Water tariffs : Methods for an Efficient Cost Recovery and for the Implementation of the Water Framework Directive in Portugal

Doutoramento em EconomiaThis work is a contribution to the study of how the Portuguese water industry can meet the goals of cost recovery and water use efficiency set out by the Water Framework Directive. We describe the Portuguese water and wastewater tariffs implemented from 1998 to 2005 and the cost recovery levels for that period. The tariff revenues collected by the water utilities are insufficient to meet the financial costs of their activities, especially regarding wastewater, and the situation has worsened in recent years. We review the existing water pricing models, highlighting some important results like the fact that efficiency requires marginal cost pricing, which may not be feasible while respecting a revenue requirement. It is not evident whether the best scheme is a two-part tariff or some other pricing mechanism like increasing block tariffs (IBT), which are abundantly used in Portugal. We incorporate the scarcity cost associated with insufficient water availability into the optimal tariff design. We show that when both demand and costs respond to climate factors, increasing marginal prices may come about as a combined result of scarcity and customer heterogeneity when the fixed charge is only allowed to cover fixed costs and the utility is required to maintain a balanced budget. Ultimately, the choice of tariff schedule design is dependent on the behavior of the price-elasticity of demand. We estimate the Portuguese residential water demand and show that the resulting recommended tariff schedule hinges crucially on the choice of functional form. After the proper specification tests, a choice between a semilogarithmic lin-log and a double-log specification is left undecided, which does not prove the superiority of IBT, but also does not enable its dismissal. We also estimate a multi-output cost function for the Portuguese water industry at the retail level. We find diseconomies of scale and scope for the average water utility. Both types of economies are more likely to exist for utilities with a large customer base.Este trabalho é um contributo para o estudo da melhor forma de atingir os objectivos de recuperação de custos e eficiência do sector da água em Portugal traçados pela Directiva-Quadro da Água. Nele se descrevem as tarifas de água e saneamento aplicadas entre 1998 e 2005 e os níveis de recuperação de custos nesse período. As receitas tarifárias angariadas pelas entidades gestoras mostram-se insuficientes para cobrir os custos da sua actividade, especialmente no que diz respeito ao saneamento e a situação tem vindo a piorar nos últimos anos. A literatura sobre modelização da determinação dos preços da água é revista, salientando alguns resultados importantes como o facto de a eficiência exigir que o preço seja equiparado ao custo marginal, algo que pode não ser possível em simultâneo com restrições de manutenção de orçamentos equilibrados. Não é evidente qual o melhor tipo de tarifário a adoptar, a combinação de uma componente fixa com um preço volumétrico constante ou outro esquema alternativo como os tarifários crescentes por blocos, largamente utilizados em Portugal. O custo de escassez é incorporado na definição do tarifário óptimo. Demonstra-se que quando a procura e a oferta reagem ambas a factores climatéricos, preços marginais crescentes podem resultar da combinação da escassez de água com a heterogeneidade dos consumidores em situações em que à componente fixa da tarifa apenas é permitido cobrir os custos fixos e é exigido à entidade gestora que mantenha um orçamento equilibrado. A escolha do melhor tarifário depende fundamentalmente do comportamento da elasticidade-preço da procura. Neste trabalho estimamos a procura residencial de água em Portugal e mostramos que a recomendação sobre o melhor tipo de tarifário depende crucialmente da escolha da forma funcional da procura. Da realização dos testes de especificação adequados, resulta uma escolha inconclusiva entre as formas funcionais semilogaritmíca (lin-log) e loglinear, o que não permite provar a superioridade dos preços crescentes por escalões, mas também não os rejeita. Estima-se também uma função de custos multi-produto para o sector de abastecimento de água e saneamento português em baixa. Para a entidade gestora de dimensão média existem deseconomias de escala e de gama. Os dois tipos de economias tendem a existir para entidades com maior número de consumidores

Orthodontic treatment for disabled children: a survey of parents’ attitudes and overall satisfaction

Background Many patients with disability require orthodontic treatment (OT) to achieve adequate oral function and aesthetic appearance. The cooperation of disabled patients and of their parents is central to the success of OT, as treatment can involve ethical dilemmas. The aim of this study was to analyze the motivation, expectations and overall satisfaction with OT among parents of patients with disabilities. Methods The parents of 60 disabled Spanish children with physical, mental and/or sensory impairment undergoing OT were surveyed on attitudes to OT and level of satisfaction with the outcomes. The survey consisted of 23 questions in 4 sections: attitude and adaptation, benefits, adverse effects, and level of satisfaction after completion of OT. A control group formed of the parents of 60 healthy children undergoing OT at the same institution were also surveyed. Results Parents of disabled children undergoing OT showed a high level of motivation and they are willing to collaborate in oral hygiene procedures. Adaptation to the removable appliances was poorer in disabled children but adaptation to fixed appliances was excellent. OT can provide a marked improvement in quality of life, social relationships and oral functionality in disabled children. Conclusions Among parents of disabled children undergoing OT, the perceived level of overall satisfaction was very high and expectations were often exceeded.S

