COVID-19: Un gran desafío para la salud pública y la economía en Colombia / COVID-19: Um grande desafio para a saúde pública e a economia na Colômbia / COVID-19: A Great Challenge for Public Health and the Economy in Colombia

La pandemia Covid- 19 está generando una gran crisis global en la que los países en desarrollo parecen ser los más afectados; en América Latina y el Caribe resulta preocupante dadas las precarias condiciones laborales y al alto índice de pobreza. El mercado laboral colombiano está seriamente perjudicado por el aislamiento social adoptado para desacelerar los contagios de COVID-19, sin embargo, son incontables las pérdidas humanas y económicas por esta pandemia que no discrimina. Enfrentar este enemigo invisible con prudencia y sensatez será la hazaña más grande de nuestra historia y la forma de lograrlo será nuestro más preciado legado para las generaciones venideras.

Clinical decision making in older adults with COVID-19 in developing countries: looking beyond chronological age

ABSTRACT Background: The coronavirus disease 2019 (COVID-19) has been declared a global pandemic. Older adults have been found as a vulnerable group for developing severe forms of disease and increased mortality. Objective: The objective of the study was to propose a pathway to assist the decision-making process for hospital resource allocation for older adults with COVID-19 using simple geriatric assessment-based tools. Methods: We reviewed the available literature at this point of the COVID-19 outbreak, focusing in older adult care to extract key recommendations for those health-care professionals who will be treating older adults in the hospital emergency ward (HEW) in developing countries during the COVID-19 pandemic. Results: We listed a series of easy recommendations for non-geriatrician doctors in the HEW and suggested simple tools for hospital resource allocation during critical care evaluation of older adults with COVID-19 in low- and middle-income countries. Conclusions: Age must not be used as the sole criterion for resource allocation among older adults with COVID-19. Simple and efficient tools are available to identify components of the comprehensive geriatric assessment, which could be useful to predict outcomes and provide high-quality care that would fit the particular needs of older adults in resource-limited settings amidst this global pandemic.

Strategies and Challenges for the Circular Economy: a Case Study in Portugal and a Panorama for Brazil

Abstract: This article is about a case study based on the participation and contact with dynamized activities through action plans for the circular economy in Europe, specifically in Portugal. It aims to identify the main in-progress actions and the challenges for the diffusion of the circular economy in the Portuguese nation and draw a panorama for Brazil, transiting through different data sources, economic sectors and stakeholders. Through data triangulation, the investigative plan contemplated participatory observations in workshops, interviews with experts, documental analyses and means of communication. After going through data cross checking for validation, the content was aggregated to a strategic analysis matrix. As a result, it was possible to identify the strengths, weaknesses, opportunities and challenges associated with the growth of the circular economy in Portugal, as well as to indicate directions and possibilities in the Brazilian context. It is possible to realize, for both countries, the importance of the international benchmarking for the recognition and promotion of circular economy actions, besides the necessity to revise laws aligned with the internal e external market rules, by increasing the offer of circular products and services.

Crises econômicas, mortalidade de crianças e o papel protetor do gasto público em saúde / Economic crises, child mortality and the protective role of public health expenditure

Resumo O objetivo do estudo foi analisar como as crises econômicas afetam a saúde infantil a nível global e entre subgrupos de países com diferentes níveis de renda. Foram utilizados dados do Banco Mundial e da OMS para 127 países entre os anos de 1995 e 2014. Foi utilizado um modelo de efeitos fixos, avaliando o efeito da mudança em indicadores macroeconômicos (PIB per capita, taxa de desemprego e de inflação, e taxa de desconforto) na taxa de mortalidade neonatal, infantil, e de menores de cinco anos. Adicionalmente, avaliou-se a modificação do efeito da associação de acordo com a renda dos países e também a influência do gasto público em saúde nessa relação. As evidências mostraram que piores indicadores econômicos (menor PIB per capita e maiores inflação, taxa de desemprego e taxa de desconforto) estão associados com maiores taxas de mortalidade infantil. Nas subamostras por estrato de renda, observa-se a mesma relação, porém com efeitos de maior magnitude entre os países de renda baixa e média. Verificou-se ainda que um maior percentual nos gastos públicos em saúde ameniza os efeitos dos indicadores econômicos nas taxas de mortalidade infantil. Desta forma, é necessário aumentar a atenção aos efeitos nocivos das crises macroeconômicas para garantir melhorias na saúde infantil.

