Welfarism and extra-welfarism: a critical overview / Welfarism e extra-welfarism: uma visão crítica / Welfarism y extra-welfarism: una visión crítica

Abstract: Rules and principles for guiding decision-making in the health care sector have been debated for decades. Here, we present a critical appraisal of the two most important paradigms in this respect: welfarism and extra-welfarism. While the former deals with the maximization of the overall sum of individual utilities as its primary outcome, the latter has been focusing on the maximization of the overall health status. We argue that welfarism has three main problems: (1) its central idea of overall sum of individual utilities does not capture societal values decisively relevant in the context of health; (2) the use of the Potential Pareto Improvement brings an unresolvable separation between efficiency and equity; and (3) individual utility may not be a good measure in the health sector, given that individuals might value things that diminish their overall health. In turn, the extra-welfarist approach is criticized regarding four main limitations: (1) the advocated expansion of the evaluative space, moving from utility to health, may have represented in reality a narrowing of it; (2) it operates using non-explicit considerations of equity; (3) it still holds the issue of "inability to desire" of unprivileged people being considered the best judges of weighing the criteria used to building the health measures; and (4) there is controversial empirical evidence about society members' values that support its assumptions. Overall, both paradigms show significant weaknesses, but the debate has still been within the realm of welfare economics, and even the new approaches to resource allocation in health care systems appear to be unable to escape from these boundaries.

Resumo: Há décadas se discutem as regras e os princípios para a tomada de decisões no setor de saúde. O artigo apresenta uma avaliação crítica dos dois paradigmas mais importantes nessa área: welfarism e extra-welfarism. O primeiro lida com a maximização da soma total das utilidades individuais como desfecho primário, enquanto o segundo concentra-se na maximização do estado geral de saúde. Argumentamos que o welfarism apresenta três problemas principais: (1) a ideia central da soma total das utilidades individuais não capta os valores da sociedade que são decisivos no contexto da saúde; (2) o uso da Potencial Melhoria de Pareto introduz uma separação irresolvível entre eficiência e equidade e (3) a utilidade individual pode não ser uma medida adequada no setor da saúde, uma vez que os indivíduos podem valorizar coisas que diminuem seu estado geral de saúde. Enquanto isso, os críticos apontam quatro limitações principais na abordagem extra-welfarist: (1) a proposta de expansão do espaço avaliativo, passando da utilidade para a saúde, na realidade pode redundar no estreitamento desse mesmo espaço; (2) a abordagem opera com considerações não explícitas de equidade; (3) ainda mantém a questão da "incapacidade de desejar" das pessoas de baixa renda que são consideradas os melhores avaliadores dos critérios utilizados para construir as medidas de saúde e (4) há controvérsias em torno das evidências empíricas sobre os valores dos membros da sociedade que sustentam as premissas. No geral, ambos os paradigmas demonstram fraquezas significativas, mas o debate continua dentro do campo da economia do bem-estar social, e mesmo as novas abordagens à alocação de recursos nos sistemas de saúde parecem ser incapazes de fugir desses limites.

Resumen: Las normas y los principios para guiar la toma de decisiones en el sector de la salud se han debatido durante décadas. Presentamos una valoración crítica de los dos paradigmas más importantes a este respecto: el welfarism y el extra-welfarism. Mientras que el primero se ocupa de la maximización de la suma global de las utilidades individuales como su resultado primario, este último se ha centrado en la maximización del estado general de salud. Argumentamos que el welfarism tiene tres problemas principales: (1) su idea central de la suma global de las utilidades individuales no captura los valores societales decisivamente relevantes en el contexto de la salud; (2) el uso de la Mejora Potencial de Pareto trae una separación insoluble entre la eficiencia y la equidad; y (3) la utilidad individual puede no ser una buena medida en el sector de la salud, dado que las personas pueden valorar cosas que disminuyen su salud general. A su vez, el enfoque extra-welfarista es criticado con respecto a cuatro limitaciones principales: (1) la expansión del espacio evaluativo propugnada, pasando de la utilidad a la salud, puede haber representado en la realidad un estrechamiento de la misma; (2) opera con consideraciones no explícitas de equidad; (3) todavía sostiene la cuestión de la "inhabilidad de deseo" de las personas no privilegiadas que se consideran los mejores jueces de pesar los criterios usados para construir las medidas de la salud; y (4) hay evidencia empírica polémica sobre los valores de los miembros de la sociedad que apoyan sus suposiciones. En general, ambos paradigmas muestran debilidades significativas, pero el debate aún se encuentra dentro del ámbito de la economía del bienestar, e incluso los nuevos enfoques para la asignación de recursos en los sistemas de atención de salud parecen ser incapaces de escapar de estos límites.

