text:
Watch: Survival: The Story of Global Health - FREE
JoGH Recommends:
Order on Amazon.com
Order on Amazon.co.uk
4.0 International License .
Follow @JGLOBHEALTH
Improving the effective maternal-child health care coverage through synergies between supply and demand-side interventions: evidence from Mexico
Edson Serván-Mori, Diego Cerecero-García, Ileana B Heredia-Pi, Carlos Pineda-Antúnez, Sandra G Sosa-Rubí, and Gustavo Nigenda
Over the last two decades, the Mexican government has released several efforts to achieve universal health coverage (UHC), based on the principles of fairness and social protection, to reduce the inequities in utilization, access, and quality of care existing in the health system. Two of the most important social public policies that have targeted the population without access to social security include the 1997 conditional cash transfers (CCT) program known as Prospera (formerly Oportunidades or Progresa) and the Seguro Popular de Salud (SPS by its Spanish initials), launched in 2003. These two programs, so far, have survived changes in the federal administrations being the most longstanding social programs targeting poor (or unprotected) populations ever in the history of modern Mexico. We tested the existence of positive synergies between demand-side (or CCT-Prospera) and supply-side (or Seguro Popular de Salud, SPS) social programs in the achievement of effective coverage (EC) of maternal-child health interventions in Mexico.
We performed a retrospective-cohort analysis to 6413 women aged 12-49 years who participated in a probabilistic survey conducted in 2012. We calculated EC as the product of three indexes: need, utilization and quality of health care. Correlates of EC were identified estimating a logistic regression model. We also presented adjusted EC by specific women groups.
EC among beneficiaries of both programs was similar to estimates in Social Security affiliates (54%). For those not affiliated to any of the programs or those who received benefits for only one of them, the EC was 47.6% and 45.5% respectively. Adjusted estimates of EC suggest that overall, having both programs (Prospera + SPS) has a positive effect on maternal and child care coverage, which makes the observed differences in EC not statistically significant between those affiliated to both programs in comparison with the observed in the population with social security.
Results support positive synergies between Prospera and SPS in the reduction of the gaps in EC. The most vulnerable population groups need to be reached by the combination of these programs so that public health efforts translate into greater EC of maternal health services and better maternal-child outcomes.
Despite extensive policy efforts to implement social policy programs, aligned to international initiatives, such as the signing of the MDGs, in Mexico, maternal health remains a pressing public health issue, particularly among poor and uninsured populations [1-4].
Monitoring the performance of health systems is fundamental to guide effective policies in order to secure the universal right to health care [5]. One metric used to evaluate the performance of the health system is the effective coverage (EC) of health interventions. EC diverges from the traditional way of measuring coverage for health interventions by measuring the fraction of potential gain in health that a health system can provide through an available intervention [6]. It is a health metric that allows a comprehensive evaluation of the performance of health systems, combining coverage, access, use and efficacy of health interventions [5,7]. There are no recent studies that document the achievements in terms of EC for maternal and child health interventions in Mexico.
Among the initiatives implemented in the international context to improve access to health services and reduce the risk for households to fall into Out-of-Pocket Expenditures on Healthcare (OOPE), as well as increasing productivity and reducing wage loss, interventions have been designed to support health financing – both, on the demand and supply sides. Examples of the former are the delivery of coupons, subsidies and conditional cash transfers (CCT) that promote changes in risk behaviors in the target population and incentives for the use of health services. Health insurance schemes for larger population groups and pay-for-performance programs for health providers are examples of interventions on the supply side [8-10].
Over the last two decades, the Mexican government has released several efforts to achieve UHC, based on the principles of fairness and social protection, to reduce the inequities in utilization, access, and quality of care that exist in the health system [11,12]. Two of the most important health policies that have targeted populations without access to social security include the 1997 CCT program known as Prospera (formerly Oportunidades or Progresa) [13] and the Seguro Popular de Salud (SPS by its Spanish initials), launched in 2003 and went into operation in 2004 [14]. It is key to mention that these two programs have survived changes in the federal administrations.
CCT-Prospera has gone through four federal administration changes and SPS through three being both the most longstanding social programs targeting poor (or unprotected) populations ever in the history of modern Mexico. In the case of SPS, the General Health Law was amended to incorporate it as a permanent policy, but this is not the case of CCT-Prospera. CCT-Prospera program, seeks to improve the provision and quality of basic social services (health, nutrition, and education), largely among the most economically and socially disadvantaged populations [15]. A collaboration agreement was signed in 2009 by public health institutions in the country in order to provide health services through their medical units to all pregnant women presenting an obstetric emergency aiming at reducing maternal and perinatal morbidity and mortality [16]. Also, the official norm NOM-007-SSA2 launched in 1993, makes antenatal care mandatory in all health units. The norm had an update in 2016 [17]. However, the supply side was not the only problem, as on the demand side, the low participation of pregnant women motivated the CCT-Prospera program on maternal health services. From its inception, Prospera has operated based on a lifeline perspective and through the introduction of demand-side incentives, such as the delivery of CCT to its beneficiaries. The program offers monetary support and scholarships in cash with a bimonthly frequency provided individually to the program's beneficiaries [15,18]. In particular, regarding reproductive health services, women enrolled in Prospera receive reproductive health consultations and health talks or "pláticas", at MoH's units, in which women are informed about family planning, pregnancy, delivery, postpartum care, and other reproductive and child health topics. Different evaluations of Prospera have shown that the program has increased the number of antenatal care (ANC) visits among its beneficiaries [15], has contributed to reduce infant mortality rates [19,20], and has improved the adequacy ANC and postnatal provide by trained personnel [19,21,22]. However, problems in access to health services persist, supply and demand for maternal health services in Mexico remain misaligned and this is aggravated mainly among the most disadvantaged communities [22-24].
It is important to note that the measurement of EC in a health system such as the Mexican one, requires considering its structural segmentation - which represents a determinant of its heterogeneous performance. In Mexico, formal workers and their families have the right to access to social security institutions by contributing a portion of their salary. Social security institutions do not receive care through service packages. In contrast, those without social security receive attention from the Ministry of Health (MoH) and other public institutions. The MoH's service structure is decentralized and with the creation of the SPS they were provided with fresh financial resources which they had historically lacked. The SPS is voluntary and establishes financial allocation mechanisms in order to ensure that available funds are used for the direct care of users based on a package of primary and secondary care services, in which maternal health interventions stands out, plus a restricted package of high cost interventions in order to maintain financial balance and an appropriate level of cost-effectiveness.
SPS seeks to guarantee the exercise of the universal right to health through facilitating and incentivizing effective access to quality health services and promoting demand of services among the population without social security. Specifically, SPS works to achieve this ambitious goal through at least four mechanisms: 1) guaranteeing a package of health interventions stipulated in the Health Services Universal Catalogue (known as CAUSES); 2) strengthening human resource and material capacities in health clinics, with a focus on first level of care, through the incremental increase of financial resources [11,14,25,26]; 3) promoting professional care of the mother-child binomial in pregnancy, childbirth, and postpartum [26]; and 4) achieving synergies with specific programs in maternal and child health [26]. The allocation of fresh funds by SPS has been shown to increase the utilization and access to maternal health services [27-29]. However, great challenges have been pointed out in the implementation of this policy, including: (1) the need for improved administrative adherence to a legal framework; (2) ensuring financial sustainability and promoting the allocation of more resources for the health system; (3) maintaining the affiliate registry with no duplication; (4) increasing access to health care; and (5) improving quality of health care [30,31].
In previous studies, SPS has not been shown to alter the probability of receiving opportune prenatal attention [29] and differences in access to prenatal care seem to differ based on insurance status [3]. Recently, we showed population-level results that suggest, from a perspective of continuity of maternal health care [2], that Mexico is located in a sub-optimal position regarding maternal health care. According to this research, this situation could be addressed through the development of supply-demand side combined interventions, in order to achieve UHC and SDG 3.7 y 3.8 [32].
Based in these elements and following our previous research [1-3], in this study we estimate the EC of interventions aimed at improving maternal and child health in Mexico by health insurance status and test the existence of positive synergies by combining supply-demand interventions in reducing existing gaps in health insurance coverage in Mexico. We hypothesized that the observed disadvantage among SPS women compared to women with social security could be boosted by CCT-Prospera program.
A retrospective cohort analysis was performed. Analysed data came from the cross-sectional Mexican National Health and Nutrition Survey conducted in 2012 (ENSANUT for its Spanish initials). ENSANUT followed a multistage, stratified design, population-based (N = 115 170 278) and representative of rural/urban strata, encompassing the 32 Mexican states and specific population groups (such as children, adolescents and adults). ENSANUT aimed to estimate the prevalence and proportions of health and nutrition conditions, access to services, health determinants, as well as coverage of health care services among the Mexican population. The ENSANUT's response rate was close to 90% [33]. The data for analysis was requested and obtained from the survey's public repository hosted in http://ensanut.insp.mx/. Ethical and research considerations about this survey have been previously documented [33].
For this analysis, we used data from the survey's reproductive health module, which had been applied to a random subsample of women aged 12-49 years (n = 23 056). From these, we selected women who had their last live birth from 2005 onwards, being covered by social security, SPS or without any health insurance, and who responded to a series of questions about their use of ANC and obstetric services (n = 7144). After excluding women without information on relevant covariables (10.2%), the final analytical sample included 6413 women (N = 9 093 785). We examined potential differences in important sociodemographic and health-related characteristics that could be associated with EC between our analytical sample and those excluded due to missing data or without significant differences.
Our main outcome is the Effective Coverage (EC) of maternal and child health care. According to previous studies [6,34], EC allows knowing "the fraction of potential gain in health that a health system can provide through an available intervention". EC is a health metric that relates coverage, utilization, and access to health services. EC in maternal and child health involved four key steps: defining measures of need, identifying health interventions, use and quality. Mathematically, EC is defined as: QijUij|(Nij=1) where Qij is the proportion of potential health gain that is achieved from the intervention j received for a women i, Uij refers to receive the intervention conditional on need Nij.
