Methodology

This article employed a qualitative comparative case study design. In line with John Stewart Mills’ Most Similar Systems (MSS) design, the purpose was to select case studies that were similar across several empirical factors while establishing variation in causality and outcomes. The cases of Brazil and Mexico were selected because of the various commonalities that they shared: first, they both have the highest prevalence of type-2 diabetes in Latin America (IDF, 2017); second, they are recently democratized nations, having implemented free-market reforms and decentralized health care services; and third, both nations experienced a rapid nutrition transition, from the consumption of healthier traditional foods to those that are high in sugar and trans fats, the product of increased international trade and globalization. Nevertheless, these nations differed in the key causal variables and outcomes mentioned earlier, in turn highlighting their unique political and institutional contexts (Skocpol and Somers, Reference Skocpol and Somers1980).

The qualitative data used for this study were obtained from peer-reviewed journal articles, policy reports and books. These data were used to verify contextual and causal claims made throughout the article. Empirical data on yearly government expenditures for specific public health programs were obtained from the official ministry of health websites and are referenced in the article. Other epidemiological data were obtained from the World Health Organization (WHO) and PAHO. Finally, this study took place between the summer and fall of 2017.

Addressing the politics of DSM

Recent research in the area of type-2 diabetes policy has focused on the creation of national prevention and treatment programs. While considerable attention has gone into how and why ministries of health prioritize and create national prevention programs (Bergman et al., Reference Bergman, Buysschaert, Schwarz, Albright, Venkat Narayan and Yach2012; Arredondo, Reference Arredondo2014; Colagiuri et al., Reference Colagiuri, Kent, Kainu, Sutherland and Vuik2015), others have focused on government commitments to providing timely treatment services, such as the provision of diabetic medication, ensuring complete access to medicines, avoiding costly OOP expenses, and helping patients with improved nutrition and lifestyle choices (Bergman et al., Reference Bergman, Buysschaert, Schwarz, Albright, Venkat Narayan and Yach2012; Beran et al., Reference Beran, Ewen and Lain2016). Others have examined efforts at the primary care level to improve the provision of educational materials in schools, family counseling, and ensuring periodic blood glucose testing (Spann et al., Reference Spann, Nutting, Galliber, Peterson, Pavlik, Dickenson and Volk2006; Penn et al., Reference Penn, Kenned, Vassilev, Chew-Graham, Protheroe, Rogers and Monks2015; Peros et al., Reference Peros, James, Nolan and Meyerhoff2016).

Ensuring the presence of reliable health care systems, such as human resources and laboratory infrastructure for the provision of type-2 diabetic treatment services, has also received scholarly attention (Spann et al., Reference Spann, Nutting, Galliber, Peterson, Pavlik, Dickenson and Volk2006; Balabanova et al., Reference Balabanova, McKee, Koroleva, Chikovani, Goguadze, Kobaladze, Adeyi and Robles2009; Huang et al., Reference Huang, Zhao, Li and Jiang2014; Juárez-Ramírez et al., Reference Juárez-Ramírez, Théodore, Villalobos, Jiménez-Corona, Lerin, Nigenda and Lewis2015). For example, adequate human resource training, such as ensuring that physicians and nurses receive proper education and experience in administering appropriate insulin levels has been examined (Zgibor and Songer, Reference Zgibor and Songer2001).

A new area of research has investigated the creation of type-2 DSM programs. In general, DSM programs entail ongoing government and private sector primary care efforts to work with patients in strengthening their commitment and ability to control their glycemic blood sugar levels through health education, self-treatment, monitoring and lifestyle changes (Kadirvelu et al., Reference Kadirvelu, Sadasivan and Shu Hui2012; Khunti et al., Reference Khunti, Gray, Skinner, Carey, Realf, Dallosso, Fisher, Campbell, Heller and Davies2012; Hall, Reference Hall2015; Penn et al., Reference Penn, Kenned, Vassilev, Chew-Graham, Protheroe, Rogers and Monks2015). Effective DSM, therefore, requires an ongoing partnership between government primary care teams, patients and supportive civil societal members, such as families and NGOs. This is especially the case in poor urban settings, where individuals often do not have the time and money needed to engage in effective DSM on their own. Furthermore, and as Table 1 illustrates above, DSM services are different from standard primary care treatment services, with key differences in the types of services provided, duration of primary care innovations and the number of stakeholders involved.

