The MalaysianDRG Casemix System: Financial Implications of Inaccurate Clinical Documentation and Coding Error

@#Introduction: A casemix system measures costs of health service provision that is crucial in the planning and hospital budgeting. The MalaysianDRG casemix system has been implemented since 2010, yet many health professionals were unaware of its importance. To highlight this problem, we estimated the miscalculation of costs in providing treatment, that occurred due to inaccurate clinical documentation and coding error in the MalaysianDRG casemix system. Methods: Using a cross-sectional study design, 226 coded case notes from two healthcare institutions in Malaysia were selected and re-coded. If a difference between codes was observed, the new code would be chosen as the final code. The cases were then re-grouped using the MalaysianDRG casemix system. The cost per case derived from the new and original codes was compared. Then, the outcomes were verified by a casemix expert from the Ministry of Health. Results: Results indicated 61.9% inaccurate clinical documentation and 25.2% coding error. The difference in costs of treatment provision, due to inaccurate clinical documentation was RM227,657 and RM 68,216 for coding error. Using paired t-test analysis, differences between mean (SD) cost per case of the original vs. new codes due to inaccurate clinical documentation [RM10,208.19(12273) vs. RM11,244.53(13785.27), p<0.05], and coding error [RM10,208.19(12273.04) vs. RM11,215.52(13798.03) p<0.05] were statistically significant. These results raised important questions regarding costly financial implications arising from inaccurate clinical documentation and coding error in the MalaysianDRG casemix system. Conclusion: To achieve the full benefit of the MalaysianDRG casemix system, the quality and accuracy of its data must first be established.

Gastos empobrecedores de salud: un desafío para la cobertura universal de salud en el Paraguay / Impoverishing health expenditure: a challenge for universal health coverage in Paraguay

El gasto de bolsillo es la principal fuente de financiamiento del sistema de salud en Paraguay. Es necesario revertir esta situación para que la Cobertura Universal de Salud sea efectiva en 2030, un logro que forma parte de los Objetivos de Desarrollo Sostenible. El objetivo de este estudio fue determinar la incidencia del Gasto Empobrecedor en Salud en los hogares paraguayos. Tomó en cuenta aquellos hogares cuyos gastos de bolsillo causaron una caída por debajo de la línea de pobreza, así como los hogares que profundizaron su pobreza a causa de estos gastos de salud. Como material y método, el estudio analizó la Encuesta Permanente de Hogares 2014; tomó la definición de los gastos de bolsillo de la Organización Mundial de la Salud y la definición oficial de pobreza monetaria del país de la Dirección General de Estadísticas, Encuestas y Censos de la STP. El resultado es que 23,387 hogares fueron empujados por debajo de la línea de pobreza debido a gastos de bolsillo en caso de enfermedad. Esto representó el 1,8% de los hogares no pobres y el 1,4% del total de hogares. Además, el 61.9% de los hogares que ya se encontraban en situación de pobreza la empeoraron debido a los gastos de bolsillo en salud. La conclusión es que los hogares paraguayos están expuestos a gastos de salud excesivos y que se requieren políticas específicas para protegerlos. Las estrategias para combatir la pobreza pueden ser más efectivas cuando se consideran los gastos de salud en caso de una enfermedad o accidente.

Out-of-pocket spending is the main financing of the health system in Paraguay. Reversing this situation is necessary for the Universal Health Coverage to be effective in 2030, an achievement that is part of the Sustainable Development Goals. The objective of this study was to determine the incidence of Impoverishment health expenditure in Paraguayan households. I take into account those households whose out-of-pocket expenses caused a fall below the poverty line, as well as households that deepened their poverty as a cause of these health expenditures. As a material and method, the study analyzed the Permanent Household Survey 2014; took the definition of the outof- pocket expenses of the World Health Organization and the official definition of monetary poverty of the country of the General Directorate of Statistics, Surveys and Census of the STP. The result is that 23,387 households were pushed below the poverty line due to out-of-pocket expenses in case of illness. This represented 1.8% of non-poor households and 1.4% of total households. In addition, 61.9% of households already in poverty worsened their poverty due to out-of-pocket health expenditures. The conclusion is that Paraguayan households are exposed to excessive health expenditures and that specific policies are required to protect the population in the area. Strategies to combat poverty can be more effective when considering health expenditures in case of the event of an illness or accident.

