Citizen engagement in social health insurance purchasing, in selected counties in Kenya

Background: National hospital insurance fund (NHIF) uses capitation as a strategic purchasing model to provide primary care health services (PCHS). This study sought information on citizen knowledge of PCHS benefit package, NHIF communication to citizens, determination of citizen views and values, NHIF accountability to citizens, citizen choice of PCHS provider and how these factors influence citizen access to NHIF, PCHS.Methods: This was a cross sectional research conducted between March 2017 to March 2018. 426 patients were sampled from Nyandarua and Nakuru Counties.Results: 366 (93%) patients knew the PCHS benefit package, 226 (57%) said NHIF communication to them was adequate, 280 (71%) said NHIF does not take into account their view and values, 272 (69%) said NHIF is not accountable to them, 269 (68%) knew how to select an outpatient facility, 111 (28%) said they did not receive NHIF, PCHS. Multivariate logistics regression analysis of citizen engagement factors and access to PCHS, indicate that NHIF communication to citizens (p<0.05, OR=2.358, 95% CI [1.399-3.975]), purchaser accountability (p<0.05, OR=2.073, 95% CI [1.017-4.226]) and provider choice (p<0.05, OR=2.990, 95% CI [1.817-4.920]) added significantly to the regression model.Conclusions: There is inadequate engagement of citizens in NHIF decision making which may hinder access to NHIF PCHS, therefore NHIF should establish citizens’ needs and preference through public forums, elicit citizens’ feedback, act on complains when raised, inform citizens on how the capitation system works and NHIF should visit health facilities regularly to establish if patients are accessing PCHS.

A Survey Regarding the Price Calculation Method for New Drugs Based on the Chuikyo-Document about the NHI Drug Price List / 医薬品情報学

In Japan, the National Health Insurance (NHI) prices of new drugs are set according to the NHI Drug Price Standard (NHI Price Standard).　The NHI Price Standard was notified by the Ministry of Health, Labour, and Welfare based on the ”Drug Price Calculation Criteria” proposed by the Central Social Insurance Medical Council (Chuikyo) in Japan.　The NHI Price Standard affects the research and development strategy of pharmaceutical companies.　In order to discover undetected relationships, the factors influencing the ”drug price” were evaluated through the association rule mining technique.　We surveyed the Chuikyo‐documents about NHI price listing over the period October 27, 2006 to February 8, 2007.　The number of approved new drugs was 874, while that of drugs completed (”drug price per day”) was 314.　The numbers of new compounds corresponding to a drug price per day of ”below 200 yen,” ”between 200 yen and 1,000 yen,” ”between 1,000 and 10,000 yen,” and ”above or equal to 10,000 yen” were 87 (27.7%), 91 (29.0%), 79 (25.2%), and 57 (18.2%), respectively.　In the association rule mining method, we observed high lift values of the combined items ”above or equal to 30,000 patients expected to be administrated” and ”drugs affecting sensory organs” in the group of drug price per day below 200 yen.　The lift values of the combinations of ”biological preparations” and ”similar efficacy comparison‐based price setting (Ⅱ)” or ”below 30,000 patients expected to be administrated” and ”antineoplastic drug” in the group of ”above or equal to 10,000 yen of drug price per day” were high.　These results provide a basis for the development and application of new drugs in Japan.

O desmonte do financiamento da seguridade social em contexto de ajuste fiscal / The dismantling of the social insurance funding in a context of fiscal adjustement

Resumo: O Orçamento da Seguridade Social (OSS) é a peça-chave para a compreensão do ajuste fiscal em curso no Brasil. Este artigo analisa o desmonte do financiamento da seguridade social, a partir dos instrumentos de política fiscal como a Desvinculação de Recursos da União e as renúncias tributárias. A apropriação das contribuições sociais do OSS tem sido determinante para a política de pagamento dos juros da dívida. Ao mesmo tempo em que o OSS está inflado por despesas que são do orçamento fiscal.

