Reação diante de medidas preventivas em saúde: uma análise econômica

There are many circumstances in which the effectiveness of preventive measures depends to a large extent on the compliance of the patient in changing his or her behavior or lifestyle. It is shown how economic techniques can be used (i) to describe the rationale of individuals and predict their behavior (Section 2); and (ii) to assess preventive measures that, by requiring a change of conduct, imply "costs" to the individual due to a decline in the quality of life (Appendix). Cigarette smoking and coronary heart disease are used as an illustration. While the analysis of Section 2 uses graphical techniques, a simple textbook-type of lifetime utility model with a mathematical emphasis is used in the Appendix. It is also shown that techniques often used to assess health care programs such as the QALYs (Quality-Adjusted Life Years) are inappropriate to the evaluation of preventive programs aiming at behavioral changes. Finally, topics that call for further research are indicated.A efetividade de muitas intervenções preventivas depende da capacidade do paciente em alterar seu comportamento ou estilo de vida. São intervenções nas quais o indivíduo exerce um papel ativo. Procurou-se mostrar como o instrumental econômico pode ser usado para: (i) prever comportamentos e descrever sua lógica; e (ii) avaliar medidas de prevenção que, por implicarem mudança de comportamento, geram "custos" em termos de queda na qualidade de vida (Apêndice). O caso do fumo e doença coronariana do coração é utilizado como ilustração. Enquanto a análise do primeiro item utiliza técnicas gráficas, a do segundo (Apêndice) utiliza-se de um modelo mais formal, porém simples (de livro-texto) para a representação de utilidade ao longo do ciclo de vida. Mostrou-se também que técnicas freqüentemente utilizadas na avaliação de programas de saúde como os "QALYs" ("Quality-Adjusted Life Years" ou Anos de Vida Qualitativamente Ajustados) são inadequados para programas preventivos voltados à alteração de comportamento. São sugeridos alguns tópicos que necessitam de investigação mais profunda

Funding and service organization to achieve universal health coverage for medicines : an economic evaluation of the best investment and services organization for the Brazilian scenario

Background: There are many health benefits since 31 years after the foundation of the National Health Service (NHS) in Brazil, especially the increase in life expectancy. However, family-income inequalities, insufficient funding, and suboptimal private sector–public sector collaboration are still areas for improvement. The efforts of Brazil to achieve universal health coverage (UHC) for medicines have resulted in increased public financing of medicines and their availability, reducing avoidable hospitalization and mortality. However, lack of access to medicines still remains. Due to historical reasons, pharmaceutical service organization in developing countries may have important differences from high-income countries. In some cases, developing countries finance and promote medicine access by using the public infrastructure of health care/medical units as dispensing sites and cover all costs of medicines dispensed. In contrast, many high-income countries use private community pharmacies and cover the costs of medicines dispensed plus a fee, which includes all logistic costs. In this study, we will undertake an economic evaluation to understand the funding needs of the Brazilian NHS to reduce inequalities in access to medicines through adopting a pharmaceutical service organization similar to that seen in many high-income countries with hiring/accrediting private pharmacies. Methods: We performed an economic evaluation of a model to provide access to medicines within public funds based on a decision tree model with two alternative scenarios public pharmacies (NHS, state-owned facilities) versus private pharmacies (NHS, agreements). The analysis assumed the perspective of the NHS. We identified the types of resources consumed, the amount, and costs in both scenarios. We also performed a budget impact forecast to estimate the incremental funding required to reduce inequalities in access to essential medicines in Brazil. Findings: The model without rebates for medicines estimated an incremental cost of US$3.1 billion in purchasing power parity (PPP) but with an increase in the average availability of medicines from 65$1.3 billion per year (30%). The impact of incremental funding is related to medicine access improvement of 25% in the second year when paying by dispensing fee. The estimate of the incremental budget in five years would be US$4.8 billion PPP. We have yet to explore the potential reduction in hospital and outpatient costs, as well as in lawsuits, with increased availability with the yearly expenses for these at US$9 billion and US$1.4 billion PPP respectively in 2017. Interpretation: The results of the economic evaluation demonstrate potential savings for the NHS and society. Achieving UHC for medicines reduces household expenses with health costs, health litigation, outpatient care, hospitalization, and mortality. An optimal private sector–public sector collaboration model with private community pharmacy accreditation is economically dominant with a feasible medicine price negotiation. The results show the potential to improve access to medicines by 25% for all income classes. This is most beneficial to the poorest families, whose medicines account for 76% of their total health expenses, with potential savings of lives and public resources

Low temperatures reduce skin healing in the Jacaré do Pantanal (Caiman yacare, Daudin 1802)

Studies of skin wound healing in crocodilians are necessary given the frequent occurrence of cannibalism in intensive farming systems. Air temperature affects tissue recovery because crocodilians are ectothermic. Therefore, the kinetics of skin wound healing in Caiman yacare were examined at temperatures of 33°C and 23°C. Sixteen caiman were selected and divided into two groups of eight maintained at 23°C or 33°C. The studied individuals' scars were photographed after 1, 2, 3, 7, 15 and 30 days of the experimental conditions, and samples were collected for histological processing after 3, 7, 15 and 30 days. Macroscopically, the blood clot (heterophilic granuloma) noticeably remained in place covering the wound longer for the caiman kept at 23°C. Microscopically, the temperature of 23°C slowed epidermal migration and skin repair. Comparatively, new blood vessels, labeled using von Willebrand factor (vWF) antibody staining, were more frequently found in the scars of the 33°C group. The collagen fibers in the dermis were denser in the 33°C treatment. Considering the delayed healing at 23°C, producers are recommended to keep wounded animals at 33°C, especially when tanks are cold, to enable rapid wound closure and better repair of collagen fibers because such lesions tend to compromise the use of their skin as leather.Fundação de Amparo à Pesquisa do Estado de Mato Grosso (FAPEMAT), 715823/2008São Paulo Research Foundation (FAPESP), 2010/04527-

