Putting health in all policies: The National Institute for Welfare Enhancement

Welfare is a rather vague term whose meaning depends on ideology, values andjudgments. Material resources are just means to enhance people s well-being, butgrowth of the Gross Domestic Production is still the standard measure of thesuccess of a society. Fortunately, recent advances in measuring social performanceinclude health, education and other social outcomes. Because what we measureaffects what we do it is hoped that social policies will change. The movementHealth in all policies and its associated Health Impact Assessment methodologywill contribute to it. The task consists of designing transversal policies thatconsider health and other welfare goals, the short term and long-term implicationsand intergenerational redistributions of resources. As long as marginalproductivity on health outside the healthcare system is higher than inside it,efficiency needs cross-sectoral policies. And fairness needs them even more,because in order to reduce social inequalities in health, a wide social and politicalresponse is needed.Unless we reduce the well-documented inefficiencies in our current health caresystems the welfare states will fail to consolidate and the overall economic wellbeingcould be in serious trouble. In this article we sketched some policy solutionssuch as pricing according to net benefits of innovation and public encouragementof radical innovation besides the small type incremental and market-ledinnovation. We proposed an independent agency, the National Institute forWelfare Enhancement to guarantee long term fair and efficient social policies inwhich health plays a central role.

La gestión sanitaria: orientaciones a futuro para el cambio organizativo, del control y la financiación

This paper offers a general view of changes in health care management in theSpanish Health System. We focus on the organisational, financing andaccountability aspects of health care provision. We do this by encompassingmanagerial changes and social change and well-grounded in theory health economicsliterature. In this way we try to link applied economics and management issues,as we did in a former paper, ten years ago on the same basis(López-Casasnovas, 2002). We emphasise mistakes and milestones in the wayforward to improve health systems by better understanding the public natureof health policies. Key aspects of this are to achieve a better allocation ofresponsibilities to providers on patients health, to incentive the organisationof medical self-managed health care institutions and to build global budgets onrisk-adjusting capitation and better integrated health care providers on acommunity basis.

Profile, cost and pattern of prescriptions for polymedicated patients in Catalonia (Spain).

OBJECTIVES: Polypharmacy is one of the main management issues in public health policies because of its financial impact and the increasing number of people involved. The polymedicated population according to their demographic and therapeutic profile and the cost for the public healthcare system were characterised. DESIGN: Cross-sectional study. SETTING: Primary healthcare in Barcelona Health Region, Catalonia, Spain (5 105 551 inhabitants registered). PARTICIPANTS: All insured polymedicated patients. Polymedicated patients were those with a consumption of ≥16 drugs/month. MAIN OUTCOMES MEASURES: The study variables were related to age, gender and medication intake obtained from the 2008 census and records of prescriptions dispensed in pharmacies and charged to the public health system. RESULTS: There were 36 880 polymedicated patients (women: 64.2%; average age: 74.5±10.9 years). The total number of prescriptions billed in 2008 was 2 266 830 (2 272 920 total package units). The most polymedicated group (up to 40% of the total prescriptions) was patients between 75 and 84 years old. The average number of prescriptions billed monthly per patient was 32±2, with an average cost of 452.7±27.5. The total cost of those prescriptions corresponded to 2% of the drug expenditure in Catalonia. The groups N, C, A, R and M represented 71.4% of the total number of drug package units dispensed to polymedicated patients. Great variability was found between the medication profiles of men and women, and between age groups; greater discrepancies were found in paediatric patients (5-14 years) and the elderly (≥65 years). CONCLUSIONS: This study provides essential information to take steps towards rational drug use and a structured approach in the polymedicated population in primary healthcare.

Can wild ungulate carcasses provide enough biomass to maintain avian scavenger populations? An empirical assessment using a bio-inspired computational model

Background: The reduction in the amount of food available for European avian scavengers as a consequence of restrictive public health policies is a concern for managers and conservationists. Since 2002, the application of several sanitary regulations has limited the availability of feeding resources provided by domestic carcasses, but theoretical studies assessing whether the availability of food resources provided by wild ungulates are enough to cover energetic requirements are lacking. Methodology/Findings: We assessed food provided by a wild ungulate population in two areas of NE Spain inhabited by three vulture species and developed a P System computational model to assess the effects of the carrion resources provided on their population dynamics. We compared the real population trend with to a hypothetical scenario in which only food provided by wild ungulates was available. Simulation testing of the model suggests that wild ungulates constitute an important food resource in the Pyrenees and the vulture population inhabiting this area could grow if only the food provided by wild ungulates would be available. On the contrary, in the Pre-Pyrenees there is insufficient food to cover the energy requirements of avian scavenger guilds, declining sharply if biomass from domestic animals would not be available. Conclusions/Significance: Our results suggest that public health legislation can modify scavenger population trends if a large number of domestic ungulate carcasses disappear from the mountains. In this case, food provided by wild ungulates could be not enough and supplementary feeding could be necessary if other alternative food resources are not available (i.e. the reintroduction of wild ungulates), preferably in European Mediterranean scenarios sharing similar and socio-economic conditions where there are low densities of wild ungulates. Managers should anticipate the conservation actions required by assessing food availability and the possible scenarios in order to make the most suitable decisions.