Abstract The aim of the study was to analyze how economic crises affect child health globally and between subgroups of countries with different levels of income. Data from the World Bank and the World Health Organization were used for 127 countries between 1995 and 2014. A fixed effects model was used, evaluating the effect of the change on macroeconomic indicators (GDP per capita, unemployment and inflation rates and misery index) in neonatal, infant and under-five mortality rates. Moreover, we evaluated whether there was a change in the association effect according to the income of the countries and also analyzed the role of public health expenditure in this association. Evidence has shown that worse economic indicators (lower GDP per capita, higher inflation, unemployment rates and misery index) are associated with higher child mortality rates. In the subsamples by income strata, the same association is observed, but with effects of greater magnitude for low- and middle-income countries. We also verified that a higher percentage in public health expenditures alleviates the effects of economic indicators on child mortality rates. Thus, more attention needs to be paid to the harmful effects of the macroeconomic crises to ensure improvements in child health.

Fiscal austerity and the health sector: the cost of adjustments / Austeridade fiscal e o setor saúde: o preço do ajuste

Abstract Fiscal austerity policies have been used as responses to economic crises and fiscal deficits in both developed and developing countries. While they vary in regard to their content, intensity and implementation, such models recommend reducing public expenses and social investments, retracting the public service and substituting the private sector in lieu of the State to provide certain services tied to social policies. The present article discusses the main effects of the recent economic crisis on public health based on an updated review with consideration for three dimensions: health risks, epidemiological profiles of different populations, and health policies. In Brazil, the combination of economic crisis and fiscal austerity policies is capable of producing a direr situation than those experienced in developed countries. The country is characterized by historically high levels of social inequality, an under-financed health sector, highly prevalent chronic degenerative diseases and persisting preventable infectious diseases. It is imperative to develop alternatives to mitigate the effects of the economic crisis taking into consideration not only the sustainability of public finance but also public well-being.

Resumo Políticas de austeridade fiscal têm sido utilizadas como respostas à crise econômica e deficit fiscal tanto em países desenvolvidos como em desenvolvimento. Embora variem quanto ao conteúdo, intensidade e cronograma de implementação, tais modelos preconizam a redução do gasto público, promovendo também a diminuição do investimento social, a retração da máquina pública e a substituição do Estado pelo setor privado na provisão de determinados serviços vinculados a políticas sociais. Este artigo debate os principais efeitos da crise econômica recente sobre a saúde da população, tendo sido baseado em uma revisão atualizada, considerando-se três dimensões: riscos à saúde, perfil epidemiológico das populações e políticas de saúde. A crise econômica no Brasil, combinada com a política de austeridade fiscal, pode produzir um contexto mais grave do que o vivenciado pelos países desenvolvidos. O país apresenta altos níveis históricos de desigualdade social, subfinanciamento do setor saúde, alta prevalência de doenças crônico-degenerativas e persistência de doenças infeciosas evitáveis. É imperativo que se construam alternativas para se mitigar os efeitos da crise econômica, levando-se em conta não apenas a sustentabilidade das finanças públicas, mas também o bem-estar da população.

Caracterización clínico-epidemiológico de pacientes perinatalmente expuestos al VIH en el Hospital Nacional Mario Catarino Rivas / Clinical-epidemiological characterization of perinatally exposed HIV patients. Mario Catarino Rivas National Hospital

Antecedentes: En los países con escasos recursos, la infección por VIH infantil tiene dimensiones alarmantes. Más del 90% de los niños que viven con VIH en los países en desarrollo se infectaron por transmisión de madre a hijo durante el embarazo, parto o lactancia. Con el fin de reducir el número de niños infectados por el VIH, se ha enfatizado en los programas de prevención de la transmisión vertical, encontrándose una reducción de la transmisión del virus, actualmente menos del 1% en niños de bajo riesgo. Objetivo: Caracterizar clínica y epidemiológicamente a los pacientes perinatalmente expuestos al VIH atendidos en el Hospital Nacional Mario Catarino Rivas enero 2018 - junio del 2019. Pacientes y Métodos: Estudio cuantitativo, observacional, descriptivo; se realizó la revisión de 42 expedientes clínicos, se aplicó un cuestionario de 23 preguntas abiertas y cerradas, evaluando variables clínicas y epidemiológicas. Resultados: el 85% de las madres conocían el diagnostico de ser VIH positivo, 66% diagnosticadas previo al embarazo, 80% en tratamiento con ARV, 26% con carga viral no detectable, 78% finalizo su embarazo vía cesárea, 53% fueron categorizados como alto riesgo, 85% recibió terapia ARV por 4 semanas, incidencia de VIH fue de 4.7%, 2 de los 42 pacientes,19% están perdidos en seguimiento, 88% recibió profilaxis con TMP-SMX.Conclusiones: El diagnóstico precoz de VIH en la infancia mediante la realización de pruebas vi * Médico Residente tercer año de Pediatría, UNAH-VS. ** Médico Pediatra, Servicio de Atención Integral, HNMCR. *** Médico Pediatra, Servicio de Atención Integral, HNMCR. Dirigir correspondencia a: damavibau_723@hotmail.com Recibido: 20 de Diciembre 2019 Aprovado:15 de marzo 2020 favorece al inicio temprano de tratamiento antirretroviral con un pronóstico de vida más favorable...(AU)