Gasto catastrófico y cobertura universal de salud: Análisis en el Sistema Nacional de Salud del Paraguay / Catastrophic health expenditure and universal health coverage: Analysis in the National Health System of Paraguay

Introducción: La cobertura universal de salud es una meta de salud de los Objetivos del Desarrollo Sostenible de las NNUU para el 2030. Un componente de la cobertura en salud es la protección financiera para recibir atención médica ante una enfermedad. Y, un indicador de la protección financiera es la incidencia de Gastos Catastróficos por motivos de salud. Objetivo: El objetivo de este trabajo es describir la evolución del Gasto Catastrófico de salud de los hogares paraguayos entre el 2000 y el 2015. Materiales y Métodos: El material utilizado fue la Encuesta Permanente de Hogares de la DGEEC. El Gasto Catastrófico fue definido como aquellos gastos de bolsillo ≥ al 30% de la capacidad de pago de los hogares. Resultados: Los resultados indican que, durante ese periodo, la proporción de hogares afectados por gastos catastróficos varió entre 2,8% y 4,33%, siendo la mediana 4,10%. Los más afectados fueron los hogares rurales y los pobres. La proporción de hogares afectados presentó una tendencia al descenso, sobre todo para hogares urbanos y no pobres. Conclusión: La conclusión es que los hogares paraguayos están expuestos a gastos catastróficos por motivos de salud. La ocurrencia es mayor según las referidas características socioeconómicas. El desempeño actual del sistema nacional de salud no será suficiente para alcanzar la cobertura universal con protección financiera para todos. Por tanto, es necesario implementar nuevas políticas para la población más expuesta.

Introduction: Universal health coverage is a health goal of the UN Sustainable Development Goals by 2030. One component of health coverage is the financial protection to receive medical care for a disease. And, an indicator of financial protection is the incidence of Catastrophic Expenditures for health reasons. The objective of this paper is to describe the evolution of the Catastrophic Health Expenditure of Paraguayan households between 2000 and 2015. Materials and Methods: The material used was the Permanent Household Survey of the DGEEC. Catastrophic Expenditure was defined as those out-of-pocket expenses ≥ 30% of the household's payment capacity. Results: The results indicate that during this period, the proportion of households affected by catastrophic expenses ranged between 2.8% and 4.33%, with the median being 4.10%. Rural households and the poor were the most affected. The proportion of affected households showed a downward trend, especially for urban and non-poor households. Conclusion: In conclusion, Paraguayan households are exposed to catastrophic expenses for health reasons. The occurrence is greater according to the referred socioeconomic characteristics. The current performance of the national health system will not be enough to achieve universal coverage with financial protection for all. Therefore, it is necessary to implement new policies for the most exposed population.

Alternativas para la adopción de políticas centradas en el acceso a medicamentos / Alternatives for adopting policies centered on access to medicines

América Latina está incorporando regulaciones que incidan en el costo y el gasto en medicamentos. Sus objetivos centrales son cuatro: i) garantizar la competitividad en el mercado, ii) asegurar precios asequibles a los consumidores individuales (canal comercial), iii) contener el gasto público en medicamentos (canal institucional) y iv) garantizar la eficiencia del gasto en medicamentos. La experiencia de América Latina difiere de la de los países de regiones desarrolladas. En estas últimas los países tienden a converger en sus políticas, tanto en la promoción de medicamentos genéricos y estrategias de control de precios, como en las medidas de racionalización y contención del gasto farmacéutico. En contraste, en América Latina ciertas debilidades institucionales impiden la consolidación y aplicación de una política regulatoria efectiva. El presente trabajo revisa la experiencia acumulada en la adopción de regulaciones económicas dirigidas a reducir el gasto y mejorar el acceso a los medicamentos, postula lecciones aprendidas a nivel internacional y ofrece recomendaciones para los países de América Latina. Su propósito es aportar elementos clave para los decisores de política y las autoridades de los países interesados en llevar adelante la regulación económica de medicamentos.