Integrative review of managed entry agreements : chances and limitations

Introduction: Managed Entry Agreements (MEAs) consist of a set of instruments to reduce the uncertainty and the budget impact of new high priced medicines; however, there are concerns. There is a need to critically appraise MEAs with their planned introduction in Brazil. Accordingly, the objective is to identify and appraise key attributes and concerns with MEAs among payers and their advisers, with the findings providing critical considerations for Brazil and other high- and middle-income countries. Methods: An integrative review approach was adopted. This involved a review of MEAs across countries. The review question was ‘What are the health technology MEAs that have been applied around the world?’ This review was supplemented with studies not retrieved in the search known to the senior level co-authors including key South American markets. Afterall, involved senior level decision makers and advisers providing guidance on potential advantages and disadvantages of MEAs and ways forward. Results: 25 studies were included in the review. Most MEAs included medicines (96.8%), focused on financial arrangements (43%), and included mostly antineoplastic medicines. Most countries kept key information confidential including discounts or had not published such data. Few details were found in the literature regarding South America. Our findings and inputs resulted in both advantages including reimbursement and disadvantages including concerns with data collection for outcome-based schemes. Conclusion: We are likely to see a growth in MEAs with the continual launch of new high priced and often complex treatments, coupled with increasing demands on resources. Whilst outcome based MEAs could be an important tool to improve access to new innovative medicines there are critical issues to address. Comparing knowledge, experiences and practices across countries is crucial to guide high- and middle-income countries when designing their future MEAs

Occupational Safety and Health in Latin America and the Caribbean: Overview, Issues and Policy Recommendations.

This policy brief addresses safety and security in the workplace in Latin America and the Caribbean. Occupational Safety and Health (OSH) issues have received little attention in Latin America and the Caribbean due to the widespread, and culturally rooted, lack of awareness regarding the importance of a safe and healthy work environment, and to the weakness of the institutions responsible for the promotion and enforcement of better working conditions. Work-generated illnesses, injuries and deaths are often seen as an unintended consequence, a negative externality, of the production process. This paper will present and discuss in detail the dimension of the occupational safety and health problem in the region. The next section analyzes the specific characteristics of Latin American and Caribbean economies and institutions that determine the high exposure to occupational hazards faced by the workers of the region. As discussed in the final section of this paper, there are several non-mutually exclusive policy mechanisms and instruments that can be implemented to deal with occupational safety and health problems.

Seguridad y salud en el trabajo en América Latina y el Caribe: Análisis, temas y recomendaciones de política

En este documento se discute el tema de la seguridad y la salud en el trabajo en América Latina y el Caribe. Abordar esta problemática es una tarea sumamente compleja que requiere tratar las responsabilidades que se superponen entre los ministerios de trabajo y salud y entre aseguradores privados e institutos de seguridad social. Requiere también la participación de asociaciones empresariales y sindicatos de trabajadores, negociadores de comercio internacional y expertos en medio ambiente. Además se necesita tomar decisiones con consecuencias distributivas y sanitarias importantes. Afortunadamente, como se trata en la sección final de este documento, hay varios mecanismos e instrumentos normativos que no se excluyen unos a otros y que pueden implantarse para abordar los temas de salud en el trabajo.

III - Impacto econômico das causas externas no Brasil: um esforço de mensuração

The study seeks to make a first estimate of the economic impact of lesions and poisonings in Brazil, measured in terms of hospital expenses on internments - in days of general permanence and in Intensive Care Units. Internments is hospital under contracts with the United Health System are analysed by means of the AIH - Authorization for Hospital Internment. These internments involve expenses per annum corresponding to approximately 0.07% of the GNP of the country. With regard to mortality, the economic impact has been analysed by the use of the Potential Years of Life Lost indicator. It may be verified that accidents and acts of violence represented about 2.6 million years of life lost in 1981, and 3.4 millions in 1991. The increase was thus of about 30%, even though for the total of data deaths showed a reduction. Despite some limitations, it is possible to estimate the general magnitude of the economic impact of external causes of death. It is hoped that these limitations may serve as a stimulus to new and deeper investigations.Procurou-se obter uma primeira estimativa do impacto econômico das lesões e envenenamentos no Brasil, medido através dos gastos hospitalares com internação - dias de permanência geral e em Unidades de Terapia Intensiva. São analisadas internações em hospitais conveniados com o Sistema Único de Saúde, através das AIH- Autorização de Internação Hospitalar, sendo verificado que essas internações geram um gasto anual, correspondendo a, aproximadamente, 0,07 do Produto Interno Bruto do País. Com relação à mortalidade, o impacto econômico foi analisado por meio do indicador Anos Potenciais de Vida Perdidos. Os acidentes e violências representaram cerca de 2,6 milhões de anos de vida perdidos, em 1981, e 3,4 milhões, em 1991. O aumento verificado foi cerca de 30%, enquanto que para o conjunto de dados os óbitos apresentaram-se em queda. Apesar de algumas limitações, é possível estimar a dimensão geral do impacto econômico das causas externas. Espera-se que essas limitações sirvam de estímulo a novas investigações e aprofundamentos