Abstratct: The social insurance budget is the key to understanding the current fiscal adjustment in Brazil. This article analyzes the dismantling of social insurance funding, based on fiscal policy instruments such as the Untying Resources of Union and tax expenditure. The appropriation of the social contributions of the budget has been decisive for the policy of payment of interest of the debt. At the same time the insurance budge is inflated by expenses that are from the fiscal budget. The costs of the social security are inflated with the expenditures of the fiscal area, but whithout the due entrance of financial recourses.

The burden of disease of cancer in the Mexican Social Security Institute / La carga de la enfermedad debida al cáncer en el Instituto Mexicano del Seguro Social

Abstract: Objective: To estimate the disease burden of cancer in the affiliate population of the Mexican Social Security Institute (Instituto Mexicano del Seguro Social, IMSS) in 2010 by delegation. Materials and methods: The Disability-Adjusted Life Years (DALYs), Years of Life Lost (YLL) due to premature mortality and Years Lived with Disability/Disease (YLD) for 21 specific cancers and a subgroup of other malignant neoplasms were calculated based on the methodology of the Global Burden of Disease Study (GBD) for each of the 35 delegations of the IMSS. Results: In 2010, cancer represented the fifth overall leading cause of disease burden in IMSS affiliates (16.72 DALYs/1000 affiliates). A total of 75% of the cancer disease burden in each delegation is due to ten specific cancers, particularly breast cancer, which ranks first in 82% of the delegations. Prostate cancer; tracheal, bronchial, and lung cancers; leukemia, and colorectal and stomach cancers occupy the second to fourth positions in each delegation. With the exception of breast and prostate cancer, for which the contribution of YLD to the DALYs was higher than 50%, the greatest contribution to the DALYs of the other cancers was premature mortality, which accounted for more than 90% of the DALYs in some cases. Conclusion: The results obtained in this study allow for the identification of intervention priorities with regard to cancer at the institutional level and also for the focus at the delegation level to be placed on cancers ranking in the top positions for disease burden.

Resumen: Objetivo: Estimar, por delegación, la carga de enfermedad debida al cáncer en la población derechohabiente del Instituto Mexicano del Seguro Social (IMSS) para el año 2010. Material y métodos: Se calcularon los años de vida perdidos ajustados por discapacidad (AVISA), los años perdidos por muerte prematura (APMP) y los años vividos con discapacidad (AVD) para 21 cánceres específicos y un subgrupo de otras neoplasias malignas, con base en la metodología del Global Burden of Disease Study (GBD) para cada una de las 35 delegaciones en las que se divide el IMSS al interior del país. Resultados: En el año 2010, el cáncer representó la quinta causa de carga de enfermedad en derechohabientes del IMSS (16.72 AVISA/1000 derechohabientes). El 75% de la carga de enfermedad por cáncer en cada delegación se debe a diez cánceres específicos entre los que destaca el cáncer de mama, que ocupa el primer lugar de importancia en 82% de las delegaciones. Los cánceres de próstata, tráquea, bronquios y pulmón, leucemias, de colon y recto, así como el de estómago, se ubican entre las segundas y cuartas posiciones en cada delegación. Con excepción del cáncer de mama y de próstata, cuya contribución de los AVD a los AVISA fue superior a 50%, en los demás cánceres la mayor contribución fue debida a la mortalidad prematura, en algunos superior a 90% de los AVISA. Conclusión: Los resultados obtenidos en este estudio permiten identificar las prioridades de intervención en materia de cáncer a nivel institucional y focalizarlas a nivel delegacional para los cánceres que ocupan los primeros lugares de carga de enfermedad.

Legislation on the new rural cooperative medical system from the perspective of social insurance / 中华医院管理杂志

Based on an observation of the evolution in rural cooperative medical system,the author proposed the concepts and legal nature of the system.He held that the system is a non-voluntary social insurance,with the country and society as the subjects of liability and oriented to peasants at large.With focused reference of legislation experiences in the USA,Japan and Germany,and summary of local experiments,the author recommended to draft laws and decrees of the system without delay,regulating the conception,goal,legal nature,functionality,regulators,fund raising,and supervision of the system.