Pensando en políticas de cuidados de larga duración para América Latina / Thinking about long-term care policies for Latin America

América Latina envejece. Lo hace muy rápido, en condiciones poco saludables y con bajos niveles de ingreso. En las próximas décadas aumentará vertiginosamente el número de personas mayores que no podrán realizar las actividades de su vida diaria por sí mismas. Este fenómeno ya lo han enfrentado los países ricos en las últimas tres décadas pero, a diferencia de ellos, la región no dispone ni de los recursos ni de los sistemas de protección social de esos países. Pensar y planificar políticas de salud asociadas a este fenómeno debería ser una prioridad de los gobiernos latinoamericanos. En el presente trabajo se define en qué consisten estos cuidados, qué modelos han desarrollado los países ricos y a qué costo. Posteriormente se analiza la situación de América Latina y se propone una serie de discusiones para abordar en el futuro cercano.

Latin America is aging. The process is occurring quickly and in unhealthy conditions with low levels of income. The number of older people who can no longer perform their daily activities will dramatically increase in the coming decades. Developed countries have already been facing this phenomenon over the last three decades, but Latin America has neither the resources nor the social protection systems of these countries. Formulating and planning health policies associated with this phenomenon should be a priority of the governments of Latin America. This paper defines what these care policies are, the models of care rich countries have developed, and the cost of such models. The situation in Latin America is then analyzed and conclusions and a series of discussions to address in the near future are proposed.

Factor Configurations with Governance as Conditions for Low HIV/AIDS Prevalence in HIV/AIDS Recipient Countries: Fuzzy-set Analysis

This paper aims to investigate whether good governance of a recipient country is a necessary condition and what combinations of factors including governance factor are sufficient for low prevalence of HIV/AIDS in HIV/AIDS aid recipient countries during the period of 2002-2010. For this, Fuzzy-set Qualitative Comparative Analysis (QCA) was used. Nine potential attributes for a causal configuration for low HIV/AIDS prevalence were identified through a review of previous studies. For each factor, full membership, full non-membership, and crossover point were specified using both author's knowledge and statistical information of the variables. Calibration and conversion to a fuzzy-set score were conducted using Fs/QCA 2.0 and probabilistic tests for necessary and sufficiency were performed by STATA 11. The result suggested that governance is the necessary condition for low prevalence of HIV/AIDS in a recipient country. From sufficiency test, two pathways were resulted. The low level of governance can lead to low level of HIV/AIDS prevalence when it is combined with other favorable factors, especially, low economic inequality, high economic development and high health expenditure. However, strengthening governance is a more practical measure to keep low prevalence of HIV/AIDS because it is hard to achieve both economic development and economic quality. This study highlights that a comprehensive policy measure is the key for achieving low prevalence of HIV/AIDS in recipient country.

Patterns of Health Expenditures and Financial Protections in Vietnam 1992-2012

Health financing has been considered as an important building block of a health system and has a key role in promoting universal health coverage in the Vietnam. This paper aims to describe the pattern of health expenditure, including total health expenditure and composition of health expenditure, over the last two decades in Vietnam. The paper mainly uses the data from Vietnam National Health Account and Vietnam Living Standards Survey. We also included data from other relevant published literature, reports and statistics about health care expenditure in Vietnam. The per capita health expenditure in Vietnam increased from US$ 14 in 1995 to US$ 86 in 2012. The total health expenditure as a share of GDP also rose from 5.2% in 1995 to 6.9% in 2012. Public health expenditure as percentage of government expenditure rose from 7.4% in 1995 to nearly 10% in 2012. The coverage of health insurance went up from 10% in 1995 to 68.5% in 2012. However, health financing in Vietnam was depending on private expenditures (57.4% in 2012). As a result, the proportion of households with catastrophic expenditure in 2012 was 4.2%. The rate of impoverishment in 2012 was 2.5%. To ensure equity and efficient goal of health system, policy actions for containing the health care out-of-pocket payments and their poverty impacts are urgently needed in Vietnam.