Table 1.

Primary care diabetic treatment vs diabetic self-care management services

Those examining DSM processes have placed a lot of attention on health systems reform and capacity. For example, while researchers have focused on improvements to the decentralized provision of DSM services through primary health care agencies working with local communities and families (Stellefson et al., Reference Stellefson, Dipnarine and Stopka2013; Colagiuri et al., Reference Colagiuri, Kent, Kainu, Sutherland and Vuik2015; Dube et al., Reference Dube, Van den Broucke, Dhoore, Kalweit and Housiaux2015), others have focused on the ministry of health’s assurance that there is an adequate supply of health care workers and infrastructure at the primary care level, such as beds and technological equipment (Murrells et al., Reference Murrells, Ball, Maben and Lee2013; Huang et al., Reference Huang, Zhao, Li and Jiang2014; Peros et al., Reference Peros, James, Nolan and Meyerhoff2016; Tai et al., Reference Tai, Chuang, Tsai and Huang2006). The reform of primary care teams and their work with families, schools and communities has also been of interest (Spann et al., Reference Spann, Nutting, Galliber, Peterson, Pavlik, Dickenson and Volk2006; Grillo et al., Reference Grillo, Neumann, Scain, Rozeno, Gross and Leitão2013; Arredondo Reference Arredondo2014; Erny-Abrecht et al., Reference Erny-Abrecht, Bywood and Oliver-Baxter2015), as well as the important role that families, community councils, NGOs, schools and broad social support networks between government health care providers and civil society play in helping patients achieve effective DSM (Kadirvelu et al., Reference Kadirvelu, Sadasivan and Shu Hui2012; Ansari et al., Reference Ansari, Dixon and Browning2013; Weaver et al., Reference Weaver, Lemonde, Payman and Goodman2014; Ansari et al., Reference Ansari, Dixon and Coles2015; Juárez-Ramírez et al., Reference Juárez-Ramírez, Théodore, Villalobos, Jiménez-Corona, Lerin, Nigenda and Lewis2015).

Yet, few studies have taken a political science approach to better understanding the implementation of DSM programs. Indeed, of the scant literature that exits discussing the political factors shaping type-2 diabetes policies, researchers have primarily focused on the role of international health agencies and activist networks in pressuring governments to prioritize spending for diabetes policies (Agudelo-Suárez et al., Reference Agudelo-Suárez, Ruiz-Cantero, González-Zapata, Restrepo-Medrano and Ortiz-Barreda2012; Takian and Kazempour-Ardebili, Reference Takian and Kazempour-Ardebili2016). Alternatively, some have examined the challenges that health care bureaucrats have in obtaining presidential and legislative attention and support for type-2 diabetes programs – and other non-communicable diseases not perceived by politicians as posing urgent health care issues (Mayes and Armistead, Reference Mayes and Armistead2013). In short, this literature has focused on agenda-setting processes for diabetes treatment and prevention programs in general.

Nevertheless, two problems emerge. First, this research does not address the national presidential and legislative politics of implementing DSM programs. That is, after governments have prioritized creating these programs, what are the political party conditions and motivations for ensuring that primary care systems have the financial and human resources needed to ensure policy effectiveness? And second, this literature fails to address the consequences of unintended policy spillover effects: that is, for example, how the creation of anti-poverty programs at the national level can generate increased political attention and incentives to assist ministries of health in implementing DSM programs. And finally, the existing literature is silent on addressing how policy legacies of centralized government assistance in public health can lead to subsequent innovations in health care decentralization processes and how this, in turn, facilitates the ministry of health’s ability to fund and expand DSM primary care innovations.

