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107
Health Services Provision for Migrants
Repatriated through Tijuana, Baja California:
Inter-agency Cooperation and Response Capacity
*
Oferta de servicios de salud a migrantes repatriados
por Tijuana, Baja California: Cooperación y capacidad
de respuesta interinstitucional
Yetzi ROSALES MARTÍNEZ
**
Ietza BOJORQUEZ CHAPELA
***
René LE YVA F LORE S
****
César INFANTE XIBILLE
*****
A
BSTR ACT
is article explores the institutional capacity to respond to the health needs of Mexican mi-
grants repatriated through Tijuana, Baja California, Mexico. Twenty-one semi-structured in-
terviews with governmental and civil society organizations were conducted. e information
was analyzed using the concept of “cooperation.” Results show an informal inter-institutional
network based on common goals and interdependence of resources. Health service provision
is not completely functional, due in part to lack of trust between some actors and to demand
overload in the most important public provider of secondary and tertiary care services in Tijuana.
Keywords: 1. health services, 2. repatriated migrants, 3. cooperation, 4. Tijuana, 5. Mexico.
R
ESUMEN
Este artículo explora la capacidad de respuesta institucional a las necesidades de salud de mi-
grantes repatriados por Tijuana, Baja California, México. Se realizaron 21 entrevistas semies-
tructuradas a actores gubernamentales y de la sociedad civil. La información fue analizada
usando el concepto cooperación. Se encontró la presencia de una red interinstitucional informal
basada en objetivos comunes y una interdependencia de recursos. La oferta de servicios de salud
no es del todo funcional debido, en parte, a la ausencia de conf ianza entre algunos actores y a
la saturación del más importante proveedor público de segundo y tercer nivel de atención en
salud en Tijuana.
Palabras clave: 1. servicios de salud, 2. migrantes repatriados, 3. cooperación, 4. Tijuana,
5. México.
Date of receipt: July 11, 2016.
Date of acceptance: October 18, 2016.
* Text and quotations originally written in Spanish.
** Conacyt-El Colegio de la Frontera Norte, México, romy@colef.mx.
*** El Colegio de la Frontera Norte, México, ietzabch@colef.mx.
**** Instituto Nacional de Salud Pública, México, rene.leyva@insp.mx.
***** Instituto Nacional de Salud Pública, México, cesar.infante@insp.mx.
FRONTERA NORTE, VOL. 29, NÚM. 57, ENERO-JUNIO DE 2017, PP. 107-130
108 FRONTER A NORTE, VOL. 29, NÚM. 57, ENERO-juNiO DE 2 017
INTRODUCTION
is article addresses the relationship between return migration and the health
of migrants from a human rights and inter-agency management perspective. e
intense population mobility seen today between Mexico and the United States of
America requires states to carry out actions and strategies to guarantee the rights
of the mobile groups. In Mexico, “the democratization of health” began to be-
come part of the national discourse during the f irst decade of the 2000s, mak-
ing explicit the necessity of involving more social actors in the processes linked
to health service provision to the population without health insurance, among
them return migrants (Arredondo et al., 2013). In the area of public policy for
migration and health, adjustments to mechanisms of coordination and coopera-
tion between local, national, and international bodies have become imperative in
order to respond to the health needs of the mobile population (Zimmerman, Kiss,
and Hossain, 2011). In particular, return migration entails upheavals of greater
complexity in physical and mental health due to the accumulation of risks mi-
grants have been exposed to since leaving their places of origin, during their jour-
ney, possible detentions, and their forced or voluntary return. Despite that, this
problem has not received enough attention from academia and decision-makers
(Davies et al., 2011).
Since 2007, a federal program for the orderly reception of Mexican migrants
called Programa de Repatriación Humanitaria (Humanitarian Repatriation Pro-
gram, known by its Spanish initials
PRH
), and including a health care component,
has been in operation in Mexico through the Instituto Nacional de Migración
(National Migration Institute). It is a relatively pioneering model where action
is taken by dif ferent levels and dependencies of the government, by the bina-
tional initiative known as Comisión de Salud Fronteriza México-Estados Unidos
(United States-México Border Health Commission), and by local and interna-
tional civil society organizations. e provision of health services by this joint
initiative has enjoyed a series of successes; there also are areas of opportunity that
need to be studied to improve the services functioning and overall health care for
this vulnerable population.
e objective of this article is to explore the response capacity to address the
health needs of the population repatriated to Mexico from the United States,
by governmental and organized civil society actors in Tijuana, Baja California. e
following sections will describe the services provided, the actors involved, and
the path to access health services for those repatriated, beginning at the National
ROSALES-BOJÓRQUE Z-LEYVA-INFANTE / HEA LTH SERVIc ES PROVISION FOR MIgR ANTS REPATRI ATEd 109
Migration Institutes El Chaparral receiving point. e description of the interac-
tions and the inter-agency coordination established among these actors is done
utilizing the concept of cooperation. F inally, strengths and weaknesses are iden-
tif ied, and specif ic recommendations suggested.
COOPERATION AS RESOURCE AND STRATEGY
Cooperation plays a role in this study as a conceptual guide for interpreting the
information collected in the f ield. e literature relative to this construct generally
makes reference to the cooperation between governmental actors at their dif ferent
levels, or between companies. In this work the def ining elements of cooperation
are adapted to understanding the interaction between governmental actors and
civil society organizations.
e act of cooperating is justif ied by the scope of common objectives among
organizations (Smith, Carroll, and Ashford, 1995). As modern societies pose chal-
lenges that are dif f icult for just one organization to resolve, an integration of activi-
ties involving a number of actors becomes an advisable strategy (Lundin, 2007).
