El concepto de willingness-to-pay en tela de juicio

La idoneidad del concepto de willingness to pay (disponibilidad a pagar) es revisado en las evaluaciones económicas que se realizan en el campo de la salud. Por un lado, existe dentro de la literatura económica un número importante de investigadores que señalan los múltiples problemas metodológicos que entrañan las estimaciones de willingness to pay. Por otro lado, aún el debate teórico-conceptual acerca de la agregación de las preferencias individuales dentro de una demanda agregada no ésta del todo resuelto. Sin embargo, durante los últimos 20 años la estimación de la disponibilidad a pagar dentro de las investigaciones económicas ha aumentado de forma significativa, siendo en muchos casos uno de los principales factores de la toma de decisión en políticas de salud. Plantease alguna de las limitaciones de esta técnica, así como el posible efecto distorsionador que podría tener sobre las evaluaciones económicas que se realizan en el área de la economía de la salud.

EU Commission participation in the Troika mission: is there a European Union price to pay?

The article is intended to debate two questions regarding the involvement of the Commission in the Troika's action: firstly, considering the nature of financial assistance programs, it aims to discuss the effect of the Commission's participation in Troika negotiations on the balance of power of the EU institutions; and secondly, the article raises the issue of the Commission's liability for the results achieved by the financial assistance program, taking into account the extent of the conditions imposed, as well as the intensity of scrutiny by the Troika.

Cost-Effectiveness of High, Moderate and Low-Dose Statins in the Prevention of Vascular Events in the Brazilian Public Health System

Background:Statins have proven efficacy in the reduction of cardiovascular events, but the financial impact of its widespread use can be substantial.Objective:To conduct a cost-effectiveness analysis of three statin dosing schemes in the Brazilian Unified National Health System (SUS) perspective.Methods:We developed a Markov model to evaluate the incremental cost-effectiveness ratios (ICERs) of low, intermediate and high intensity dose regimens in secondary and four primary scenarios (5%, 10%, 15% and 20% ten-year risk) of prevention of cardiovascular events. Regimens with expected low-density lipoprotein cholesterol reduction below 30% (e.g. simvastatin 10mg) were considered as low dose; between 30-40%, (atorvastatin 10mg, simvastatin 40mg), intermediate dose; and above 40% (atorvastatin 20-80mg, rosuvastatin 20mg), high-dose statins. Effectiveness data were obtained from a systematic review with 136,000 patients. National data were used to estimate utilities and costs (expressed as International Dollars - Int$). A willingness-to-pay (WTP) threshold equal to the Brazilian gross domestic product per capita (circa Int$11,770) was applied.Results:Low dose was dominated by extension in the primary prevention scenarios. In the five scenarios, the ICER of intermediate dose was below Int$10,000 per QALY. The ICER of the high versus intermediate dose comparison was above Int$27,000 per QALY in all scenarios. In the cost-effectiveness acceptability curves, intermediate dose had a probability above 50% of being cost-effective with ICERs between Int$ 9,000-20,000 per QALY in all scenarios.Conclusions:Considering a reasonable WTP threshold, intermediate dose statin therapy is economically attractive, and should be a priority intervention in prevention of cardiovascular events in Brazil.

The kiwifruit in Chile and in the world

The kiwi is a fruit that, has only been in Europe for about 60 years, which signifies a great potential for the development of its consumption and great difficulty in the educational process of the product. Currently there is a growing increase in world production, which to date is above the growth in demand. This means that the kiwi categories are not growing significantly and, on the contrary, the kiwi is at a crossroad that will be resolved in the coming years. The changing global economic scenario affects high-value products such as kiwis, making it hard to predict their commercial results. The worldwide market has clearly indicated through the demand and the prices that it is interested in the sweeter yellow varieties. Asian markets have been and are expected to continue to grow. The increase in world production has also generated overlap in stocks between the hemispheres, which makes it necessary to closely monitor commercial strategies regarding the start and end of the season. In this way, the market entry of the southern hemisphere kiwifruit is conditioned according to the presence of fruit from the Northern Hemisphere. The unique features and uses of the kiwi make it one of the most interesting fruits present in the world. For this reason it is also a fruit with high purchase value. In spite of the described variables and market trends, there is a growing demand for consuming better quality kiwis and willingness to pay a higher price.

Renegociação da dívida pública interna em condições de sobreendividamento

Renegotiation of the public debt in conditions of excessive debt. This paper studies the debt overhang models and maturity management models, and analyses both theoretically and historically the debt renegotiations which the final outcome is a lower public debt burden. From the theoretical view the renegotiation plans can be Pareto improving, both creditors and debtors can be better-off, and the value of the new debt will price the new reputation and debtors' willingness to pay. From the historical point of view, funded debts were the instrument that debtors used to improve reputation.