Nij was approached by the self-reported of pregnancy among women aged 12 to 49 that reported having had an obstetric episode from 2005 to 2012 whose product was a child born alive. Uij was based in a continuity of health care approach [3] and defined a full reception of ANC from the product of the following five binary (1/0): (i) skilled ANC; (ii) timely (initial ANC visit during the first trimester of pregnancy); (iii) frequent (at least four ANC visits during the pregnancy); (iv) adequate content of ANC that include eight procedures measured in the survey according to official guidelines [17]; and (v) two indicators related to the delivery process and postnatal care (institutional and skilled delivery). In line with our previous work [3,35], all ANC procedures were weighted equally. For the definition of these indicators, our conceptual approach was based on the continuum of maternal and childcare framework, a key strategy of intervention programs for improving the health and well-being of mothers and newborns. This approach establishes that continuity of care (CoC) follows a path or route from pregnancy, to childbirth, to postpartum, where each step adds value to ensure better health outcomes for mothers and newborns and contributes to the reduction of maternal and neonatal mortality [36-38].
Finally, health gains or quality of care (Qij) was approached by two binary (1/0) variables: no maternal complication during childbirth and the normal birth weight (in kg), measured by reviewing the official certificate or self-reported by the mother or guardian of the child. The external validity of the birth weight values collected by the ENSANUT 2012 has been previously proved [35]. We calculate the EC as the product of Qij, Uij and Nij.
Our key independent variables were the self-reported health insurance condition (social security -employment based insurance-, SPS-health insurance for the poor- and none) and an indicator for being a part of a beneficiary household of the CCT Prospera program.
Other covariates included: women schooling (years), indigenous status, a standardized asset and housing index as a measure of socioeconomic status based on assets and household infrastructure, developed using polychoric correlation matrices [39], where more positive scores indicate a greater number of assets and better housing conditions, while lower socioeconomic status households have more negative scores; the type of the locality (metropolitan/urban or rural); and a social deprivation index of the place of residence (based on locality level access to basic public services, housing conditions and wage earnings). We also included maternal characteristics at the time of the most recent birth: year of the index live birth, parity, diagnosis of a health problem during pregnancy, at least one stillborn child or a child who died before the first year of life, history of abortion or miscarriage, type of delivery, frequent ANC provider (social security, the Ministry of Health-MoH- and private), and the childbirth care provider (social security, MoH and private).
The data were analysed using the Stata MP Package v15.1. We first describe socio-demographic and pregnancy and childbirth characteristics and each component of EC by the participation in the following women groups: social security, SPS + CCT, SPS or CCT and without health insurance + CCT. We used bivariate regression models and bivariate χ2 test to compare the groups. In order to identify correlates of the EC, we estimated the following logistic multiple regression model:
where was a vector containing socio-demographic and household characteristics for each i women, as well as covariates related to the residence context; characteristics of the respondents that related to her pregnancy history and the prenatal period and the pregnancy and delivery care indicators mentioned above. β was a vector of parameters to estimate.
This model was adjusted using maximum likelihood approach including robust standard errors and fixed effects at municipality level. For ease of interpretation we calculated adjusted odds ratios (aORs) and the corresponding 95%CI. The aOR represents the adjusted odds that an EC will occur given any specific exposure (ie, SPS + CCT), compared to the odds of the outcome occurring in the absence of that exposure. After the estimated model we adjust EC across each i women with social security, SPS + CCT, SPS or CCT and without health insurance + CCT, and by specific socio-demographic characteristics such as schooling, age at time of the most recent childbirth, indigenous status, socioeconomic status and deprivation level of locality, and by pregnancy and childbirth characteristics such as the number of children at time of the most recent childbirth, diagnosed with some health problem during pregnancy and type of delivery.
Table 1 shows the characteristics of the sample population by health insurance status. In comparison with individuals without social security (SPS and without health insurance), those with social security had more years of schooling (10.8), a higher age at the time of the most recent childbirth (27.1 years), less prone to belong to an indigenous household (4.7%), higher assets and housing index, lower deprivation index at the locality level, and more likely to dwell in urban areas (83.5%). In relation to pregnancy and childbirth characteristics, individuals with social security had slightly more probability of being diagnosed with a health condition during pregnancy (60.2%), and of having at least one miscarriage or abortion episode (18.9%). This group had also the lowest probability of vaginal delivery (48.7%). In terms of antenatal and childbirth care, individuals with SPS were the least likely to make use of private services (12.2% and 11.5%), and an important proportion of individuals without health insurance reported having made use of MoH services for antenatal and childbirth care (46.2% and 47.0%).
Table 1. Main socio-demographic, pregnancy and childbirth characteristics (mean or %, 95% CI) of the population studied
With Social Security
With SPS and CCT-Prospera
Only with SPS or CCT- Prospera
Without health insurance and CCT- Prospera
(n = 1902; 29.7%) (n = 1293; 20.2%) (n = 2339; 36.5%) (n = 879; 13.7%)
PANEL A: Socio-demographic characteristics:
Schooling (years)* 10.8 (10.6-10.9) 6.8 (6.7-7.0) 8.3 (8.2-8.4) 9.1 (8.9-9.4)
Age at time of the most recent childbirth* 27.1 (26.8-27.4) 27.3 (26.9-27.7) 24.3 (24.0-24.5) 24.5 (24.1-25.0)
Indigenous* 4.7 (3.8-5.7) 22.7 (20.4-24.9) 8.7 (7.5-9.8) 7.7 (6.0-9.5)
Socioeconomic index (SD)* 0.5 (0.5-0.6) -0.6 (-0.7–0.6) -0.1 (-0.2–0.1) 0.1 (0.1-0.2)
Residence context – Urban/metropolitan (≥2500 inhabitants)* 83.5 (81.9-85.2) 40.9 (38.2-43.6) 65.8 (63.8-67.7) 79.2 (76.5-81.9)
Deprivation index of residence context (SD)* -0.5 (-0.5–0.5) 0.8 (0.7-0.8) 0.1 (0.0-0.1) -0.2 (-0.3–0.2)
PANEL B: Pregnancy and childbirth characteristics:
Year of obstetric episode – 2005 to 2006* 17.9 (16.1-19.6) 14.2 (12.3-16.1) 11.1 (9.8-12.4) 14.7 (12.3-17.1)
Year of obstetric episode – 2007 to 2009‡ 50.5 (48.3-52.8) 49.4 (46.6-52.1) 45.5 (43.5-47.5) 49.1 (45.8-52.5)
Year of obstetric episode – 2010 to 2012* 31.6 (29.5-33.7) 36.4 (33.8-39.1) 43.4 (41.4-45.4) 36.2 (33.0-39.4)
Number of children at time of the most recent childbirth* 1.2 (1.2-1.3) 2.2 (2.1-2.3) 1.2 (1.2-1.3) 1.2 (1.1-1.3)
Diagnosis of some health problem during pregnancy*,§,‖ 60.2 (58.0-62.4) 52.0 (49.2-54.7) 58.3 (56.3-60.3) 54.8 (51.5-58.2)
Child dead during the 1st year or dead at childbirth* 4.2 (3.3-5.1) 7.5 (6.1-9.0) 5.6 (4.7-6.6) 4.4 (3.1-5.8)
At least one miscarriage or abortion 18.9 (17.1-20.6) 16.6 (14.6-18.7) 16.1 (14.6-17.6) 15.6 (13.2-18.1)
Vaginal delivery* 48.7 (46.4-50.9) 65.9 (63.3-68.5) 58.8 (56.8-60.8) 51.3 (48.0-54.7)
Urgent cesarean-section 26.5 (24.5-28.4) 22.8 (20.5-25.1) 25.5 (23.7-27.3) 25.1 (22.2-28.0)
Planned cesarean-section* 24.9 (22.9-26.8) 11.3 (9.6-13.0) 15.7 (14.2-17.2) 23.6 (20.7-26.4)
Frequent ANC provider – Social Security* 65.6 (63.4-67.7) 11.8 (10.0-13.5) 11.4 (10.1-12.7) 18.0 (15.4-20.5)
Frequent ANC provider – Ministry of Health* 13.3 (11.8-14.8) 83.7 (81.6-85.7) 71.8 (69.9-73.6) 43.2 (39.9-46.5)
Frequent ANC provider – Private* 21.1 (19.3-22.9) 4.6 (3.4-5.7) 16.9 (15.3-18.4) 38.9 (35.6-42.1)
Childbirth care provider – Social Security* 59.7 (57.5-61.9) 12.6 (10.8-14.5) 12.2 (10.9-13.6) 20.3 (17.6-23.0)
Childbirth care provider – Ministry of Health* 23.9 (22.0-25.8) 80.2 (78.0-82.4) 73.4 (71.6-75.2) 44.7 (41.4-48.0)
Childbirth care provider – Private* 16.4 (14.7-18.1) 7.1 (5.7-8.6) 14.3 (12.9-15.8) 35.0 (31.8-38.2)
CI – confidence interval, SPS – Seguro Popular de Salud, CCT – conditional cash transfer, ANC – antenatal care, SD – standard deviation
*P < 0.001.
†P < 0.01.
‡P < 0.05.
§Includes high blood pressure, vaginal bleeding, threat of miscarriage, preeclampsia or eclampsia, gestational diabetes, or infections.
‖Reported characteristics for 6312 women who received prenatal care.
Descriptive statistics for five process indicators and two health outcomes among the three comparison groups are shown in Table 2. We showed the unadjusted probabilities of occurrence for each of the outcomes. We observed that individuals with social security outperformed their counterparts in the following indicators: medical (99.2%), timely (89.4%) and frequent ANC (87.1%), and adequate content of ANC (77.5%). Concerning institutional delivery, nearly all surveyed individuals reported delivery by medical staff. Roughly, 60% of women reported no complications during childbirth among those with social security in comparison with women without social security – of which only 50% reported no complications. We also observed significant differences in the percentage of newborns with normal weight. Among women with social security almost 60% of newborns had normal birth weight whereas less than 50% of newborns on the other groups had normal birth weight.
Table 2. Components of effective maternal-child health coverage: unadjusted estimates of conditional coverages (mean or %, 95% CI)
With SPS and CCT- Prospera
Need (N) (n = 1902; 29.7%) (n = 1293; 20.2%) (n = 2339; 36.5%) (n = 879; 13.7%)
Utilization (U):
Coverage of skilled health care during ANC, %* 99.2 (98.7-99.6) 98.5 (97.9-99.2) 98.1 (97.6-98.7) 97.5 (96.5-98.5)
Coverage of timely ANC, %*,§ 89.4 (88.0-90.8) 80.0 (77.9-82.2) 78.8 (77.2-80.5) 79.6 (77.0-82.3)
Coverage of frequent ANC, %*,‖ 87.1 (85.6-88.6) 77.3 (75.1-79.6) 75.7 (74.0-77.5) 75.1 (72.2-77.9)
Coverage of adequate content of ANC, %*,¶ 77.5 (75.7-79.4) 65.3 (62.7-67.9) 64.7 (62.7-66.6) 63.9 (60.8-67.1)
Coverage of institutional delivery, %* 77.4 (75.6-79.3) 65.1 (62.5-67.7) 64.6 (62.6-66.5) 63.6 (60.4-66.8)
Quality (Q):
Women without complication during childbirth, %*,** 63.5 (61.3-65.6) 52.7 (49.9-55.4) 51.8 (49.8-53.8) 51.5 (48.2-54.8)
Percentage of newborns with normal birth weight, %*,†† 57.8 (55.6-60.0) 47.3 (44.5-50.0) 45.8 (43.8-47.9) 45.2 (41.9-48.5)
CI – confidence interval, SPS – Seguro Popular de Salud, ANC – antenatal care, CCT – conditional cash transfer
§1st ANC visit during the first quarter.
‖At least four consultations.
¶≥75% of content of ANC consultation (include measurement of height, weight, and blood pressure, urinalysis, blood examination, blood glucose examination, syphilis detection-VDRL-, ultrasound, tetanus vaccine, folic acid, vitamins/iron/food supplement.
**Include preeclampsia or eclampsia, hemorrhage, miscarriage, threat of miscarriage, obstructed delivery, wrong position of the fetus, premature childbirth, or some complication due to a previous disease.
††Normal birth weight: 2.5-4.0 kg.
Table 3 shows the aORs for EC considering exposure groups, socio-demographic, pregnancy and birth characteristics, and the locality where the mother resides. We observed that women who are beneficiaries of SPS or CCT only, as well as those without SPS and CCT, have a lower possibility of receiving EC, with respect to women who do have social security. In the case of women who received benefits from SPS and CCT we did not observe any significant difference with those with social security. Regarding the years of study, we observed that only those women with 12 years or more of education increased their chances of receiving EC with respect to women with 6 years or less. Similarly, we found that women who were 29 or older at the birth of their last child have a greater chance of receiving EC, with respect to those who were 19 years old or younger. Compared with vaginal delivery, the planned cesarean is also a factor that increases the possibility of EC. On the other hand, factors such as having two or more children, being diagnosed with a health problem during pregnancy and presenting an emergency cesarean, decrease the possibility of EC in pregnancy care. We did not observe any differences associated with the mother's residence.
Table 3. Adjusted odds ratios (and robust 95% confidence intervals) from regression analyses identifying correlates for effective maternal-child health care coverage
robust CI9 5%
Exposure variable:
Social Security Ref.
Seguro Popular de Salud and CCT- Prospera 0.99 0.79-1.25
Only Seguro Popular de Salud or CCT- Prospera 0.74† 0.61-0.89
Without health insurance and CCT- Prospera 0.67* 0.54-0.82
Sociodemographics:
Schooling – 0 to 6 years Ref.
Schooling – 6 to 8 years 1.12 0.90-1.40
Schooling – 9 to 11 years 1.12 0.90-1.38
Schooling – 12 or more years 1.39† 1.09-1.77
Age at time of the most recent childbirth – 12 to 19 years Ref.
Age at time of the most recent childbirth – 19 to 24 years 1.12 0.93-1.35
