Estimating health service utilization for treatment of pneumococcal disease: the case of Brazil.

BACKGROUND: Health service utilization (HSU) is an essential component of economic evaluations of health initiatives. Defining HSU for cases of pneumococcal disease (PD) is particularly complex considering the varying clinical manifestations and diverse severity. OBJECTIVE: We describe the process of developing estimates of HSU for PD as part of an economic evaluation of the introduction of pneumococcal conjugate vaccine in Brazil. METHODS: Nationwide inpatient and outpatient HSU by children under-5 years with meningitis (PM), sepsis (PS), non-meningitis non-sepsis invasive PD (NMNS), pneumonia, and acute otitis media (AOM) was estimated. We assumed that all cases of invasive PD (PM, PS, and NMNS) required hospitalization. The study perspective was the health system, including both the public and private sectors. Data sources were obtained from national health information systems, including the Hospital Information System (SIH/SUS) and the Notifiable Diseases Information System (SINAN); surveys; and community-based and health care facility-based studies. RESULTS: We estimated hospitalization rates of 7.69 per 100,000 children under-5 years for PM (21.4 for children <1 years of age and 4.3 for children aged 1-4 years), 5.89 for PS (20.94 and 2.17), and 4.01 for NMNS (5.5 and 3.64) in 2004, with an overall hospitalization rate of 17.59 for all invasive PD (47.27 and 10.11). The estimated incidence rate of all-cause pneumonia was 93.4 per 1000 children under-5 (142.8 for children <1 years of age and 81.2 for children aged 1-4 years), considering both hospital and outpatient care. DISCUSSION: Secondary data derived from health information systems and the available literature enabled the development of national HSU estimates for PD in Brazil. Estimating HSU for noninvasive disease was challenging, particularly in the case of outpatient care, for which secondary data are scarce. Information for the private sector is lacking in Brazil, but estimates were possible with data from the public sector and national population surveys.

Cost-effectiveness analysis of universal childhood vaccination against varicella in Brazil.

This study conducts a cost-effectiveness analysis of a childhood universal varicella vaccination program in Brazil. An age and time-dependent dynamic model was developed to estimate the incidence of varicella for 30 years. Assuming a single-dose schedule; vaccine efficacy of 85% and coverage of 80%, the program could prevent 74,422,058 cases and 2905 deaths. It would cost R$ 3,178,396,110 and save R$ 660,076,410 to the society and R$ 365,602,305 to the healthcare system. The program is cost-effective (R$ 14,749 and R$ 16,582 per life-year saved under the societal and the healthcare system's perspective, respectively). The program's cost-effectiveness is highly sensitive to the vaccine price and number of doses.

Association between ambient air pollution and birth weight in São Paulo, Brazil.

OBJECTIVES: Previous studies have implicated air pollution in increased mortality and morbidity, especially in the elderly population and children. More recently, associations with mortality in infants and with some reproductive outcomes have also been reported. The aim of this study is to explore the association between exposure to outdoor air pollution during pregnancy and birth weight. DESIGN: Cross sectional study using data on all singleton full term live births during a one year period. For each individual birth, information on gestational age, type of delivery, birth weight, sex, maternal education, maternal age, place of residence, and parity was available. Daily mean levels of PM(10), sulphur dioxide, nitrogen dioxide, carbon monoxide, and ozone were also gathered. The association between birth weight and air pollution was assessed in regression models with exposure averaged over each trimester of pregnancy. SETTING: São Paulo city, Brazil. RESULTS: Birth weight was shown to be associated with length of gestation, maternal age and instruction, infant gender, number of antenatal care visits, parity, and type of delivery. On adjusting for these variables negative effects of exposure to PM(10) and carbon monoxide during the first trimester were observed. This effect seemed to be more robust for carbon monoxide. For a 1 ppm increase in mean exposure to carbon monoxide during the first trimester a reduction of 23 g in birth weight was estimated. CONCLUSIONS: The results are consistent in revealing that exposure to air pollution during pregnancy may interfere with weight gain in the fetus. Given the poorer outlook for low birthweight babies on a number of health outcomes, this finding is important from the public health perspective.

[Evaluation of health programs, services and technologies]. / Avaliação de programas, serviços e tecnologias em saúde.

The field of program, services and technology evaluation in general, and in health care in particular, is going through an important growth and conceptual and methodological diversification. It is also the object of an increasing demand for its participation as an effective supportive instrument in the decision-making process, and a constant need in the dynamics of health systems and services. In this paper, based on literature review, nuclear criteria involved in the organization of all evaluation processes are identified, and articulated with the existing institutionalized evaluation practices in developed countries, that is, program evaluation, quality assessment and management and technology assessment. In conclusion, the incipient development of a methodological evaluation output in Brazil is analyzed.