In the remaining sections of this article, the cases of Brazil and Mexico are introduced in order to address these neglected issues in the literature. These case studies reveal that the success of implementing DSM programs, as seen in Brazil, may at times be the unintended byproduct of populist anti-poverty programs, and that a rich, preexisting tradition of health policy centralization can facilitate and reinforce the implementation of DSM programs after decentralization has occurred. Nevertheless, the case of Brazil also introduces an important caveat: that an excessive focus on anti-poverty programs in a context of economic and political crisis can gradually decrease political support for DSM and other NCD programs, especially when the latter do not provide immediate political payoffs in a context of growing political uncertainty.

Brazil

The emergence of the president Luiz Inacio ‘Lula’ da Silva administration in 2003 saw the introduction of national programs geared towards eradicating poverty and hunger while providing political support for his governing political party, the PT (Partido dos Trabalhadores, Worker’s Party). Two programs helped Lula and the PT maintain strong political support and eventually his re-election as president in 2008: Zero Fome and Bolsa Familia (Zucco and Power, Reference Zucco and Power2013). The former’s focus was on guaranteeing access to food among the poor, essentially eradicating hunger through the provision of basic foods; the latter provided a minimum monthly allowance to families of R$70 reis in exchange for enrolling their children in primary schools and obtaining required state vaccinations. Both programs were successful in eradicating hunger and under-nutrition for thousands, especially in the poorest Northeast areas of the country, while securing Lula and the PT’s ongoing political support and influence (Zucco and Power, Reference Zucco and Power2013).

But these anti-poverty programs also helped to increase the government’s attention to previously neglected NCDs associated with malnourishment. Through the CONSEA (Conselho Nacional de Segurança Alimentar e Nutricional, National Council for Nutritional Security), which was suspended under the Fernando Cardoso administration but reintroduced under Lula (Leão and Maluf, Reference Leão and Maluf2012), the government worked with civil society and MOH officials to prioritize the latter’s focus on malnutrition, anemia and other food-related disorders (ibid). The new focus on these ailments led to increased political and financial support for related NCDs, such as type-2 diabetes and obesity (Gómez, Reference Gómez2018). This renewed support contributed to an increase in federal funding for programs providing primary care DSM services, such as the FHP. Between 2002 and 2011, for example, federal funding for these programs increased from R$ 793,294.00 to R$37,769,940.00 (Brazil, 2017).

During this period, the FHP also proved successful in working with state and municipal health departments to provide DSM services. Comprised of a physician, nurse, and several health care workers, FHP teams periodically met with type-2 diabetic patients to provide a host of services; these ranged from the distribution of educational pamphlets on how to manage diabetes and advice on nutrition and educational information provided through SUS’ Support Network for Diabetes (Baptista et al., Reference Baptista, Thieme, Reis, Pontarolo and Correr2015). FHP teams also provide consistent reminders to patients about the importance of adhering to their prescribed drug treatment regimens, such as insulin use and tablets, while providing assistance on finding places to engage in physical education (De Almeida-Pititto et al., Reference De Almeida-Pititto, Dias, Franco de Moraes, Ferreira, Franco and Eliaschewitz2015). Other studies found that FHP home care visits have provided important partnerships with patients, helping provide the repeated encouragement and motivation needed to help change individual behaviors and meet treatment targets (Vargas et al., Reference daCruz Vargas, Cecilio, Brasil and de Carvalho Torres2015).

SUS primary care workers were also successful in providing motivational counseling sessions with type-2 patients, which studies revealed encouraged patient adherence to their drug regimen, lower A1C blood glucose levels and increased physical activity (Valle Nascimento et al., Reference Valle Nascimento, Resnicow, Nery, Brentani, Kaselitz, Agrawal, Mand and Heisler2017). Periodic household visits by FHP workers were also reported to have increased co-responsibility, co-accountability and strong partnerships with patients, in turn encouraging patients to improve their lifestyle behaviors and meet treatment targets (Vargas et al., Reference daCruz Vargas, Cecilio, Brasil and de Carvalho Torres2015).