Age at time of the most recent childbirth – 29 or more years 1.25‡ 1.00-1.55
Indigenous 0.92 0.70-1.22
Socioeconomic level – Lowest Ref.
Socioeconomic level – Moderate 1.01 0.86-1.19
Socioeconomic level – Highest 1.15 0.96-1.39
Pregnancy and childbirth characteristics:
Year of obstetric episode – 2005 to 2006 Ref.
Year of obstetric episode – 2007 to 2009 1.06 0.89-1.26
Number of children at time of the most recent childbirth – Zero Ref.
Number of children at time of the most recent childbirth – One 0.99 0.84-1.17
Number of children at time of the most recent childbirth – Two or more 0.77† 0.64-0.93
Diagnosed with some health problem during pregnancy 0.75* 0.67-0.85
Type of delivery – Vaginal delivery Ref.
Type of delivery – Urgent cesarean-section 0.34* 0.30-0.40
Type of delivery – Planned cesarean-section 1.19‡ 1.01-1.40
Frequent ANC provider – Social Security Ref.
Frequent ANC provider – Ministry of Health 0.81 0.63-1.03
Frequent ANC provider – Private 0.96 0.74-1.23
Childbirth care provider – Social Security Ref.
Childbirth care provider – Ministry of Health 0.98 0.78-1.22
Childbirth care provider – Private 0.99 0.76-1.30
Residence context:
Deprivation level – Lowest Ref.
Deprivation level – Moderate 0.94 0.72-1.22
Deprivation level – Highest 0.99 0.72-1.37
Urban or metropolitan Ref.
Rural 0.89 0.71-1.11
Constant 1.88‡ 1.07-3.30
Observations 6,312
McFadden's R2 0.11
Log likelihood -3,672.93
AIC 1.48
Hosmer-Lemeshow χ2 (P > χ2) 15.30 (0.05)
Link test for model specification:
hat (P > |z|) 0.00
hatsq (P > |z|) 0.37
Area under the ROC curve 0.72
SPS – Seguro Popular de Salud, aOR – adjusted odds ratio, CI – confidence interval, CCT – conditional cash transfer, AIC – Akaike information criterion
‡P < 0.05.The difference in the number of observations between Table 1 and Table 2 is due to the responses about the place of frequent prenatal care and the detection of health problems during pregnancy were obtained among women who received prenatal care.
Table 4 shows the adjusted estimations of maternal and child effective coverage among our comparison groups. In panel A, we show socio-demographic characteristics and panel B shows pregnancy and childbirth characteristics. We observed that our global estimate of EC shows no differences between women receiving both programs – SPS + Prospera – and those with social security for each comparison group. This finding suggests that the combination of these two interventions can reduce the gap in EC between these groups. In addition, we observed that the adjusted estimates for these two groups maintain a statistically significant difference with respect to the other two most vulnerable groups. The adjusted estimations for women with only SPS or CCT did not result statistically different from those who do not have any of these benefits. This suggests that in terms of EC of maternal health services we can only observe a relevant change through the synergy of SPS and CCT.
Table 4. Adjusted estimations (adjusted effective coverage and robust 95% CI) of effective maternal-child health care coverage among specific women groups
Only with SPS or CCT-Prospera
Without health insurance and CCT-Prospera
GLOBAL ESTIMATES 54.1 (51.3-56.9) 53.9 (50.6-57.2) 47.6 (45.4-49.8) 45.5 (42.1-48.9)
Schooling (years):
0 to 6 50.8 (45.9-55.7) 50.6 (45.6-55.7) 44.2 (39.8-48.7) 42.2 (37.1-47.3)
12 or more 57.8 (54.3-61.2) 57.6 (53.4-61.9) 51.3 (47.8-54.8) 49.2 (44.9-53.5)
Age at time of the most recent childbirth (years):
12 to 19 51.4 (47.0-55.7) 51.2 (46.5-55.9) 44.8 (41.0-48.7) 42.8 (38.3-47.3)
Indigenous status:
Non-indigenous 54.3 (51.4-57.1) 54.1 (50.8-57.5) 47.7 (45.5-50.0) 45.7 (42.2-49.1)
Indigenous 52.6 (46.5-58.7) 52.4 (46.1-58.8) 46.0 (40.1-52.0) 44.0 (37.6-50.4)
Socioeconomic level:
Lowest 53.0 (49.2-56.7) 52.8 (48.9-56.7) 46.4 (43.3-49.5) 44.3 (40.3-48.4)
Highest 56.0 (52.8-59.3) 55.9 (51.8-59.9) 49.5 (46.4-52.6) 47.4 (43.4-51.5)
Deprivation level of residence context:
Number of children at time of the most recent childbirth:
Zero 56.3 (52.7-59.9) 56.2 (52.0-60.3) 49.8 (46.5-53.0) 47.7 (43.5-51.9)
One 56.2 (52.9-59.5) 56.0 (52.2-59.9) 49.7 (46.7-52.6) 47.6 (43.7-51.6)
Two or more 50.8 (47.4-54.3) 50.7 (47.0-54.4) 44.3 (41.3-47.2) 42.3 (38.4-46.1)
Diagnosed with some health problem during pregnancy 51.5 (48.5-54.5) 51.4 (47.8-54.9) 45.0 (42.5-47.4) 42.9 (39.3-46.5)
Type of delivery:
Vaginal delivery 59.4 (56.3-62.4) 59.2 (55.7-62.7) 52.6 (50.1-55.2) 50.5 (46.7-54.3)
Planned cesarean-section 63.0 (59.2-66.8) 62.9 (58.6-67.1) 56.4 (52.8-60.0) 54.3 (49.8-58.8)
SPS – Seguro Popular de Salud, CCT – conditional cash transfer, CI – confidence interval
We corroborate our hypothesis that the complementary use of these interventions can reduce the gaps in EC for maternal health services among population groups with specific characteristics of social vulnerability.
First, adjusted estimates of EC suggest that overall, having both programs – Prospera + SPS – has a positive effect on maternal and child care coverage, which makes the observed differences in EC not statistically significant between those affiliated to both programs in comparison with the observed in the population with social security. It is important to note that EC in the social security system is not the ideal and that there are many areas of improvement in these institutions. However, they represent the best possible value of EC in the country and therefore a point of national reference. Second, the participation to only one of the programs or not being affiliated to any health insurance was associated with a significant reduction on the coverage of maternal care, in comparison with the other groups analyzed. Our findings are consistent with previous studies that have shown that the combination of strategies from the supply and demand sides increases the likelihood of using health services [10]; however, they also mentioned that even when there are high levels of access to primary health care, other determinants of health services utilization must be addressed particularly for lower-income populations [8,10]. A woman who is a Prospera beneficiary has to compulsorily attend antenatal consultations, however, as our results suggest, Prospera by itself cannot guarantee the utilization of those services as it only induces the demand of these services calling from a timely response from a supply-side program (SPS) to increase their utilization. There is also the same gap in the use of health care services among women only covered by SPS, suggesting a lack of communication and dissemination campaigns that promote and encourage the use of maternal and child health care services.
We also identified population subgroups for which being affiliated or not to the programs analyzed did not make a difference in the EC of maternal and childcare services. This is the case for women with fewer years of schooling (0-6 years.), adolescents, and indigenous women, which is consistent with the widely evidenced association between mother education and child health [8]. In these population subgroups, no significant differences were found between the four scenarios evaluated (with social security, with Prospera + SPS, with Prospera or SPS and without Prospera nor health insurance). This reflects that for the most vulnerable groups the benefits of the analyzed programs are not enough to achieve significant changes in the EC of maternal and child health services and that more comprehensive policy efforts are needed to revert these indicators, generate greater equity and obtain better results in maternal and child health outcomes. Additionally, subgroups where only the combination of both programs equals the coverage of maternal health services to those observed in the population with social security. This is the case of women 29 years of age or older, non-indigenous women, those who live in households with a higher score in the asset index, those who live in highly marginalized areas, and those diagnosed with complications during pregnancy. Particular attention should be paid for those subgroups of population from urban areas with low socioeconomic status, without health insurance and without any access to other type of social programs such as Prospera. That is the case of young women who are not having any support from the demand side, through the access to social programs, focus on improving the adequate use of reproductive health services of young women, or some support from the supply side, through the coverage of a health insurance. The combination of both strategies could increase the chances to approach effective reproductive health services by these subgroups.
Previous studies have documented the effects of supply and demand-side interventions and showed an increase in the use of health care services and in the reduction of child mortality, mortality among children 5 years of age and under and maternal mortality [8,9]. However, they highlight to pay special attention to the organizational, logistic, and administrative aspects from the supply side of health services. For example, attention should be paid to avoid corrupt practices and lack of transparency that reduce the possibility that these financing schemes really have an impact on the reduction of direct out-of-pocket spending by users and that contribute to a loss of confidence in the way these interventions are implemented. Another aspect to be considered and that has been documented, is the need to increase efficiency in the use of resources. Inefficiency in the provision of health services is another element that puts at risk the possibility of achieving the objectives proposed by these interventions. In this respect, we have recently shown that the steady escalation of financial resources in the public health subsystem over the past 15 years has yielded sub-optimal results as regards coverage for essential maternal health interventions among the poorest; suggesting that the Mexican government must put in place a set of measures to guarantee efficiency in the system's performance without affecting equity gains [40].
A key element to take into consideration to adequately weight the value of these programs and their joint positive effect is the political use that have been made of them. On the SPS side, inefficiencies of allocation, inexperienced management, and diversion of resources by local political actors have been documented [41,42]. These factors reduce the capacity of the program to maximize achievements in the production of services, the reduction of out-of-pocket expenditure, and the improvement of health conditions. In the case of Prospera improper use of funds for the unjustified purchase of goods and services, and the allocation of subsidies to promote the vote in favor of the party in the government have been observed. The shielding of these programs against these types of abuse and deviations could raise the possibility of increasing the positive effect shown by the study.
We show that some factors such as years of study (12 or more), age (being 29 or older), and having a planned cesarean are factors associated with higher EC. Also, these factors might be highly associated with more information, empowerment and, autonomy of the mother. For this reason, in the case of policies from the demand side, it is necessary to strengthen the communication mechanisms in the communities, increasing the maternal knowledge of health, and empowerment and autonomy of women to increase the use of maternal and child health services, through communication and dissemination campaigns about adequate health services to expect better care, as well as social support to ask for a better care, and maximize the potential benefits in those population groups with the greatest need. More information about their rights and the benefits of these interventions improves the population empowerment and their ability to benefit from these policy initiatives.
There are some limitations to our study. First, although ENSANUT is a high-quality, population-based survey, our study shares the limitations of any study based on self-reported data; therefore, we only include births in the past 5 years to reduce the probability of recall bias. Second, this is a cross-sectional study and we report associations, not causal effects. Third, although it would be ideal to rely on clinical data to evaluate receipt and content of ANC, obstetric outcomes and birth weight; however, and unfortunately in Mexico such a data set does not exist. Fourth, it is important to highlight that our analysis uses an indicator that allows us to approximate not only the use of services when there is a need (in this case pregnancy), but also includes an element that allows us to measure the gain in health through the reception of a quality service (according to official norms) during the maternal care continuum. Previous studies have also identified that for these interventions to be successful, they must be offered with quality, in order to cover the expectations of the users and be based on respectful care [8]. The analytical approach based on the continuity of care could help to dimension and assess more objectively the performance of the Mexican health system, as well as identify the "bottlenecks" in the stages of maternal care and the scope of the various policy initiatives implemented. Finally, we did not fail to mention that the participation in the social programs included in our study (Prospera and SPS) could be limited since it is based on self-report of the participants and not on administrative records. Although the self-report could have errors, it has been also documented problems of incorporation into the SPS [43] or that its beneficiaries are not correctly classified according to their socio-economic condition [44]. In this sense, it is difficult to establish what the impact of this situation would be on the estimates presented. However, in favor of our study, we can mention that several studies have proved the close relationship between living conditions and self-report of belonging to the social programs analyzed or social security [45-47].