Latin America is adopting regulations that bear on medicinal costs and spending. The regulations have four main goals: i) to guarantee a competitive market, ii) to ensure affordability for individual consumers (commercial channel), iii) to contain public spending on medicines (institutional channel), and iv) to guarantee efficient spending on medicines. The experience of Latin America differs from that of countries in developed regions. In the latter, the countries tend to have similar policies, both in promoting generic medicines and in price control strategies, and in optimizing and containing pharmaceutical expense. In contrast, in Latin America, certain institutional weaknesses impede the consolidation and application of an effective regulatory policy. This paper reviews the experience gained through the adoption of economic regulations aimed at reducing spending and improving access to medicines, suggests lessons learned at the international level, and offers recommendations for the countries of Latin America. Its purpose is to offer key elements to decision-makers and the authorities of the countries concerned in pursuing economic regulation of medicines.

El gasto de bolsillo en salud: el caso de Chile, 1997 y 2007 / Out-of-pocket health spending: the case of Chile, 1997 and 2007

Objective. Determine the impact, characteristics, and changes in out-of-pocket health spending of households in Chile in 1997 and 2007. Methods. A descriptive econometric study was conducted based on household surveyswith cross-sectional information on spending in two years—1997 and 2007—for Greater Santiago. The evolution of indicators of per capita household spending by quintile was reviewed. The method proposed by the World Health Organization was used for econometric analysis of the determinants of out-of-pocket spending and catastrophic spending. The Gini indices were also calculated to analyze equity. Results. Out-of-pocket health spending in the households of Greater Santiago increased significantly (39.5% per capita). The ratio of health spending in quintile 5 compared to quintile 1 decreased, but the increase in spending was less in quintile 5. In 2007, out-of-pocket spending was still determined by the presence of risk groups: under 5 years and, although to a lesser extent, over 65 years of age. Catastrophicspending decreased slightly and the presence of older adults continues to increase this risk. The presence of women of childbearing age tends to minimize out-of-pocket spending.Conclusions. Out-of-pocket health spending in the households is high and has increased. It continues to have a significant influence on inequality. The effects of out-of-pocket spending containment programs such as AUGE are evident, but new financial protection policies that address the problem are needed.

Objetivo. Determinar el impacto, las características y los cambios del gasto de bolsillo en salud de los hogares en Chile entre 1997 y 2007. Métodos. Estudio descriptivo y econométrico basado en encuestas de hogares con información transversal sobre gasto en dos años —1997 y 2007— para el Gran Santiago. Se revisa la evolución de indicadores del gasto por quintiles de gasto per cápita del hogar. Se utiliza lametodología propuesta por la Organización Mundial de la Salud para el análisis econométrico de los determinantes del gasto de bolsillo y del gasto catastrófico. También se calculan índices Gini para el análisis de equidad.Resultados. El gasto de bolsillo en salud de los hogares del Gran Santiago aumentó significativamente (39,5% per cápita). La razón de gasto en salud del quintil 5 respecto al 1 disminuyó,pero en razón de que el aumento fue menor en el quintil 5. El gasto de bolsillo en 2007 sigue estando determinado por la presencia de grupos de riesgo: menores de 5 años de edad y,aunque en menor medida, mayores a 65 años. El gasto catastrófico disminuyó levemente y la presencia de adultos mayores persiste en aumentar dicho riesgo. La presencia de mujeres enedad fértil tiende a ser un atenuador del gasto de bolsillo. Conclusiones. El gasto de bolsillo en salud de los hogares ha crecido y es alto, y su influencia en la desigualdad sigue siendo significativo. Se detectan efectos de programas como el AUGE en la contención del gasto de bolsillo, pero se necesitan nuevas políticas de protección financiera que ataquen el problema.

Evolución del consumo de medicamentos de alto costo en Colombia / Evolution of consumption of high-cost drugs in Colombia