And in 2008, to further augment the FHP’s work in providing DSM services, the MOH created the Núcleo de Apoio á Saúde da Família (Nucleus of Support for Family Health, NASF) (Jaime et al., Reference Jaime, Feldenheimer, Cavalcante de Lima and Bortolini2011). Funded by the MOH, the NASF provides an additional team of health care workers following up with FHP patients to ensure that they are adhering to their diabetic treatment plans, changing their lifestyles, and providing counseling support (ibid). The number of these teams increased from 4230 in 2015 to 4481 in 2016 (Brazil, Ministry of Health, 2015, 2016) and has been important for ensuring the ongoing primary care provision of DSM services and other related ailments, such as obesity prevention (Gómez, Reference Gómez2015, Reference Gómez2018).

Furthermore, the NASF provides a good example of how the MOH is maintaining its centralized policy influence in a context of health care decentralization. The NASF is a federal MOH program that provides auxiliary support to FHP workers. By providing this additional human resource support, the MOH is able to help ensure that the FHP and municipal health agencies are achieving the MOH’s DSM objectives.

Further aiding the MOH’s endeavors has been the government’s receptivity to international assistance. The World Diabetes Federation (WDF) and other agencies, such as the PAHO has, for example, provided financial and technical assistance to municipal health departments in order to provide training on how to provide DSM services (WDF, 2010). In 2010, the WDF supported a program helping municipal health agencies nominate individuals to form local diabetes teams (ibid). These teams were organized in 51 cities across Brazil and received 20 hours of training from WDF officials (ibid). These teams then provided 8 hours of training for FHP officials on how to improve their DSM services, who, in turn, selected and worked with community leaders to serve as an additional resource for diabetes patients (ibid). According to the WDF (2010), 4806 municipal health care professionals have learned to implement self-care management services through this program, while 9473 community health agents have received additional training (ibid). Thus far this program has reached an estimated 216,000 type-2 diabetics (ibid).

In other poorer states in Brazil, such as Bahia, the WHO has provided funding for centers such as the Centre de Prevenção e Reabilitação da Pessoa com Defiência (Center for Prevention and Rehabilitation of Persons with Disabilities), CEPRED (Martino, Reference Martino2016). Through CEPRED, the WHO has helped municipal health officials and FHP personnel provide prevention diagnosis, early detection and self-care management services (ibid). This international assistance has been vital in a context where FHP and community health care workers have in the past lacked sufficient DSM training (Valle Nascimento et al., Reference Valle Nascimento, Resnicow, Nery, Brentani, Kaselitz, Agrawal, Mand and Heisler2017).

But what evidence do we have that SUS’ DSM services contributed to patient adherence and improved blood glucose levels? Interestingly, select survey evidence and articles seem to suggest that patient adherence to drug regimens has not improved throughout several regions, leading to poor control of glycemic blood levels (Vianna et al., Reference Vianna, Leitão, Kramer, Zucatti, Jezini, Felicio, Valverde, Chacra, Azevedo and Gross2013; Coutinho and Silva Júnior, Reference Coutinho and Silva Júnior2015; Pains, Reference Pains2017) For example, surveys conducted by Vianna et al. (Reference Vianna, Leitão, Kramer, Zucatti, Jezini, Felicio, Valverde, Chacra, Azevedo and Gross2013) of 5750 type 2 diabetics in the North, Northeast, Midwest, Southeast and Southern regions of Brazil reported a low level of drug adherence and poor glycemic control, with approximately 26% of the population meeting the WHO suggested benchmark of <7. Nevertheless, Vianna et al. (2013) also found that the poorest glycemic controls were found in the poorer Northeast region; this is where SUS’ primary care efforts have had the most challenges due to a scarcity of SUS health care workers. When seen from this perspective, these findings confirm our position that effective SUS primary care services are important for glycemic control.

