Catastrophic expenditure on medicines in Brazil / Gasto catastrófico com medicamentos no Brasil

ABSTRACT OBJECTIVE To describe the magnitude of the expenditure on medicines in Brazil according to region, household size and composition in terms of residents in a situation of dependency. METHODS Population-based data from the national household survey were used, with probabilistic sample, applied between September 2013 and February 2014 in urban households. The expenditure on medicines was the main outcome of interest. The prevalence and confidence intervals (95%CI) of the outcomes were stratified according to socioeconomic classification and calculated according to the region, the number of residents dependent on income, the presence of children under five years and residents in a situation of dependency by age. RESULTS In about one of every 17 households (5.3%) catastrophic health expenditure was reported and, in 3.2%, the medicines were reported as one of the items responsible for this situation. The presence of three or more residents (3.6%) and resident in a situation of dependency (3.6%) were the ones that most reported expenditure on medicines. Southeast was the region with the lowest prevalence of expenditure on medicines. The prevalence of households with catastrophic health expenditure and on medicines in relation to the total of households showed a regressive tendency for economic classes. CONCLUSIONS Catastrophic health expenditure was present in 5.3%, and catastrophic expenditure on medicines in 3.2% of the households. Multi-person households, presence of residents in a situation of economic dependency and belonging to the class D or E had the highest proportion of catastrophic expenditure on medicines. Although the problem is important, permeated by aspects of iniquity, Brazilian policies seem to be protecting families from catastrophic expenditure on health and on medicine.

RESUMO OBJETIVO Descrever a magnitude do gasto catastrófico em medicamentos no Brasil segundo região, tamanho das famílias e composição familiar em termos de moradores em situação de dependência. MÉTODOS Utilizados dados de inquérito domiciliar nacional, de base populacional, com amostra probabilística, aplicado entre setembro de 2013 e fevereiro de 2014 em domicílios urbanos. O gasto catastrófico em medicamentos foi o principal desfecho de interesse. As prevalências e intervalos de confiança de 95% (IC95%) desses desfechos foram estratificados segundo classificação socioeconômica e calculadas de acordo com a região, o número de moradores dependentes da renda, a presença de crianças menores de cinco anos e de moradores em situação de dependência, por idade. RESULTADOS Em cerca de um de cada 17 domicílios (5,3%) foi relatado gasto catastrófico em saúde e, em 3,2%, os medicamentos foram reportados como um dos itens responsáveis por esta situação. Presença de três ou mais moradores (3,6%) e morador em situação de dependência jovem (3,6%) foram as situações com maior relato de gasto catastrófico em medicamentos. O Sudeste foi a região com menor prevalência de gasto catastrófico em medicamentos. As prevalências de domicílios com gasto catastrófico em saúde e medicamentos em relação ao total de domicílios apresentaram tendência regressiva para as classes econômicas. CONCLUSÕES O gasto catastrófico em saúde esteve presente em 5,3% e o gasto catastrófico em medicamentos, em 3,2% dos domicílios. Domicílios pluripessoais, presença de moradores em situação de dependência econômica e pertencimento à classe D ou E tiveram a maior proporção de gasto catastrófico em medicamentos. Ainda que o problema se mostre importante, permeado por aspectos de iniquidade, as políticas brasileiras parecem estar protegendo as famílias do gasto catastrófico em saúde e em medicamentos.

Encuestas nacionales de ceguera y deficiencia visual evitables en Argentina, El Salvador, Honduras, Panamá, Perú y Uruguay / National surveys of avoidable blindness and visual impairment in Argentina, El Salvador, Honduras, Panama, Peru, and Uruguay