Development-assistance Strategies for Stroke in Low- and Middle-income Countries

While communicable diseases still pose a serious health threat in developing countries, previously neglected health issues caused by non-communicable diseases such as stroke are rapidly becoming a major burden to these countries. In this review we will discuss the features and current status of stroke in low- and middle-income countries (LMICs). Overall the global burden of hemorrhagic stroke is larger than ischemic stroke, with a disproportionately greater burden, measured in incidence and disability-adjusted life-years, regionally localized in LMICs. Patients in poorer countries suffer due to insufficient primary care needed to control risk factors such as hypertension, and inadequate emergency care systems through which sudden events should be managed. In light of these situations, we emphasize two strategic points for development assistance. First, assistance should be provided for bolstering, integrating, and coordinating both the primary health and emergency care systems, in order to prevent stroke and strengthen stroke management, respectively. Second, the assistance needs to focus on programs at the community level, to reduce life-style risks of stroke in a more sustainable manner, and to improve stroke outcomes more effectively.

Republic of Korea's Health Aid Governance: Perspectives from Partner Countries

The Republic of Korea (ROK) has a remarkable development history, including its status as the first country to transition from aid recipient to member of the Organization for Economic Cooperation and Development Development Assistance Committee (DAC). However, since becoming a donor country, the ROK has struggled to achieve internationally accepted agreements related to aid effectiveness and several evaluations have identified the ROK as being one of the weakest DAC member countries at providing good aid. A survey was conducted to assess partner countries' perceptions of the ROK's governance of health official development assistance (ODA). The survey was administered to government officials based in partner countries' Ministries of Health and therefore presents the unique perspective of ODA recipients. The survey questions focused on governance principles established in the internationally-accepted Paris Declaration on Aid Effectiveness. The total response rate was 13 responses out of 26 individuals who received the email request (50%). The survey results indicate that progress has been made since earlier international evaluations but the ROK has not overcome all areas of concern. This confirms that the ROK is continuing to develop its capacity as a good donor but has yet to achieve all governance-related targets. The results of this survey can be used to inform a future aid strategy.

Factors that influence a career choice in primary care among medical students from high-, middle-, and low-income countries: a systematic review / Factores que influyen en la elección de una carrera en atención primaria entre estudiantes de medicina de países de ingresos altos, medianos y bajos: una revisión sistemática

OBJECTIVE: To determine which factors influence a medical student's decision to choose a career in primary care; and to establish if these factors are similar or different among students in high-, middle- and low-income countries. METHODS: An extensive search was done of PubMed, Google Scholar, and Virtual Library of Health for articles on primary care careers published in 2003-2013 in English, Spanish, and/or Portuguese. Initially, 600 records were identified; 74 full-text articles were assessed for eligibility and 55 were selected (42 from high-income countries; 13 from middle- and low-income). These were assessed to identify intrinsic and extrinsic factors that influence career choice among medical students from high-, middle-, and low-income countries. RESULTS: A comparison framework with common and specific factors that influence career choice in primary care among medical students from high-, middle- and low-income was developed. Factors were classified as extrinsic or intrinsic, and as facilitators or barriers. Several factors common to all countries were identified: facilitators were exposure to rural location, role models, working conditions; barriers were low income, prestige, and medical school environment. Some factors specific to middle- and low-income countries were: understanding of rural needs and intellectual challenge. Other factors specific to high-income countries were: attitude towards social problems, voluntary work, influence of family, and length of residency. CONCLUSIONS: Further studies on the subject are needed, especially in low- and middle-income countries. Identifying factors as barriers or facilitators for career choice will promote a better understanding of the reasons behind the shortage of primary care professionals and will contribute to policy building, improved training, and recruitment and retention of these professionals.

OBJETIVO: Determinar los factores que influyen en la decisión de un estudiante de medicina de dedicarse profesionalmente a la atención primaria; y establecer si estos factores son similares o diferentes entre estudiantes de países de ingresos altos, medianos y bajos. MÉTODOS: Se llevó a cabo una extensa búsqueda en PubMed, en Google Académico y en la Biblioteca Virtual en Salud de artículos sobre selección de carrera en atención primaria publicados entre 2003 y 2013 en inglés, español o portugués. Inicialmente, se seleccionaron 600 registros; se evaluó la idoneidad de 74 artículos de texto completo, y de estos se seleccionaron 55 (42 de países de ingresos altos, 13 de países de ingresos medianos y bajos). Se evaluaron los artículos con el objeto de determinar cuáles eran los factores intrínsecos y extrínsecos que influían en la elección profesional de los estudiantes de medicina de países de ingresos altos, medianos y bajos. RESULTADOS: Se elaboró un marco de comparación de los factores comunes y específicos que influyen en la elección profesional de atención primaria por parte de los estudiantes de medicina de países de ingresos altos, medianos y bajos. Los factores se clasificaron como extrínsecos o intrínsecos, y como facilitadores o barreras. Se determinaron varios factores comunes a todos los países: la exposición a un entorno rural, los modelos a imitar y las condiciones laborales actuaban como facilitadores; los ingresos bajos, el escaso prestigio y el entorno propio de las facultades de medicina actuaban como barreras. Algunos factores específicos de países de ingresos medianos y bajos fueron la comprensión de las necesidades rurales y el desafío intelectual. Otros factores específicos de países de ingresos altos fueron la actitud hacia los problemas sociales, el haber trabajado como voluntario, la influencia de la familia y la duración del período de residencia. CONCLUSIONES: Se requieren nuevos estudios sobre el tema, especialmente en países de ingresos medianos y bajos. Determinar si estos factores actúan como barreras o facilitadores de la elección profesional ayudará a comprender los motivos de la escasez de profesionales de atención primaria y contribuirá a la elaboración de políticas, a mejorar la capacitación, y a captar a estos profesionales y garantizar su permanencia.