O impacto da reforma da previdência social rural brasileira nos arranjos familiares: uma análise para entender a composição dos domicílios dado o aumento da renda dos idosos / The impact of the Brazilian rural social insurance reform on family composition: an analysis of the structure of homes after the increase in the income of the elderly / /El impacto de la reforma de la Seguridad Social rural brasileña en las estructuras familiares: un análisis para entender la composición de los domicilios por el aumento de renta en la tercera edad

Esta pesquisa explorou o efeito de uma variação exógena na renda, devido à reforma da previdência social brasileira de 1992 para os trabalhadores rurais, nos arranjos domiciliares rurais no Brasil. Realizou-se uma avaliação do impacto do aumento da renda dos idosos sobre a composição dos domicílios, nos termos de mudanças possíveis nos arranjos familiares. Especificamente, esta pesquisa tratou os arranjos familiares (ou a composição dos domicílios) como uma variável endógena em contraste com a literatura sobre o tema, a qual costuma abordar a composição do domicílio como uma variável exógena ao ambiente econômico do domicílio. Os objetivos foram: estimar as diferenças, em termos de arranjos familiares, entre domicílios com presença de idosos aptos a receberem o benefício da reforma e domicílios que não possuem idosos, antes da reforma (1989) e após (1998); estimar em que medida as diferenças em termos de arranjos familiares podem ser explicadas pela mudança causada pela reforma da previdência rural; e verificar se os efeitos da presença de pessoas elegíveis para receberem a aposentadoria nos arranjos domiciliares variam em função do sexo da pessoa que recebe aposentadoria. Quanto à relevância da pesquisa, a mesma está centrada no fato de que os resultados poderão ser úteis para a compreensão dos impactos primários e secundários de uma política que visa incrementar a renda de um segmento da população que vem crescendo aceleradamente no Brasil: os idosos. E mais, tal impacto, em termos do tipo de arranjo mais preponderante, apresenta um componente relacionado com o sexo da pessoa elegível, em que as mulheres que recebem os benefícios da reforma (com características elegíveis) tendem a viver em arranjos mais complexos do que seu oposto (homens ou mulheres fora do critério de elegibilidade).

This study aimed to assess the effect of an exogenous change in income, due to the 1992' reform of Brazilian social insurance for rural workers, on the structure of rural homes in Brazil. We assessed the impact of the increase in the income of the elderly on the composition of homes, regarding possible changes in family arrangements. In particular, this study considered household arrangement (or household composition) as an endogenous variable, contrasting to the existing literature that considers it an exogenous variable to the economic environment of the household. The objectives of the study were: to estimate differences in family arrangement between families with an elderly member eligible to receive the reform benefits, and families without an elderly member, before (1989) and after (1998) the reform; to assess how the differences in family arrangements can be explained by the changes caused by the rural social insurance reform; and to assess if the effects of the presence of a member eligible for retirement in family arrangements vary as a function of the gender of the beneficiary. The importance of the study is that its results might help understand the primary and secondary impacts of a policy that aims to increase the income of a growing segment of the Brazilian population: the elderly. According to the results, it is possible to state a statistically significant impact on household arrangements due to the 1992 rural social insurance reform. This is showed by the differences in family composition between the groups that are eligible and non-eligible for benefits of the reform. Additionally, when the most predominant type of family composition is considered, this impact is associated to the gender of the eligible member, that is, when the eligible individual is a female, the household composition tends to be more complex than for non-eligible males or females.