Profile, cost and pattern of prescriptions for polymedicated patients in Catalonia, Spain

OBJECTIVES: Polypharmacy is one of the main management issues in public health policies because of its financial impact and the increasing number of people involved. The polymedicated population according to their demographic and therapeutic profile and the cost for the public healthcare system were characterised. DESIGN: Cross-sectional study. SETTING: Primary healthcare in Barcelona Health Region, Catalonia, Spain (5 105 551 inhabitants registered). PARTICIPANTS: All insured polymedicated patients. Polymedicated patients were those with a consumption of ≥16 drugs/month. MAIN OUTCOMES MEASURES: The study variables were related to age, gender and medication intake obtained from the 2008 census and records of prescriptions dispensed in pharmacies and charged to the public health system. RESULTS: There were 36 880 polymedicated patients (women: 64.2%; average age: 74.5±10.9 years). The total number of prescriptions billed in 2008 was 2 266 830 (2 272 920 total package units). The most polymedicated group (up to 40% of the total prescriptions) was patients between 75 and 84 years old. The average number of prescriptions billed monthly per patient was 32±2, with an average cost of 452.7±27.5. The total cost of those prescriptions corresponded to 2% of the drug expenditure in Catalonia. The groups N, C, A, R and M represented 71.4% of the total number of drug package units dispensed to polymedicated patients. Great variability was found between the medication profiles of men and women, and between age groups; greater discrepancies were found in paediatric patients (5-14 years) and the elderly (≥65 years). CONCLUSIONS: This study provides essential information to take steps towards rational drug use and a structured approach in the polymedicated population in primary healthcare.

Impact of multimorbidity on disability and quality of life in the spanish older population

BACKGROUND: Population aging is closely related to high prevalence of chronic conditions in developed countries. In this context, health care policies aim to increase life span cost-effectively while maintaining quality of life and functional ability. There is still, however, a need for further understanding of how chronic conditions affect these health aspects. The aim of this paper is to assess the individual and combined impact of chronic physical and mental conditions on quality of life and disability in Spain, and secondly to show gender trends. METHODS: Cross-sectional data were collected from the COURAGE study. A total of 3,625 participants over 50 years old from Spain were included. Crude and adjusted multiple linear regressions were conducted to detect associations between individual chronic conditions and disability, and between chronic conditions and quality of life. Separate models were used to assess the influence of the number of diseases on the same variables. Additional analogous regressions were performed for males and females. RESULTS: All chronic conditions except hypertension were statistically associated with poor results in quality of life and disability. Depression, anxiety and stroke were found to have the greatest impact on outcomes. The number of chronic conditions was associated with substantially lower quality of life [β for 4+ diseases: -18.10 (-20.95,-15.25)] and greater disability [β for 4+ diseases: 27.64 (24.99,30.29]. In general, women suffered from higher rates of multimorbidity and poorer results in quality of life and disability. CONCLUSIONS: Chronic conditions impact greatly on quality of life and disability in the older Spanish population, especially when co-occurring diseases are added. Multimorbidity considerations should be a priority in the development of future health policies focused on quality of life and disability. Further studies would benefit from an expanded selection of diseases. Policies should also deal with gender idiosyncrasy in certain cases.

Price policies and Price dispersion in the private healthcare insurance industry: The Catalan case

We present an overlapping generations model that explains price dispersion among Catalonian healthcare insurance firms. The model shows that firms with different premium policies can coexist. Furthermore, if interest rates are low, firms that apply equal premium to all insureds can charge higher average prices than insurers that set premiums according to the risk of insured. Economic theory, health insurance, health economics.

Social Determinants of Child Health in Colombia: Can Community Education Moderate the Effect of Family Characteristics?

Contextual effects on child health have been investigated extensively in previous research. However, few studies have considered the interplay between community characteristics and individual-level variables. This study examines the influence of community education and family socioeconomic characteristics on child health (as measured by height and weight-for-age Z-scores), as well as their interactions. We adapted the Commission on Social Determinants of Health (CSDH) framework to the context of child health. Using data from the 2010 Colombian Demographic and Health Survey (DHS), weighted multilevel models are fitted since the data are not self-weighting. The results show a positive impact of the level of education of other women in the community on child health, even after controlling for individual and family socioeconomic characteristics. Different pathways through which community education can substitute for the effect of family characteristics on child nutrition are found. The interaction terms highlight the importance of community education as a moderator of the impact of the mother’s own education and autonomy, on child health. In addition, the results reveal differences between height and weight-for-age indicators in their responsiveness to individual and contextual factors. Our findings suggest that community intervention programmes may have differential effects on child health. Therefore, their identification can contribute to a better targeting of child care policies.