Our results suggest that: i) the synergistic effect in the combination of coverage for the SPS and Prospera, is associated with levels of EC of maternal health services similar to those observed in the population with social security coverage; ii) the most vulnerable population groups need to be reached by the combination of both programs, so that public health policy efforts are reflected in greater EC of maternal health services and better maternal and child outcomes. Special attention must be offered for the most vulnerable groups (women with fewer years of schooling, adolescents, and indigenous women), for whom the benefits of the analyzed programs are not enough to achieve significant changes in the EC of maternal and child health services. These results identify potential groups in which the gains from directing programs that increase the EC of maternal health services can be cost-effective and highlight gaps in the performance of the Mexican health system and identified several gaps in the cascade of the maternal-child care. Our study also provides evidence that allows us to measure the potential gains of more comprehensive policy efforts needed to revert these indicators and generate greater equity. These results are relevant given the major changes that the Mexican Health System is undergoing, and the redefinition of the strategies that the Mexican government is undertaking to achieve universal and effective health coverage.
The authors declare that views expressed in the submitted article are their own and not an official position of the institution. The local Committees of Research, Biosafety and Ethics at the National Institute of Public Health (INSP) in Mexico approved the National Health and Nutrition Survey (ENSaNut). All subjects provide informed consent prior to taking part.
[1] Funding: The study does not have any funding or other support that facilitated conduct of the work described in the article or the writing of the article itself.
[2] Authorship contributions: ESM, IBHP designed the study, outlined the idea for the paper, analyzed the data and wrote the first draft of the manuscript. DCG, CPA, SGSR and GN substantially revised the drafts. All authors were involved in the revision and approved the final manuscript
[3] Competing interests: The authors completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available upon request from the corresponding author) and declare no conflicts of interest.
[1] Serván-Mori E, Avila-Burgos L, Nigenda G, Lozano R. A Performance Analysis of Public Expenditure on Maternal Health in Mexico. Ciccozzi M, editor. PLoS One. 20164;11:e0152635.
[2] E Serván-Mori, D Contreras-Loya, O Gomez-Dantés, G Nigenda, SG Sosa-Rubí, and R Lozano. Use of performance metrics for the measurement of universal coverage for maternal care in Mexico. Health Policy Plan.. 2017;;32::625--33. . DOI: 10.1093/heapol/czw161. [28453712]
[3] I Heredia-Pi, E Serván-Mori, BG Darney, H Reyes-Morales, and R Lozano. Measuring the adequacy of antenatal health care: a national cross-sectional study in Mexico. Bull World Health Organ.. 2016;;94::452--61. . DOI: 10.2471/BLT.15.168302. [27274597]
[4] I Heredia-Pi, E Serván-Mori, H Reyes-Morales, and R Lozano. Brechas en la cobertura de atención continua del embarazo y el parto en México. Salud Publica Mex.. 2013;;55::S282--8. . DOI: 10.21149/spm.v55s2.5122
[5] M Ng, N Fullman, JL Dieleman, AD Flaxman, CJL Murray, and SS Lim. Effective coverage: A metric for monitoring Universal Health Coverage. PLoS Med.. 2014;;11::e1001730. DOI: 10.1371/journal.pmed.1001730. [25243780]
[6] B Shengelia, A Tandon, OB Adams, and CJL Murray. Access, utilization, quality, and effective coverage: An integrated conceptual framework and measurement strategy. Soc Sci Med.. 2005;;61::97--109. . DOI: 10.1016/j.socscimed.2004.11.055. [15847965]
[7] CG Victora, B Fenn, J Bryce, and BR Kirkwood. Co-coverage of preventive interventions and implications for child-survival strategies: evidence from national surveys. Lancet.. 2005;;366::1460--6. . DOI: 10.1016/S0140-6736(05)67599-X. [16243091]
[8] SF Murray, BM Hunter, R Bisht, T Ensor, and D Bick. Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review. BMC Pregnancy Childbirth.. 2014;;14::30 . DOI: 10.1186/1471-2393-14-30. [24438560]
[9] D Bowser, J Gupta, and A Nandakumar. The effect of demand- and supply-side health financing on infant, child, and maternal mortality in low- and middle-income countries. Healt Syst Reform.. 2016;;2::147--59. . DOI: 10.1080/23288604.2016.1166306. [31514642]
[10] FC Guanais. The Combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998–2010. Am J Public Health.. 2013;;103::2000--6. . DOI: 10.2105/AJPH.2013.301452. [24028257]
[11] FM Knaul, E González-pier, H Arreola-ornelas, FM Knaul, E González-pier, and O Gómez-dantés. The quest for universal health coverage: achieving social protection for all in Mexico. Lancet.. 2012;;380::1259--1279. . DOI: 10.1016/S0140-6736(12)61068-X. [22901864]
[12] O Gómez Dantés, S Sesma, VM Becerril, FM Knaul, H Arreola, and J Frenk. Sistema de salud de México. Salud Publica Mex.. 2011;;53::s220--32. .[21877087]
[13] J Frenk and O Gómez-Dantés. Quasi-experimental study designs series-paper 2: Systematic generation of evidence through public policy evaluation. J Clin Epidemiol.. 2017;;89::17--20. . DOI: 10.1016/j.jclinepi.2017.03.013. [28365310]
[14] FM Knaul and J Frenk. Health Insurance In Mexico: Achieving Universal Coverage Through Structural Reform. Health Aff (Millwood).. 2005;;24::1467--76. . DOI: 10.1377/hlthaff.24.6.1467. [16284018]
[15] Levy S, Rodríguez E. El Programa de Educación, Salud y Alimentación, PROGRESA–Programa de Desarrollo Humano Oportunidades. Ensayos Sobre Desarro Económico y Soc México Mex City Fondo Cult Económica. 2004
[16] Centro Nacional de Equidad de Género y Salud Reproductiva. Convenio general de colaboración de la Secretaria de Salud, El Instituto Mexicano del Seguro Social y el Instituto se Seguridad y Servicios Sociales de los trabajadores del Estado. Mexico City: CNEGSR; 2011.
[17] Secretaría de Gobernación. Norma Oficial Mexicana NOM-007-SSA2–2016, Para la atención de la mujer durante el embarazo, parto y puerperio y de la persona recién nacida [Internet]. México: Diario Oficial de la Federación (DOF); 2016.
[18] Secretaría de Gobernación. Acuerdo por el que se emiten las Reglas de Operación de PROSPERA Programa de Inclusión Social, para el ejercicio fiscal 2018. México: Diario Oficial de la Federación (DOF); 2017.
[19] SL Barber and PJ Gertler. Health workers, quality of care, and child health: Simulating the relationships between increases in health staffing and child length. Health Policy.. 2009;;91::148--55. . DOI: 10.1016/j.healthpol.2008.12.001. [19147250]
[20] T Barham. A healthier start: The effect of conditional cash transfers on neonatal and infant mortality in rural Mexico. J Dev Econ.. 2011;;94::74--85. . DOI: 10.1016/j.jdeveco.2010.01.003
[21] SL Barber and PJ Gertler. Empowering women to obtain high quality care: evidence from an evaluation of Mexico's conditional cash transfer programme. Health Policy Plan.. 2009;;24::18--25. . DOI: 10.1093/heapol/czn039. [19022854]
[22] SG Sosa-Rubí, D Walker, E Serván, and S Bautista-Arredondo. Learning effect of a conditional cash transfer programme on poor rural women's selection of delivery care in Mexico. Health Policy Plan.. 2011;;26::496--507. . DOI: 10.1093/heapol/czq085. [21278371]
[23] SL Barber, SM Bertozzi, and PJ Gertler. Variations In prenatal care quality for the rural poor in Mexico. Health Aff (Millwood).. 2007;;26::w310--23. . DOI: 10.1377/hlthaff.26.3.w310. [17389636]
[24] R Rodríguez-Franco, E Serván-Mori, O Gómez-Dantés, D Contreras-Loya, and C Pineda-Antúnez. Old principles, persisting challenges: Maternal health care market alignment in Mexico in the search for UHC. PLoS One.. 2018;;13::e0199543. DOI: 10.1371/journal.pone.0199543. [29966002]
[25] E González-Pier, C Gutiérrez-Delgado, G Stevens, M Barraza-Lloréns, R Porras-Condey, and N Carvalho. Priority setting for health interventions in Mexico's System of Social Protection in Health. Lancet.. 2006;;368::1608--18. . DOI: 10.1016/S0140-6736(06)69567-6. [17084761]
[26] Comisión Nacional de Protección Social en Salud. Sistema de Protección Social en Salud: Informe de resultados enero-diciembre 2017. Mexico, D.F.; 2018
[27] SG Sosa-Rubí, O Galárraga, and JE Harris. Heterogeneous impact of the "Seguro Popular" program on the utilization of obstetrical services in Mexico, 2001-2006: a multinomial probit model with a discrete endogenous variable. J Health Econ.. 2009;;28::20--34. . DOI: 10.1016/j.jhealeco.2008.08.002. [18824268]
[28] C Strouse, R Perez-Cuevas, M Lahiff, J Walsh, and S Guendelman. Mexicos Seguro Popular appears to have helped reduce the risk of preterm delivery among women with low education. Health Aff (Millwood).. 2016;;35::80--7. . DOI: 10.1377/hlthaff.2015.0594. [26733704]
[29] E Serván-Mori, V Wirtz, L Avila-Burgos, and I Heredia-Pi. Antenatal care among poor women in Mexico in the context of Universal Health Coverage. Matern Child Health J.. 2015;;19::2314--22. . DOI: 10.1007/s10995-015-1751-9. [26093688]
[30] A Chemor Ruiz, AEO Ratsch, and GA Alamilla Martínez. Mexico's Seguro Popular: Achievements and challenges. Healt Syst Reform.. 2018;;4::194--202. . DOI: 10.1080/23288604.2018.1488505. [30207901]
[31] Laurell A. Impacto del seguro popular en el sistema de salud mexicano. 1ra ed. CLACSO, editor. Buenos Aires, Argentina: CLACSO-CORP; 2013.
[32] United Nations. Sustainable Development Goals Report 2016. New York: UN; 2016.
[33] M Romero-Martínez, T Shamah-Levy, A Franco-Núñez, S Villalpando, L Cuevas-Nasu, and JP Gutiérrez. Encuesta Nacional de Salud y Nutrición 2012: diseño y cobertura. Salud Publica Mex.. 2013;;55::S332--40. . DOI: 10.21149/spm.v55s2.5132. [24626712]
[34] R Lozano, P Soliz, E Gakidou, J Abbott-Klafter, DM Feehan, and C Vidal. Benchmarking of performance of Mexican states with effective coverage. Lancet.. 2006;;368::1729--41. . DOI: 10.1016/S0140-6736(06)69566-4. [17098091]
[35] E Serván-Mori, SG Sosa-Rubí, E Najera-Leon, and BG Darney. Timeliness, frequency and content of antenatal care: which is most important to reducing indigenous disparities in birth weight in Mexico? Health Policy Plan.. 2016;;31::444--53. . DOI: 10.1093/heapol/czv082. [26329891]
[36] KJ Kerber, JE de Graft-Johnson, ZA Bhutta, P Okong, A Starrs, and JE Lawn. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet.. 2007;;370::1358--69. . DOI: 10.1016/S0140-6736(07)61578-5. [17933651]
[37] W Wang and R Hong. Levels and determinants of continuum of care for maternal and newborn health in Cambodia-evidence from a population-based survey. BMC Pregnancy Childbirth.. 2015;;15::62 . DOI: 10.1186/s12884-015-0497-0. [25885596]
[38] World Health Organization. The Partnership for Maternal, Newborn, and Child Health: Conceptual and Institutional Framework. Geneva: WHO; 2006.
[39] Kolenikov S, Angeles G. The Use of Discrete Data in PCA: Theory, Simulations, and Applications to Socioeconomic Indices. Chapel Hill: Carolina Population Center, University of North Carolina. Chapel Hill; 2004.
[40] E Serván-Mori, C Chivardi, MÁ Mendoza, and G Nigenda. A longitudinal assessment of the technical efficiency in the outpatient production of maternal health services in Mexico. Health Policy Plan.. 2018;;33::888--97. . DOI: 10.1093/heapol/czy074. [30137317]
[41] Niño-Zarazúa M. Mexico's Progresa-Oportunidades-Prospera and the raise of social assistance in Latin America. Helsinki, Finland; 2017.
[42] G Nigenda, LM González-Robledo, C Juárez-Ramírez, and T Adam. Understanding the dynamics of the Seguro Popular de Salud policy implementation in Mexico from a complex adaptive systems perspective. Implement Sci.. 2016;;11::68 . DOI: 10.1186/s13012-016-0439-x. [27177618]
[43] JM Lakin. The end of insurance? Mexico's Seguro Popular, 2001–2007. J Health Polit Policy Law.. 2010;;35::313--52. . DOI: 10.1215/03616878-2010-002. [20498304]
[44] Scott J. Seguro Popular Incidence Analysis. In: Fomento BI de R y, editor. Decentralized Service Delivery for the Poor. 1st ed. Washington: World Bank; 2006.
[45] VJ Wirtz, Y Santa-Ana-Tellez, E Serván-Mori, and L Avila-Burgos. Heterogeneous effects of health insurance on out-of-pocket expenditure on medicines in Mexico. Value Health.. 2012;;15::593--603. . DOI: 10.1016/j.jval.2012.01.006. [22867767]
[46] R García-Díaz, SG Sosa-Rubí, E Serván-Mori, and G Nigenda. Welfare effects of health insurance in Mexico: The case of Seguro Popular de Salud. PLoS One.. 2018;;13::e0199876. DOI: 10.1371/journal.pone.0199876. [29965976]
[47] E Serván-Mori, L Avila-Burgos, G Nigenda, and R Lozano. A performance analysis of public expenditure on maternal health in Mexico. PLoS One.. 2016;;11::e0152635. DOI: 10.1371/journal.pone.0152635. [27043819]
Journal of Global Health (ISSN 2047-2986), Edinburgh University Global Health Society

