypertension. Mexico, D. F., Mexico: Secretara de
Salud, 2009.
41. Secretara de Salud. Mexican Official Norm for
Prevention, Diagnosis and Treatment of Diabetes
Mellitus. Mexico, D. F., Mexico: Secretara de
Salud, 2010.
42. Kidney Disease Improving Global Outcomes
(KDIGO). KDIGO 2012 Clinical Practice Guideline
for the Evaluation and Management of Chronic
Kidney Disease. Official Journal of the International
Society of Nephrology 2013; 3.
43. Carlos Slim Institute of Health. Diabediario.
Mexico, D. F., Mexico: Carlos Slim Institute of
Health, 2012.
Downloaded from rsh.sagepub.com at DIRSA/TABASCO on April 25, 2014
PEER REVIEW
44. Carlos Slim Institute of Health. Center for
Education in Health. Mexico, D. F., Mexico:
Carlos Slim Institute of Health. Available online
at: http://www.educacion-icss.org.mx/ (Last
accessed August 2013).
45. Carlos Slim Institute of Health. Portafolio Digital
[Digital Portfolio]. Mexico, D. F., Mexico: Carlos
Slim Institute of Health. Available online at: http://
www.salud.carlosslim.org/casalud/portafolio-
digital/ (Last accessed August 2013).
46. Lindstrom J, Ilanne-Parikka P, Peltonen M,
Aunola S, Eriksson JG, Hemio K, et al. Sustained
reduction in the incidence of type 2 diabetes by
lifestyle intervention: Follow-up of the Finnish
Diabetes Prevention Study. The Lancet 2006;
368: 16739.
47. Gerstein HC, Miller ME, Byington RP, Goff DC Jr,
Bigger JT, Buse JB, et al. Effects of intensive
glucose lowering in type 2 diabetes. The New
England Journal of Medicine 2008; 358: 2545
59.
48. Patel A, MacMahon S, Chalmers J, Neal B, Billot
L, Woolward M, et al. Intensive blood glucose
control and vascular outcomes in patients with
type 2 diabetes. The New England Journal of
Medicine 2008; 358: 256072.
49. Duckworth W, Abraira C, Moritz T, Reda D,
Emanuele N, Reaven PD, et al. Glucose control
and vascular complications in veterans with type
2 diabetes. The New England Journal of
Medicine 2009; 360: 12939.
50. Tapia R, Gallardo H, Saucedo R. Project Model
of the National Strategy against Obesity and
Diabetes. Mexico, D. F., Mexico: Secretara de
Salud and Carlos Slim Institute of Health,
2013.
Perspectives in Public Health 11
22/11/2013 6:31:08 PM