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Breast cancer is a serious threat to the health of women globally, and an unrecognised priority in middle-income countries. This paper presents data from Mexico. It shows that breast cancer accounts for more deaths than cervical cancer since 2006. It is the second cause of death for women aged 30-54 and affects all socio-economic groups. Data on detection, although under-reported, show 6,000 new cases in 1990, and a projected increase to over 16,500 per year by 2020. Further, the majority of cases are self-detected and only 10% of all cases are detected in stage one. Mexico's social security systems cover approximately 40-45% of the population, and include breast cancer treatment. As of 2007, the rest of the population has the right to breast cancer treatment through the Popular Health Insurance. Despite these entitlements, services are lacking and interventions for early detection, particularly mammography, are very limited. As of 2006 only 22% of women aged 40-69 reported having a mammogram in the past year. Barriers exist on both the demand and supply sides. Lobbying, education, awareness-building and an articulated policy response will be important to ensure expanded coverage, access to and take-up of both treatment and early detection. [ABSTRACT FROM AUTHOR]

Context: Inequities and gaps in palliative care access are a serious impediment to health systems especially in low- and middle-income countries and the accurate measurement of need across health conditions is a critical step to understanding and addressing the issue. Serious Health-related Suffering (SHS) is a novel methodology to measure the palliative care need and was originally developed by The Lancet Commission on Global Access to Palliative Care and Pain Relief. In 2015, the first iteration - SHS 1.0 - was estimated at over 61 million people worldwide experiencing at least 6 billion days of SHS annually as a result of life-limiting and life-threatening conditions., Objectives: In this paper, an updated methodology - SHS 2.0 - is presented building on the work of the Lancet Commission and detailing calculations, data requirements, limitations, and assumptions., Methods and Results: The updates to the original methodology focus on measuring the number of people who die with (decedents) or live with (non-decedents) SHS in a given year to assess the number of people in need of palliative care across health conditions and populations. Detail on the methodology for measuring the number of days of SHS that was pioneered by the Lancet Commission, is also shared, as this second measure is essential for determining the health system responses that are necessary to address palliative care need and must be a priority for future methodological work on SHS., Conclusions: The methodology encompasses opportunities for applying SHS to future policy making assessment of future research priorities particularly in light of the dearth of data from low- and middle-income countries, and sharing of directions for future work to develop SHS 3.0., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: The introduction, strict enforcement and recent exit of China's one-child policy (OCP) resulted in China's demographical changes, and, alongside its epidemiological transition, disproportionately impacted caregiving needs and demands on women. This study examines women's caregiving responsibilities in contemporary China and evaluates how the OCP affected them., Methods: We simulated the female population aged 25-54 years in 2020 in China and their caregiving responsibilities based on epidemiological and demographic data for women, their parents and parents-in-law, and children under 10. Three different health states were simulated for children and the senior generation: (1) healthy, (2) end of life-decedents and (3) non-decedents in need of palliative care. We combine the care responsibility for senior family members and for children using an aggregate indicator-the Care Responsibility Score (CRS) -to compare the impact of the OCP across different generations of women., Results: Approximately 60 million working-age women are living with medium to high levels of care responsibilities (a CRS over 0.8), which is equivalent to caring for a senior family member with palliative care needs without any assistance from siblings. This includes more than one-third of the 156 million women born after the OCP and only 5% of women born before the OCP., Conclusion: For women born under the OCP, the additional responsibility generated by a lack of siblings outweighs the benefit of having four dedicated grandparents to support them in raising children., Competing Interests: Competing interests: FMK reports two research grants from EMD Serono and Merck KGaA related to measuring the economic value of women’s paid and unpaid contributions to the health sector. XK, BE and RC-A report research consulting payments from EMD Serono and Merck KGaA via the University of Miami Institute for the Advanced Studies of the Americas. Other coauthors declare no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Integration of palliative care into health care systems is considered an ethical responsibility, yet no