It is important to emphasize, however, that the MOH and its DSM programs cannot be blamed for patient lack of adherence to medicine and appropriate self-care. Primary care assistance can only go so far, and ultimately, it is up to the individual to decide if they are willing to receive SUS’ assistance. Unquestionably, the situation could be worse if type-2 patients did not have access to DSM services and their supportive government and community structures.

Finally, in recent years, the government’s support for MOH diabetes programs appears to have waned. Beginning mainly in 2013, increased civil societal protests, instigated by the Dilma administration’s inability to secure quality social services led to increased political instability and a decline in support for Dilma and the PT. Sustaining the politically popular Zero Fome and Bolsa Família programs, therefore, became a government priority. And yet, in a context of ongoing economic recession, the Dilma administration’s focus on these programs eventually led to a decline in financial support for MOH diabetes – and other NCD – programs (Gómez, Reference Gómez2018).

Mexico

Unlike Brazil, Mexico’s government never benefited from the wider health systems and NCD program effects of politically popular anti-poverty programs. Beginning in the late-1980s, former Presidents Carlos Salinas (1988–1994) and Ernesto Zedillo (1994–2000) introduced programs such as Pronasol and Progresa, respectively, in order to eradicate poverty; these programs helped the governing PRI (Partido Revolucionario Institucional, Institutional Revolutionary Party) retain political power until 2000, when the PAN’s (Partido Acción Nacional, National Action Party) presidential candidate, Vincente Fox, was elected into office. To sustain voter support, particularly among the rural poor, Fox expanded Progresa’s benefits and renamed the program Oportunidades. The latter increased coverage to the poor in rural areas (Diaz-Cayeros et al., Reference Diaz-Cayeros, Estévez and Magaloni2016). Moreover, through the creation of the Seguro Popular program in 2003, state governments were able to expand health care services to the poor (ibid). Regardless of the governing party’s political orientation, then, Mexico’s presidents saw ongoing political appeal in sustaining the government’s targeted anti-poverty programs (ibid).

Nevertheless, these populist programs did not translate to increased presidential and congressional support for the Secretariat of Health’s NCD and in particular type-2 diabetes programs. The priority behind these antipoverty programs was to expand access to education, primary health care services and improved infrastructure, with no explicit focus on eradicating starvation, improving nutrition, and thus a focus on nutrition-related ailments, such as diabetes and obesity. Consequently, the president and PRI congressional members were not politically committed to providing the Secretariat of Health with the financial, human resource and infrastructural support needed to implement DSM services (Aitken et al., Reference Aitken, Rajagopal, Marinoni and Cepeda2016).

These conditions contributed to the fact that Mexico’s Secretariat of Health never prioritized creating a single, unified DSM program, coordinating with federal and state insurance providers, ensuring the resources and infrastructural support needed at the primary care level (ibid). Furthermore, those DSM primary programs that exist are institutionally fragmented, with different types of governance arrangements, resources and infrastructural commitments between public and private health care providers – as noted earlier, the converse situation is present in Brazil, with all DSM primary care programs falling under SUS. While the IMSS and ISTEE provide DSM services for all formal sector workers and civil servants through social security contributions, respectively, Seguro Popular manages DSM services for the poor. PEMEX, Mexico’s national petroleum company, provides DSM services for its employees, while a large percentage of the middle- and upper-income classes obtain these services from private health insurance providers.

The challenge is that there is substantial variation in the quality and effectiveness of DSM services between these programs, with IMSS primary care providers, for example, proving repeatedly incapable of acquiring the financial, human resource and infrastructural support needed to implement quality DSM services. And this has occurred despite the IMSS being centrally financed and controlled by the Secretariat of Health (Aitken et al., Reference Aitken, Rajagopal, Marinoni and Cepeda2016). While in recent years, the IMSS has tried to improve its primary DSM services through the creation of the DiabetesIMSS and MIDE (Integral Program in Stages for Diabetes Management) programs, they have reached a very small percentage of the type-2 diabetic population: 100,000 for the former vs 40,000 for the latter (ibid).