Correlation between Drug Market Withdrawals and Socioeconomic, Health, and Welfare Indicators Worldwide

The relationship between the number of withdrawn/restricted drugs and socioeconomic, health, and welfare indicators were investigated in a comprehensive review of drug regulation information in the United Nations (UN) countries. A total of of 362 drugs were withdrawn and 248 were restricted during 1950-2010, corresponding to rates of 12.02+/-13.07 and 5.77+/-8.69 (mean+/-SD), respectively, among 94 UN countries. A socioeconomic, health, and welfare analysis was performed for 33 OECD countries for which data were available regarding withdrawn/restricted drugs. The gross domestic product (GDP) per capita, GDP per hour worked, health expenditure per GDP, and elderly population rate were positively correlated with the numbers of withdrawn and restricted drugs (P<0.05), while the out-of-pocket health expenditure payment rate was negatively correlated. The number of restricted drugs was also correlated with the rate of drug-related deaths (P<0.05). The World Bank data cross-validated the findings of 33 OECD countries. The lists of withdrawn/restricted drugs showed markedly poor international agreement between them (Fleiss's kappa=-0.114). Twenty-seven drugs that had been withdrawn internationally by manufacturers are still available in some countries. The wide variation in the numbers of drug withdrawals and restrictions among countries indicates the need to improve drug surveillance systems and regulatory communication networks.

The Change of the Health Insurance Policy and Social Welfare Discourse in 1970s / 의사학

This study is to analyze the change of the health insurance policy in the 1970s in relation to social welfare discourse. The public health care in Korea was in very poor condition around the first amendment of the National Health Insurance Act in 1970. Furthermore, due to the introduction of new medical technology, increasing number of big hospitals participating in the medical market, inflation, and other factors, medical expenses skyrocketed and made it hard for ordinary people to enjoy medical services. Accordingly, the social solution to the problem of medical expenses which an individual found hard to deal with became of demand. And as the way to the solution, it was inevitable to consider the introduction of health insurance as social insurance. In this condition, Park regime began to stress the social development from the 1960s. It was to aim to settle various social problems triggered by the rapid industrialization in the 1960s through social development as well as economic development. As the social development was emphasized, the matter of social welfare appeared of importance and led to the first amendment of the National Health Insurance Act in 1970. However, it was impossible for Korean government to enforce a nationwide health insurance. The key issue was how to fund it. Park regime was reluctant to use government fund; it was also hard to burden private companies. Even while the health insurance policy was not determined yet for this reason, the social demand for health insurance became large and large. In particular, in the midst of the first "Oil Shock" which gave a big blow to people's living condition from the late 1973, some reported issues in relation to health service, such as hospitals' rejection of the poor, became a big problem. Coupled with the social demand for a health insurance system, the changes occurred within the medical community was also important. Most of all, hospitals was facing the decrease of the effectiveness of their medical facilities. Therefore, they began to see health insurance as a means of developing potential demand for medical service. In addition, the business world, which already expanded their own corporate welfare for employees from the early 1970s, sharing the idea that it was impossible to keep the issue of public health insurance unsolved, showed an enthusiastic attitude. These factors finally enabled Park regime to adopt the public health insurance system. Likewise, it is critical to understand the establishment of the public health insurance system in Korea through pursuing the process to it. What matters is the discoursive changes as well as the changes in social condition around the establishment, not merely the policy changes per se. Then most people, including decision makers in Park regime, thought of social welfare as a privilege developed countries. Thus, in the 1970s when unbalanced industrialization brought about widening gap between social classes, the employment of a social welfare policy could be recognized as a symbol of an escape from backwardness. In fact, with the introduction of the national health insurance in the 1970s, Park regime could fortify the material fundamental of a social welfare discourse which would be mobilized to strengthen the dichotomous discourse of developedness and backwardness and to dump the social crisis caused by Park regime's industrialization drive on the next generation.