The drift of public spending towards the elderly: A generational analysis of the trend of public policies in Spain

The tendency for public welfare spending to be increasingly aimed at the elderly has been pointed out for the US and other developed countries. While population ageing is a common trend, it is not obvious why the shift in spending exceeds the trend in ageing, or why per capita spending on the elderly increases.We show that this is the case in Spain, identify the losers from this development, discuss the policies that underlie this trend, and propose adjustments based on Musgrave s fixed proportions rule as an inter-generationally fair distribution.

How accurate are surveyed preferences for public policies? Evidence from a unique institutional setup

Opinion polls are widely used to capture public sentiments on a varietyof issues. If citizens are unwilling to reveal certain policy preferences toothers, opinion polls may fail to characterize population preferences accurately.The innovation of this paper is to use unique data to measurebiases in opinion polls for a broad range of policies. I combine data on184 referenda held in Switzerland between 1987 and 2007, with postballotsurveys that ask for each proposal how the citizens voted. Thedifference between stated preferences in the survey and revealed preferences at the ballot box provides a direct measure of bias in opinion polls.I find that these biases vary by policy areas, with the largest ones occurring in policies on immigration, international integration, and votesinvolving liberal/conservative attitudes. Also, citizens show a tendencyto respond in accordance to the majority.

A multilevel analysis on the determinants of regional health care expenditure. A note

We apply a multilevel hierarchical model to explore whether anaggregation fallacy exists in estimating the income elasticity of healthexpenditure by ignoring the regional composition of national healthexpenditure figures. We use data for 110 regions in eight OECD countriesin 1997: Australia, Canada, France, Germany, Italy, Spain, Sweden andUnited Kingdom. In doing this we have tried to identify two sources ofrandom variation: within countries and between-countries. Our resultsshow that: 1- Variability between countries amounts to (SD) 0.5433, andjust 13% of that can be attributed to income elasticity and the remaining87% to autonomous health expenditure; 2- Within countries, variabilityamounts to (SD) 1.0249; and 3- The intra-class correlation is 0.5300. Weconclude that we have to take into account the degree of fiscaldecentralisation within countries in estimating income elasticity ofhealth expenditure. Two reasons lie behind this: a) where there isdecentralisation to the regions, policies aimed at emulating diversitytend to increase national health care expenditure; and b) without fiscaldecentralisation, central monitoring of finance tends to reduce regionaldiversity and therefore decrease national health expenditure.

Social spending and demographics: The role of public policies in the intergenerational redistribution of income. Empirical evidence from Spain and Catalonia

The demographic shift underway in Southern Europe requires a revision of some of thefundamental principles of the traditional welfare state. We analyze the evolution of several aspects of welfare and social expenditure over the last two decades. We find that in the context of the present demographic changes and real estate boom current social and pension policy leads to a new distribution of benefits and burdens which is highly intergenerationally unequal. We argue for a revised definition of public policy based on Musgrave's proposition as a possible rule for an intergenerationally fair distribution.

Regional differences in socio-economic health inequalities in Spain

This paper reports an analysis of income related health inequalities at the AutonomousCommunity level in Spain using the self assessed health measure in the 2001 edition of theEncuesta Nacional de Salud. We use recently developed methods in order to cardinalise andmodel self assessed health within a regression framework, decompose the sources ofinequality and explain the observed differences across regions. We find that the regions with the highest levels of mean health tend to enjoy the lowest degrees of income related health inequality and vice-versa. The main feature characterizing regions where income related health inequality is low is the absence of a positive gradient between income and health. In turn, the regions where income related health inequality is greater are characterized by a strong and significant positive gradient between health and income. These results suggest that policies aimed at eliminating the gradient between health and income can potentially lead to greate r reductions in socio-economic health inequalities than policies aimed at redistributing income.

Drug price differentials caused by de-listing and price cap policies

This paper analyses the behaviour of pharmaceutical companies that face the threat of having their drugs excluded from reimbursement and the markets characterised also by price caps. We conclude that price elasticity of demand and cost differentials cause the price discounts which drug firms offer to health care organisations. Additionally, we conclude that price cap regulations affect the time path of prices, resulting in higher prices for new products and lower prices for old products.

Drug price differentials caused by de-listing and price cap policies

This paper analyses the behaviour of pharmaceutical companies that face the threat of having their drugs excluded from reimbursement and the markets characterised also by price caps. We conclude that price elasticity of demand and cost differentials cause the price discounts which drug firms offer to health care organisations. Additionally, we conclude that price cap regulations affect the time path of prices, resulting in higher prices for new products and lower prices for old products.