Social impacts of technological diffusion: prenatal diagnosis and induced abortion in Brazil.

Scientific and technological development plays an essential part in shaping contemporary societies, and medicine and health care are considered to be particularly receptive to the incorporation of new concepts, techniques and products, producing impacts not only on the health problems for which they were originally intended, but also varied 'side-effects', less frequently recognised and studied. In this study the point of departure was the hypothesis that the intensive diffusion in Brazil of prenatal ultrasound would create new problems for individuals (pregnant women, their families and health professionals) and society in coping with foetal malformations, due to the existence of a very restrictive induced abortion legislation. The objective of the research was to study the social visibility of these problems, in the written mass media. The period under analysis went from 1991 to 1996. The four most important daily newspapers and two medical council journals were studied, with a criteria oriented selection of articles, and their macrotextual thematic analysis. The results indicate that the basic elements in the relationships between medical technology, prenatal diagnosis, foetal malformations and induced abortions stayed the same along the period - a restrictive Penal Code, the public recognition of the disseminated and usually tolerated practice of induced abortion, done in risky conditions for the majority of women, with very evident consequences on maternal health, a divided Congress, a divided 'public opinion', religious opposition and new scientific and technological practices in health care. Nevertheless, tension between these 'contradictory' factors increases, so much so, that new elements are introduced which make an accommodation possible, without implying in major changes of position. This is achieved through the development of new alliances between Science, the judiciary and obstetrical leaders, which benefit individual initiatives, instead of leading to a public recognition of the problem and changes in the law.

[Training of local health managers: process of identification of strategic actions]. / Formação de gestores locais de saúde: processos para identificar estratégias de atuação.

In Brazil, in recent years, as a result of the increasing participation of county authorities in health care, a need for tools which would contribute to the better preparation of local administrators, complementary to the activities of a more academic nature, has been recognized. One of the possible alternatives is the exploitation of experiences, regarded as successful, in local health care planning and administration, by using them as material for "case studies" in activities with selected groups of health care administrators thus, stimulating the identification of those elements which contributed to the favorable results attained, and their interactions, in the quest for analogies which would facilitate the identification of new perspectives for their own situations. In this article an experience of a "case studies" development, in response to a demand from UNICEF, based on 8 counties in from the North and Northeast, which were successful in using a "focus approach" in their organization of data and their utilisation in a seminar with 21 local managers from both regions, is presented. During the seminar the local health managers attained greater knowledge of the strategies implemented and identified feasible intervention alternatives. The methodological proposition of teaching on the basis of case studies, using a conceptual strategy of grouping experiences according to specific dimensions enabled local health managers to learn from their practical experiences.

Hospitals in Latin America and the Caribbean.

Health services provided by public or private institutions at the primary and hospital referral levels should be coordinated so that the available resources are distributed equitably to meet the needs and aspirations of the population. The challenge is to improve the quality of hospital care and the existing pattern of public and private services in Latin America and the Caribbean.

[Reorganization of the health sector: contribution to education in the administration of health services]. / Reorganización del sector salud: contribución a la educación en administración de servicios de salud.

This article discusses some of the difficulties traditionally encountered in endeavors to reorganize health services and the various obstacles to be surmounted if the changes proposed by planners are to be brought about and their goals achieved. In view of the need for the countries of the Americas to find alternative ways to reorganize their health sectors so that all members of their populations can be properly served, the author considers the utility of the so-called "matrix" criterion, which has been used in economics and general administration for the past decade. It is admitted that problems can arise in efforts to apply this approach, but it is felt that, if the resources of the different units and sectors are used jointly under the responsibility of a coordinator of operations, it will be possible to work in an integrated way toward the established goals.

Reorganizacion del sector salud: contribucion a la educacion en administracion de servicios de salud. / Reorganization of the health sector: contribution to the education in health service administration

En este articulo se analizan algumas de las dificultades con que se tropieza tradicionalmente al tratar de reorganizar los servicios de salud y los obstaculos de diversa natureza que hay que superar al respecto si se quieren implantar los cambios necesarios y las metas propuestas por los planificadores. Ante la necesidad de que los paises de las Americas encuentren soluciones alternativas de reorganizacion del sector salud a fin de servir adecuadamente a toda la poblacion, el autor considera la conveniencia de aplicar al respecto el criterio denominado "matricial", que se ha venido utilizado en economia y en la administracion en general desde el pasado decenio. Se admite que pueden surgir algunos problemas al tratar de implantar ese enfoque, pero se estima que al utilizar los recursos de distintas unidades y sectores en forma conjunta y bajo la responsabilidad de un coordinador de las actividades, podra trabajarse de manera integrada para alcanzar las metas que se desea alcanzar