For Gulati (1999), resource needs lead to the emergence of networks or strategic
partnerships def ined as voluntary links of inter-organizational cooperation. Accord-
ing to this author, when one organization faces exogenous restrictions or situations
out of its control, there is a tendency to establish links with other organizations that
have the necessary resources and capabilities to overcome these restrictions.
According to Lundin (2007), cooperation between government actors occurs
as a function of interdependence of resources, shared objectives, and trust. When
the achievement of certain objectives depends on the exchange of resources, the
organizations tend to cooperate among themselves until establishing a mutual de-
pendence; nevertheless, if one actor does not trust the other, the objectives will
not be met even though both pursue the same ones. A central issue is the pos-
sibility of developing trust when the individual actors frequently have face-to-face
contact and personal preferences and interests come to be familiar between them
(Meijboom, 2004).
From a perspective of dynamics and process, cooperation changes in terms of
the disposition of each group or organization, as they evaluate the des irability
of interacting with others (Smith, Carroll, and Ashford, 1995). Despite the mu-
tual recognition of the advantages of cooperating, it is not easy to carry this
out in practice (Meijboom, De Haan, and Verheyen, 2004; Mur-Veeman, van
110 FRONTERA NORTE, VOL. 29, NÚM. 57, ENERO-ju NiO DE 2017
Raak, and Paulus, 1999). ese partnerships carry risks resulting from the un-
certainty of partnering, above all when there is little to no information about the
competences of the other party, bringing forward doubts about the other partys
trustworthiness (Gulati, 1999). Furthermore, Lundin (2007) mentions that the
organizations avoid cooperation when costs exceed benef its. e interdependence
of resources involves the participating organizations seeking to obtain advantages
such as information, human resources, f inancing, etc., that bring about a decline
in its autonomy.
In the study of public administration, cooperation is tied to what is called the
“new governance.” is term emerges from a context of a redrawing of national
and international relations that outlines public needs and problems of greater
scale and complexity. In the face of the decline of the welfare state, governments
show an insuf f icient response capacity that results in new public management
challenges. In this context, other “governmentally independent” actors enter the
scene, optimizing resources through strategic partnerships and contributing to
fulf ill social functions (Aguilar, 2010). is idea is called “associated management”
by Moreno (2010). It is expected that the state will promote a horizontal coop-
eration without political interests interfering, propitiate conf idence between the
parties, and strengthen the management capacity of the civil society organizations.
Some indicators that have been used to assess the joint work among organi-
zations are: frequency of communication, the regularity with which persons are
transferred between organizations, and the amount of help that a central organiza-
tion receives from other organizations, as well as the use of various coordination
methods such as inter-agency committees and work groups (Lundin, 2007). is
conceptual framework is useful for understanding our study case. e provision
of health services to repatriated migrants brings with it a series of negotiations,
conf licts, and means of arriving at a consensus established in an implicit or explic-
it way among the various actors. In Tijuana, a complex context involving public
health services overload and the eventual return of more compatriots with health
care needs frames the experience of the cooperation between governmental actors
and civil society organizations studied in this work.
CONTEXT OF THE STUDY
Between 2012 and September 2015, there were a little more than a million events
of repatriation from the United States to Mexico through the National Migration
ROSALES-BOJÓRQUE Z-LEYVA-INFANTE / HEA LTH SERVIc ES PROVISION FOR MIgR ANTS REPATRI ATEd 111
Institute. Sixty-f ive percent of these events took place at local receiving points in
Mexicali, Tijuana, Ciudad Acuña, Nuevo Laredo, and Matamoros. In particu-
lar, the receiving point El Chaparral in Tijuana recorded 33 621 repatriations in
2014. Of the total number of people repatriated during this period, 95 percent
were older than 17, and 90 percent were men. In the f irst semester of 2015, Ti-
juana received 49.8 percent of the total of those repatriated through Baja Califor-
nia, and 14.7 percent of the total who entered through the nine receiving points
distributed throughout Mexicos northern border (Segob, 2015).
Although some of those repatriated arrive in Mexico needing medical atten-
tion, the exact number of those who are ill is not known. e Secretaría de Salud
(Health Ministry) does not record information about the number of repatriated
migrants that it provides care for (González-Block and De la Sierra, 2011). For
its part, the National Migration Institute has a register of the demand for medi-
cal care for those repatriated who voluntarily accept health services. According
to available data, from January to September 2015 the
PRH
provided medical as-
sistance to 3 388 people at the receiving point in Tijuana, 15.4 percent of those
repatriated through that point during the same period (Segob, 2015).
e scarce literature in Mexico about this issue reports a diversity of illnesses
in the population that voluntarily returns or is forced to return. e repatriated
migrants who were detained by the Border Patrol shortly after crossing the bor-
der often have traumatisms and musculoskeletal problems, while those deported
from the interior of the United States more often have chronic health problems
(González-Block et al., 2011). e health damages that the migrants suf fer are
linked not only to their stay in the United States but also with the overall migra-
tion process (Salgado de Snyder et al., 2007; Ruiz et al., 2014; Nigenda et al.,
2009). is overview generates the urgency for a governmental response in keep-
ing with the migrants needs, focused on guaranteeing them accessible and quality
services in their place of origin, in transit, at their destination, and upon their
return (Zimmerman, Kiss, and Hossain, 2011).
In normative terms, the right of migrants in transit and those repatriated to re-
ceive health services in national territory is stated in Article 4 of the Constitution
(H. Congreso de la Unión, 2016) and in of f icial documents such as Programa Sec-
torial de Salud 2013-2018 (Sectoral Health Program 2013–2018) (Segob, 2013)
and Programa Especial de Migración 2014-2018 (Special Program for Migration
2014–2018) (Segob, 2014). To date, the implementation of the governmental
health strategies directed at migrants has been ef fected through the Humanitarian
112 FRONTERA NORTE, VOL. 29, NÚM. 57, ENERO-juNiO DE 2 017
Repatriation Program and the Sistema de Protección Social en Salud (Social Health
Protection System) through Seguro Popular (Popular Insurance).