OBJETIVO: Describir la justificación y metodología usadas en la Evaluación Rápida de Ceguera Evitable empleada para efectuar encuestas a nivel nacional entre 2011 y 2013 en Argentina, El Salvador, Honduras, Panamá, Perú y Uruguay. MÉTODOS: La encuesta se dirige a personas de 50 años o más, lo que reduce al mínimo los requisitos de tamaño de la muestra, que oscila entre 2 000 y 5 000 personas. Se emplean sistemas simples de muestreo y técnicas de examen; el análisis de datos es automático y no requiere de un experto en estadística. Es relativamente económica, ya que no toma mucho tiempo, no requiere equipos oftalmológicos costosos y puede ser llevada a cabo por el personal local. Los informes son generados mediante el propio programa informático de la evaluación. RESULTADOS: Los indicadores generados son la prevalencia de la ceguera y la deficiencia visual severa y moderada (discriminadas por causas evitables y cataratas); la prevalencia de afaquia o pseudofaquia; la cobertura de la cirugía de cataratas; el resultado visual de las cirugías de cataratas; las causas de resultados malos; las barreras de acceso a la cirugía de cataratas; y los indicadores de servicio de la cirugía de cataratas. Los resultados de cada una de las encuestas serán publicados de manera secuencial en números sucesivos de la revista, y en un artículo final de resumen se hará un análisis de los resultados en su conjunto y comparativo entre las encuestas y con aquellas publicadas anteriormente, que aportará un estado de la situación actual en ese grupo de países. CONCLUSIONES: La Evaluación Rápida de Ceguera Evitable es una metodología sólida, sencilla y económica para determinar la prevalencia de ceguera y deficiencia visual y la cobertura y calidad de los servicios de salud ocular, y representa una herramienta muy valiosa para medir el progreso de los programas de prevención de la ceguera y su impacto en la población.

OBJECTIVE: Describe the rationale and methodology of the Rapid Assessment of Avoidable Blindness applied in surveys at the national level in 2011-2013 in Argentina, El Salvador, Honduras, Panama, Peru, and Uruguay. METHODS: The survey includes individuals aged 50 years and older, minimizing required sample sizes, which vary from 2 000 to 5 000 people. It uses straightforward sampling and examination techniques, and data analysis is automatic and does not require a statistician. It is relatively inexpensive, as it does not take a long time, does not require expensive ophthalmic equipment, and can be carried out by local staff. Reports are generated by the assessment software package. RESULTS: Indicators measured are prevalence of blindness and of moderate and severe visual impairment (broken down into avoidable causes and cataracts); prevalence of aphakia or pseudophakia; cataract surgical coverage; visual outcome of cataract surgeries; causes of poor outcomes; access barriers to cataract surgery; and cataract surgery service indicators. Results of each survey will be published sequentially in successive issues of the Journal, and a final summary article will analyze results as a whole and in comparison with the other surveys in this group and with those previously published, which will provide a current picture of the situation in this group of countries. CONCLUSIONS: The Rapid Assessment of Avoidable Blindness is a robust, simple, and inexpensive methodology to determine prevalence of blindness and visual impairment as well as eye health service coverage and quality. It is a very valuable tool for measuring progress by blindness prevention programs and their impact on the population.

Tamanho de amostra e estimativa de custo em levantamento epidemiológico de cárie dentária / Sample size and costs estimate in epidemiological survey of dental caries

O objetivo do presente estudo foi analisar como a prevalência e a distribuição da cárie dentária influenciam o tamanho da amostra em levantamentos epidemiológicos, e os custos para sua realização. Foram utilizados dados de levantamentos realizados em escolares de 12 anos em Bauru nos anos de 1976, 1984, 1990, 1994 e 2001, e em Piracicaba nos anos de 2001 e 2005. Os tamanhos amostrais foram dimensionados considerando-se a média e o desvio padrão obtidos, fixando-se erro amostral em 1 por cento, 2 por cento, 5 por cento e 10 por cento. Os custos foram estimados considerando material permanente, de consumo e recursos humanos. Verificou-se aumento no tamanho das amostras em ambos os municípios, variando de 119 em 1976 para 1.118 em 2001 em Bauru, e de 954 em 2001 para 1.252 em 2005 em Piracicaba, considerando-se um erro amostral de 10 por cento. Considerando-se diferentes erros amostrais, verificou-se o custo para o levantamento, sendo que o mesmo depende do quanto o pesquisador se permite errar em relação ao verdadeiro valor da média da população. Conclui-se que a diminuição da prevalência da cárie dentária determinou o aumento no tamanho das amostras e a elevação dos custos para realização dos levantamentos.

This study aimed to analyze how the prevalence and the distribution of dental caries influence the sample size in epidemiological surveys, and how much are the costs. Secondary data of oral health surveys in 12-year-old schoolchildren from Bauru in 1976, 1984, 1990, 1994, and 2001, and from Piracicaba in 2001 and 2005 were studied. Sample sizes were estimated taking into account the mean DMFT and standard deviation of each survey, establishing sampling errors of 1 percent, 2 percent, 5 percent, and 10 percent. Costs were estimated considering permanent material, consumption material and human resources. The sample size in both towns needed to be increased, ranging from 119 in 1976 to 1,118 in 2001 in Bauru, and from 954 in 2001 to 1,252 in 2005 in Piracicaba, when a sampling error of 10 percent was considered. The cost of dental caries surveys was verified considering different sampling errors. This cost depends on how acceptable is the margin of difference between the true mean and the one found in the survey. In conclusion, the reduction in the prevalence of dental caries has determined the need for increase in sample size and in costs for conducting the surveys.