Anemia na doença renal crónica : a suplementação de ferro em adultos

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2015A Doença renal crónica (DRC) é um importante problema de saúde pública, estando associada a inúmeras comorbilidades, entre as quais a anemia. Esta está associada a uma diminuição significativa de qualidade e esperança média de vida dos doentes com DRC. A anemia na DRC é de etiologia multifatorial e, apesar de a deficiência de eritropoietina ser a sua principal causa, existem muitas outras situações que a podem potenciar. Após o diagnóstico de anemia, num indivíduo com DRC, é necessário realizar uma investigação detalhada de modo a esclarecer outras causas ou fatores que possam contribuir para o seu desenvolvimento. A deficiência de ferro é muito prevalente nesta população, especialmente em doentes medicados com agentes estimuladores da eritropoiese (ESAs) e pode aumentar a resistência à ação da eritropoietina, sendo por isso importante a avaliação das reservas de ferro destes doentes. O tratamento envolve o uso de ESAs e a correção da deficiência de ferro. Esta última permite muitas vezes diminuir a dose necessária de ESAs e, em alguns casos, até evitar a sua utilização. A suplementação com ferro está indicada na deficiência absoluta de ferro e também quando coexistem valores de ferritina <500ng/mL e TSAT <30% (caso se pretenda um aumento da hemoglobina - Hb - ou uma redução da dose de ESAs). A suplementação de ferro por via oral poderá ser utilizada em doentes que não realizam terapêutica de substituição renal, enquanto a suplementação IV deve ser preferida em indivíduos que não respondam ou não toleram o ferro oral ou que realizam hemodiálise/diálise peritoneal. A administração de ferro oral está associada a efeitos adversos gastrointestinais (obstipação ou diarreia, náuseas e dor abdominal), enquanto a suplementação IV pode levar a sobrecarga de ferro, stress oxidativo, aumento do risco de infeções e reações de hipersensibilidade. Estão em investigação fármacos que pretendem desenvolver novas estratégias para lidar com a deficiência de ferro na DRC. Em suma, a suplementação de ferro tem um papel de destaque no tratamento desta patologia. No entanto, algumas questões continuam a necessitar de investigação adicional, nomeadamente a toxicidade a longo prazo desta terapêutica, o tratamento de indivíduos com níveis de ferritina persistentemente elevados, marcadores para aferir com maior precisão os níveis de ferro e definição das doses ótimas de cada formulação de ferro IV.Chronic Kidney Disease (CKD) is a major public health problem and is associated with numerous comorbidities, including anemia. Anemia is associated with a significant decrease in quality and life expectancy of patients with CKD. Anemia in CKD is multifactorial and, although the erythropoietin deficiency is the main cause, many other situations may lead to this disease. After the diagnosis of anemia, in an individual with CKD, it is necessary to conduct a detailed investigation to clarify other causes or factors that may contribute to its development. Iron deficiency is highly prevalent in this population, especially in patients treated with erythropoiesis stimulating agents (ESAs) and can increase the resistance to the action of erythropoietin, so it is important the evaluation of iron stores in these patients. The treatment involves the use of ESAs and iron deficiency correction. The latter often allows reducing the dose of ESA, and in some cases even prevent its use. Iron supplementation is indicated in absolute iron deficiency and also when coexist ferritin levels <500ng/mL and TSAT <30% (if desired an increase in hemoglobin - Hb - or a reduction of the dose of ESAs). Oral iron supplementation may be used in patients who do not perform renal replacement therapy, while IV supplementation should be preferred in patients who do not respond or cannot tolerate oral iron or are in hemodialysis/peritoneal dialysis. Oral iron administration is associated with gastrointestinal side effects (constipation or diarrhea, nausea and abdominal pain), while IV supplementation can lead to iron overload, generation of oxidative stress, increased risk of infections and hypersensitivity reactions. There are some drugs in research that aim to develop new strategies to deal with iron deficiency in CKD. In conclusion, iron supplementation has a prominent role in the treatment of this disease. However, some issues still need further investigation, including the long-term toxicity of this therapy, the treatment of individuals with persistently elevated ferritin levels, markers to assess more accurately the iron levels of an individual and definition of optimal doses of each formulation IV iron

Sexual quality of life in inflammatory bowel disease: A multicenter, national-level study

Background: The impact of inflammatory bowel disease (IBD) on sexual health is a leading concern among patients. Most studies focus on sexual dysfunction rather than patient-perceived sexual quality of life (SQoL). We aimed to assess SQoL in IBD patients compared with healthy controls. Methods: This is a multicenter, cross-sectional study of IBD patients (n = 575 with Crohn's disease and n = 294 with ulcerative colitis), compared with healthy controls (n = 398), that used an anonymous self-administered questionnaire. This multimodal questionnaire included sociodemographic data and 4 validated instruments: Short IBD Questionnaire, Social Desirability Scale, Sexual QoL Questionnaire-Male/Female, Nine-item Patient Health Questionnaire. Results: Inflammatory bowel disease patients reported lower SQoL (men: 77.29 vs 83.83; P < 0.001; women: 70.40 vs 81.63; P < 0.001) compared with controls. Among IBD patients, SQoL was positively correlated with health-related quality of life (HRQoL) and negatively correlated with depression symptoms. Perianal disease was associated with lower HRQoL and higher incidence of depression, but only impacted SQoL in men. In linear regression analysis for men, SQoL was associated with age, marital status, and depression (beta, -2.101; 95% confidence interval [CI], -2.505 to -1.696; P < 0.001). In women, SQoL was associated with depression (beta, -1.973; 95% CI, -2.313 to -1.632; P < 0.001) only. Conclusions: Patients with IBD had impaired SQoL compared with healthy controls. Age, widow status, and depression were independent predictors of SQoL in men with IBD, whereas in women depression was the only independent predictor. Emotional and self-esteem issues were the main concerns reported by IBD patients regarding sexual health.North Portugal Regional Operational Programme under the PORTUGAL 2020 Partnership Agreement [NORTE-01-0145-FEDER-000016]European Regional Development FundEuropean Commissioninfo:eu-repo/semantics/publishedVersio