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: Prove if $c$ is algebraic over $F$, so are $c + 1$ and $kc$ (where $k\in F$) This question originates from Pinter's Abstract Algebra, Chapter 27, Exercise D1.

Prove that if $c$ is algebraic over $F$, so are $c + 1$ and $kc$ (where $k\in F$).

By definition, $c$ is algebraic over $F$ if it is the root of some nonzero polynomial $a(x)$ in $F[x]$.
Let $a(x)=a_0+a_1x+\cdots+a_nx^n$.
Consider $a(c+1) = a_0+a_1(c+1)+\cdots+a_n(c+1)^n = a(c) + b(c)$ for some nonzero polynomial $b(x)\in F[x]$ where $\operatorname{deg} b(x) < n$.
So $a(c) = a(c+1)-b(c) = 0$.  Suppose $b(x)=b_0+b_1x+\cdots + b_{n-1}x^{n-1}$. Let $b'(x) = b_0 + b_1(x-1)+\cdots +b_{n-1}(x-1)^{n-1}$ so that $b'(x+1)=b(x)$.
$a(c+1)-b(c) = 0\implies a(c+1)-b'(c+1) = 0 = s(c+1)$ for some nonzero polynomial $s(x) = a(x) - b'(x)\in F[x]$. Note $s(x)$ is a nonzero polynomial for $\operatorname{deg} b'(x) < \operatorname{deg} a(x)$. Hence $c+1$ is algebraic over $F$.
If $k=1$, then $kc=c$ which is by assumption algebraic over $F$.
If $k=0$, then any nonzero polynomial $a(x)$ with a zero constant term can satisfy $a(kc) = 0$; so $kc=0$ is trivially algebraic over $F$.  Note as a nonzero polynomial that has a root, $a(x)$ must be a non-constant polynomial.
Suppose $k\ne 0$ and $k\ne 1$. $a(kc) = a_0+a_1(kc)+\cdots+a_n(kc)^n = a(c) + a_1(k-1)c +\cdots + a_n(k^n-1)c^n = a(c) + b(c)$ for
$b(x) = a_1(k-1)x +\cdots +a_n(k^n-1)x^n$.
If $b(x)$ is the zero polynomial, we are done, since $a(kc)=a(c)=0$.
Suppose $b(x)$ is a nonzero polynomial in $F[x]$. So $a(kc) - b(c) = a(c) = 0$.  Let $\displaystyle b'(x)= a_1\frac{k-1}{k}x +\cdots + a_n\frac{k^n-1}{k^n}x^n$ so that $b'(kx) = b(x)$.
$a(kc)-b(c) = 0\implies a(kc)-b'(kc) = 0 = s(kc)$ for some nonzero polynomial $s(x)=a(x)-b'(x)\in F[x]$. Note $s(x)$ is a nonzero polynomial for $\displaystyle\frac{k^i-1}{k^i} \ne 1$ for $0 < i \le n$.  Hence $kc$ is algebraic over $F$.
Does this look reasonable?