The German Social Democratic Party(SPD) and the Debate on the Fertility Decline in the German Empire (1870~1918) / 의사학

This paper aimed to examine the debate over the fertility decline in the German Empire, focusing on the role of the SPD. During the German Empire, the fertility rate dramatically declined and the growing awareness of a continuous decline in the birth rate prompted a massive debate among politicians, doctors, sociologists, and feminist activists. The fertility decline was negatively evaluated and generated consciousness of crisis. However, it was not the only way to face this new phenomenon. Indeed, the use of birth control among the upper class was interpreted as a part of a modernizing process. As the same phenomenon reached the working class, it suddenly became a social problem and was attributed to the SPD. The debate over the fertility decline in imperial German society ridden with a fierce class conflict was developed into a weapon against the SPD. Contrary to the assumption of conservative politicians, the SPD had no clear-cut position on this issue. Except for a few politicians like Kautsky and the doctors who came into frequent contact with the workers, the "birth strike" was not listed as the main interest of the SPD. Even Clara Zetkin, the leader of the Social Democratic women's organization viewed it as a concern of the individual person which could not be incorporated in the party program. The women's organization of the SPD put priority on class conflict rather than issues specific to women. As a result, the debate over the birth rate decline within the SPD was not led by the women themselves. There could have been various means to stimulate the birth rate. Improvement in the welfare system, such as tax relief for large families, better housing conditions, and substantial maternity protection, could have been feasible solutions to the demographic crisis. However, Germany chose to respond to this crisis by imposing legal sanctions against birth control. In addition to paragraphs 218-220 of the German criminal law enacted in 1872 which prescribed penal servitude for anyone who had an abortion or people who helped to practice it, Paragraph 184.3 of the civil code was enacted in order to outlaw the advertising, display, and publicizing of contraceptives with an 'indecent' intention, although selling or manufacturing contraceptives was not forbidden. Such a punitive approach was especially preferred by the government and conservative parties because it was easy to implement and "cheap" in comparison with the comprehensive social welfare program. What made the SPD different from other conservative parties was the fact that the SPD opposed the government's attempt to prohibit contraception by means of strengthening a penal code. According to the SPD, it was not only morally unacceptable, but also technically impossible for the government to intervene in family limitation. Moreover, politicians from the SPD criticized that such a punitive policy targeted the working class because the upper echelon of the society could easily evade the ban on contraceptives. However, the SPD did not proceed to draft comprehensive social welfare measures in order to fight the fertility decline. The miserable condition of working class women remained as an invisible social phenomenon even within the SPD. The German women who could not find the proper means to practice contraception were driven to have abortions. Annually, hundreds of the women were accused of practicing abortion and imprisoned. In sum, German society ran about in confusion and did not know how to properly respond to the unprecedented decline in fertility. By defining the fertility decline just as a social disease due to moral decay and influence of socialism, German society lost a chance to rationalize itself. Given that women, the main actors, had no way to take part in the debate over this issue, it is not surprising that German society fought against the symptom of the disease, not against its root.

Problems faced by Korean patients with chronic liver disease and the role of the Korean Association for the Study of the Liver: Emphases on social discrimination, insufficiency of reimbursement coverage, and deficiency of the welfare system / 대한간학회지

No abstract available.