Objective. Determine the patterns of consumption of high-cost drugs (HCD) during the 2005–2010 period in a population of Colombian patients enrolled in the General System of Social Security in Health. Methods. An observational descriptive study was conducted. The prescription dataof formulas of any drug considered to be high-cost dispensed to all users (1 674 517) in 20 cities of Colombia between 2005 and 2010 were analyzed. The anatomical therapeutic classification was considered, and the number of patients as well as monthly invoicing for each drug, the daily dose defined, and the cost per 1 000 inhabitants/day were defined. Results. Over the entire study period, the amount invoiced for HCDs increased by 847.4%. Antineoplastic and immunomodulator drugs accounted for 46.3% of the totalinvoicing. The other drugs were anti-infectives (15.2%), systemic hormonal preparations (9.5%), and drugs for the nervous system (9.1%). Most of these drugs were prescribed at the daily doses defined as recommended by the World Health Organization, but with high costs per 1 000 inhabitants/day. Conclusions. In Colombia a crisis has occurred in recent years due to the high spending generated by the most expensive drugs. The progressive growth of pharmaceutical spending is greater than the increased coverage by the country’s health system. The Colombian health system should evaluate how much it is willing to pay for the most expensive drugs for some diseases and what strategies should be implemented to cover these expenses and thus guarantee access to the insured.

Objetivo. Determinar el comportamiento del consumo de medicamentos de alto costo (MAC) durante 2005–2010 en una población de pacientes colombianos afiliados al Sistema General de Seguridad Social en Salud. Métodos. Estudio descriptivo observacional; se analizaron datos de prescripción de fórmulas dispensadas desde 2005 a 2010 a todos los usuarios (1 674 517) de algún medicamento considerado de alto costo en 20 ciudades de Colombia. Se consideró la clasificación anatómicaterapéutica y el número de pacientes, así como la facturación mensual por cada medicamento, la dosis diaria definida y el costo por 1 000 habitantes/día. Resultados. En todo el período de estudio, el valor facturado por MAC creció 847,4%. Losantineoplásicos e inmunomoduladores constituyeron 46,3% del total facturado, antinfecciosos 15,2%, preparaciones hormonales sistémicas 9,5% y fármacos para el sistema nervioso 9,1%. La mayoría de estos medicamentos fueron prescritos a las dosis diarias definidas recomendadaspor la Organización Mundial de Salud, pero con altos costos por 1 000 habitantes y día. Conclusiones. En Colombia durante los últimos años se ha presentado una crisis debida al elevado gasto generado por los medicamentos más costosos. El crecimiento progresivo del gasto farmacéutico es mayor que el aumento de la cobertura del sistema sanitario del país. El sistema sanitario colombiano debe evaluar cuánto está dispuesto a pagar por los medicamentosmás costosos para algunas morbilidades y qué estrategias debe implementar para sufragar estos gastos y así garantizar el acceso a los asegurados.

Costos directos de atención médica en pacientes con diabetes mellitus tipo 2 en México: análisis de microcosteo / Direct costs of medical care for patients with type 2 diabetes mellitus in Mexico micro-costing analysis

OBJETIVO: Estimar los costos directos de la atención médica a pacientes con diabetes mellitus tipo 2 (DM2) en el Instituto Mexicano del Seguro Social (IMSS). MÉTODOS: Se revisaron expedientes clínicos de 497 pacientes que ingresaron a unidades de segundo y tercer nivel de atención durante el período 2002-2004. Los costos se cuantificaron utilizando el enfoque de costeo de enfermedad (CDE) desde la perspectiva del proveedor, la técnica del microcosteo y la metodología de abajo-arriba (bottom-up). Se estimaron costos promedio anuales de diagnóstico, por complicación y total de la enfermedad. RESULTADOS: El costo total anual de los pacientes con DM2 para el IMSS fue de US$452 064 988, correspondiente a 3,1 por ciento del gasto de operación. El costo promedio anual por paciente fue de US$3 193,75, correspondiendo US$2 740,34 para el paciente sin complicaciones y US$3 550,17 para el paciente con complicaciones. Los días/cama en hospitalización y en unidad de cuidados intensivos fueron los servicios con mayor costo. CONCLUSIONES: Los elevados costos en la atención médica a pacientes con DM2 y complicaciones representan una carga económica que las instituciones de salud deben considerar en su presupuesto, a fin de poder brindar un servicio de calidad, adecuado y oportuno. El empleo de la metodología de microcosteo permite un acercamiento a datos reales de utilización y manejo de la enfermedad.