A: Your solution is mixed up between polynomials $f(x)$ over $F$ where $x$ is a variable, and the value $f(c)$ of such a polynomial for some $c \in F$. For the first part you need to show that, if $a(x)$ is a polynomial function of $x$ with $c$ as a root, then the function $x \mapsto a(x - 1)$ is a polynomial function of $x$ that has $c + 1$ as a root. Similarly, for the second part.

A: Let $c$ be algebraic over $F$, say $c$ is the root of $f(x) = a_0 + a_1x + \dots + a_nx^n$, that is, $f(c)= 0$.
To show $c + 1$ is a root, let $\beta = c + 1 \iff \beta -1 = c$ suggesting $f(x - 1)$ to be the desired polynomial.
For $kc$, if $k = 0_F$, then $f(x) - a_0$ is the desired polynomial. If $k \neq 0_F$, then $\beta = kc \iff \beta/k = c$ suggesting $f(x/k)$ to be the desired polynomial.

A: Part one looks good. For part two, $b(x)$ may be the zero polynomial. For example, when $k=1$, $b(x)=0$. Even if $k\neq 1$, you still need to show why $b(x)$ is a non-zero polynomial.
Edit:
If $k\neq 1$, $k^{n}-1$ can still be zero. If $a_{1},\ldots,a_{n-1}=0$, then $b(x)$ is still zero.

redpajama_set_name: RedPajamaStackExchange


text:
Q: React-native: call a function on go back from a scene I'm working in an app that it have to pass data between scenes or views. My escenario is simple, I have a Navigator component as a father of two scenes:

*

*Dashboard: Contains a listview with some data.

*Details: Shows the data of the element selected in the previous listview.

The next lines explains the behaviour I want to get:

*

*Enter to Dashboard: request the data from rest server and draw it in the listview.

*Go to Details: select an item from the dashboard.

*Modify an item: Modify a property of the item that I selected, then go back.

*Return to Dashboard: request the data from rest server and draw it in the listview (like the first point, I want to get new data if it was generated from point one to third.
My question is about how can I refresh my scene or call a function of the scene when it takes the focus(the fourth point explained above). This is so because it wasn't unmounted.
I've also checked the react-native docs an I tried with the next methods componentWillReceiveProps(), shouldComponentUpdate(), componentWillUpdate(),etc. but none worked.
Thanks you.

A: check out react-redux . Setting state/properties at global level will pass properties across screens. The components are also re-rendered based on the properties used.
Another option would be to pass props to the dashboard component if there are any changed made in the detail.Based on the properties passed you can trigger the RefreshControl for Dashboard(ListView)


Denver's DIY Irish folk-punks Bourbon Brawlers just dropped their new 10 song album Befriend Your Sins and a music video for the single "Irish Yoga". The 7 piece outfit is the Colorado flag bearer for working class folk-punk angst and heart with songs about drinking, revolution, friends no longer with us and more drinking. The album is loose, festive, and full of great punk jams with an overall theme of having fun while you can. Befriend Your Sins has 8 songs streaming online with a bonus 2 tracks ("Whiskey Souls" and "Kevin and Bob.") only available on the physical copy of the album.


The current status of individual invasive species in Lincolnshire is not well understood, as species are generally only recorded on a site specific basis. As a part of our environmental obligations, we record the presence of invasive species within our drains, and report this annualy to the GLNP in an effort to improve understanding.
Witham First District IDB don't currently have any invasive species in their watercourses, however species with a known potential to cause problems include Japanese Knotweed and Himalayan Balsam. The main issue with these species from an operational perspective is the disruption to routine maintenance in terms of restriction of access to banks. From a conservation perspective, invasive species can cause a reduction in diversity and habitat quality, as they often out-compete native flora. Japanese Knotweed in particular spreads very easily-particularly in ripeain areas where high water flows can disperse fragments of the plant downstream, where new colonies can form. It is therefore very difficult and expensive to control and eradicate. Further problems occur during the winter months when the species isn't present, as it leaves areas of exposed ground, therefore increasing the risk of erosion.


LOS ANGELES – Oct. 24, 2013 – For the first time ever, the American hard rock band CLUTCH will perform live on AXS TV CONCERTS, Thursday, Nov. 14 at 11 p.m. ET | 8 p.m. PT from the Ogden Theatre in Denver. The band will perform its new hit single "Crucial Velocity," as well as other popular songs and rarities amassed from their 10 studio album career during the live, unedited performance on AXS TV.
The Maryland-based band has been playing together since 1990 and is celebrating the 20-year anniversary of their 1993 debut album "Transnational Speedway League." Band members are Neil Fallon (vocals), Dan Maines (bass), Jean Paul Gaster (drums), and Tim Sult (guitar).
Known for their high-energy style, CLUTCH's music has not only climbed the charts, but has been featured on several high profile television series including "The Walking Dead," "Sons of Anarchy" and numerous other sports networks.
In anticipation of the telecast, the band will be giving away 10 signed copies of their brand new "Earth Rocker Live" picture disc through a social media contest here: http://bit.ly/1cvUIo7. This double LP is a limited edition release that will be available in stores on Nov. 26.


There are resources all around you and people who want to help. Who would you feel comfortable talking to? Besides the people in your family, there are people in your school, in the spiritual community and in the community at large who are there for you. There is also support available through community services and community activities.


Updating the FIMMA to include Custom Attributes in the FIM Portal.
You may find yourself creating new Custom Attributes or even a custom Resource in the FIM Portal. If you only plan on managing these Custom Resources and or Attributes in the FIM Portal than you would not need to add them to the Synchronization Service and FIMMA, but if you intend to manage these new custom resources and attributes with the Synchronization Service than you will need to update the Synchronization Service to include these Resources and / or Attribute. This posting is to assist with the Updating of the FIMMA .
Before you continue verify that the new Resources and / or attributes have been added to the Metaverse. The following Post can assist with adding resources and attributes to the Synchronization Service. Resource Management - Configure Synchronization Service to manage New Resource.
If you dont see the new custom attribute that you want to add to the FIMMA select Show All.
After you locate the new attribute (in the post we will be adding the "Employee Status" attribute) Select the attribute.
Add this as an Import and an Export attribute flow.


Postcard of a white dock on a placid lake with a snow capped mountain in the distance, described as "Lake Washington Boulevard and Mount Rainier, Seattle, Washington." The message on the back is illegible. The postcard is addressed to "Mr. Carroll E. Ward Texas Ice Co. Beaumont, Texas."
Creator: Unknown. September 19, 1934.
May 20, 2015, 3:07 p.m.
[Postcard of Lake Washington Boulevard and Mount Rainier], postcard, September 19, 1934; Seattle, Washington. (https://texashistory.unt.edu/ark:/67531/metapth562834/: accessed April 25, 2019), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting McFaddin-Ward House Museum.


text:
Jessica Kourkounis/Getty Images News/Getty Images
What You Should Know About Martial Law
by Emily Lee
President Trump has been in office for less than two weeks and he has already signed 13 executive orders. It's been a busy week for the president, as well as an unsettling start to the next four years for many American citizens. It's not only Trump's executive orders that have people worried about the future of our country either: Trump took to Twitter last week, sharing statistics from The Chicago Tribune which detailed the rise in homicides happening in the city. "If Chicago doesn't fix the horrible 'carnage' going on, 228 shootings in 2017 with 42 killings (up 24% from 2016), I will send in the Feds!" Trump declared, which has many people wondering if the President is seriously considering implementing martial law in the United States.
The Merriam-Webster dictionary defines martial law as "the law applied in occupied territory by the military authority of the occupying power," or as the law "administered by military forces that is invoked by a government in an emergency when the civilian law enforcement agencies are unable to maintain public order and safety." While the threat of martial law is scary, especially considering it's often connected with the suspension of civil laws and rights, the United States does have systems in place that help prevent a President from authorizing martial law — so whether or not that actually happens, it's still unsurprisingly concerning to those who've lived through actual martial law.
Martial law is limited in the United States because of the Posse Comitatus Act, which was passed by Congress in 1878. The act states that congress must approve of all military involvement in domestic law enforcement. Habeas corpus in another element of United States law that helps prevent martial law from going into effect. Habeas corpus is the right of civilian to report an unlawful detention or imprisonment before a court, which basically means that the United States judiciary is able to supervise law enforcement. According to Article 1, Section 9 of the United States Constitution, "The Privilege of the Writ of Habeus Corpus shall not be suspended, unless when in Cases of Rebellion or Invasion the public safety may require it."
Trump's tweet about Chicago's crime rates didn't come right out and say martial law, however, the implication was clear for many. Aaron Morrison, a senior staff writer at Mic, pointed out that martial law has been proven to lead to "higher rates of death, incarceration and civil liberties violations." He spoke with native Chicagoan and criminal justice professor Nicole Gonzalez Van Cleve about the possibility of martial law being implemented in Chicago. "When you take the history of his rhetoric and his campaign promises, this martial law approach presents a different twist," Van Cleve told Mic. "There is no violence-prevention expert in America that would agree that martial law works."
Most recently, concerns over martial law have come to a head following the various immigration ban protests taking place across the country. "Now what?" one journalist wrote on Twitter Sunday, responding to reports that attorneys looking to assist detained refugees using a federal judge's executive order stay had been denied by Customs and Border Patrol (CBP) agents. "If judge grants contempt order [against CBP agents] & sends Federal Marshals against CBP, & [the White House] sides w/CBP in defiance — who or what defends [the] Constitution?"
"If we're following a pattern here Trump is telling us he's about to start WWIII," one writer tweeted.
"Unbelievable that CBP are openly defying federal court order," echoed one Twitter user. "This is what beginnings of martial law looks like."
It will be interesting to see how Trump moves forward from here. Despite using Twitter to threaten martial law, there are systems in place that will hopefully prevent our president from doing just that — whether those systems are fail-proof is still up in the air.


I first saw Tegland's work at The Bemis Center for Contemporary Arts Annual Art Auctions. Tegland's work stood out. At that time, I had never heard of the artist, nor had I ever seen work like his. The black paintings with graphite drawing atop, were magical. The way the light hits the works create a living thriving piece of art.
Almost black on black, the graphite lines bring shape and form in a graphic manner to the work. The work captivates the viewer to stay and watch them come to life.
I asked Mike are these paintings or drawings, he stated both. Tegland is an artist that works and stays out of the spotlight. He works for the art of the art. This will be his first solo show and so over due. His talents are known by The Bemis and many art collectors. Come see the work. One of the greatest aspects of having a gallery is the ability to find and show the works of top notch artist like Mike Tegland.
There will no Art Talk for this show, the work speaks volumes.


Dr. Teoh specializes in Education Psychology and has many years of experiences in teaching and providing his services as a lecturer and counselor in various higher education institutions and secondary schools. He was also appointed as the Head of Curriculum Department in the United Chinese School Committees' Association of Malaysia. Currently, he works as a part-time lecturer in several colleges/universities such as Wawasan Open University (WOU) and Tunku Abdul Rahman University College (TARUC), teaching educational related subjects. In addition to that, Dr. Teoh provides trainings to educator in independent Chinese schools and organized various camps and workshop for students and youth all around the country. When he is not lecturing or providing talks, Dr. Teoh conducts educational research. Some of his works were being published in The International Journal of The Humanities, American Journal of Applied Psychology and Journal of Educational and Social Research.
Dr. Teoh has high interest in youth issues, and is highly involved in organizing camp and workshop related to youth activities. His areas of specialties in public lecture are on life education, motivation, and parenting styles. At InPsych, Dr. Teoh provides consultation to parents, teachers and youths on education related issues such as how to improve learning, identifying learning strengths and weaknesses, managing exam stress and improving learning motivation.


