Facilitators and barriers to advancing binational health coverage strategies for undocumented Mexican migrants in the United States of America

Background: Within the framework of a new national health program with emphasis on universal coverage strategies and in the context of revision/adjustments to the North American Free Trade Agreement (NAFTA/TEMEC), the present study aimed to identify barriers, facilitators and challenges for the development of strategies on social protection in the health of migrants and their families. Material and methods: Evaluative research based on a qualitative analysis with a cross-sectional design. The techniques of documentary analysis, applied political analysis (mapping of actors), in-depth interviews and case studies were used. In the first stage, key actors were mapped at the federal level and senior executives and health officials, federal deputies, senators and members of the Mexican foreign service were interviewed. In the second stage, field work was carried out in the state of Guanajuato and California; State health service officials, state government officials, municipal officials, health unit workers, representatives of CSOs and relatives of migrants were interviewed. The analysis of the interviews was carried out through the ATLAS-Ti software, as well as the mapping of actors and feasibility analysis through the POLICY MAKER software. Results: The main results allowed to identify indicators on barriers and facilitators regarding social actors, binational agreements under NAFTA/TEMEC, institutional spaces, interaction between social actors, as well as the impact and type of relations for a greater advance in binational health policies. Several obstacles were reported, including the fears that undocumented emigrants have in the U.S. of being arrested and deported if they use public health services in the U.S. The stakeholders also believed that many Mexican emigrants do not have a culture that values health insurance. Conclusions: In the context of reforms and adjustments of health systems that are being discussed in parallel in the revision and adjustments of NAFTA/TEMEC (United States of

The issue of lack of protection in social security and health, takes on high relevance because more than half of Mexican undocumented migrants between 18 and 64 years of age do not have health insurance in Mexico or California (4). In this context, the strategy of developing new coverage strategies supported by lines of action for greater access to health services, the approach to the health needs of Mexican migrants has allowed us to document various risk factors and health care needs. Situations suggesting barriers to access to services and medical insurance in places of origin and destination have been analyzed (5). Various analyzes have shown that the provision of social health protection services to migrants and their families is the subject of a broad debate in Mexico and the United States.
The available information on the health services offer shows that more than half of Mexican migrants aged 18 to 64 did not have health insurance (6)(7). Based on this, the creation of binational health programs and public or private medical insurance has been promoted, but its implementation, implementation and possible implementation scenarios have been poorly documented (8)(9)(10).
There are initiatives aimed at carrying out events that promote access and improvement of health among Mexican residents who live and work in the United States and who do not have health insurance, such as the Binational Health Week (see: http: // hia .berkeley.edu). The Vete Sano Regresa Sano program, where the Institute of Mexicans Abroad participates, a decentralized body of the Ministry of Foreign Affairs (11)(12)(13)(14).
However, in some studies it has been shown that since the implementation of the NAFTA, all these programs face resistance from the cultural, to the political, legal and administrative (15)(16)(17)(18).
Initiatives have also been developed to expand the supply of health services for this population, particularly in the border area. Such is the case of organizations such as Health Net (19) and the Health Window of Mexican consulates in various US cities (20)(21).
These mechanisms for offering health services represent an opportunity to characterize governance mechanisms related to access to health care, especially by illegal immigrants in California. This approach seeks to identify opportunities that favor health governance through social protection and the provision of health services to a vulnerable population in a scenario of high feasibility.
In recent years, the issue of actions on social protection in health, addressed to Mexican emigrants has been raised in multiple forums, while it has been used for various purposes in the political agendas of Mexico and the United States, in favor in one case and subject to circumstances of the political and economic environment in the other (22)(23)(24). However, it requires more information, new indicators and the construction of high feasibility scenarios, to identify agreements and necessary arrangements to be able to advance in the creation of a binational health social protection system, as well as to establish its scope. in the current and future scenario (25)(26)(27)(28).
In order to dimension the problems related to the governance and social protection in health of migrants, it is considered relevant to establish the map of actors (the normative frameworks, the processes, their interactions, etc.) linked to the creation and promotion of health services in the framework of the national health program 2018-2024 (29)(30)(31). To this end, the review of trade agreements on programs, services and medical insurance was examined, as well as an analysis of the legal frameworks that support the supply and access to health services in both countries, incorporating economic indicators of equity and access to health (32)(33). On the other hand, it is also very important to identify the key social actors involved, as well as the type of interactions and interaction spaces between the different actors of the health system. This information is strategic in the identification of governance indicators and their relationship with facilitators, barriers and challenges for a public policy of greater social protection in health for the benefit of migrants (34)(35)(36).
In summary, the objective of this manuscript is to present the main indicators on facilitators and barriers for the implementation of binational strategies in the area of social protection in the health of migrants.