Questões emergentes na análise demográfica: o caso brasileiro / New issues in demographic analysis: the case of Brazil

Este artigo levanta questões emergentes para a análise demográfica brasileira. O trabalho começa com uma análise dos três componentes da dinâmica demográfica, enfatizando a questão sobre o declínio da fecundidade e a possibilidade de a mesma atingir níveis abaixo da reposição. As tendências futuras de emigração internacional também são discutidas. Passando para as conseqüências demográficas desta dinâmica, o texto aborda, ainda, a demografia dos efeitos de composição, ressaltando as conseqüências demográficas do diferencial de fecundidade por educação materna e mostrando que a dinâmica de melhoria educacional das mães mais que compensa este diferencial. O dividendo demográfico é discutido tanto conceitualmente quanto empiricamente, ficando indicada uma agenda para estudos futuros. Finalmente, uma discussão mais conceitual sobre transferências intergeracionais tenta colocar o debate na perspectiva do gasto público brasileiro, enfatizando trabalhos relevantes que começam a ser desenvolvidos.

This article begins with a review of the three components of demography, stressing the decline in fertility, with the possibility of the country's reaching a level of below replacement fertility. Studies on new trends in Brazilian emigration are considered relevant for future research. The demography of compositional effects is discussed in terms of an exercise with fertility differentials according to the mothers´ education. The exercise shows that the historical improvement in mothers´ education has offset the possible adverse effects of high fertility among mothers with low levels of education. The demographic dividend is discussed both conceptually and empirically, and directions for future studies are indicated. Finally, the article presents a conceptual discussion on intergenerational transfers, with emphasis on public expenditures and social policy. New studies being developed on this topic are also mentioned.

Las personas con discapacidad: su calidad de vida y la de su entorno / The people with discapacidad: its quality of life and the one of its surroundings

El presente artículo se dirige no solo a los profesionales del área de la salud, sino a todas las personas interesadas en el mejoramiento de la calidad de vida de las personas con discapacidad, mediante la explicación de la diferencia entre los conceptos de discapacidad y minusvalía, y con argumentos que permiten el cambio de mentalidad hacia los individuos que la presentan

Inserçäo no mercado de trabalho: diferenças por sexo e conseqüências sobre o bem-estar / Insert in work market: difference by sex and consequences about the welfare

Relata que, no período recente, a participação das mulheres na força de trabalho tem melhorado rapidamente, qualitativa e quantitativamente, em resposta a mudanças culturais e econômicas. Aponta que, no Brasil, as mulheres apresentam nível educacional médio superior ao dos homens, o que deveria resultar em melhores oportunidades de emprego. Afirma que essa predição não é verdadeira resultando numa perda de bem-estar. Mensura essa perda. Conclui que a melhora no padrão de inserçao feminino no mecado de trabalho tem efeitos bastante limitados sobre o bem-estar familiar.

A transposiçäo de teorias sobre a institucionalizaçäo do "Welfare State" para o caso dos países subdesenvolvidos / The transposition of theories about the institutionalization of the \"Welfare State\"to the case of developing coutries

Analisa a transposição de algumas teorias bem consolidadas sobre a trajetória do "welfare State" nos países desenvolvidos da América do Norte ou da Europa Ocidental para países subdesenvolvidos. Destaca que devido a diferenças entre países desenvolvidos e subdesenvolvidos em aspectos como segmentação da sociedade, peculiaridades da cultura política, nível de influência dos movimentos de trabalhadores e capacidade de governo da burocracia, adaptações nessas teorias são necessárias para que a transposição seja realizada de forma adequada.

O acesso ao capital dos idosos brasileiros: uma perspectiva do ciclo da vida / The acess to the capital of Brazilian old-aged: a perspective of the life cicle

Descreve o acesso aos diversos tipos de capital por grupos etários, dando especial ênfase aos chefes de família idosos. Utiliza perfis etários estáticos e análises de coorte. Estrutura a análise da posse de recursos em três grupos: Capital Físico (bens duráveis, moradia e serviços públicos), Capital Humano (escolaridade, educacão técnica, experiência e treinamento) e Capital Social (emprego, sindicatos e associações, participação política e estrutura familiar). Analisa os efeitos da posse de ativos sobre o nível de bem-estar social em três categorias.