When it comes to repatriated migrants, the universe of public health services
is limited to the Health Ministry,
1
which provides medical care through the 2
nd
Health District of Baja California. e installed capacity is insuf f icient to care for
all those without health insurance, which between 2010 and 2014 increased by
35 714, to 659 000 in 2014.
2
e health district has 0.29 hospital beds and 0.75
doctors
3
per 1 000 inhabitants without health insurance, while at the national
level this indicator is 0.59 beds and 1.5 doctors per 1 000 (
DGIS
, 2014).
ese public services constitute the governmental health provision that those
repatriated f ind upon arrival in Tijuana. e important presence of organized civil
society that provides ambulatory health services to migrants also merits mention-
ing. In this city, there are around a dozen legally constituted civil organizations
linked to serving migrants. Most operate as non-prof it shelters with assistentialist
ends and depend on public resources and donations (Moreno and Niño, 2013).
METHODOLOGY
Tijuana was selected as a case of study for being the place where health service
provision to repatriated Mexicans by the
PRH
has gained the most experience
compared with other border cities. An instrumental case study was undertaken
4
to
understand the nature and functioning of a particular phenomenon (Stake, 2013).
is exploration required the collection of information about its background, so-
cial context, and groups of actors. is research method allows the examination
1
e Mexican health sector operates under a segmented model of providers based on the
populations employment status. e population without health insurance, inserted in the in-
formal economy or unemployed, constitutes the target population of the Health Ministry.
2
is refers to the population that is not covered by Instituto Mexicano del Seguro Social
(the Mexican Social Security Institute, also known by its Spanish acronym
IMSS
, Instituto de
Seguridad y Servicios Sociales de los Trabajadores del Estado (the Institute for Social Security
and Services for State Workers, or
ISSSTE
, Petróleos Mexicanos (the state oil company also
known as Pemex), the Ministry of Defense (Sedena), or the Ministry of the Navy (Semar).
3
Includes doctors in contact with patient in outpatient and inpatient services.
4
ere are three types of case studies: intrinsic, instrumental, and collective. e f irst
is to understand the particulars of a case; the second focuses on a conceptual or empirical
problem illustrated as a “case”; and the third includes various “case studies” to analyze more
general phenomena.
ROSALES-BOJÓRQUE Z-LEYVA-INFANTE / HEA LTH SERVIc ES PROVISION FOR MIgR ANTS REPATRI ATEd 113
of the complexity of a unique case def ined by the limits of time and space and
shaped by a sequence of interrelated events (Gundermann, 2001).
e information was collected f irsthand during May and June 2015. Semi-
structured interview was employed as a data collection technique with the pur-
pose of exploring the perceptions and experiences of the informants about health
service provision for migrants. An interview guide was designed that included the
following sections: 1) perception about possible changes in the demand for health
services on the part of the repatriated population, 2) information systems about
the sociodemographic prof ile of this population, 3) the of ferings and characteris-
tics of health services provided by the actors interviewed, 4) barriers to access to
health services, 5) f inancing, and 6) inter-agency coordination.
A purposive sample of 21 actors was put together (Table 1). e informants
worked in governmental initiatives at the federal, state, and local levels, as well as
in civil society organizations whose functions focused on the migrant population.
5
e criteria of selection of the participants was to have accurate, in-depth, and
trustworthy information about health care for the population repatriated through
Tijuana through their activities as health service providers, institutional links, or
as managers of research projects directed at the migrant population.
T
ABLE
1. Number of Interviewees, by Type of Actor
*
Type of actor Geopolitical reach Number
Governmental Federal
State
Local
4
3
4
Mixed Binational (Mexico-
United States) 1
Civil society organizations International
Local
1
8
Total 21
*
Leaders of the organizations were interviewed in all cases.
Source: Authors calculation based on f ieldwork.
5
e study did not seek to interview the repatriated population, because the purpose of
this work was to explore the health services from the standpoint of the supply and not from
the demand of those repatriated.
114 FRONTE RA NORTE, VOL. 29, NÚM. 57, ENE RO-juNiO DE 2017
e identif ication of the informants took place through an online search and
consultations with experts on migration and health. A directory of actors was built;
contact was established with them through an institutional letter. In a second stage,
they were invited by phone to participate in the study. Once the f irst interviews
were done, more informants were identif ied through the snowball technique.
e research project was approved by the Ethics, Research, and Biosecurity
Committees of the National Public Health Institute of Mexico. Verbal consent of
the participants was obtained and the contact information of those responsible
for the research project was provided. e interviews lasted an average of 40
minutes, were audio recorded and transcribed verbatim.
e information was systematized through previously designed codes based on
the instrument of collection, and open coding was used with the goal of reduc-
ing, examining, and comparing the data, and seeking similarities or dif ferences in
peoples statements. Furthermore, a selective axial coding was done to regroup
categories and subcategories
6
(Strauss and Corbin, 2002). is analytical exercise
allowed the reduction of a large number of statements to a compact set of data
for the elaboration of a f lowchart and to establish relationships (Saldaña, 2013).
After the f irst systematization of the information, a technical meeting with some
of those interviewed was held with the goal of presenting preliminary results and
getting feedback.