Inseguridad alimentaria: variables asociadas y elementos para la política social / Food insecurity: associated variables and issues for public policy

Introducción. La vigencia de las explicaciones cambia con las transiciones demográfica, epidemiológica y nutricional. Objetivo. Establecer la magnitud de inseguridad alimentaria y sus variables asociadas. Materiales y métodos . Se clasificaron 432 hogares mediante cinco métodos; se utilizaron las escalas de percepción de seguridad alimentaria (EPSA), la latinoamericana y caribeña (ELCSA), y otros tres: a) según el consumo usual de energía del jefe del hogar, b) según el consumo usual de energía de todos los miembros, y c) según un algoritmo basado en el consumo y la condición de los menores. Mediante regresión binomial, se establecieron las variables asociadas a la inseguridad alimentaria. Resultados. La inseguridad varió entre 35,9 y 87 %. Según la ELCSA y b), los hogares con menores tienen menor riesgo de inseguridad 0,51 (IC95% 0,25-0,90) y 0,72 (IC95% 0,48-0,96). Según la EPSA y la ELCSA, no pagar los servicios públicos 1,75 (IC95% 1,23-2,28) y que el jefe del hogar declare que no accede a los alimentos 1,48 (IC95% 1,20-1,68), aumentan la inseguridad. Obtener ingresos esporádicamente se asoció con el método a), 1,34 (IC95% 1,04-1,53) y el método b), 1,32 (IC95% 1,03-1,52). Pagar arriendo 1,12 (IC95% 1,01-1,16), el tiempo de permanencia en el municipio 0,59 (IC95% 0,23-0,93) y no contar con alcantarillado 1,13 (IC95% 1,01-1,16), se asociaron a la inseguridad por el método c). Conclusiones. No es pertinente o útil recomendar estos métodos con fines de elaborar la política social.

Introduction. The validity of the explanations change over time according to the state of demographic, epidemiological and nutritional transitions. Objective. Five methods were compared to establish t he magnitude of food insecurity and related variables. Material and methods. Four hundred and thirty-two households in Colombia were classified using five methods, including (1) the scale of perceptions of food safety (EPSA),(2) the Latin American and Caribbean scale (ELCSA), (3) the usual intake of energy from the head of household, (4) the usual consumption of energy of all members of the home, and (5) an algorithm based on consumption and status of children. Binomial regression established variables associated with food insecurity. Results . Insecurity varied between 35.9% and 87.0%. According ELCSA and method 3, households with children have a lower risk of insecurity, 0.51 (95% CI 0.25 to 0.90) and 0.72 (95% CI 0.48 to 0.96). Under the EPSA and ELCSA, increased insecurity is associated with nonpayment of utilities, 1.75 (95% CI: 1.23 to 2.28) and the head of household declared limited access to food, 1.48 (95% CI: 1, 20 to 1.68). Sporadic income was associated with the method 3, 1.34 (95% CI 1.04 to 1.53) and method 4, 1.32 (95% CI 1.03 to 1.52). Paying rent, 1.12 (95% CI: 1.01 to 1.16), time spent in the municipality, 0.59 (95% CI 0.23 to 0.93) and not having sewer, 1.13 (95% CI 1.01 to 1.16) were associated with the food insecurity using method 5. Conclusions . Since the country has reliable information that is obtained routinely it is not relevant or useful to use these methods with the purpose of developing social policies.