Esta investigación trató sobre el efecto de una variación exógena en la renta, debido a la reforma de la Seguridad Social brasileña de 1992, en el grupo de los trabajadores rurales y sus estructuras domiciliarias rurales en Brasil. Se realizó una evaluación del impacto en el aumento de la renta de la tercera edad sobre la composición de los domicilios, en lo referente a posibles cambios en las estructuras familiares. Esta investigación se centró en las estructuras familiares como una variable endógena, en contraste con la literatura sobre el tema, que solía abordar la composición del domicilio como una variable exógena al ambiente económico del domicilio. Los objetivos fueron: estimar las diferencias, en términos de estructuras familiares, entre domicilios con presencia de miembros de la tercera edad aptos para recibir los beneficios que les corresponden por la reforma, y domicilios que no poseen miembros de la tercera edad, antes de la reforma (1989) y después (1998); estimar en qué medida las diferencias, en términos de estructuras familiares, pueden ser explicadas por el cambio causado por la reforma de la Seguridad Social rural; y verificar si los efectos de la presencia de personas susceptibles de recibir la pensión en las estructuras domiciliarias varían en función del sexo de la persona que recibe la pensión.

Movimentação financeira: a base de uma contribuição para o INSS em substituição à folha de pagamentos / Financial transaction: the basis for a contribution to the INSS, replacing the payroll

Em média, os salários no Brasil são onerados em 42,5 por cento do seu valor bruto, somando-se a parte que é descontada do salário do trabalhador com a que incide sobre a folha de pagamentos das empresas. Isso torna o país uma das economias que mais tributam rendimentos do trabalho assalariado no mundo. O maior ônus sobre os salários recai sobre as empresas, estimulando práticas como a contratação de empregados sem carteira de trabalho assinada e a terceirização, fazendo da informalidade um dos elementos determinantes dos crescentes déficits do INSS. A folha de pagamentos é tributada em média em 35 por cento, sendo a contribuição previdenciária o tributo de maior peso. Após diagnosticar o problema, este texto discute aspectos relacionados aos regimes previdenciários e as bases de incidência adequadas a cada um deles. Mostra ainda que o regime geral da previdência no Brasil assumiu conotação de política pública de renda complementar. Nesse sentido, propõe-se a substituição do INSS patronal, uma base restrita, por uma contribuição de 0,61 por cento sobre as movimentações nas contas-correntes bancárias, uma base universal, e compara os efeitos sobre a economia de um tributo cumulativo com os produzidos por um imposto sobre o valor agregado. Utilizando o modelo de input-output de Leontief como mecanismo de análise, o trabalho revela que uma contribuição sobre as transações bancárias implica menor carga tributária sobre os preços setoriais e menor distorção alocativa que os 20 por cento cobrados sobre a folha de salários das empresas para o INSS. Por fim, o texto procura desmistificar a crítica envolvendo a cumulatividade tributária.

Wages and labor income are taxed in Brazil at the rate of 42.5% on the average, considering payments of both employers and employees. This makes it one of highest taxed labor markets in the world. The tax burden falls mostly on firms. Thus fact stimulates labor informality and outsourcing. This is one of the main reasons for the growing social security deficits. Payrolls are taxed in Brazil at the rate of approximately 35%, and social security contributions account for most of burden. After diagnosing the problem, this essay discusses issues related to the social security regimes used in Brazil, and the various forms of financing most adequate to each of them. It is shown that the basic social security regime, called general social security regime, became a program quite similar to a public system of complementary income. As such, this paper proposes replacing the social security contributions made by firms, which have a restricted pattern of incidence, by a general contribution based of bank transactions with a rate of 0,61%, which shows a universal pattern of incidence. It then compares the economic implications of such cumulative taxation with a conventional value added social security contribution. The analytical model is based on Leontief´s input-output framework, and it shows that a contribution levied on bank transactions implies a lighter sectoral tax load on consumer prices, and less distortionary effects on alocation of resources, than the revenue equivalent contribution of 20% on payrolls presently in use. This paper attempts to show tax pyramiding may not have such harmful economic effects as usually assumed by critics of cumulative taxation.