ACTORS AND THE PROCESS OF HEALTH SERVICE
PROVISION TO REPATRIATED MIGRANTS
In Tijuana, the institutional response to the health needs of repatriated migrants
begins at the receiving point El Chaparral. Governmental actors and civil society
organizations work together there under the framework of the
PRH
. is pro-
gram operated by the National Migration Institute has the purpose of carrying
out an ordered and assisted repatriation through the of fering of various services
of legal advice, health coverage, food, and access to phone calls and the internet,
among other things. e agencies and programs of the government that participate
in the health component of the
PRH
are the Popular Insurance, the federal Health
Ministry, the United States-México Border Health Commission (whose initials in
6
is work did not seek to arrive at the level of conceptualization, but rather to take the
concept of “cooperation” as its research guide.
ROSALES-BOJÓRQUE Z-LEYVA-INFANTE / HEA LTH SERVIc ES PROVISION FOR MIgR ANTS REPATRI ATEd 115
Spanish are
CSF
),
7
and Grupo Beta, a National Migration Institute unit that aids
migrants (Herrera, 2010).
e Popular Insurance works through a membership of f ice. e Régimenes
Estatales de Protección Social en Salud (State Regimes for Social Protection in
Health, known by the Spanish initials
REPSS
) can provide 90-day health insurance
policies to the population repatriated from the United States. e benef iciaries
obtain this policy by showing their repatriation document issued by the National
Migration Institute and have the option of renewing it once while they seek other
documentation that certif ies they are Mexicans. is Popular Insurance policy
exempts the migrants from having to cover the costs for illnesses treated at the
Health Ministrys facilities in any federal entity, provided that these illnesses are
included in a limited catalog of treatments (Secretaría de Salud, 2014).
8
Up to
October 2015, the Popular Insurance had 12 315 repatriated migrants as mem-
bers through 90-day policies,
9
a number that represents half of those repatriated
through the El Chaparral port of entry until then.
For its part, the Health Ministry and the
CSF
operate a health module of fering
quick tests for detection of
HIV
, general health care, a protocol for psychological
crisis intervention, and management of referrals to secondary and tertiary levels of
care. e medical personnel who serve the module are social service interns of the
Universidad Autónoma de Baja California (Autonomous University of Baja Cali-
fornia) commissioned by the local of f ice of the Health Ministry, and psycholo-
gists and health promoters contracted using the resources of the
CSF
. e Border
Health Commission is a management initiative focused on training and research
as inputs for decision-making in terms of migration and border health.
Grupo Beta also has a paramedic team that provides help to migrants inside
and outside El Chaparral. An ambulance donated in 2014 by the state govern-
ment for the exclusive care of migrants is used for taking them from the border to
the hospital. F inally, the Programa de Repatriación de Connacionales Enfermos
Graves (Repatriation of Gravely Ill Compatriots) of the Secretaría de Relaciones
7
Binational organization with independent legal status created by presidential decree
in 2000.
8
Known as the Catálogo universal de servicios de salud (Universal Catalogue of Health
Services). In 2014, this catalogue included 285 treatments.
9
Information provided by the Popular Health Insurance membership coordinator in Ba ja
California.
116 FRONTE RA NORTE, VOL. 29, NÚM. 57, ENE RO-juNiO DE 2017
Exteriores (Foreign Ministry) defrays the cost of air transport of those who are
routed from U.S. hospitals to Mexican ones.
Furthermore, organized civil society has an important presence inside the
PRH
through a module of attention for repatriated migrants operated by the Coalición
Pro Defensa del Migrante (Coalition for the Defense of Migrants). is organiza-
tion created in 1996 brings together six other organizations and provides legal
advice in terms of human rights to those repatriated, guarantees the provision of
quality medical services, and helps transport those repatriated from El Chaparral
to the shelters, among other activities.
In this study, health service provision for those repatriated through Tijuana
was systematized based on their health situation. With this criterion, one group of
repatriated people is those having such grave ailments that they cannot travel by
themselves, for which reason they are transported by land or air from a U.S. hos-
pital to a Mexican hospital with the assistance of Mexican consulates, the Health
Ministry, and the Foreign Ministry. e receiving hospitals can be located in Ti-
juana or in other Mexican cities that have resources available to care for the ill-
nesses of those repatriated. Once sent to the hospitals in Mexico, there is no
institutional follow-up; this means that it is not known what kind of care or treat-
ment those repatriated subsequently receive. A second group of repatriated people
includes those who are healthy, or apparently healthy, who are transferred by land
from the United States to the receiving station at El Chaparral. ey have the op-
tion of going voluntarily to the health module located at the port of entry. Ac-
cording to a medical intern, of every 40 repatriated people, on average 25 agree to
go to the medical check-up. From this health module, there are three possible
destinations for repatriated people who received medical care: 1) referral to the
Hospital General de Tijuana (Tijuana General Hospital) when a grave health
problem is diagnosed; 2) referral to a shelter when the repatriated person is healthy;
or, 3) going into Tijuana on their own if that is their preference. On the other
hand, not all of those repatriated who did not agree to go to the health module are
necessarily healthy; they can present possible symptoms of ailments that were not
diagnosed in the United States or in Mexico and that wind up being treated at the
shelters they are channeled to.
Of the three destinations mentioned, the transfer to shelters is the most com-
mon. e health service provision by these civil society organizations basically
consists of preventive and ambulatory treatment in basic medical dispensaries.
is care is complemented by visits to the shelters of the Red Cross and Grupo
ROSALES-BOJÓRQUE Z-LEYVA-INFANTE / HEA LTH SERVIc ES PROVISION FOR MIgR ANTS REPATRI ATEd 117
Beta, who use their ambulances as mobile clinics on designated days depending
on the demand for care. When those who are repatriated and living in the shelters
need specialized care, they are channeled to the Tijuana General Hospital or to
specialized rehabilitation centers. As a representative of one civil organization said,
referrals to secondary care by the shelters is done in an informal manner: “… we
send a brief letter to the General Hospital, where we say, ‘Please take care of this
migrant for us,’ but there is no written partnership agreement, only a verbal one.