While Seguro Popular’s DSM primary care programs are decentralized and administered by state health secretariats, they also lack sufficient federal government financial, human resource and infrastructural support (Fernández, Reference Fernández2013; McClellan and Conyer, Reference McClellan and Conyer2016). Seguro Popular programs also vary considerably in DSM coverage and effectiveness based on state differences in fiscal revenue capacity and willingness to provide resources to primary care teams; and this has occurred even after the central government has prioritized providing complete health insurance coverage for the poor through Seguro Popular (Barquera et al., Reference Barquera, Campos-Nonato, Aguilar-Salinas, Lopez-Ridaura, Arredondo and Rivera-Dommarco2013). In this context, primary care workers providing DSM services, particularly physicians, have not been motivated to meet with diabetic patients in a consistent manner (Fleck, Reference Fleck2017).

While studies suggest that those enrolled in Seguro Popular have experienced increased access to insulin and blood glucose monitoring (Sosa-Rubí et al., Reference Sosa-Rubí, Galárraga and López-Ridaura2009), it is important to emphasize that this does not entail the long-term, ongoing provision of DSM services, such as primary care provider repeated follow-up with patients, families, nutritional and physical exercise counseling – as seen in Brazil. In this context, informal rural community health care workers have played an important role in providing DSM services, such as financial and social support, and arguably have been more successful than Seguro Popular primary care providers in rendering DSM services. These findings lead researchers to conclude that federal and state level primary care providers have lacked the proper organizational structures and procedures needed to provide effective DSM services (Barquera et al., Reference Barquera, Campos-Nonato, Aguilar-Salinas, Lopez-Ridaura, Arredondo and Rivera-Dommarco2013; Aitken et al., Reference Aitken, Rajagopal, Marinoni and Cepeda2016). An ongoing problem, moreover, is that primary care providers within all government insurance programs still behave in a reactionary rather than proactive manner, that is, waiting for problems in self-care management to occur rather than trying to proactively work with patients to avoid them (Flores-Hernández et al., Reference Flores-Hernández, Saturno-Hernández, Reyes-Morales, Barrientos-Gutiérrez, Villalpando and Hernández-Ávila2015).

While the federal Secretariat of Health sought to address these primary care shortcomings through the recently created National Strategy for the Prevention and Control of Overweight, Obesity, and Diabetes, this has yet to be achieved (Aitken et al., Reference Aitken, Rajagopal, Marinoni and Cepeda2016). The National Strategy emphasized three areas: public health, medical attention and health regulation. While the National Strategy does emphasize the importance of consistent drug treatment adherence (e.g., adhering to physician prescribed daily dosages of insulin) for diabetics, it is not an issue that has been thoroughly discussed, especially how primary care teams in the aforementioned insurance programs can address the obstacles to drug adherence – which falls under DSM purview. Policy analysts emphasize that the MOH through the IMSS and Seguro Popular needs to focus on targeting type-2 patients more effectively and to help them manage their conditions (ibid). What’s more, the National Strategy has not prioritized implementing a unified model of type-2 diabetes care and a set of guidelines adopted by all public and private health care providers (ibid).

While federal pilot programs, such as UNEMES Cronicas, have helped fund primary care clinics to treat obesity, diabetes, dyslipidemias and high blood pressure, replete with an interdisciplinary team of health care workers such as psychologists, dietitians, social workers and physicians (somewhat similar to the aforementioned Núcleo de Apoio in Brazil), meeting with patients and using recent technological innovations for monitoring and evaluating patients, they have not been provided the support needed to engage in effective DSM services. Again, lack of sufficient resources and training continues to be a problem (Aitken et al., Reference Aitken, Rajagopal, Marinoni and Cepeda2016). Furthermore, these UNEMES clinics have been too few in number to have a substantial impact on ensuring quality DSM services (Barquera et al. Reference Barquera, Campos-Nonato, Aguilar-Salinas, Lopez-Ridaura, Arredondo and Rivera-Dommarco2013).