Effectiveness and cost analysis of community-based rehabilitation service in Bangkok.

This paper aimed to clarify the effectiveness and the cost of the community-based rehabilitation service in Klong Toey slum after a three year study period. One hundred and seventy eight patients used community-based rehabilitation during the three year period. One hundred and fifty-seven patients (86.5%) reported that their problems/conditions were cured or improved. Only nine patients (5.1%) reported that they stopped using community-based rehabilitation because their problems/conditions did not improve. A statistically significant improvement in pain level and walking velocity assessment, in 105 and 78 patients respectively, was demonstrated. Total cost and cost per patient-day of the community-based rehabilitation were Bt 559,920 and Bt 111.1 respectively. Cost per-patient-day of this community-based rehabilitation service was compared with an estimated cost per patient-day of using rehabilitation services at Chulalongkorn University Hospital and was found to be cheaper. This study supported the role of community-based rehabilitation in Thailand. The need for a health service study in rural areas was also noted.

Gasto federal en salud en población no asegurado: México 1980-1995 / Federal expenditure in health for non insured population: Mexico 1980-1995

Las crisis económicas que ha afectado a México desde principios de los años ochenta han influido de manera determinante en el gasto público en salud. En este trabajo se discute la relación que ha existido entre las estrategias de ajuste y el gasto en salud en población no asegurada, así como la distribución de este gasto por regiones. En la primera parte se describe la evolución del gasto público general, el gasto en bienestar social y el gasto público en salud en México entre 1980 y 1995. En la segunda parte se describe con mayor detalle la distribución del gasto público en salud en ese mismo periodo entre la población no asegurada de las cinco regiones en las que dividió al país la Encuesta Nacional de Salud II. La principal conclusión que se desprende de este trabajo es que en el periodo 1980-1995 se mantuvieron las brechas en el gasto en salud para población no asegurada que desde tiempos remotos existen entre las cinco regiones de México. Estas brechas afectan sobre todo a los estados más marginados -que se ubican en su gran mayoría en el sur del país-, no guardan ninguna relación con las diferencias regionales en las condiciones de salud y corren el riesgo no sólo de mantenerse sino incluso de profundizarse como resultado de los nuevos recortes relativos del gasto en bienestar social que contempla la política de ajuste adoptada por la presente administración

A construçäo da pobreza como objeto de política pública / The poverty building as object of the public policy

Trata da construçäo da pobreza como objeto de política pública e está dividido em duas partes. Na primeira reconstitui os termos do debate sobre a pobreza, nos países de capitalismo avançado, analisando: (i) como a representaçäo social e o tratamento político da pobreza prevalecentes nos anos 60/70 se diferenciam dos atuais; (ii) em que medida a emergência do que diversos autores vêm chamando de "nova pobreza" se constitui efetivamente em uma problemática teórica e prática nova; e (iii) que mudanças se delineiam no papel do Estado e no desenho das políticas públicas relativas à pobreza, tendo os EUA e a França como casos paradigmáticos. Na segunda parte, desloca a análise para o caso brasileiro, chamando a atençäo para o fato de que apesar do quadro de desigualdades, pobreza e exclusäo existente no país, a questäo social é eclipsada por temas econômicos, sem lograr produzir uma política global, que mobilize e articule os esforços do Estado e da sociedade civil.

El estado de bienestar y sus efectos distributivos: parte del problema o parte de la solución / Social welfare: solution or problem?

Presenta un examen de algunos de los principales argumentos contra el Estados de Bienestar que esgrimen las fuerzas neoliberates a ambos lados del Atlántico y información empírica que muestra la naturaleza, más ideológica que científica, de tales argumentos. Alternativas a las políticas de austeridad que defienden las fuerzas contrarias al Estado de Bienestar, propuestas basadas en la expansión del carácter universalista del Estado de Bienestar y en su democratización, con la participación activa de los municipios en la administración de los servicios de Estado de Bienestar y en el desarrollo de las políticas reflaccionarias destinadas a guiar la producción y estimular el consumo