It has functioned well this way” (Luján, interview, 2015).
On the other hand, some government agencies at the state and local level away
from El Chaparral also are involved in the provision of medical services to mi-
grants. e local Health Ministry has a network of outpatient facilities that of fer
free services to repatriated people who are af f iliated with the Popular Insurance.
Furthermore, the Centro Ambulatorio para la Prevención y Atención en
SIDA
e In-
fecciones de Transmisión Sexual (Ambulatory Center for Prevention and Care of
AIDS
and Sexually Transmitted Diseases, known by its Spanish acronym
CAPASITS
)
receives repatriated people who have
HIV
or sexually transmitted diseases referred
from Health Ministry facilities or the shelters. Also, the Sistema de Desarrollo
Integral de la Familia (System for Comprehensive Family Development, known
by its Spanish acronym
DIF
) at the state level receives unaccompanied repatriated
children and adolescents, and at the local level repatriated adults; in both cases
they are given ambulatory medical care. Special or exclusive initiatives to provide
care for migrants and their health problems do not exist and they are cared for
using the installed capacity of these services.
ere are 40 Health Ministry outpatient facilities distributed throughout the
city (
DGIS
, 2014). Nevertheless, the majority of those repatriated are referred to
one health center in the central zone of Tijuana because of its geographical close-
ness to El Chaparral. is facility is three kilometers from the port of entry and
has 12 consulting stations, X-rays, and a laboratory, among other services. In
terms of its functioning, one state of f icial said: “e Tijuana Health Center already
has 55 000 people assigned to it; this means that we are charging just one center
with all the care [of migrants]” (Pérez, interview, 2015). It is worth mentioning
that the Popular Insurance also of fers a “collective policy” directed at shelters that
satisfy a series of administrative requirements.
10
is type of policy covers medical
10
Constitutive act, the Federal Taxpayer Registry, a legal representative, and proof of
residency.
118 FRONTERA NORTE, VOL. 29, NÚM. 57, ENERO-ju NiO DE 2017
services for repatriated people who in their passage through the port of entry did
not accept the temporary policy. Subsequently, upon being placed in shelters that
have the collective policy, they have the right to receive treatment in the health
center closest to their shelter.
Tijuana General Hospital, and to a lesser extent the Red Cross, are the only
options for medical care for repatriated people with complex ailments. According
to a municipal of f icial, the hospital receives repatriated patients referred by U.S.
hospitals, from the health module at the port of entry, and from the shelters.
11
“All
we have is the General Hospital or, on some occasions the Red Cross helps us, but
that is it … many hospitals are private” (López, interview, 2015). e General
Hospital users are treated without taking account of their migrant status; there-
fore, those repatriated and the general population are subject to the same wait
times. e only variant in medical treatment for those repatriated occurs when
there is an institutional accompaniment on the part of Grupo Beta paramedics.
In this case, the service for those repatriated is expeditious and of greater quality,
because the Grupo Beta paramedics are authorized to do medical procedures in-
side the hospital with the goal of not overburdening the personnel contracted by
the hospital. F igure 1 shows, from left to right, the described health care process.
Other actors are involved in second level services in a tangential way. e pri-
vate religious hospital is an atypical case that only interacts under a verbal agree-
ment with one of the shelters interviewed. e shelter refers only cases of extreme
urgency to the private hospital when the wait time to be seen in the Tijuana Gen-
eral Hospital is so long that it could have fatal consequences.
12
On the other hand,
the Mental Health Hospital of Tijuana is not considered to be very accessible for the
migrant population because of the high cost for its care.
e Logics of a Cooperation “under Construction”
In Tijuana, the provision of health services to the repatriated population involves
the participation of governmental actors and organized civil society. e govern-
ment has an impact through migration policy and the Health Ministry at the
federal and local level; simultaneously, organized civil society of fers ambulatory
11
A process of formal counter-reference between the shelters and the Tijuana General
Hospital does not exist; on occasions those repatriated return to the shelters on their own to
ask for medicines they were not supplied with at the hospital.
12
e private hospital assumes the cost of the service.
F
IGURE
1. Process of Ambulatory and Inpatient Medical Care Provision to Migrants Repatriated through Tijuana, 2015
Repatriated
Repatriated
personrejects
service
2
Healthmodulein
service
2
ElChaparral
(optionalservice
ii )
Ra
p
d
prov
i
s
i
on
)
Re
p
atriated
an
d
p
personaccepts
service
a
tion
Yes
p
atri
a
o
fre
p
Processbegins
Repatriated
people
o
int
o
P
r
re
r
alp
o
ho
a
par
r
E
lCh
a
End of
process
1
Needingurgent
care,referredTijuana
E
process
fromtheU.S. General
Hospital
Tijuana
Mental
Referraltosecondaryor
Health
Hospital
tertiarycare
Oth
Regional
Oth
er
cities
Regional
referral
hospitals
Ed f
E
n
d
o
f
process
Cityof
Ti
j
uana
p
idscreeningtests
ddi l hk
j
d
me
di
ca
l
c
h
ec
k
‐up
No
No
No
Referral to
Referral to
Referral
to
shelters(medical
care)
Referral
to
General
Hos
p
ital
p
Primary care
Dispensary RedCross
ambulance
Primary
care
centersofHealth
Ministr
y
Grupo Beta
ambulance
r
ivate
ligious
y
spital*
Referraltosecondaryortertiarycare
Y
Y
es
No
End ofprocess
*
is private hospital only has an agreement with one shelter.