country in the Eastern Mediterranean Region (EaMReg) has achieved integration. Data on palliative care need and cost are crucial forEaMReg health care planners and implementers in the region. Using data from the Lancet Commission on Palliative Care and Pain Relief, we estimated the number of people in each EaMReg country who needed palliative care in 2015 and their degree of access. In three countries, we estimated the number of days during which an encounter for palliative care was needed at each level of the health care system. This enabled calculation of the number of full-time equivalents (FTEs) of clinical and non-clinical staff members needed at each level to administer the essential package of palliative care recommended by WHO. In 2015, 3.2 million people in the EaMReg needed palliative care, yet most lacked access to it. The most common types of suffering were pain, fatigue, weakness, anxiety or worry, and depressed mood. To provide safe, effective palliative care at all levels of health care systems, between 5.4 and 11.1 FTEs of trained and supervised community health workers per 100,000 population would be needed in addition to 1.0-1.9 FTEs of doctors, 2.2-4.3 FTEs of nurses, and 1.4-2.9 FTEs of social workers. Data from our study enables design of palliative care services to meet the specific needs of each EaMReg country and to calculate the cost or cost savings., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Krakauer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In 2003, the Mexican Congress approved a major reform to provide health care services to the poor population through the public insurance scheme Seguro Popular. This program was dismantled in 2019 as part of a set of health system reforms and substituted with the Health Institute for Welfare (INSABI). These changes were implemented during the initial phases of the coronavirus (COVID-19) pandemic. We aimed to examine the impact of these reforms and the COVID-19 pandemic on financial risk protection in Mexico between 2018 and 2020., Methods: We performed a population-based analysis using cross-sectional data from the 2018 and 2020 rounds of the National Household Income and Expenditures Survey. We used a pooled fixed-effects multivariable two-stage probit model to determine the likelihood of catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and excessive health expenditure (EHE) among Mexican households. We also mapped the quintiles of changes in EHE in households without health insurance by state., Results: The percentage of households without health insurance almost doubled from 8.8% (three million households) in 2018 to 16.5% (5.8 million households) in 2020. We also found large increases in the proportion of households incurring in CHE (18.4%; 95% confidence interval (CI) = 6.1, 30.7) and EHE (18.7%; 95% CI = 7.9, 29.5). Significant increases in CHE, IHE, and EHE were only observed among households without health insurance (CHE: 90.7%; 95% CI = 31.6, 149.7, EHE: 73.5%; 95% CI = 25.3, 121.8). Virtually all Mexican states (n/N = 31/32) registered an increase in EHE among households without health insurance. This increase has a systematic territorial component affecting mostly central and southern states (range = -1.0% to 194.4%)., Conclusions: The discontinuation of the Seguro Popular Program and its substitution with INSABI during the first stages of the COVID-19 pandemic reduced the levels of health care coverage in Mexico. This reduction and the pandemic increased out-of-pocket expenditure in health and the portion of CHE and EHE in the 2018-2020 period. The effect was higher in households without health insurance and households in central and southern states of the country. Further studies are needed to determine the specific effect both of recent policy changes and of the COVID-19 pandemic on the levels of financial protection in health in Mexico., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2023 by the Journal of Global Health. All rights reserved.)

This dataset covers national and subnational non-pharmaceutical interventions (NPI) to combat the COVID-19 pandemic in the Americas. Prior to the development of a vaccine, NPI were governments' primary tools to mitigate the spread of COVID-19. Variation in subnational responses to COVID-19 is high and is salient for health outcomes. This dataset captures governments' dynamic, varied NPI to combat COVID-19 for 80% of Latin America's population from each country's first case through December 2021. These daily data encompass all national and subnational units in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru. The dataset includes individual and aggregate indices of nine NPI: school closures, work suspensions, public event cancellations, public transport suspensions, information campaigns, local travel restrictions, international travel controls, stay-at-home orders, and restrictions on the size of gatherings. We also collected data on mask mandates as a separate indicator. Local country-teams drew from multiple data sources, resulting in high-quality, reliable data. The dataset thus allows for consistent, meaningful comparisons of NPI within and across countries during the pandemic., (© 2023. Springer Nature Limited.)