The cost-effectiveness of enzyme replacement therapy (ERT) for the infantile form of Pompe disease: comparing a high-income country's approach (England) to that of a middle-income one (Colombia) / Costo-Efectividad de la terapia del reemplazo enzimático (TRE) para la forma infantil de la enfermedad Pompe: perspectiva económica comparativa de un país ingresos altos (Inglaterra) vs uno de ingresos medios (Colombia)

Objectives Determining the cost-effectiveness of enzyme replacement therapy (ERT) for the classical infantile form of Pompe disease (complete acid a-glucosidase deficiency-related) in two different settings: England and Colombia. Pompe disease is very rare (1:40,000 births incidence). Methods A literature review was made and historic databases searched for National Health Service (NHS) reimbursed costs in England and by health insurers in Colombia; expert opinion was elicited. Two Markov models were constructed for comparing both countries; alive with symptoms and dead were the transition states used. Patients aged < 6 months receiving ERT were assumed to have 75 % survival rate and better health-related quality of life (HR-QoL) compared to those without treatment (0.700 HR- QoL using the EQ-5D scale). Results The incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained was £234,307.7 for England and £109,991 for Colombia. Uncertainty about Anal HR-QoL with ERT, disease progression and cost from palliative care had the biggest impact on the ICER in both models. If ERT costs were reduced to 10,000 times per dose and HR-QoL was 0.750-0.820 ICER, then £165,000 could be attainable for England and £65,000 for Colombia. Transaction costs per case in Colombia were high. Conclusions ERT was more effective than no ERT in treating infantile Pompe disease, but high levels of uncertainty still remain about survival and progression rates and QoL in the long-run. ICERs were high compared to CE thresholds. Manufacturers' ERT costs and monopoly had a major impact on Anal CEA results.

Objetivo Determinar la costo-efectividad de la TRE como indicación para la forma clásica de la enfermedad de Pompe (relacionada con deficiencia completa de a-glucosidasa ácida) desde dos perspectivas, Inglaterra y Colombia. La enfermedad de Pompe es muy rara (incidencia 1:40000 nacimientos). Métodos Revisiónbibliográfica y bases de datos para calcular costosasociados al tratamiento en NHS en Inglaterra, aseguradores de salud en Colombia y opinión de expertos. Dos procesos de Markov fueron construidos para comparar entre países; los estados de transición fueron: vivo sintomático y fallecido. En pacientes de < 6 meses de edad con TRE, se asume un incremento de 75 % de sobrevida y mejor calidad de vida comparada con los que no reciben TRE (HR-QoL 0.700 usando EQ-5D). Resultados Inglaterra alcanzo ICER por QALY ganado £234307, 7 y Colombia £109991. Incertidumbre sobre HR-QoL con TRE, progresión de enfermedad y costo de cuidado paliativo tuvieron el mayor impacto en losICERs;sí el costo de TREfuera 10.000 menor y la HR-QoLalcanzara 0.750-0.820 ICERs de £165000y £65000 podrían obtenerse para Inglaterra y Colombia respectivamente. Los costos transaccionales en Colombia son representativos. Conclusiones La TRE es más efectiva que no dar tratamiento, pero incertidumbre sobre tasas desobrevida, progresión y HR-QoLpermanecen en el largo plazo. Los ICERsson altos comparados a los umbrales establecidos de CE. Los costos de TRE y el podermonopolístico del fabricante tienen un impacto importante en los resultados Anales de CEA. Investigación adicional debe realizarsea futuro.

El financiamiento internacional para la cooperación al desarrollo de la salud de América Latina y el Caribe / International financing for cooperation to develop health in Latin America and the Caribbean

El presente estudio tuvo como objetivos a) conocer en qué medida América Latina y el Caribe (ALC) se vio beneficiada por los aumentos de la asistencia internacional para el desarrollo de la salud (ADS) a nivel mundial y si la tendencia observada después de la Cumbre del Milenio, también fue una tendencia observada en la Región, b) determinar si existen diferencias en la distribución de esta asistencia, según el ingreso bruto per cápita de los países, c) identificar el posible efecto de la crisis financiera internacional de 2008 en la ayuda oficial bilateral y d) comparar las tendencias que tuvo el gasto público salud con respecto a la ADS antes y después de la Cumbre del Milenio Se encontró que la ADS en ALC sigue un curso muy diferente al de otras regiones del mundo. A partir de 1997 se entra en un período de estancamiento fluctuante que se extiende hasta 2008, con desembolsos promedios anuales de US$ 1 200 millones. La banca multilateral tuvo una participación de 79 por ciento de los desembolsos promedios entre 2002 y 2008 en los países de ingreso medio alto, mientras que la ayuda oficial bilateral registró la mayor participación (61 por ciento) en los países de ingresos medios bajos y bajos. En este período la ayuda bilateral tiene un crecimiento anual de 13 por ciento, pero en el año posterior a la crisis los desembolsos caen en US$ 20 millones. El 64 por ciento de la ayuda bilateral provino de Estados Unidos, España y Canadá, y el 29 por ciento de la misma se destinó a VIH/Sida y enfermedades de transmisión sexual. Después de la Cumbre del Milenio la ADS canalizada hacia los gobiernos disminuyó en un 30 por ciento entre 2001-2006 y su participación con respecto al gasto público en salud regional fue de 0,30 por ciento en el mismo período, con una proporción igualmente marginal con respecto al gasto total en salud para 2008 (0,37 por ciento; US$ 2 per cápita). Se concluye que después de la Cumbre del Milenio la ADS en ALC no creció ni logró igualar las tendencias antes del 2000 y el gasto público en salud siguió su tendencia de crecimiento histórico, sin mayores incrementos con respecto al producto interno bruto regional. Frente a este panorama y por ser ALC la región más desigual pero no la más pobre del mundo, resulta imperativo replantearse las formas de pensar, conducir y entregar la cooperación para el desarrollo de la salud con enfoques innovadores y mecanismos alternativos de financiamiento que respondan más y mejor a las realidades de la región.