Methodology
An evaluative research design was developed based on qualitative analysis of key documents, in-depth interviews with key actors and case studies in localities of Guanajuato, Mexico and California, US. Both states were selected at their convenience, in response to a binational call, which proposed involving academic institutions from Mexico and the United States with a large influx of migrants. Under a collaborative scheme with colleagues from University of California in Los Angeles, contact was made in the field with Mexican families from Guanajuato, who had the destination of the state of California, which further strengthened the collaboration and political mapping. The "snowball" method was used to carry out the interviews, combining two strategies; In the first case, the government actors contacted each other directly, sending them letters and emails.
With the state actors, some personal recommendations were used with families and members of migrant federations, who in turn recommended other contacts from which the interviews were conducted. The methodological procedures comprised three stages:  The main integrated facilitators are highlighted below based on the recommendations, suggestions and findings of the sources of information selected and reviewed for that purpose. The NAFTA documents, government reform projects as well as national and international Civil Society Organizations (CSOs), make recommendations for a binational health policy. In this context, they establish that the challenges of the social protection system in health tend to coincide with the challenges of the national economy, in the sense of increasing access, coverage and quality at the lowest possible cost and improving administration to increase the efficiency To address these challenges, as opportunities or facilitators to develop, the following aspects are highlighted: • New mechanisms to standardize and certify units of medical care, licensing and certification of professionals, technology assessment and financial equity, and adjustments of the regulatory framework based on recommendations issued by the World Health Organization, which establish the expansion of public offer through participation of public and private providers.
• From the design of reform programs in social protection in health for different population groups, take advantage of the development of the wide range of commercial and investment transactions that operate within the framework of NAFTA/TEMEC through trilateral governmental and non-governmental institutions (including health aspects).
• There is already a normative framework that establishes that there must be a trinational or binational cooperation (Mexico-US-Canada) regarding the migration issue and collateral problems such as social protection. This opening includes the development of including new and innovative legal migration routes, new and effective mechanisms for law enforcement with rights and obligations in the workplace and a series of welfare support mechanisms to strengthen the supply of jobs and social protection programs.
• Strengthen the binational dialogue to find beneficial solutions to the migratory phenomenon in general, and to the resolution on social protection actions in the particular. This will allow the improvement of policy coordination and management within each government, both at the federal and state and municipal levels.
• Binational agreements have been signed for cooperation in health and education. Such agreements have been promoted between the health and labor authorities of Mexico and the US. These agreements make it easier for Mexicans in the United States to access information about health and education services available to them. In a context of more legal migration and less illegal, the bilateral cooperation of these agreements proposes to develop binational health coverage schemes, including those that give attention to undocumented workers.
• From the perspective of some US analysts, it was promising that the reform of the • There are limitations regarding the regulation of health insurers in Mexico, which limit a foreign company to control a certain percentage of the domestic insurance market.
• The transnational scope of actions of the health system of the United States in Mexico is generally limited to preventing the spread of infectious-contagious diseases originating in Mexico in its transit to North American territory.
• Different documents express that from the Mexican side there are conceptual and normative differences as barriers for bilateral cooperation in matters of public health and social protection in health.
• Unlike situations related to public health, Mexican private doctors expressed more interest than their counterparts in the development of coordination mechanisms for medical care, pointing out various forms of lack of reciprocity of doctors from the United States.
• The opinions of American doctors in this regard coincide with some problems referred to in recent years, such as the perception that Mexican doctors are not adequately trained.
• Since the implementation of NAFTA, there has been a lack of definition of frameworks for the implementation of binational programs in the field of health systems. Eight facilitators were identified, of which four were qualified with a high prospect and four with a medium prospect. Table 1 presents the facilitators with high impact prospects, while linking them with groups of potential actors and coalitions to exploit them.
Facilitators with a medium impact prospect are described in table 2, and include actors from the social and government sectors, as well as CSOs. This pattern suggests that the greatest opportunities were concentrated in political and governmental actors at the federal level, while, to the extent that the analysis is directed at the local level, greater barriers and feasibility challenges are outlined.     Financial. 2-Paradoxical effects of remittances in terms of financial protection in health. The increase in remittances from migrants-family promotes addressed invest more in private institutions than in public institutions where is offered the health coverage program.
Financial. 3-Problems of financial sustainability to ensure all inputs required for free in all interventions and total coverage of medicines under the new effective universal coverage scheme.
Organizational. 4-Little interest and motivation in the new insurance schemes for major medical expenses, mainly due to the expectation of offering free services to all public sector institutions.
Culturalorganizational 5-Uncertainty generated by ignorance of users about that problems can be addressed from the basic package services of popular health insurance and which are not.
Organizational 6-High tendency to limit migrant programs to basic programs of promotion and prevention and poorly to treatment and rehabilitation.
Culturalorganizational. 7-Perception of poor quality of care, especially in the treatment of chronic diseases such as diabetes and hypertension.
Geographical. 8-Geographical access problems due to lack of transport or topographic difficulty to access easily from home to health center assigned.
Culturalorganizational. 9-Users, networks migrant families and community groups continue to have a passive role in decisions about the balance between what they need and what insurance coverage offers.
Organizational. 10-Absence of reliable indicators and targets to assess performance and effective coverage in addressing health problems of migrants and their families.

Type of Facilitator Facilitator
Political. 1 -Broad opportunity to strengthen social protection in populations of origin for community actors by the offer of government programs (Popular Insurance "3 x 1"). Organizational. 6-There are new schemes for greater interaction between committees of the legislative branch (migration, health and social security commissions), community leaders and civil society organizations for the development and monitoring of welfare programs, including health needs.
Culturalorganizational. 7-The new national health program 2018-2024 includes the design and strategies for continuous improvement in the quality of care.
Geographical. 8-From the Ministry of Communication and Transportation and Social Welfare, a proposal is being developed to implement a road infrastructure development plan that allows greater access of marginalized communities to public services, including health services.
Culturalorganizational. 9-The current program of coverage has contemplated that by 2024 in all the states of the country a promotion, detection and prevention plan has been implemented with a broad participation of users in public health activities.
Organizational. 10-The National Council of Humanities, Science and Technology is rethinking the support of financial resources to emphasize and promote the development of research and generation of knowledge on evaluation indicators that guarantee the effective implementation of the different programs and policies of the new development plan, among them the new health programs and policies.