A historical overview of the United States-Mexico border diabetes prevention and Control Project / Perspectiva histórica del Proyecto de Prevención y Control de la diabetes en la frontera México-Estados Unidos

Diabetes is a serious public health problem in the border region between the United States of America and Mexico, reflecting and by some measures surpassing the extent of national diabetes burden of each country. The U.S.-Mexico Border Diabetes Prevention and Control Project, a two-phase prevalence study on type 2 diabetes and its risk factors, was conceived and developed by culturally diverse groups of people representing more than 100 government agencies and nongovernmental organizations; health care providers; and residents of 10 U.S. and Mexican border states, using a participatory approach, to address this disproportionate incidence of diabetes. This report describes the project's history, conceptualization, participatory approach, implementation, accomplishments, and challenges, and recommends a series of steps for carrying out other binational participatory projects based on lessons learned.

La diabetes es un problema grave de salud pública en la zona fronteriza entre México y los Estados Unidos, que refleja y, en cierta medida, sobrepasa la magnitud de la carga nacional de la diabetes de cada país. El Proyecto de Prevención y Control de la Diabetes en la Frontera México-Estados Unidos, un estudio de prevalencia de dos fases sobre la diabetes tipo 2 y sus factores de riesgo, se ideó y elaboró por grupos de personas culturalmente diversos que representaban a más de 100 organismos estatales y organizaciones no gubernamentales, profesionales de salud y residentes de 10 estados de la zona fronteriza entre México y los Estados Unidos, con la aplicación de un enfoque participativo, a fin de estudiar esta desproporcionada incidencia de diabetes. En este informe se describen la historia, la conceptualización, el enfoque participativo, la ejecución, los logros y los retos del proyecto, y se recomienda una serie de pasos para la realización de otros proyectos participativos binacionales, a partir de las lecciones aprendidas.

United States-Mexico border diabetes prevalence survey: lessons learned from implementation of the project / Encuesta de prevalencia de diabetes en la zona fronteriza entre México y los Estados Unidos: lecciones aprendidas de la ejecución del proyecto

This paper reviews and discusses the main procedures and policies that need to be followed when designing and implementing a binational survey such as the United States of America (U.S.)-Mexico Border Diabetes Prevalence Study that took place between 2001 and 2002. The main objective of the survey was to determine the prevalence of diabetes in the population 18 years of age or older along U.S.-Mexico border counties and municipalities. Several political, administrative, financial, legal, and cultural issues were identified as critical factors that need to be considered when developing and implementing similar binational projects. The lack of understanding of public health practices, implementation of existing policies, legislation, and management procedures in Mexico and the United States may delay or cancel binational research, affecting the working relation of both countries. Many challenges were identified: multiagency/multifunding, ethical/budget clearances, project management, administrative procedures, laboratory procedures, cultural issues, and project communications. Binational projects are complex; they require coordination between agencies and institutions at federal, state, and local levels and between countries and need a political, administrative, bureaucratic, cultural, and language balance. Binational agencies and staff should coordinate these projects for successful implementation.

En este artículo se analizan los principales procedimientos y normas que se deberían seguir al diseñar y ejecutar una encuesta binacional, como el estudio de prevalencia de la diabetes en la zona fronteriza entre México y los Estados Unidos que se llevó a cabo entre el 2001 y el 2002. El objetivo principal de la encuesta fue determinar la prevalencia de diabetes en las personas de 18 años o mayores en los condados y municipios fronterizos entre México y los Estados Unidos. Se definieron diversos aspectos políticos, administrativos, financieros, legales y culturales como factores fundamentales que se deben tener en cuenta al elaborar y ejecutar proyectos binacionales similares. La falta de comprensión de las prácticas de salud pública, la ejecución de las normas existentes, la legislación y los procedimientos de gestión en México y los Estados Unidos pueden retardar o cancelar las actividades de investigación binacional, y afectar las relaciones de trabajo entre ambos países. Se señalaron muchas dificultades con respecto a la multiplicidad de organismos y fuentes de financiación, las autorizaciones de carácter ético y presupuestario, la gestión del proyecto, los procedimientos administrativos, los procedimientos de laboratorio, los aspectos culturales y la comunicación del proyecto. Los proyectos binacionales son complejos; requieren coordinación entre los organismos y las instituciones a escalas federal, estatal, local y entre países, y precisan un equilibrio político, administrativo, burocrático, cultural e idiomático. El personal y los organismos binacionales deben coordinar estos proyectos con objeto de lograr su eficaz ejecución.