2023 marks the 20-year anniversary of the creation of Mexico's System of Social Protection for Health and the Seguro Popular, a model for the global quest to achieve universal health coverage through health system reform. We analyse the success and challenges after 2012, the consequences of reform ageing, and the unique coincidence of systemic reorganisation during the COVID-19 pandemic to identify strategies for health system disaster preparedness. We document that population health and financial protection improved as the Seguro Popular aged, despite erosion of the budget and absent needed reforms. The Seguro Popular closed in January, 2020, and Mexico embarked on a complex, extensive health system reorganisation. We posit that dismantling the Seguro Popular while trying to establish a new programme in 2020-21 made the Mexican health system more vulnerable in the worst pandemic period and shows the precariousness of evidence-based policy making to political polarisation and populism. Reforms should be designed to be flexible yet insulated from political volatility and constructed and managed to be structurally permeable and adaptable to new evidence to face changing health needs. Simultaneously, health systems should be grounded to withstand systemic shocks of politics and natural disasters., Competing Interests: Declaration of interests FMK is President and Founder of Tómatelo a Pecho. FMK participated in the design, financial calculations, and implementation of the Seguro Popular, collaborating with Mexico's Ministry of Health. She is married to JF who was Minister of Health of Mexico from 2000 to 2006. FMK was employed by the Ministry of Education and the Ministry of Social Development of Mexico during the administration of President Vicente Fox. FMK received research grants from Merck and EMD Serono to the University of Miami outside the scope of the submitted work and from Merck Sharp & Dohme, Avon Cosmetics, and S de R L de C V to Tómatelo a Pecho, all outside the scope of the submitted work. FMK received research grants from the US Cancer Pain Relief Committee to the University of Miami and the Medical Research Council to the University of Miami and Funsalud (Mexican Health Foundation) for work related to palliative care. FMK has also received consulting fees from Merck and EMD Serono and Instituto Tecnológico y de Estudios Superiores de Monterrey, Mexico outside the scope of the submitted work. FMK is a member of the Board of Directors of the International Association for Hospice and Palliative Care. FMK collaborates as a Sistema Nacional de Investigadores researcher at the Mexican Health Foundation, where she has been affiliated since 2000. HA-O is a Research Professor of the Institute for Obesity Research of Tecnológico de Monterrey, is Executive Director of Tómatelo a Pecho, and participates as an Associate Researcher at Funsalud (Mexican Health Foundation). HA-O received consultancy fees from Merck through the University of Miami outside the scope of the submitted work and from Merck Sharp & Dohme, Avon Cosmetics, and S de R L de C V to Tómatelo a Pecho, AC outside the scope of the submitted work. HA-O received consultancy fees from the US Cancer Pain Relief Committee to the University of Miami and the Medical Research Council to the University of Miami and Funsalud (Mexican Health Foundation) for work related to palliative care. HA-O collaborates as a Sistema Nacional de Investigadores researcher at the Mexican Health Foundation, where he has been affiliated since 2003. TM receives consulting fees for research and writing from the University of Miami Institute for Advanced Studies of the Americas. OG-D and ES-M were partly funded by the National Institute for Health and Care Research (NIHR) Global Health Policy and Systems Research researcher-led grant (NIHR150067) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK Government. OG-D was Director General for Performance Evaluation at the Ministry of Health of Mexico during 2000–06, which was the initial period of implementation of the Seguro Popular. PK was Vice Minister of Health of Mexico from December, 2011, to December, 2018, under the administration of Enrique Peña Nieto. AM-V participated in the design and implementation of the Seguro Popular between 2001 and 2007. AM-V was also Director General of Planning and Evaluation at the National Coordination of the Oportunidades Program between 2009 and 2011. He also served as the Deputy Director General of the Economic Analysis Unit between 2013 and 2016, and Director General of Evaluation between 2013 and 2019, both at the Ministry of Health. JF was responsible for the design and implementation of the Seguro Popular. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Mexico declared an obesity epidemic in 2000, and in response, became an early adopter of public policies in the form of natural experiments, which have not been evaluated for their effect on high BMI. We focus on children younger than 5 years due to the long-term outcomes of childhood obesity., Methods: We used the Global Burden of Disease data to evaluate time trends in high BMI, defined as being overweight or obese based on the International Obesity Task Force standards, between 1990 and 2019. Marginalisation and poverty estimates from Mexico's Government were used to identify differences in socioeconomic groups. The time variable reflects the introduction of policies between 2006 and 2011. Our hypothesis was that poverty and marginalisation modify the effects of public policies. We tested for the change in prevalence of high BMI over time using Wald-type tests, correcting for the effect of repeated measures. We stratified the sample by gender, marginalisation index, and households under the poverty line. Ethics approval was not required., Findings: Between 1990 and 2019, high BMI in children younger than 5 years increased from 23·5% (95% uncertainty interval 38·6-14·3) to 30·2% (46·0-20·4). After a period of sustained increase to 28·7% (44·8-18·6) in 2005, high BMI decreased to 27·3% (42·4-17·4; p<0·001) in 2011. Afterwards, high BMI increased constantly. We found an average gender gap of 12·2%, with a higher rate in males, in 2006, which remained constant. With respect to marginalisation and poverty, we observed a reduction in high BMI across all strata, except for the uppermost quintile of marginalisation in which high BMI remained flat., Interpretation: The epidemic affected groups across different socioeconomic levels, thus weakening economic explanations for the decrease in high BMI, while gender gaps point to behavioural explanations of consumption. The observed patterns warrant investigation through more granular data and structural models to isolate the effect of the policy from secular trends in the population, including other age groups., Funding: Tecnológico de Monterrey Challenge-Based Research Funding Program., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: The Lancet Commission on Palliative Care (PC) and Pain Relief quantified the burden of serious health-related suffering (SHS), proposing an Essential Package of PC (EPPC) to narrow the global PC divide. We applied the EPPC framework to analyze PC access in Chile, identify gaps in coverage, and provide recommendations to improve PC access., Methods: Total SHS and population in need of PC was estimated using official 2019 government data. We differentiated between cancer and non-cancer related SHS given guaranteed Chilean PC coverage for cancer. We calculated differences between the Chilean PC package and the Lancet Commission EPPC to estimate the cost of expanding to achieve national coverage of palliative care., Findings: In 2019, nearly 105,000 decedent and non-decedent Chileans experienced SHS with a lower-bound estimate of 12.1 million days and an upper-bound estimate of 42.4 million days of SHS. Each individual experienced between 116 and 520 days of SHS per year. People living with a cancer diagnosis had PC access with financial protection, accounting for almost 42% of patients in need. People with non-cancer diagnoses-about 61 thousand patients-lacked PC coverage. Expanding coverage of the EPPC for all patients in need would cost just above $123 million USD, equivalent to 0.47% of Chilean National Health Expenditure., Interpretation: Achieving universal PC access is urgent and feasible for Chile, classified as a high-income country. Expanding PC services and coverage to the EPPC standard are affordable and critical health system responses to ensuring financial protection for patients with SHS. In Chile, this requires closing large gaps in PC coverage pertaining to patients with non-cancer conditions and treatment of symptoms that go beyond pain. Our research provides an empirical approach for applying the Lancet Commission SHS framework to estimate the cost of achieving national universal PC access anchored in a package of health care services., Funding: This research was partially funded by the Chilean Government through the Fondo Nacional de Ciencia y Tecnología (Fondecyt Regular) grant number 1201721, the U.S. Cancer Pain Relief Committee grant AWD-003806 awarded to the University of Miami and by the University of Miami Institute for Advanced Study of the Americas. We acknowledge NIH/NCI award P30CA008748., Competing Interests: WER serves as a consultant for The Global Palliative Care and Pain Relief Research Hub at the University of Miami–Institute of Advanced Study of the Americas. FMK is a member of the Board of directors for the International Association for Hospice and Palliative Care, a position for which is not compensated. All authors declare no competing interests., (© 2023 The Authors.)

Background: Overweight and obesity (OW/OB) represent a serious challenge in Mexico, with effects on health, society and economy. Demographic, epidemiological, nutritional, social and economic factors have exacerbated this problem., Objective: To analyze mortality and years of healthy life lost in Mexico due to OW/OB in the 1990-2021 period., Material and Methods: The Global Burden of Disease and Risk Factors 2021 study was used to analyze data on elevated body mass index (BMI) as a risk factor and its evolution in Mexico., Results: In 2021, 118 thousand deaths attributable to high BMI were recorded, which accounted for 10.6% of total deaths and more than 4.2 million disability-adjusted life years lost., Conclusions: The obesogenic environment, influenced by social determinants of health, has had a significant impact on mortality, burden of disease, and economic costs. Addressing OW/OB requires multisector interventions to strengthen the Mexican health system., (Copyright: © 2023 Permanyer.)

Competing Interests: FMK was the chair of the Lancet Commission on global access to palliative care and pain relief; is the founding President of Tómatelo A Pecho, a Mexican non-governmental organisation; is on the board of the International Association for Hospice & Palliative Care; and reports grants and consulting fees from EMD Serono, a business of Merck KGaA, Darmstadt, Germany, outside the scope of the current work. HA-O reports research grants from EMD Serono, a business of Merck KGaA, Darmstadt, Germany, outside the scope of the current work. WER and RSN declare no competing interests. WER acknowledges the US National Institutes of Health National Cancer Institute (NCI) Cancer Center support grant P30 CA008748 and is supported by the NCI award number T32 CA009461. We thank Barbara M Sorondo and Vera Spika for guidance on the bibliometric search, and Valentina Vargas Enciso for excellent comments and suggestions.

