La Política Fiscal en la encrucijada. El caso de América Central

La política fiscal en América Central enfrenta serios problemas. Los niveles actuales de inversión en infraestructura y de gasto público en educación, salud y seguridad son claramente insuficientes frente a lo que se requiere para impulsar un proceso sostenido de crecimiento con bienestar y equidad en un contexto de globalización y democracia. Verificar de manera sistemática, pública y comprensiva la eficacia con que se utilizan los recursos públicos en el ámbito nacional y local para alcanzar los resultados y las metas de desarrollo es todavía una asignatura pendiente

Effects of PACK guide training on the management of asthma and chronic obstructive pulmonary disease by primary care clinicians: a pragmatic cluster randomised controlled trial in Florianópolis, Brazil

Introduction The Practical Approach to Care Kit (PACK) guide was localised for Brazil, where primary care doctors and nurses were trained to use it. Methods Twenty-four municipal clinics in Florianópolis were randomly allocated to receive outreach training and the guide, and 24 were allocated to receive only the guide. 6666 adult patients with asthma or chronic obstructive pulmonary disease (COPD) were enrolled, and trial outcomes were measured over 12 months, using electronic medical records. The primary outcomes were composite scores of treatment changes and spirometry, and new asthma and COPD diagnosis rates. Results Asthma scores in 2437 intervention group participants were higher (74.8%, 20.4% and 4.8% with scores of 0, 1 and 2, respectively) than in 2633 control group participants (80.0%, 16.8% and 3.2%) (OR for higher score 1.32, 95% CI 1.08 to 1.61, p=0.006). Adjusted for asthma scores recorded in each clinic before training started, the OR was 1.24 (95% CI 1.03 to 1.50, p=0.022). COPD scores in 1371 intervention group participants (77.7%, 17.9% and 4.3% with scores of 0, 1 and 2) did not differ from those in 1181 control group participants (80.5%, 15.8% and 3.7%) (OR 1.21, 95% CI 0.94 to 1.55, p=0.142). Rates of new asthma and COPD diagnoses, and hospital admission, and indicators of investigation, diagnosis and treatment of comorbid cardiovascular disease, diabetes and depression, and tobacco cessation did not differ between trial arms. Conclusion PACK training increased guideline-based treatment and spirometry for asthma but did not affect COPD or comorbid conditions, or diagnosis rates

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Costa Rica: Política tributaria para el desarrollo humano

El presente trabajo constituye una versión resumida de un estudio más amplio elaborado en el marco del proyecto Reforma tributaria para el desarrollo humano en América Central y República Dominicana. El autor realiza un análisis de la estructura tributaria de Costa Rica y considera que la posibilidad de una crisis fiscal en Costa Rica surge simultáneamente de la insuficiencia de los ingresos del sector público y de la rigidez y baja calidad del gasto público. En consecuencia, uno de los elementos centrales de un programa orientado a evitar que la situación fiscal se agrave es un incremento permanente de los ingresos fiscales, sin perjuicio de que simultáneamente se adopten medidas para garantizar el equilibrio fiscal de largo plazo y para mejorar la calidad del gasto público. En una segunda sección el análisis se focaliza en la evaluación de las diversas opciones para el incremento de la recaudación tributaria a partir de diferentes escenarios, utilizando modelos de simulación impositiva

The Organization of Public-Private Cooperation for Productive Development Policies

Productive development policies (PDPs), what used to be called industrial policies, are increasingly recognized as an essential part of the development toolkit, and the need for public-private cooperation is increasingly viewed as a key element for the successful design and implementation of such policies. If so, how should the cooperation be organized and how should the public sector organize itself to successfully participate in it? This paper suggests that public sector organization should be a response to three key variables: the scope of the PDP, the scope of the intended cooperation, and the organizational characteristics of the private sector. It further proposes the appropriate selection of public sector participants; the alignment of policy, political, and organizational time frames; the ensured quality of the bureaucracy; the protection against private and bureaucratic capture and against unbounded financial risk; and a reasonable regulatory environment of key elements for success.

Costa Rica: Política tributaria para el desarrollo humano

El presente trabajo constituye una versión resumida de un estudio más amplio elaborado en el marco del proyecto Reforma tributaria para el desarrollo humano en América Central y República Dominicana. El autor realiza un análisis de la estructura tributaria de Costa Rica y considera que la posibilidad de una crisis fiscal en Costa Rica surge simultáneamente de la insuficiencia de los ingresos del sector público y de la rigidez y baja calidad del gasto público. En consecuencia, uno de los elementos centrales de un programa orientado a evitar que la situación fiscal se agrave es un incremento permanente de los ingresos fiscales, sin perjuicio de que simultáneamente se adopten medidas para garantizar el equilibrio fiscal de largo plazo y para mejorar la calidad del gasto público. En una segunda sección el análisis se focaliza en la evaluación de las diversas opciones para el incremento de la recaudación tributaria a partir de diferentes escenarios, utilizando modelos de simulación impositiva.Desarrollo social, Crisis financieras y estabilización económica, Política fiscal, Costa Rica, Desarrollo humano, NFP

Endogenous Switching Systems: Issues, Options, and Application to the U.S. Dairy Sector

This research explores the theoretical and applied issues associated with endogenous switching systems where market prices are bounded by policy instruments such as price supports Options for estimation of model parameters and their associated standard errors are identifdied and explored Application to the US dairy sector illustrates the research tradeoffs between conceptual rigor and empirical tracrability that characterize these models Results suggest that failure to explicitly address the endgenous switching context compromises the estimation result