Cooperación transfronteriza en investigación sobre diabetes mellitus tipo 2: México-Estados Unidos / U.S.-Mexico cross-border cooperation in research on diabetes mellitus type 2

OBJETIVO: Describir y analizar con un enfoque de estudio de caso el Proyecto de Prevención y Control de la Diabetes en la Frontera México-Estados Unidos (PDF-México/Estados Unidos), un esfuerzo de cooperación en investigación en salud en el que participaron instituciones federales, estatales y locales de ambos países. MÉTODOS: El proyecto utilizó un modelo de igual representación, participación, consenso y liderazgo compartido, con la participación de más de 130 instituciones coordinadas por organismos de ambos países. Se estudió una muestra aleatoria, multietápica, estratificada y por conglomerados de 4 020 personas mayores de 18 años que respondieron un cuestionario de preguntas relacionadas con la diabetes mellitus tipo 2 (DM2) y la salud. El análisis estadístico de la información muestral obtenida tuvo en cuenta el efecto del diseño. RESULTADOS: La prevalencia de DM2 diagnosticada fue de 14,9 por ciento (intervalo de confianza de 95 por ciento [IC95 por ciento]: 12,5-17,6) y la prevalencia de DM2 diagnosticada ajustada por edad fue de 19,5 por ciento (IC95 por ciento: 16,8-22,6) en la parte mexicana y de 16,1 por ciento (IC95 por ciento: 13,5-19,2) en la estadounidense. La prevalencia de la DM2 y los factores de riesgo no fueron exactamente iguales a lo largo de la frontera. CONCLUSIONES: La ejecución del PDF-México/Estados Unidos ha permitido por primera vez considerar la franja fronteriza entre ambos países como una unidad para la investigación epidemiológica. En iniciativas fronterizas futuras, se sugiere fortalecer el entendimiento mutuo de la estructura sociopolítica y de las formas de actuación por parte de las instituciones y otras entidades participantes en ambos lados de la frontera.

OBJECTIVE: To describe and analyze, utilizing a case study approach, the U.S.- Mexico Border Diabetes Prevention and Control Project, a health research cooperation initiative incorporating the participation of federal, state, and local institutions of both countries. METHODS: A model of equal representation, participation, consensus, and shared leadership was used, with the participation of more than 130 institutions. A sample of 4 020 people over 18 years of age was obtained by a random, multistage, stratified, clustered design. A questionnaire about diabetes mellitus type 2 (DM2) and health was applied. The statistical analysis took into account the design effect. RESULTS: The prevalence of diagnosed DM2 was 14.9 percent (95 percent confidence interval [95 percent CI]: 12.5-17.6) and the prevalence of diagnosed DM2 adjusted by age was 19.5 percent (95 percent CI: 16.8-22.6) on the Mexican side of the border and 16.1 percent (IC95 percent: 13.5-19.2) on the U.S. border side. There were differences between the DM2 prevalence and risk factors along the border. CONCLUSIONS: The U.S.-Mexico Border Diabetes Prevention and Control Project allowed the border zone between the two countries to be considered, for the first time ever, as a unit for epidemiological research. A shared understanding among all participating institutions and entities of sociopolitical structures and procedures is required for effective border health cooperation initiatives.

Phsicians'perception of evidence based medicine: a survey in Lahore, Pakistan

EBM is a growing worldwide movement in health care, that aims to bring the best evidence from medical research to the bedside, clinic and community. EBM appeared early in 1990 and since then it has developed and expanded worldwide. It has met a considerable success over the past three decades in promoting critical scientific and practical awareness of the status of different after research claims to therapeutic knowledge. This subject of EBM is only theoreticcally known to only some of our physicians. We assessed physician's attitude towards EBM in a cross-sectional study conducted in the district of Lahore, Pakistan; from March 2005 to August 2006, by a self-administered questionnaire [proforma], which included questions on whether the physicians were in favour of EBM, and at what level EBM should be taught. A fairly reasonable response [63.6%] was received from the physicians and among these, most had a fair idea about EBM. They believed that EBM, if practiced, will improve patient care [68.8%], can reduce health care cost [59.1%] and will update the knowledge of the physicians [92.7%]. A large majority [91%] believed that EBM and its usefulness should be taught only at postgraduate level