Nonpharmaceutical interventions such as stay-at-home orders continue to be the main policy response to the COVID-19 pandemic in countries with limited or slow vaccine rollout. Often, nonpharmaceutical interventions are managed or implemented at the subnational level, yet little information exists on within-country variation in nonpharmaceutical intervention policies. We focused on Latin America, a COVID-19 epicenter, and collected and analyzed daily subnational data on public health measures in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru to compare within- and across-country nonpharmaceutical interventions. We showed high heterogeneity in the adoption of these interventions at the subnational level in Brazil and Mexico; consistent national guidelines with subnational heterogeneity in Argentina and Colombia; and homogeneous policies guided by centralized national policies in Bolivia, Chile, and Peru. Our results point to the role of subnational policies and governments in responding to health crises. We found that subnational responses cannot replace coordinated national policy. Our findings imply that governments should focus on evidence-based national policies while coordinating with subnational governments to tailor local responses to changing local conditions.

This viewpoint addresses the lack of gender diversity in medical leadership in Latin America and the gap in evidence on gender dimensions of the health workforce. While Latin America has experienced a dramatic change in the gender demographic of the medical field, the health sector employment pipeline is rife with entrenched and systemic gender inequities that continue to perpetuate a devaluation of women; ultimately resulting in an under-representation of women in medical leadership. Using data available in the public domain, we describe and critique the trajectory of women in medicine and characterize the magnitude of gender inequity in health system leadership over time and across the region, drawing on historical data from Mexico as an illustrative case. We propose recommendations that stand to disrupt the status quo to more appropriately value women and their representation at the highest levels of decision making for health. We call for adequate measurement of equity in medical leadership as a matter of national, regional, and global priority and propose the establishment of a regional observatory to monitor and evaluate meaningful progress towards gender parity in the health sector as well as in medical leadership., Competing Interests: FMK advises to the CEO of Merck KGaA, Darmstadt, Germany/EMD Serono advising the company's strategy related to the Healthy Women, Healthy Economies and Embracing Carers initiatives, as well as on sustainable development and women in leadership. No compensation was received from this consulting agreement for work on the current paper. BME and HAO report research grants from MerckKGaA/EMD Serono via the University of Miami Institute for the Advanced Studies of the Americas. All other authors declare no conflict of interest., (© 2022 The Authors.)

Colombia's health sector reform has been recognized for its universal health (UHC) coverage scheme. However, this reform evolved without palliative care (PC), thereby omitting a core element of UHC. In this paper, we analyze the Colombian health system reform and health policies in relation to PC. We present the history, innovations, successes, and shortcomings of the reform and summarize the lessons learned to strengthen efforts leading to PC integration. Our analysis is based on the WHO public health framework for PC (policy, access to medicines, education, service provision). For several years and especially during the last decade, the government enacted laws and regulations to improve access to essential medicines and to integrate PC. Relative to other countries in Latin America, Colombia was the first to launch a PC service and to accredit palliative medicine as a specialty, the second to establish a national PC association and one of the few countries with a specific PC law. However, data shows that there are still too few services to meet the PC needs of approximately 250,000 adult patients annually. Our analysis shows that the country's failure to integrate PC most likely is a result of limited health worker education. Advocacy efforts should include deans of schools and provosts, in addition to policy makers and regulators. Other possible factors affecting uptake and implementation of existing national policies are civil unrest and limited collaboration between government offices. Additional research is needed to evaluate the impact of these and other related factors on PC integration in Colombia., (Copyright © 2021 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Competing Interests: BME and HA-O are paid research consulting fees through The University of Miami Institute for Advanced Study of the Americas, which has received funding from Merck EMD Serono for projects related to measuring the gendered value of paid and unpaid contributions to health. FMK has received consulting fees from Merck KGaA Darmstadt outside of the area of work commented on here. All other authors declare no competing interests. The authors acknowledge the Research Hub on Gender Equity in Health Systems and Caring Economies for thought leadership and research that informed this commentary. We are also grateful to Renu Nargund and Valentina Vargas Enciso for research support. FMK and BME are joint first authors.