Source: Authors calculation based on 21 interviews with key informants during May and June of 2015.
120 FRONT ERA NORTE, VOL. 29, NÚM. 57, ENERO-ju NiO DE 2017
health care. e shared objective of attending to the health needs of the repatri-
ated migrants has led the actors interviewed to mutually depend on terms of ex-
change of material and human resources to increase their response capacity to the
health problems of those repatriated. However, the incipient development of trust
identif ied between government and organized civil society, as well as the demand
overload on health infrastructure, above all in tertiary care, eventually limits the
potential for the inter-agency cooperation that is underway. To organize the infor-
mation, three elements of cooperation were used as a guide: common objectives,
resource interdependence, and trust (Lundin, 2007).
According to Flamand and Moreno (2014), governmental entities, more than
collaborating, compete among themselves to obtain resources. Moreover, in the
scheme of a decentralized federal government that operates under a multilevel in-
frastructure, conf licts are more frequent due to the double challenge of coordinat-
ing “horizontally” between dif ferent government agencies and “vertically” among
the federal, state, and local orders. In the case concerned, the conf licts in the rela-
tionships between government actors are infrequent and are linked to an inade-
quate communication that precisely derives from a complex structure of multilevel
government. One of the main f indings was inef f icient spending due to a duplica-
tion of ef forts. To combat this problem, some government agencies have been able
to combine activities directed at migrants under the framework of the
PRH
. An
initiative proposed by personnel attached to the Secretaría de Desa rrollo Social
(Social Development Ministry, known by its Spanish acronym Sedesol) promoted
the coming together of institutional ef forts between agencies to make migrant care
more ef f icient through a module: “In view of the needs, you have to knock on
doors, and I thought, why dont we all get together? Participating now in the mod-
ule to care for migrants are the National Migration Institute, Grupo Beta, the
DIF
and us” (Cortés, interview, 2015). is initiative illustrates inter-agency cooperation
based on similar objectives that strengthen the health service of ferings for those re-
patriated through the coordination of ef forts around common ground.
However, not all the governmental actors focused on serving migrants work in
a collaborative way. e Consejo Estatal de Atención al Migrante (State Council
for Migrant Support), created in 2014, undertook strategic coordination activities
based on the Ley para la protección de los derechos y apoyo a los migrantes del estado de
Ba ja California [Law for the Protection of the Rights and Support of Migrants of
the State of Baja California (Congreso del Estado de Baja California, 2014)]. Up
to the time of the interviews, the work of the state council consisted of convening
ROSALES-BOJÓRQUE Z-LEYVA-INFANTE / HEA LTH SERVIc ES PROVISION FOR MIgR ANTS REPATRI ATEd 121
some governmental actors and civil society organizations to participate in monthly
sessions; however, there were governmental actors who said they were never invited.
On the other hand, with respect to the dynamics of the sessions organized by
the State Council, some representatives of shelters said they did not see fruitful
results in terms of service to migrants. “e State Council needs direction. Some-
thing like 100 of us arrive for the meeting … and all its worth is a cup of cof fee.
ere is no structured project …” (Ojeda, interview, 2015). Despite not having
a clear objective, this initiative has had a strong convening power that could be
exploited to overhaul the functions of the participating actors and strengthen in-
stitutional cooperation.
Interdependence of Resources
e relationship between government and civil society ref lects an interdependence
of resources founded on the shared goal of providing health services to migrants.
According to one informant, the inter-agency coordination between shelters and
the National Migration Institute responds to the limited infrastructure of the in-
stitute to cover the demand for public services for those repatriated.
Another element that illustrates the interdependence of resources is f inanc-
ing. e management capacity of the civil society organizations is strengthened
through budget allocations earmarked and put out for bid by the government. To
be able to benef it from this resource, civil society organizations must be registered
in a catalog of civil organizations in the entity and must comply with requirements
established in the Ley de fomento a las actividades de bienestar y desarrollo social
para el estado de Baja California [Promotion of Welfare and Social Development
Law for the State of Baja California (Congreso del Estado de Baja California,
2001)]. Additionally, some shelters mentioned receiving a governmental subsidy
that complements other sources of funding: “the state government basically covers
50 percent of the shelters costs, it is a subsidy we have had for seven or eight years.
Persons or institutions of goodwill provide 25 percent, and the rest comes from
training workshops that we give” (Jiménez, interview, 2015).
is interdependence of resources is also complemented in terms of health per-
sonnel, infrastructure, and medicines. e shelters that participated in this study
have medical personnel available through a number of modalities. e shelters that
receive the most repatriated migrants
13
had three sources for this care: 1) formal
13
Casa del Migrante, Salvation Army, Casa
YMCA
, and Instituto Madre Asunta.
122 FRONTERA NORTE, VOL . 29, NÚM. 57, ENERO-ju NiO DE 2017
agreements with Health District No. 1 that guarantee a weekly visit of interns do-
ing their social service through the program “Health Caravans,” 2) contracting or
having agreements with general practitioners and/or psychologists, and 3) the par-
ticipation of volunteer doctors.