RAK Ceramics' quarterly net profits were down 51 per cent to Dh55.1 million but its revenues remained stable and its core gross profit margin reached an all-time high of 34.7 per cent, the firm said on Thursday.
The reason for the fall in net profits was due to the Dh34.8 million sale last year of RAK Warehouse, which pushed the quarterly net for Q2 2017 to Dh113.2 million. Disregarding that sale indicates a 29.7 per cent fall in net, according to Gulf News' calculations.
"Net profit was also impacted by an increase in energy costs, foreign exchange losses, general and distribution expenses and investments in Saudi Arabian entities, brand building expenses in India and in the US for the tableware business," the firm said in a media statement.
RAK Ceramics Group CEO Abdallah Massaad said, "Our performance this quarter was stable and in line with expectations. Tile and sanitary ware sales were strong in the UAE, Saudi Arabia, India and Europe.
"Our tableware business has performed well, driven by growth in the US market and the taps and faucets business has also shown growth in the UAE and Europe.
Overall revenues fell 0.3 per cent to Dh719.2 million, due to a 31.9 per cent fall in non-core revenues as it discontinued its rough grading business in line with its value creation plan, the firm said.
RAK Ceramics' core revenue grew by 2.6 per cent year on year, led by strong sales in the UAE and India, as well as strong performance by the tableware business driven by growth in Europe and the US markets.
Tile and sanitary ware revenues in the UAE, Saudi Arabia, India and Europe increased by 2.7 per cent, 17.2 per cent, 2.2 per cent and 6 per cent respectively year on year.
Total gross margin increased 110 basis points to an all-time high of 24.4 per cent, with core gross margins up 50 basis points to an all-time high of 34.7 per cent, the statement added.


Bolton Wanderers have confirmed that a deal has been reached to sell the club to former Watford owner Laurence Bassini, subject to clearance from the EFL.
The club confirmed the news on their official website, writing: "Bolton Wanderers Football Club are delighted to announce that a sale and purchase agreement has been signed which will see Ken Anderson's shareholding in Burnden Leisure Limited being sold to Mr Laurence Bassini.
Back in 2013, Bassini was handed a three-year ban prohibiting him from getting involved with any EFL club after he was found guilty of misconduct in Watford's financial dealings between 2011 and 2012.
Performances on the field have been just as disappointing, with Phil Parkinson's side nearing relegation from the Championship - a fate which would be confirmed with defeat against fifth-placed Aston Villa on Friday.


Ah, married life! It's not a venture for the faint-hearted or uncommitted heart. It is, however, the perfect adventure for those inclined to create a work of art within the most sacred of personal relationships—marriage. Rilke famously quoted, "For one human being to love another: that is perhaps the most difficult of all our tasks, the ultimate, the last test and proof, the work for which all other work is but preparation." As both a psychologist and a newlywed, I couldn't agree more.
As I rolled into the fourth month of marriage, I realized that a sea of change had enveloped me. Every bit of my life seemed unfamiliar and vastly different. I had moved into my husband's home. His furniture and belongings—his very manliness—surrounded me at every turn. Feminine to my very core, his taste for all things masculine seemed to deter my ability to create a nest within his nest. Before we wed, we had made many big and thoughtful decisions. One of these biggies was where to live—his place or mine. Knowing him as I do, I knew—despite his protestations—that moving to my world would be too harsh a transition for my proud, sensitive guy who thrives on consistency and all things familiar. I had known, almost instinctively, that he needed his man-identity, man-cave, and man-world much more than I needed my familiar Carla-world.
Leaving my realm to be with my love didn't seem like too much to ask of myself, but my psyche ultimately decided otherwise. It was the consequences of decisions such as these that began to hit me with the reality of a California earthquake. The good news is that most California earthquakes cause no real harm; once the shaking and shuddering fade away, so does the fear. The earthquake metaphor works beautifully for adjusting to married life; the stress of the upheaval and change are more a matter of fear than any real threat.
Let's talk dirty. My sweetheart loves motorcycles and all things mechanical. He loves the dirt. He loves to play. His childhood mascot might have been Charlie Brown's "Pigpen." Me? I'm the queen of tidy and neat. I, too, love dirt; but I prefer to leave it outside where it belongs. I, too, love motorcycles and race cars; but in the living room? When I met my darling, he had one vintage motorcycle displayed beautifully in the living room (yes, the living room). Now, another motorcycle has arrived and is proudly displayed in the foyer. Although she is an admittedly gorgeous machine, she's a stark departure from the baby grand piano I left behind. My husband—being so willing to please his new bride—asked my opinion before the new décor arrived.
Staring into his beautiful brown eyes—and knowing the right answer in my heart—I smiled and told him the motorbike would be a perfect addition. He stares into my eyes with his knowing, devilish grin; we break out into peals of laughter and embrace. As he holds me tightly, I revel in knowing how right it feels to honor him in such small and simple ways. While others might laugh at our odd décor, I feel blessed each time I spy one motorcycle in the living room and another in the foyer. How's that for a testament to the art of tenderness, flexibility, and love?
I am finding that marriage is truly more than a connection between two people—it is the creation of a third entity: the marriage itself. If nothing else, the second quarter of my newlywed months has taught me to respect and care for the marriage itself. Yes, I need to tend to my needs. Yes, I need to tend to my sweetheart with love and respect. And, yes, I surely need to remain aware that my husband and I are forming the essential components of our married life that will carry us through the beautiful days and years ahead.
Truly intimate connection takes thoughtful energy and awareness. Creating a foundation of love, mutual respect, and soulful compromise takes thoughtful work and dedication. Yet, with each week of continued effort and care, I am embraced by an even deeper sense of knowing that I am—that we are—assuredly on the right path.


text:
'Signs Of Promise' In Latest COVID-19 Surge In Chicago, But City's Top Doctor Says It's Too Early To Say Cases Have Peaked – CBS Chicago
January 11, 2022 by Lonny Benson
CHICAGO (CBS) — While Chicago is still seeing a huge number of COVID-19 infections on a daily basis, Public Health Commissioner Dr. Allison Arwady said Tuesday there are some encouraging signs that cases are starting to decline, though she warned it's too soon to say the latest surge has reached its peak.
"There are some signs of promise in terms of the Omicron surge here," she said during a regular Tuesday Q&A session on social media. "I want to be very clear here that we need to see signs of progress for a number of days here."
READ MORE: DCFS Had Been In Touch With 6-Year-Old Damari Perry's Family Before He Was Killed; His Mother And Siblings Are Now Charged In His Death
Chicago is currently averaging 4,793 new COVID-19 cases per day over the past week, down 8% from one week ago. The city's test positivity rate stands at 18.9%, down from 21% one week ago.
Arwady said case rates in Chicago are still "extremely high," but she said she's encouraged that the rate of infection appears to be slowing.
"We are on it, and we are following closely, but I just want people to recognize we do need to see some more days of improvement here before we could for sure say that things have peaked," Arwady said later Tuesday at City Hall.
Meantime, Chicago is averaging 187 hospitalizations per day, up 37% from a week ago, Arwady said, noting hospitalizations lag behind infections. Chicago is also averaging 17 COVID-19 deaths per day, up 25% from one week ago.
The number of ICU beds and ventilators in use for COVID-19 patients remain below the levels seen during the first two waves of the pandemic in 2020, and Arwady said that is because of how many people have been vaccinated, putting them at lower risk of severe illness. She also noted the vast majority of COVID patients currently on ventilators in Chicago are infected with the Omicron variant and are not vaccinated.
READ MORE: Chicago Public Schools Teachers Return To Classrooms Amid Tentative COVID-19 Safety Deal With Teachers' Union; Students To Return To Class Tomorrow
Arwady said it's still critical for people to double down on mitigations against COVID-19, particularly by getting vaccinated and getting a booster shot.
Vaccinations are on the rise in recent days in Chicago, with the city averaging 11,521 doses administered per day over the past week, up 19 percent from one week ago.
Meantime, Chicago made no changes to its COVID-19 travel advisory list on Tuesday, with every state and territory remaining on the list for the second week in a row.
Case rates in individual states and territories must drop below 15 per 100,000 population for two weeks in a row to be removed from the travel advisory.
City officials recommend people who aren't vaccinated get tested for COVID one to three days before heading to a state or territory on the travel advisory list, and again three to five days before returning to Chicago.
Public health officials also recommend unvaccinated people who visit a state or territory on the travel advisory list quarantine for at least seven days upon arriving in Chicago, even if they test negative. Unvaccinated people who don't get a COVID test should quarantine for at least 10 days.
MORE NEWS: No States Removed From Chicago's Travel Advisory
The Chicago Department of Public Health said it's been almost a year (February 2021) since every state and territory has been the city's travel advisory.