We present a new concept, Punt Politics , and apply it to the COVID-19 non-pharmaceutical interventions (NPI) in two epicenters of the pandemic: Mexico and Brazil. Punt Politics refers to national leaders in federal systems deferring or deflecting responsibility for health systems decision-making to sub-national entities without evidence or coordination. The fragmentation of authority and overlapping functions in federal, decentralized political systems make them more susceptible to coordination problems than centralized, unitary systems. We apply the concept to pandemics, which require national health system stewardship, using sub-national NPI data that we developed and curated through the Observatory for the Containment of COVID-19 in the Americas to illustrate Punt Politics in Mexico and Brazil. Both countries suffer from protracted, high levels of COVID-19 mortality and inadequate pandemic responses, including little testing and disregard for scientific evidence. We illustrate how populist leadership drove Punt Politics and how partisan politics contributed to disabling an evidence-based response in Mexico and Brazil. These cases illustrate the combination of decentralization and populist leadership that is most conducive to punting responsibility. We discuss how Punt Politics reduces health system functionality, providing lessons for other countries and future pandemic responses, including vaccine rollout., Competing Interests: The authors declare no competing interest., (© 2021 The Author(s). Published by Elsevier Ltd.)

Introduction: To present an analysis of the Brazilian health system and subnational (state) variation in response to the COVID-19 pandemic, based on 10 non-pharmaceutical interventions (NPIs)., Materials and Methods: We collected daily information on implementation of 10 NPI designed to inform the public of health risks and promote distancing and mask use at the national level for eight countries across the Americas. We then analyse the adoption of the 10 policies across Brazil's 27 states over time, individually and using a composite index. We draw on this index to assess the timeliness and rigour of NPI implementation across the country, from the date of the first case, 26 February 2020. We also compile Google data on population mobility by state to describe changes in mobility throughout the COVID-19 pandemic., Results: Brazil's national NPI response was the least stringent among countries analysed. In the absence of a unified federal response to the pandemic, Brazilian state policy implementation was neither homogenous nor synchronised. The median NPI was no stay-at-home order, a recommendation to wear masks in public space but not a requirement, a full school closure and partial restrictions on businesses, public transportation, intrastate travel, interstate travel and international travel. These restrictions were implemented 45 days after the first case in each state, on average. Rondônia implemented the earliest and most rigorous policies, with school closures, business closures, information campaigns and restrictions on movement 24 days after the first case; Mato Grosso do Sul had the fewest, least stringent restrictions on movement, business operations and no mask recommendation., Conclusions: The study identifies wide variation in national-level NPI responses to the COVID-19 pandemic. Our focus on Brazil identifies subsequent variability in how and when states implemented NPI to contain COVID-19. States' NPIs and their scores on the composite policy index both align with the governors' political affiliations: opposition governors implemented earlier, more stringent sanitary measures than those supporting the Bolsonaro administration. A strong, unified national response to a pandemic is essential for keeping the population safe and disease-free, both at the outset of an outbreak and as communities begin to reopen. This national response should be aligned with state and municipal implementation of NPI, which we show is not the case in Brazil., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Mexican state governments' actions are essential to control the COVID-19 pandemic within the country. However, the type, rigor and pace of implementation of public policies have varied considerably between states. Little is known about the subnational (state) variation policy response to the COVID-19 pandemic in Mexico., Material and Methods: We collected daily information on public policies designed to inform the public, as well as to promote distancing, and mask use. The policies analyzed were: School Closure, Workplace Closure, Cancellation of Public Events, Restrictions on Gatherings, Stay at Home Order, Public Transit Suspensions, Information Campaigns, Internal Travel Controls, International Travel Controls, Use of Face Masks We use these data to create a composite index to evaluate the adoption of these policies in the 32 states. We then assess the timeliness and rigor of the policies across the country, from the date of the first case, February 27, 2020., Results: The national average in the index during the 143 days of the pandemic was 41.1 out of a possible 100 points on our index. Nuevo León achieved the highest performance (50.4); San Luis Potosí the lowest (34.1). The differential between the highest versus the lowest performance was 47.4%., Conclusions: The study identifies variability and heterogeneity in how and when Mexican states implemented policies to contain COVID-19. We demonstrate the absence of a uniform national response and widely varying stringency of state responses. We also show how these responses are not based on testing and do not reflect the local burden of disease. National health system stewardship and a coordinated, timely, rigorous response to the pandemic did not occur in Mexico but is desirable to contain COVID-19., Competing Interests: The authors have declared that no competing interests exist.