14
e convergence of public and private medical
care constitutes one more indicator of resource interdependence. In this regard, an
of f icial in the health district said: “Mobile Unit 8 is designated for attending to the
migrant population in the mornings. Its only one for everyone, and sometimes
it attends to them on a Monday, other times on a Tuesday, and other times two
or three days a week. It provides consultation, it takes them medications, it
does glucose testing, deals with diabetes and hypertension, provides vaccinations,
and distributes pamphlets” (Ortega, interview, 2015). In terms of medications,
the exchange between shelters and the governments goes in both directions. In the
shelters, dispensaries are supplied by public sources (the health district) and pri-
vate ones (donations by pharmacies or the general public). In turn, these civil
organizations sometimes supply prescriptions to repatriated people who did not
receive their medications in the Tijuana General Hospital because its stocks were
depleted (Table 2).
ere is also a communications network between the civil society organiza-
tions (shelters) for exchange of support in medical care for migrants. e coop-
eration between these organizations is closer and more solid: “its more informal,
more involving trust. ey help us and we help them … its sharing services and
resources” (Guzmán, interview, 2015). When a shelter is overf lowing, it commu-
nicates with another to take in migrants. e lack of public provision of mental
health services in Tijuana is a problem pending resolution in light of the high
prevalence of psychiatric disorders among those repatriated.
Trus t
As for the subject of trust, no statements gathered showed total reciprocity be-
tween governmental actors and shelters. e representatives of the civil society or-
ganizations admitted maintaining a certain reserve with some government actors,
above all during their political participation in election campaigns: “e same
thing happens to us and other shelters, people making statements to the media
14
ere are private doctors who donate their services for free in the shelters at times of the
doctors choosing, and also doctors who receive migrants in their private practices, charging
the shelter a symbolic fee, such as in the case of the Casa del Migrante.
ROSALES-BOJÓRQUE Z-LEYVA-INFANTE / HEA LTH SERVIc ES PROVISION FOR MIgR ANTS REPATRI ATEd 123
T
ABLE
2. Interdependence of Resources Identif ied in Interviewed Shelters
Shelters (civil
organizations)
Ambulatory
medical
service
oerings
inside the
shelter
*
General practitioners
Stock of
medicines
in the
shelter
Origin of medicines
Referral to
secondary
and
tertiary
care
Interns
referred
by Health
District
No. 2
(Sesa)
**
Private
doctors
(volunteers
or hired by
the shelters)
Public
(Health
District
No. 2)
Private
(private
donations
or from
Mexican
and U.S.
pharmacies)
Casa del
Migrante
✓ ✓ ✓ ✓ ✓
Tijuana
General
Hospital,
Red Cross
Instituto Madre
Asunta
✓ ✓ ✓ ✓ ✓
Tijuana
General
Hospital,
Red Cross,
Private
hospital
Casa
YMCA
✓ ✓
Tijuana
General
Hospital
Salvation Army
✓ ✓ ✓
Tijuana
General
Hospital,
Red Cross
Desayunador
Padre Chava
(soup kitchen)
✓ ✓ ✓ ✓
Tijuana
General
Hospital,
Red Cross
Casa de los
Pobres
(House for the
Poor) ✓ ✓ ✓ ✓
Tijuana
General
Hospital,
Red Cross
CIRAD
(Rehabilitation
center) ✓ ✓ NA NA NA
Tijuana
General
Hospital
Las Memorias
✓Does not have doctors ✓ ✓ ✓
Tijuana
General
Hospital
Note: Some shelters also have ambulance support from Grupo Beta and the Red Cross.
*
Restricted hours.
**
Servicios Estatales deSalud (State health agencies).
Source: Authors calculation based on 21 interviews with key actors in May and June 2015.
124 FRONTERA NORTE, VOL . 29, NÚM. 57, ENERO-ju NiO DE 2017
in our buildings. ey are just a distraction to us. ey always announce millions
and millions of pesos for the care of migrants in the state but nobody has ever seen
it” (Ojeda, interview, 2015; Román, interview, 2015). In contrast, the percep-
tion of public of f icials about the joint work with civil organizations was expressed
as a solid and unconditional support that would be dif f icult to take away. “We
have communication with the Casa del Migrante, the Salvation Army, and with
[Instituto] Madre Asunta [which helps repatriated women and children] … If a
migrant comes here and doesnt know where to go, we talk with the Casa del
Migrante so that it will give him shelter” (Calleja, interview, 2015).
On the other hand, some civil society organizations mention that the support
they receive from the government generally is based on interpersonal trust that does
not manage to permeate the institutional environment. e direct contact they have
established with the employees of the General Hospital has facilitated access to the
hospital for migrants to be treated without going through an institutional proto-
col; thus, the referral process f lows thanks to verbal agreements at times sustained
through old friendships, as one member of Grupo Beta said: “we have a number
of years in the f ield and we know people from the General Hospital; this in one
way or another facilitates the f low of treatment” (Pérez, interview, 2015).
One of the factors that hinder the development of trust between the govern-
ment and civil society organizations is the rotation of personnel that occurs with
changes in government. is historic lack of continuity in programs and those
responsible for them in Mexico brings about a lethargy in the processes and makes
the provision of services to migrants less ef f icient since civil society organizations
must establish contact with new of f icials in each sexenio (six-year term).
On the other hand, some representatives of the civil society organizations
spoke of the existence of an inter-agency network that is being consolidated. e
principal characteristic of this network is that it does not originate with consen-
sual planning in the medium or long term, but rather in the resolution of daily
emerging needs. A representative of a shelter said this network “… is intuitive and
hidden; it moves from below, it is not institutional, and exists because experience
allows it” (Jiménez, interview, 2015). e formalization of this network does not
appear to be a pressing issue for its members upon seeing that the informal rela-
tionships at the interpersonal level traditionally established between them have
been successful for the provision of health services to migrants; moreover, some
considered that formalizing the inter-agency relationship would decrease the f lu-
idity of care. Civil society organizations did not have unanimity when it came to
ROSALES-BOJÓRQUE Z-LEYVA-INFANTE / HEA LTH SERVIc ES PROVISION FOR MIgR ANTS REPATRI ATEd 125
how they viewed the participation of the government in building a network of
health services for migrants. While some rejected cooperating with governmental
actors because this involved implicit political interests, other found working with
the government to be indispensable in making the inter-agency work of providing
health care to migrants more ef f icient.