The purpose of this study is (a) to examine the ways in which Latin America and the Caribbean (LAC) have benefited from increases in international development assistance for health (DAH) at the global level and whether the trend observed after the Millennium Summit has also applied to the Region; (b) to determine whether there are differences in the distribution of this assistance, based on the gross per capita income of each country; (c) to identify the possible effects of the 2008 international financial crisis on official bilateral assistance; and (d) to compare trends in public health expenditure in relation to DAH before and after the Millennium Summit. The study has found that DAH in LAC follows a very different pattern than in other regions of the world. The period from 1997 to 2008 was one of fluctuating stagnation, with average annual disbursements of US$ 1 200 million. Multilateral financial institutions accounted for 79 percent of the average disbursements in the upper-middle income countries between 2002 and 2008, while official bilateral assistance held the greatest share (61 percent) in the low- and lower-middle income countries. Bilateral assistance grew at an annual rate of 13 percent during this period, but in the year after the crisis, disbursements fell to US$ 20 million. Sixty-four percent of bilateral assistance came from the United States, Spain, and Canada, with 29 percent of it being directed to HIV/AIDS and sexually transmitted diseases. After the Millennium Summit DAH channeled to governments decreased 30 percent in the period 2001-2006, and its share of public health expenditure in the region was 0.3 percent for the same period, with an equally marginal proportion in relation to total health expenditure for 2008 (0.37 percent; US$ 2 per capita). The study concludes that after the Millennium Summit, DAH in LAC did not grow nor did it equal the trends prior to 2000, and public health expenditure followed its historical growth trend, without further increases in relation to the regional gross domestic product. Given these realities and the fact that LAC is the world's most unequal region, but not its poorest, it is imperative to reconsider the concepts, management, and delivery of cooperation in the development of health, using innovative approaches and alternative financing mechanisms that respond more effectively to the realities of the region.

Medicamentos de alto costo: análisis y propuestas para los países del Mercosur / Costly drugs: analysis and proposals for the Mercosur countries

OBJETIVO: Determinar la forma en que los países del Mercosur acceden, regulan y financian los medicamentos de alto costo (MAC) y proponer estrategias de selección y financiación conjunta a nivel sub-regional. MÉTODOS: Diseño cualitativo, utilizando análisis de contenido de fuentes primarias y secundarias, revisiones documentales, entrevistas, grupos focales y análisis de casos Las variables seleccionadas incluyeron: criterios de selección, acceso, financiación y regulación en los distintos países. Los MAC se clasificaron en aquellos que no modifican el curso natural de la enfermedad y aquellos que tiene eficacia demostrada, utilizando la dosis diaria definida para comparar los costos entre tratamientos clásicos y los realizados con MAC. RESULTADOS: Los países del Mercosur carecen en su gran mayoría de estrategias formales para enfrentar las demandas de MAC, y gobiernos y aseguradoras terminan por financiarlos por vía judicial. Los análisis de casos muestran que existen MAC sin eficacia comprobada que igualmente generan demanda. Las compras atomizadas, los compromisos internacionales respecto a propiedad intelectual y el bajo poder de negociación incrementan los precios de MAC exponencialmente, poniendo en riesgo la economía de los sistemas sanitarios. CONCLUSIONES: Los MAC deben ser regulados y seleccionados racionalmente permitiendo que solo aquellos que beneficien sustantivamente a la población sean aceptados. Para financiar los MAC así seleccionados se requieren estrategias comunes entre países que incluyan opciones tales como flexibilidades de acuerdos comerciales, creación de fondos nacionales de recursos o compra conjunta entre países para potenciar su poder de negociación.