In the absence of effective national and sub-national DSM primary care programs, families and NGOs have helped to provide patients with the financial, emotional and social support needed to manage their diabetic condition (Juárez-Ramírez et al., Reference Juárez-Ramírez, Théodore, Villalobos, Jiménez-Corona, Lerin, Nigenda and Lewis2015). Yet, researchers caution that such support has been “helpful but does not guarantee the quality of attention nor enable the self-management of treatment” (ibid, p.1). For instance, in a random national survey of 553 diabetic patients, Juárez-Ramírez et al. (Reference Juárez-Ramírez, Théodore, Villalobos, Jiménez-Corona, Lerin, Nigenda and Lewis2015) found that patients still need access to medication, primary care facilities and primary care workers that can help them, especially in rural areas (ibid). Patients also reported having to pay out of pocket for medications, contributing to their poverty level (ibid).

Furthermore, instead of directly providing financial and human resource support to primary care teams, as seen in Brazil, beginning in 2007 the Secretariat of Health supported the creation of diabetic ‘self-support groups’ throughout the country; by 2013, there were an estimated 11,000 such groups (ibid). Nevertheless, these groups operate with very limited government support, mainly by way of guidelines and medical certifications (ibid). These groups operate on their own, funding their own programs, personnel training and patient outreach.

And finally, increased patient adherence to prescribed diabetic medication and treatment, as well as individual control of blood glucose levels, has not been achieved. Through national surveys conducted between 2006 and 2012, Flores-Hernández et al. (Reference Flores-Hernández, Saturno-Hernández, Reyes-Morales, Barrientos-Gutiérrez, Villalpando and Hernández-Ávila2015) found a low level of compliance with HbA1C testing recommendations, medication use, and recommended exercise regimens. Consequently, most diabetic patients have not been able to successfully control their glycemic blood levels, failing to achieve the WHO-recommended <7 level (Barquera et al., Reference Barquera, Campos-Nonato, Aguilar-Salinas, Lopez-Ridaura, Arredondo and Rivera-Dommarco2013; Alegre-Díaz et al., Reference Alegre-Díaz, Herrington, López-Cervantes, Gnatiuc, Ramirewz, Hill, Baignent, McCarthy, Lewington, Collins, Whitlock, Tapia-Conyer, Peto, Kuri-Morales and Emberson2016). The absence of a comprehensive DSM program further compounds these results and will limit the prospect of individuals being able to improve their ability to control their blood glucose levels in the future.

Comparative health outcomes

When compared to each other, what further empirical evidence exists suggesting that Brazil has been more effective than Mexico in controlling type-2 diabetes and its associated ailments? Recent statistical indicators from the WHO and PAHO seem to lend credence to this notion. Since 2011, for example, the total number of diabetics (per 100,000) decreased from 36.3 to 31.3 in Brazil, while Mexico saw an increase from 87.3 to 91.8 (per 100,000) for the same time period (WHO, 2018). Data on fasting blood glucose levels (i.e., >7 mmol/l, with anything above 7 being abnormally high), obtained from random sample population sizes, at age-standardized estimates – which reveals the level of sugar within an individual’s bloodstream, presence of diabetes and its control – was also higher in Mexico, increasing from 10.7 in 2010 to 11.2 in 2014, vs 7.8 and 8.3 in Brazil for the same time period (WHO, 2018). Additionally, the total number of deaths attributed to diabetes in Brazil increased slightly from 54,855 in 2010 to 57,843 in 2014, while in Mexico, deaths were substantially higher, increasing from 81,320 to 91,957 for the same time period (PAHO, 2018). Related health ailments, such coronary heart disease (commonly associated with type-2 diabetes), also decreased in Brazil from 65.7 per 100,000 in 2010 to 58.5 in 2015, while Mexico saw an increase from 75.8 to 76.6 per 100,000 for the same time period (PAHO, 2018).