Sistemas de salud locales: Análisis de la relación entre aseguramiento y mecanismos de contratación y pago en Córdoba, Salta y Tucumán / Local health systems: analysis of the relationship between insurance and contract and payment mechanisms in Cordoba, Salta and Tucuman

INTRODUCCIÓN: Los mecanismos de contratación y pago en salud generan un impacto diverso en la cantidad y calidad de los servicios médicos, en la transferencia de riesgo entre actores y en la eficiencia de la utilización de los recursos. OBJETIVO: Analizar la estructura del mercado de servicios de salud en las provincias de Córdoba, Salta y Tucumán durante los últimos cinco años. MÉTODO: Se consideraron las condiciones socio-económico-sanitarias locales, el marco institucional, la historia de los actores más relevantes del sector y las conductas adquiridas como respuesta a la estructura. La metodología incluyó un mapeo de los actores claves del sector salud cada provincia así como la administración de un cuestionario a una muestra de establecimientos públicos y privados de cada jurisdicción. RESULTADOS: Los ministerios de salud provinciales son los principales financiadores del sistema público de salud y el Instituto Nacional de Servicios Sociales para Jubilados y Pensionados (PAMI) y las obras sociales provinciales lo son del sistema privado. CONCLUSIONES: PAMI tiene una política nacional que lo torna menos flexible para contemplar las particularidades locales, mientras que las obras sociales provinciales se presentan como los actores idiosincrásicos, siendo más permeables a las demandas locales. En la medida en que el PAMI coordine con los ministerios y la obra social provincial, se podría converger a modelos más homogéneos de atención y mecanismos de pago, generando incentivos para una mayor eficiencia en la asignación de recursos y una mayor equidad en salud

INTRODUCTION: The contracting and payment mechanisms in health generate different impact on the quantity and quality of medical services, the transfer of risk among actors and the efficient use of resources. OBJECTIVES: To analyze the market structure of health services in the provinces of Cordoba, Salta and Tucuman during the past five years. We considered the local socioeconomic and health conditions, institutional framework, the history of the most relevant actors, and their behaviour in response to the structure. The methodology included a mapping of key actors in the health sector in each province and the administration of a questionnaire to a sample of local public and private health institutions. RESULTS: The results show that the provincial ministries of health are the primary funders of the public services and the national insurance for retired people (PAMI) and the provincial social insurances are the primary funders of the private system. CONCLUSION: PAMI has a national policy which makes it self less flexible to consider the local particularities,while the provincial social insurances present themselves as idiosyncratic actors, being more receptive to local demands. If PAMI were coordinated with the structure of the local social insurance and the ministries of health, it could beachieved homogeneous models of health care and payment mechanisms, generating incentives for a more efficient resources allocation and equity in health

An Introduction on the Changes of the Occupational Health and Safety Systems in Germany: from the 19th Century to the Weimar Republic / 의사학

The purpose of this paper is to introduce and summarize the developmental process of the occupational health and safety systems from the 19th century to the Weimar Republic in Germany. The German occupational health system has changed with its unique character reflecting its sociopolitical backgrounds. In the 19th century, Germany, as the aftercoming capitalistic country in Europe, showed a flourishing industrial development. But this industrial development evoked many side effects, including long working hours, bad work environment, frequent occupational accidents and occupational diseases. The health and safety systems for German workers were established under the influences of the political interest groups and the social movement. In 1884 Bismarck made the law of the occupational accident insurance(Berufsgenossenschaft) in order to oppress the movement of socialists and radical workers and to secure his regimes. Then the way to control the work conditions of factories had three paths: technical supervision by the autonomic engineers, factory inspectors from the occupational accident insurance and the governmental factory supervisors. In the Weimar Republic the needs of the protection for both workers and machines were rising and became one of the main tasks of the government. Therefore, in 1925 the law for the occupational diseases was first established and then some occupational diseases were acknowledged as the occupational accidents and insured by the occupational accident insurance. Many factory doctors, factory hygienists, factory engineers and chemists organized the specialists' supervising and consulting groups for the occupational health and safety. And the workers themselves also started to participate in the factory committee in order to guard their own health and interests.