OBJECTIVE: Determine how the Mercosur countries access, regulate, and finance costly drugs and propose joint selection and financing strategies at the subregional level. METHODS: Qualitative design, using content analyses of primary and secondary sources, document reviews, interviews, focus groups, and case studies. The variables selected included: selection criteria, access, financing, and regulations in the various countries. Costly drugs were divided into those that do not alter the natural course of the disease and those with demonstrated efficacy, using the defined daily dose to compare the costs of classical treatments and those involving costly drugs. RESULTS: The Mercosur countries generally lack formal strategies for dealing with the demand for costly drugs, and governments and insurers wind up financing them by court order. The case studies show that there are costly drugs whose efficacy has not been established but that nonetheless generate demand. The fragmentation of procurement, international commitments with regard to intellectual property, and low negotiating power exponentially increase the price of costly drugs, putting health system finances in jeopardy. CONCLUSIONS: Costly drugs must be regulated and rationally selected so that only those that substantively benefit people are accepted. To finance the drugs so selected, common country strategies are needed that include such options as flexible in trade agreements, the creation of national resource funds, or joint procurement by countries to enhance their negotiating power.

Feasibility of community-based health insurance in rural tropical Ecuador / Factibilidad de un seguro de enfermedad comunitario en una zona rural tropical de Ecuador

OBJECTIVE: The main objective of this study was to assess people's willingness to join a community-based health insurance (CHI) model in El Páramo, a rural area in Ecuador, and to determine factors influencing this willingness. A second objective was to identify people's understanding and attitudes toward the presented CHI model. METHODS: A cross-sectional survey was carried out using a structured questionnaire. Of an estimated 829 households, 210 were randomly selected by two-stage cluster sampling. Attitudes toward the scheme were assessed. Information on factors possibly influencing willingness to join was collected and related to the willingness to join. To gain an insight into a respondent's possible ability to pay, health care expenditure on the last illness episode was assessed. Feasibility was defined as at least 50 percent of household heads willing to join the scheme. RESULTS: Willingness to join the CHI model for US$30 per year was 69.3 percent. With affiliation, 92.2 percent of interviewees stated that they would visit the local health facility more often. Willingness to join was found to be negatively associated with education. Other variables showed no significant association with willingness to join. The study showed a positive attitude toward the CHI scheme. Substantial health care expenditures on the last illness episode were documented. CONCLUSIONS: The investigation concludes that CHI in the study region is feasible. However, enrollments are likely to be lower than the stated willingness to join. Still, a CHI scheme should present an interesting financing alternative in rural areas where services are scarce and difficult to sustain.

OBJETIVO: El objetivo principal de este estudio fue evaluar la voluntad de los habitantes de El Páramo, una zona rural en el Ecuador, de participar en un seguro de salud comunitario y determinar los factores que influían en dicha voluntad. Otro objetivo fue identificar la comprensión y las actitudes de la población hacia el modelo presentado. MÉTODOS: Se llevó a cabo una encuesta transversal usando un cuestionario estructurado. De unos 829 hogares, 210 se escogieron aleatoriamente mediante un muestreo por conglomerados en dos etapas. Se analizaron las actitudes hacia un esquema de seguro de enfermedad, se recopiló información sobre los factores que posiblemente influían en la voluntad de participar y se correlacionaron con esta última. Para comprender la posible capacidad de pago de un entrevistado, se evaluó el gasto en atención de la salud en el último episodio de enfermedad. Se definió "factibilidad" como la existencia de voluntad de participar en el esquema de seguro de enfermedad en al menos 50 por ciento de los jefes de hogar. RESULTADOS: La voluntad de participar en un modelo de seguro de enfermedad por un costo de US$ 30 por año fue de 69,3 por ciento. El 92,2 por ciento de los entrevistados declararon que, en el caso de adherirse al programa, concurrirían al establecimiento de salud local más a menudo. El nivel educativo presentó una correlación negativa con la voluntad de participar, pero otras variables no mostraron ninguna asociación significativa con ella. El estudio reveló una actitud positiva hacia el esquema del seguro de enfermedad. Se documentaron gastos de atención de salud importantes en el último episodio de enfermedad. CONCLUSIONES: La puesta en marcha de un seguro de enfermedad en la zona de estudio es factible. Sin embargo, es probable que la participación real sea inferior a la voluntad de participar declarada. Aun así, un esquema de seguro de enfermedad podría representar una opción financiera interesante en las zonas rurales donde los servicios son escasos y difíciles de mantener.