OBJECTIVE: Estimate the direct cost of medical care incurred by the Mexican Social Security Institute (IMSS, Instituto Mexicano del Seguro Social) for patients with type 2 diabetes mellitus (DM2). METHODS: The clinical files of 497 patients who were treated in secondary and tertiary medical care units in 2002-2004 were reviewed. Costs were quantified using a disease costing approach (DCA) from the provider's perspective, a micro-costing technique, and a bottom-up methodology. Average annual costs by diagnosis, complication, and total cost were estimated. RESULTS: Total IMSS DM2 annual costs were US$452 064 988, or 3.1 percent of operating expenses. The annual average cost per patient was US$3 193.75, with US$2 740.34 per patient without complications and US$3 550.17 per patient with complications. Hospitalization and intensive care bed-days generated the greatest expenses. CONCLUSIONS: The high cost of providing medical care to patients with DM2 and its complications represents an economic burden that health institutions should consider in their budgets to enable them to offer quality service that is both adequate and timely. Using the micro-costing methodology allows an approximation to real data on utilization and management of the disease.

La coparticipación provincial por salud en el Gran Buenos Aires: reflexiones en torno a la política local (2000-2005) / Provincial health funds distribution in the Gran Buenos Aires: thoughts about local policy (2000-2005)

En las últimas décadas el sector salud sufrió en la provincia de Buenos Aires un agudo proceso de descentralización de servicios hacia los municipios. El mismo, no estuvo acompañado por la definición de un modelo prestacional que instituyera los niveles a ser garantizados por cada una de las unidades territoriales menores. Este trabajo pone el foco en las consecuencias que han tenido en la política local los criterios de distribución de los fondos de coparticipación en "salud" desde el Estado provincial hacia los municipios. Interesa comprender cómo estos criterios incentivan, restringen y organizan la política sanitaria local dando lugar a una fragmentación que genera diferentes condiciones de ejercicio del derecho a la salud en cada espacio local. Como parte de un proyecto colectivo más general, el estudio busca reconstruir para los 24 municipios del Gran Buenos Aires las condiciones a nivel macro en que se desenvuelve la política local para detectar la existencia de "patrones típicos" frente a la crisis del año 2001, que permitan explicar la orientación de las estrategias locales.

In recent decades the health sector in the province of Buenos Aires has suffered an acute process of decentralization of services towards municipalities. This process was not accompanied by the definition of a benefit model establishing the level to be guaranteed in every smaller territorial unit. This work focuses on the impact that funds distribution criteria in "health" -from the provincial state to municipalities- have had in local policy. The objective of this study is to understand how this distribution encourages, restricts and organizes local health policy, generating a fragmentation that creates different conditions for exercising the right to Health in each local area. As part of a collective project, the study seeks to reconstruct the 24 municipalities of Gran Buenos Aires macro conditions of local policy in order to detect the existence of "typical patterns" during the crisis of 2001, which will help to explain the perspective of local strategies.

Costs of bariatric surgery in a teaching hospital and the financing provided by the Public Unified Health System / Os custos da cirurgia bariátrica em hospital universitário e a remuneração do Sistema Único de Saúde

Purpose: Analyze the effect of some measures on the costs of bariatric surgery, adopting as reference the remuneration of the procedure provided by the Unified Health System (SUS). Methods: A retrospective evaluation conducted in the Costs Section of the University Hospital of Ribeirão Preto, of the costs involved in the perioperative period for patients submitted to bariatric surgery from 2004 to 2007. Changes in the routines and protocols of the service aiming at the reduction of these costs during the study period were also analyzed. RESULTS: Nine patients in 2004 and seven in 2007 submitted to conventional vertical banded "Roux-en-Y" gastric bypass were studied. All patients presented good postoperative evolution. The average cost with these patients was R$ 6,845.17 in 2004. Even though an effort was made to contain expenditures, the cost in 2007 was of R$ 7,525.64 because of the increase in the price of materials and medicines. The Government remuneration of the procedure in the two years was R$ 3,259.72. Conclusion: Despite the adoption of diverse measures to reduce the expenditures of bariatric surgery, in fact there was an increase in the costs, a fact supporting the necessity of permanent evaluation of the financing of public health.