hot rolling aluminium fore mill for sale. hot sale bailing brand flotation cell in south america. hot sale flotation machine reverse flotation machine. 2014 hot sale rotary screening machine for organic fertilizer. hot sales stone crusher machine. hot selling high efficient thickener supplier.
High Weir Spiral Classifier. hot sale bailing brand flotation cell in iran. hot sale bailing brand flotation cell in iran_mechanical flotation cell for sale in iranhot sale bailing brand flotation cell in iran Founded in 1997, Shandong Xinhai .
Zinc Ores, Zinc Ores Suppliers and Manufacturers hot sale bailing brand flotation cell in morocco. zinc ores for sale . JBS BRAND HOLDINGS LLC . Henan Bailing Machinery . Factory price South Africa Hot Sale Gold Ball Mill Machine for Copper/ Zinc/ Iron Mineral Flotation machine for copper,lead,zinc ore ..
hot sale bailing brand flotation cell in germany. Xinhai has provided mineral processing plant services for more than 500 mines in the world. The projects spread more than 20 countries around the world with good benefits and stable operation!
hot sale bailing brand flotation cell in honduras; hot sale bailing brand flotation cell in honduras. Seller Of Lead Ore Wholesale, Lead Ore Suppliers Mining Equipment. Order). JBS BRAND HOLDINGS LLC Lead Ore. Add to Compare. Contact Supplier . 50 Metric Tons (Min. Order). Metal Minerals Co. Quality lead ore for sale.
Henan Bailing Machinery Co., Ltd. Add to Favorites. Copper Ore . High efficiency flotation machine /cell sell in Mexico. Add to Compare China leading Ore Dressing Ball Mill for sale Brand,Hot use in magnetite. Add to Compare. Get Price Mineral de antimonio. Contactar Proveedor Top Brand 99.65% pureza de mineral de antimonio compradores .
Sell Tin Ore, Wholesale Various High Quality Sell Tin Ore Products from Global Sell Tin Ore Suppliers and Sell Tin Ore Factory,Importer,Exporter at mining bailing brand flotation cell in malaysia . Hot Sale Gold Shaker Table. hot sale gold shaker table.
Henan Bailing Machinery Co., Ltd. Crusher, Ball Mill. 1100, 1200, 1400, 1600 mercury gold wet pan mill, chilean mill Zinc ore grinding ball mill used in flotation concentration plant Small mobile concrete China leading brand drying machine rotary dryer 100tph Aggregate Hot sale.
Flotation Cell, Flotation Cell Suppliers and Manufacturers hot sale bailing brand flotation cell in sweden . Flotation Cell, Wholesale Various High Quality Flotation Cell Products from Global Flotation Cell Suppliers and Flotation Cell Factory .
hot sale bailing brand flotation cell in india. A comprehensive analysis of newyorkminerals.com by ServiceHostNet. Meta Desc Shandong Xinhai Mining Technology Equipment Inc, specializing in the production of large-scale ball mill, a complete set of mineral processing equipment such as high efficiency flotation machine, mi.
hot sale bailing brand flotation cell in uk. Lead Ore Processing Plant Wholesale, Processing Plant Suppliers . Lead and Zinc Ore Flotation Machine / Flotation Processing Plant .. Hengchang XJK 1.1 Flotation machine used for lead ore processing plant hot sale . Bailing brand copper ore processing plant, gold ore processing plant for sold.
New carsTata Construction Equipment in India Details of new Tata equipment hot selling. hot sale bailing brand flotation cell in cameroon. ball mil. more Get Price. Flotation Cells For Sale Wholesale, Flotation Cell Suppliers Alibaba.


'Fox' – based on the much-loved children's book by Roald Dahl, 'The Fantastic Mr Fox' – is exactly what you would want in a children's production. It is bright, colourful and charming and pretty near everyone left the room smiling.
It's one of the more accessible pieces of physical theatre at the Fringe this year. It cleverly and quirkily depicts the trials and the adventures of Mr Fox. Rather than dialogue, a woman stands slightly off stage, turning large flashcards which describe the scene the audience is watching. At times the lack of dialogue can feel a little grating, as the actions become repetitive or even slightly confusing.
The actors were generally very good at their parts, with Aidan Cheng as a brilliantly creepy Raithbourne Ratty, while Michael Smith was a good, if slightly underused, Badger. The Young Foxes (Ellen Muriel and Joel Smith), meanwhile, well captured the bickering and over-enthusiastic energy of young children. The production as a whole was well held together by Alex Appleby's competent and charming Mr Fox, who was a competent and confident leading man.
The production also made very good use of a beautiful, but simple, set. Each item of furniture and most of the actors were used at one point or another to depict changes in scene and tempo and the progression of the Foxes on their journey. They also made good but limited use of a back-lit map, showing the progression of the Foxes with small shadow puppets. This was a clever and funny idea and one which it was a pity not to see more of.
The textures of the piece is kitsch, 1950s and housewife-y. It's not for everyone and the storyline can occasionally feel as retrogressive as the costumes – this seems particularly apparent when Mrs Fox (Ellise Kannah) and her daughter stay home to bake for the boys, while they have the time of their lives in the Cider Cellar.
While this is generally a good play, it tends to become alarmingly twee at times. It's certainly not going to be to everyone's taste. But, if you want forty-five minutes of good clean family fun, then it doesn't come much more squeaky clean than this.
A fun adaption of Roald Dahl's 'Fantastic Mr Fox' proves just how entertaining physical theatre can be, no matter who the audience are. The developing dynamic of the fox family was enchanting to watch. Lead by Alex Appleby's hilarious Mr Fox, the young foxes (Ellen Muriel and Joel Smith) face nerve-racking underground adventures, all the while keeping us constantly amused by their bickering and in-fighting. Left at home we have Mrs Fox, portrayed by Ellise Kennah, bringing a bit of a 1950s feel to the stage. Her later appearance as Madam Toad demonstrates the cast's versatility and adds an imaginative new character to the original story.
It was nice to see the production team experiment with Dahl's original and the scenes in "toad cave" really were a testimony to this. However it was a slight shame that we never got treated to a rendition of the three farmers. My childhood nightmares were certainly haunted by these vile figures and a small spotlight did not really provide the same level of suspense. That said, every other aspect of the show was well thought through and meticulously executed.
The set design and costumes were fitting and provided just the right balance between conjuring up a forest scene and allowing the anthropomorphic nature of the roles to shine through. On top of this, the underscore was incredibly well put together, allowing the cast to silently evoke every moment of jazzy excitement. Particularly Aidan Cheng's Ratty, who strutted out his part with admirable elegance, capturing his character's snuffling nature.
The fun did not merely stick to the stage. Once the tunnelling started, the whole audience were engulfed by the characters' desperate search for freedom and (more importantly) food. Some imaginative work with furniture and crockery helped keep the constant threat of the hunters in our minds. But the energetic expressions of the hounded animals were enough to heighten the tension, conjure up touching scenes of family devotion or bringing the side-splitting comedy to the forefront. In fact, the roles were executed with such skill that the additional narration was at times almost unnecessary.
'FOX' is a definite crowd pleaser. Well put together and diligently enacted, it is proof that you do not have to be a child to become completely engrossed in a children's production.


The Lilywhites kept a clean sheet, but had to settle for a point in a hard fought Lancashire derby at Deepdale.
With just 18 fit players, including a returning Tom Clarke after seven months out, it was always going to be a tough encounter, but it was a game where North End could have taken even more from it.
Their first half performance, in particular, was a positive one, after a difficult run of results, with four good opportunities to have given them what could have proved to be a decisive goal.
All those chances saw involvement from Paul Gallagher, selected in the midfield, alongside Ben Pearson, with the experienced No.12 orchestrating things and showing his recognised quality from set pieces with sumptuous deliveries that on three occasions went close to providing the necessary to bring a break through.
The game was delayed by just over five minutes after one of the stadium floodlights had gone out, but the game finally got underway amidst a boisterous derby day atmosphere and from the off the home side played at a high intensity, with and without the ball and looked to have returned to the style that served them so well in the opening weeks of the season.
And they were desperately close to getting off to a dream start when a clever short corner between Gallagher and Callum Robinson saw the latter get the ball back at a tight angle. It was very similar to his chance and goal at Charlton Athletic three years previously, but this time his shot was low and Ben Alnwick turned the ball behind for a second corner.
This time the deep ball to the back post found an unmarked Paul Huntington, but the skipper was at a very narrow angle and was unable to hit his effort on target, putting the ball back into the box.
Gallagher, approaching 200 games for the club, had another chance to put over a corner before the quarter hour mark and this time it was Huntington's central defensive partner Andy Boyle who rose highest in the box, but his powerful header squeezed an inch wide of the left hand upright.
The chances continued to flow and again it was the right boot of Gally that provided the opportunity, this time delivering a free kick from the right hand side, finding Tom Barkhuizen on the penalty spot, but he too flashed his header across the goal and inches wide of the post.
The visitors created very little to test Chris Maxwell in the North End goal, with the three-pronged Trotters attack marshalled well by the four in front of the Welsh stopper, including Kevin O'Connor, making his full home debut and Calum Woods, playing at right back after only one day's training since injuring his knee in the last home game against Aston Villa 16 days before.
The second half was much less of a spectacle than the first. Phil Parkinson's side tried to disrupt the fluency their hosts had enjoyed in the opening period, stopping the supply line to Barkhuizen and Robinson down the flanks.
And with the likes of Gallagher, Mavididi, O'Connor, Woods and Robinson having had little football in the past few months, the energy levels of the opening period weren't quite there in the closing stages.
Daniel Johnson, Josh Harrop and Daryl Horgan were all added to the attack as Alex Neil went in search of a winner that would have warmed the 15,000 plus crowd at Deepdale on a cold night, but the experienced defensive pair of David Wheater and Mark Beevers prevented Alnwick from having to make too many spots, although he was well positioned to claim from Alan Browne, Horgan and Robinson, who all hit the target during the latter period.
However, in the end, it remained goalless, for PNE's sixth clean sheet of the season and giving them a platform ahead of two tough away games at Bristol City and Norwich City to come in the next week.
PNE line-up: Maxwell, Woods, O'Connor, Pearson, Huntington (c), Boyle, Barkhuizen, Gallagher (Johnson, 75), Mavididi, Browne (Harrop, 82), Robinson (Horgan, 68). Subs not used: Rudd, Clarke, Pringle, Welsh.
Bolton Wanderers line-up: Alnwick, Little, Beevers, Vela (Buckley, 72), Ameobi, Madine, A Robinson, Armstrong (Morais, 87), Pratley (c), Henry, Wheater. Subs not used: Howard, Noone, Cullen, Derik, Hall.
Tickets can be purchased at Deepdale from 9am until 5pm on Thursday, then from 9am until after kick-off on Friday night, both in person and over the ticket hotline – 0344 856 1966.
Away end tickets will be available on the evening, with no increases for matchday purchases. Visiting Bolton Wanderers supporters can buy from the away ticket office next to the Bill Shankly Kop on Lowthorpe Road, with cash and card payments accepted.


How to Write a College Enthusiasm Essay | Elifer Vallés S.L.U.
From the time the origination of time, all people have been encouraged: inspired to thrive, triggered to vanquish, and impelled to be the greatest. But what is this notion we contact determination?
As outlined by explanatory dictionaries, motivation may be the provoking and directed of conduct, the energy powering our requires for meals, our yearning for intimate connection, and our accommodations to achieve. You may learn about presence of distinct hypotheses associated our inspired habits. One of these elaborated by Darwin thinks about habits as managed by many natural factors, including clear instincts.
Now let's picture a student, resting with document and pen, who are not able to commence to create his inspiration essay even being unable to jot lower some words. What advice do you give him to activate for customized creating his assigned determination essay?
Typically the easiest way to get motivated is to take tiny steps inside the custom made papers composing process.i need someone to write my essay for me For example, acquire a few momemts for created meditating with this "complicated" method by thinking about good reasons as well as anxieties of preventing to write determination essay.
A lot of students experience writer's prevent while producing their term documents, study tasks and inspiration essays. Probably the most useful methods to overpass this trend is always to check with make a note of all acknowledged specifics of the subject. Additionally a fantastic motivator could be a broad look for on the topic which tutorials you to definitely a much more particular viewpoint. Put down areas you need to be focused on, and results of the prior look for. This method can stimulate you into undertaking more deeply analysis on the topic of the enthusiasm essay.