DISCUSSION AND CONCLUSIONS
In Tijuana, inter-agency cooperation between the government and civil society
organizations in terms of health care for those repatriated occurs in an informal
manner and without established protocols for the referral and counter-referral of
migrants from the shelters to governmental health services. e activities of the
identif ied actors are synchronized on the basis of a common objective and an in-
terdependence of resources that has brought them to work together to resolve the
immediate health needs of the migrant population; nevertheless, the relationships
between governmental actors and civil society do not ref lect mutual conf idence in
the institutional arena.
e relationships of trust that were identif ied were of the interpersonal type.
e accumulated interaction of years of work between actors attached to the insti-
tutions and organizations has generated a close communication, permeated by a
familiarity that facilitates cooperation. A limit in these relationships of trust is that
they depend on the time that the persons stay with their organizations.
e governmental health service provision to repatriated migrants who are ill
in the United States begin with the Mexican consulates. is study found the
need to improve the work of the consulates in terms of visits to detention centers
in the United States to identify migrants with health conditions and get them
proper treatment before they are repatriated. Once those repatriated are in Mexi-
can territory, the Humanitarian Repatriation Program includes urgent medical
care, but it does not of fer a comprehensive health plan. ose repatriated have a
right to receive health services in whatever level, involving a system of referral and
counter-referral. Nevertheless, despite the existence of inter-agency cooperation,
the government commitment to provide them comprehensive care is complicated
because of the limited capacity to provide secondary and tertiary care. While the
burden of the health services the repatriated migrants may be low (González-
Block and De la Sierra-Vega, 2011), this is inserted into a historical and structural
problem of the Mexican health system; that is, a structural and organizational
126 FRONTERA NORTE, VOL . 29, NÚM. 57, ENERO-ju NiO DE 2017
service capacity that has problems of access despite the broadening of coverage
through the Popular Insurance.
Furthermore, this study concludes that the strategic partnerships established
between the actors interviewed do not totally guarantee the right to health care of
those repatriated. With the majority of medical services being of an ambulatory
nature, the support capacity focuses principally on the resolution of urgent ail-
ments and/or conditions that are not serious. On the other hand, migrants with
chronic degenerative diseases such as diabetes, hypertension, and kidney failure
are managed using the limited infrastructure available in Tijuana to later be trans-
ferred to other federal entities, but in the process of referral medical follow-up
is lost. e most evident lack of care is seen among the group of those repatri-
ated with mental illnesses such as depression, anxiety, schizophrenia, and bipo-
lar disorder, often associated with the use of drugs. is means that inter-agency
cooperation based on an interdependence of resources and interpersonal trust is
not enough to meet the shared objective. ese elements of cooperation need a
broader health infrastructure as a base.
In the framework of this associated management model (Moreno, 2010) coor-
dinated by the Humanitarian Repatriation Program, it is suggested that the cre-
ation of a coordinating agency at the local level be put forward and that it be
charged with designing a comprehensive program to support migrants and lead
the various initiatives and sectors involved to guarantee the repatriated popula-
tions right to health care.
For future research, it is recommended that the size of the repatriated popu-
lation that needs medical care be estimated. is information void means that
there is a disadvantage when it comes to managing resources to operate a health
program specif ically for those repatriated, for which reason it is important to carry
out a study to quantify their health needs, principally in Mexicos northern cities.
e health service provision model for those repatriated that was explored here
constitutes an experience with successes and areas of opportunity that serves as
a reference for similar programs to be implemented in the future in other border
cities that have a demand for public services from this vulnerable population.
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de Salud Pública/El Colegio de la Frontera Norte, May 20.
LUJÁN
, Roberto, 2015, by Yetzi Rosales [f ieldwork], “Capacidad de respuesta ins-
titucional a las necesidades de salud de los migrantes repatriados desde Estados
Unidos por la ciudad de Tijuana,” Proyecto Ford, Tijuana, Instituto Nacional
de Salud Pública/El Colegio de la Frontera Norte, May 18.
OJEDA
, Pedro, 2015, by Yetzi Rosales [f ieldwork], “Capacidad de respuesta insti-
tucional a las necesidades de salud de los migrantes repatriados desde Estados
Unidos por la ciudad de Tijuana,” Proyecto Ford, Tijuana, Instituto Nacional
de Salud Pública/El Colegio de la Frontera Norte, May 15.
ORTEGA
, Artemisa, 2015, by Yetzi Rosales [f ieldwork], “Capacidad de respues-
ta institucional a las necesidades de salud de los migrantes repatriados desde
Estados Unidos por la ciudad de Tijuana,” Proyecto Ford, Tijuana, Instituto
Nacional de Salud Pública/El Colegio de la Frontera Norte, May 25.
PÉREZ
, Alberto, 2015, by Yetzi Rosales [f ieldwork], “Capacidad de respuesta insti-
tucional a las necesidades de salud de los migrantes repatriados desde Estados
Unidos por la ciudad de Tijuana,” Proyecto Ford, Tijuana, Instituto Nacional
de Salud Pública/El Colegio de la Frontera Norte, May 19.
ROMÁN
, Salvador, 2015, by Yetzi Rosales [f ieldwork], “Capacidad de respuesta
institucional a las necesidades de salud de los migrantes repatriados desde Es-
tados Unidos por la ciudad de Tijuana,” Proyecto Ford, Tijuana, Instituto Na-
cional de Salud Pública/El Colegio de la Frontera Norte, May 22.