Objetivo: Avaliar os efeitos de algumas providências para reduzir os custos da cirurgia bariátrica, adotando como referência a remuneração do procedimento pelo Sistema Único de Saúde. Métodos: Análise retrospectiva, junto a Seção de Custos do Hospital das Clínicas de Ribeirão Preto, dos gastos com os pacientes submetidos a cirurgia bariátrica nos anos de 2004 e em 2007, após a adoção de rotinas e protocolos, no intervalo destes anos, na perspectiva de obter redução das despesas. Resultados: Nove pacientes no ano de 2004 e sete no ano de 2007, submetidos à derivação gástrica em "Y de Roux" com anel por via convencional, foram estudados. Todos pacientes apresentaram boa evolução pós- operatória. O custo médio com estes pacientes no ano de 2004 foi de R$ 6.845,17. Apesar do esforço na contenção de despesas, o custo no ano de 2007 foi de R$ 7.525,64, por conta do aumento do preço de materiais e medicamentos. A remuneração do procedimento pelo SUS nos dois anos foi de R$ 3.259,72. Conclusão: Apesar da adoção de diversas medidas para reduzir as despesas da cirurgia bariátrica, houve aumento dos custos, o que reforça a necessidade de avaliação permanente do financiamento da prestação de serviço para o SUS pelos três entes da federação.

Assistência farmacêutica no sistema público de saúde no Brasil / Pharmaceutical assistance in the Brazilian public health care system

This article deals with the organization of pharmaceutical assistance within the Brazilian Public Unified Health System (Sistema Único de Saúde, SUS) by analyzing the progress made so far and the challenges that still must be faced to ensure the right to universal therapeutic and pharmaceutical coverage in Brazil. Among the improvements, the article discusses the National List of Essential Drugs and its role to guide the supply, prescription, and dispensing of drugs within SUS. The structure of federal funding and the existing pharmaceutical programs are described, as well as the responsibilities of the Federal Government, states, and municipalities concerning allocation of financial resources. Despite the progress made, the model of access to SUS drugs has not been successful in securing universal therapeutic assistance. It is essential to consider a type of funding and organization of pharmaceutical assistance that is driven by a notion of regionalization, with financing based on health care flows rather than on the population circumscribed to a given territory. It is also essential to qualify pharmaceutical management by hiring pharmacists and support personnel, professionalizing workers, and setting up facilities with appropriate information systems and equipment.

Planos de saúde e SUS: uma análise das relações entre o financiamento público e o crescimento do mercado de planos de saúde / Health plans and SUS: an analysis of the relationship between public financing and the growth of the health insurance market

O Sistema Único de Saúde (SUS) fruto do processo da Reforma Sanitária brasileira, assegurou princípios universalistas e inclusivos no seu marco legal. Contudo esse sistema vem sendo implementado num contexto adverso, distanciando-se de aspectos fundamentais e sendo desviado por reformas do setor público. Em virtude disto, o SUS possui problemas estruturais e após vinte anos ainda carece de acordos quanto ao seu financiamento. Em paralelo, o mercado de planos de saúde vem sendo incentivado por meio da renúncia fiscal com despesas em caráter privado com a assistência à saúde. Nesse sentido, o presente estudo objetiva compreender as relações entre o financiamento do Sistema Único de Saúde, a renúncia fiscal com despesas com saúde e o crescimento do mercado brasileiro de planos de saúde no período de 1990 a 2008. Trata-se de uma pesquisa qualitativa que se configura um estudo de caso, na qual foi utilizada uma triangulação de fontes de dados tendo como instrumentos de coleta de dados primários - entrevistas e documentos - que foram analisados por meio da técnica de Análise de Conteúdo na perspectiva de Bardin (2004). Foram ainda coletados dados secundários em bases de dados oficiais. Os resultados indicam o crescimento do mercado brasileiro de planos de saúde no período de 1990 a 2008 que está associado ao padrão de financiamento público da saúde, quer seja na forma do financiamento direto do SUS, ou por meio da renúncia fiscal. Os dados obtidos espelham o modo de intervenção do estado brasileiro no setor saúde que se baseia, por um lado, no apoio à iniciativa privada, em que realiza o financiamento público no mercado de planos de saúde por meio dos benefícios tributários, e, por outro lado, na prioridade dada às diretrizes da política macro-econômica, cuja orientação é voltada para a disciplina orçamentária com contenção de gastos sociais, mantendo o equilíbrio fiscal. Desse modo, observa-se que a discussão do crescimento do mercado brasileiro de planos de saúde e suas relações com o financiamento do SUS e com a renúncia fiscal ultrapassam os limites setoriais da política de saúde, devendo ser o tema abordado de forma abrangente sob pena de empobrecer o debate e fragilizar a luta por um sistema público e universal de saúde.(AU)

The National Health System (SUS), revenue of the Brazilian Sanitary Reform process, has assured universalistic principles and inclusiveness in its legal landmark. However this system has been implemented in an adverse environment being distanced itself from fundamental aspects and being diverted by public sector reforms. Because of this, the SUS has structural problems and after twenty years still lacks of agreement about its financing. In parallel, the market for health plans has been encouraged through tax waiver with spending in private patterns with the assistance of health. Accordingly, this study aims to understand the relationship between the funding of the Unified Health System, tax waiver with spending on health and growth of the Brazilian health plans in the period from 1990 to 2008. This is a qualitative research that constitutes a case study, in which we used a triangulation of data sources having as instruments for primary data collection - interviews and documents - which were analyzed by the Content Analysis technique in Bardin's perspective (2004). Secondary data in official databases were also collected. The results indicate the growth of the Brazilian health plans in the period 1990-2008 that is associated with the pattern of health public funding, whether in the form of direct funding of SUS, or through tax waivers. The outcome reflects the mode of the Brazilian state intervention in health sector which is based, on the one hand, on support for private enterprise, which carries out public financing in the market for health insurance through tax benefits, and on the other hand, the priority given to the guidelines of macro-economic policy, the orientation of which is toward the budget discipline with the containment of social spending while maintaining fiscal balance. Thus, it is observed that the discussion of the growth of the Brazilian health plans and their relationships with SUS financing and tax waiver go beyond the sector boundaries of health policy and should be the subject addressed in a comprehensive manner under penalty of depleting the debate and undermining the fight for a health public and universal system.(AU)

Utilización y gasto en servicios de salud de los individuos en Argentina en 2005: comparaciones internacionales de diferenciales socio-económicos en salud / Use of and spending in health services by individuals in Argentina in 2005: international comparisons of socio-economic differentials in health

Este trabajo, continuidad de un relevamiento nacional anterior (2003), intenta actualizar las pautas de utilización y gasto en servicios de salud explorando, como en el pasado, las bases sociales de tales comportamientos. La indagación contempló el interés de políticas públicas en este sentido. Los resultados considerados, surgidos de una muestra nacional a 1.546 personas de 0 años y más, muestran que -dentro de lo esperado- el gasto en salud es relevante dentro del gasto total de los hogares y que el gasto de bolsillo en medicamentos es una proporción muy importante (40 por ciento) de ese gasto en salud. Como parte sustantiva del artículo, se agrega un apartado especial referido a aspectos de desigualdad en salud. La posibilidad de comparar resultados locales tomando como parámetro Japón resulta de indudable interés para evaluar los diferenciales socioeconómicos en salud. La metodología básica es similar en ambos estudios, descansando en ecuaciones de regresión logística.

This paper, a follow-up to a previous national survey (2003), intends to update the health care services use and expenditure patterns by exploring, as in the past, the social bases for such behaviors. The survey included public policy interest in this regard. The results analyzed, from a national population sample of 1.546 persons aged 0 and older, show that -as expected- health expenditure is significant within total household expenditure and that out-of-pocket-expenses in medication are a very important proportion (40 percent) of this health expenditure. As a fundamental part of this article, there is a special section on health inequality aspects. The possibility of comparing local results using Japan as a parameter is of unquestionable interest to evaluate socioeconomic differentials in this field. The basic method is similar in both studies, relying on logistic regression equations.

Fomento à publicação científica e proteção do conhecimento científico

The main purpose of a study is its publication on a scientific journal. Research financing agencies are important institutions so that studies can be developed and published. The most important research financing agencies that are discussed in this article are: "Coordenação de Aperfeiçoamento de Pessoal de Nível Superior" (CAPES), "Conselho Nacional de Desenvolvimento Científico e Tecnológico" (CNPq) and "Fundação de Amparo à Pesquisa do Estado de São Paulo" (FAPESP). CAPES' activities can be grouped in four different strategy lines: a) it evaluates the stricto sensu, at the post-graduation level; b) it provides access and development of scientific research; c) it provides investment on the development of high qualified human resources in Brazil and abroad, and d) it promotes international scientific cooperation. Although CAPES does not support directly scientific publications, almost all actions of this agency contribute to the development of scientific research and publication. CNPq has two main purposes: financing researches and development of human resources. It provides the researchers with financial aid to scientific publication. The grants for editing were specifically created for supporting the national scientific and technical publications edited by Brazilians institutions or societies. CNPq can also support Congresses, Symposiums and similar short-term courses. The Plataforma Lattes is also a branch of CNPq on which the Curriculum Lattes is available. This site has the curriculum vitae of the scientific community and is of great value for researchers. FAPESP also finances journal publications, articles and books that bring up original results of studies made by researchers from the state of São Paulo. It finances, partially, the travel expenses of innovative papers authors in meetings within the country or abroad. Brazilian authors are increasing the number of international publications. Universities, research institutes, financing agencies and private companies are more and more concerned with knowledge property. Researchers must understand the need of knowledge property and the financing agencies have to consider the patents achieved as a criteria of evaluation of scientific production.

O trabalho científico atinge sua finalidade maior através de sua publicação. É indiscutível a importância atual das agências de fomento à pesquisa para que se possa desenvolver, finalizar e publicar os trabalhos científicos. As principais agências de fomento abordadas neste artigo são: a Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), o Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) e a Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP). As atividades da CAPES podem ser agrupadas em quatro grandes linhas de ação: a) avaliação da pós-graduação stricto sensu; b) acesso e divulgação da produção científica; c) investimentos na formação de recursos de alto nível no país e exterior e d) promoção da cooperação científica internacional. Embora não haja uma linha direta de apoio à publicação científica, praticamente todas as ações da CAPES acabam por contribuir para a concretização de trabalhos científicos e suas publicações. O CNPq tem duas atividades básicas: o fomento à pesquisa e a formação de recursos humanos. Disponibiliza aos pesquisadores auxílio à divulgação e publicação científicas. O auxílio à editoração tem como objetivo apoiar publicações técnico-científicas nacionais, mantidas e editadas por instituição ou sociedade científica brasileira de âmbito nacional. Através do auxílio à promoção de eventos científicos, o CNPq apóia realização no país de congressos, simpósios e outros eventos similares de curta duração. O CNPq disponibiliza a Plataforma Lattes através da qual é possível preencher e acessar o Curriculum Lattes, hoje indispensável aos pesquisadores. A FAPESP financia publicação de periódicos, artigos e livros que exponham resultados originais de pesquisa realizada por pesquisador do Estado de São Paulo. Financia parcialmente a participação de pesquisadores em reuniões científicas ou tecnológicas, no Brasil ou no exterior, para apresentação de trabalho de sua autoria, não publicado, que exponha resultados inéditos. O Brasil vem aumentando sua participação nas publicações científicas internacionais. A nova realidade exige, além da publicação, uma preocupação com a proteção do conhecimento. A mudança da cultura da publicação para a da publicação com proteção do conhecimento é recente no país, tanto por parte das empresas, dos institutos de pesquisa, das universidades como das agências de fomento à pesquisa. Os pesquisadores devem-se conscientizar da necessidade de proteção do conhecimento e as agências de fomento considerar, como critérios de avaliação de produtividade científica, um peso mais equilibrado entre as publicações científicas, os resultados patenteáveis e o know how.

El financiamiento de organismos internacionales para programas de salud / Financing of health programs through international agencies

En este artículo se describe el papel que han jugado los organismos internacionales en el financiamiento de los programas de salud. Se identifican los diferentes tipos de organismos de acuerdo con el tipo de apoyo que proporcionan, la naturaleza de su relación con los países receptores y su carácter público o privado. Finalmente, se analizan los principales problemas del financiamiento externo de los programas de salud y se presenta el caso de la Fundación W.K. Kellogg como ejemplo de organismo internacional involucrado en programas de salud en México

This paper discusses the role that the international agencies have played in financing health programs. The different types of organisms are identified and classified according to the support they offer, the nature of their relationship with the recepient countries and their public or private character. The main problems associated with external financing of health problems are also discussed and the case of the W.K. Kellogg Foundation is presented to illustrate some of the issues previously analyzed.