The principle of autonomy in Brazil: one needs to discuss it ...

The principle of patient autonomy is a cornerstone of bioethics. According to this concept, patients should be given the power to make decisions related to their treatment. It is an important component of modern medical ethics, which has received much interest in current literature. However, the rate of participation of patients and their willingness to participate are variable according to the cultural, social and family environments in which they are inserted. The aim of this paper is to promote a brief descriptive review on autonomy, the preferences of patients and the use of informed consent as an instrument for the exercise of autonomy in literature, and to stress the lack of debate, as well as the pressing need for discussion of these current issues nationwide.

HIV rapid testing as a key strategy for prevention of mother-to-child transmission in Brazil

OBJECTIVE: To assess the feasibility of HIV rapid testing for pregnant women at maternity hospital admission and of subsequent interventions to reduce perinatal HIV transmission. METHODS: Study based on a convenience sample of women unaware of their HIV serostatus when they were admitted to delivery in public maternity hospitals in Rio de Janeiro and Porto Alegre, Brazil, between March 2000 and April 2002. Women were counseled and tested using the Determine HIV1/2 Rapid Test. HIV infection was confirmed using the Brazilian algorithm for HIV infection diagnosis. In utero transmission of HIV was determined using HIV-DNA-PCR. There were performed descriptive analyses of sociodemographic data, number of previous pregnancies and abortions, number of prenatal care visits, timing of HIV testing, HIV rapid test result, neonatal and mother-to-child transmission interventions, by city studied. RESULTS: HIV prevalence in women was 6.5% (N=1,439) in Porto Alegre and 1.3% (N=3.778) in Rio de Janeiro. In Porto Alegre most of women were tested during labor (88.7%), while in Rio de Janeiro most were tested in the postpartum (67.5%). One hundred and forty-four infants were born to 143 HIV-infected women. All newborns but one in each city received at least prophylaxis with oral zidovudine. It was possible to completely avoid newborn exposure to breast milk in 96.8% and 51.1% of the cases in Porto Alegre and Rio de Janeiro, respectively. Injectable intravenous zidovudine was administered during labor to 68.8% and 27.7% newborns in Porto Alegre and Rio de Janeiro, respectively. Among those from whom blood samples were collected within 48 hours of birth, in utero transmission of HIV was confirmed in 4 cases in Rio de Janeiro (4/47) and 6 cases in Porto Alegre (6/79). CONCLUSIONS: The strategy proved feasible in maternity hospitals in Rio de Janeiro and Porto Alegre. Efforts must be taken to maximize HIV testing during labor. There is a need of strong social support to provide this population access to health care services after hospital discharge.

Challenges and perspectives of academic evaluation

Academic evaluation has been an essential component of modern science since its inception, as science has moved away from personalized patronage toward its contemporary role as an essential enterprise of contemporary, democratic societies. In recent years, Brazil has experienced sustained growth in its scientific output, which is nowadays fully compatible with its status as a high middle-income country striving to become a fully developed, more equitable country in the years to come. Growth usually takes place amidst challenges and dilemmas and, in Brazil as elsewhere, academic evaluation is not exempt from such difficulties. In a large, profoundly heterogeneous country with a national evaluation system and nationwide on-line platforms disseminating information on the most disparate fields of knowledge, the main challenges refer to how to pay attention to detail without losing sight of comprehensiveness and how to handle social and regional diversity while preserving academic excellence as the fundamental benchmark.

Socioeconomic inequality in catastrophic health expenditure in Brazil

OBJECTIVE To analyze the evolution of catastrophic health expenditure and the inequalities in such expenses, according to the socioeconomic characteristics of Brazilian families.METHODS Data from the National Household Budget 2002-2003 (48,470 households) and 2008-2009 (55,970 households) were analyzed. Catastrophic health expenditure was defined as excess expenditure, considering different methods of calculation: 10.0% and 20.0% of total consumption and 40.0% of the family’s capacity to pay. The National Economic Indicator and schooling were considered as socioeconomic characteristics. Inequality measures utilized were the relative difference between rates, the rates ratio, and concentration index.RESULTS The catastrophic health expenditure varied between 0.7% and 21.0%, depending on the calculation method. The lowest prevalences were noted in relation to the capacity to pay, while the highest, in relation to total consumption. The prevalence of catastrophic health expenditure increased by 25.0% from 2002-2003 to 2008-2009 when the cutoff point of 20.0% relating to the total consumption was considered and by 100% when 40.0% or more of the capacity to pay was applied as the cut-off point. Socioeconomic inequalities in the catastrophic health expenditure in Brazil between 2002-2003 and 2008-2009 increased significantly, becoming 5.20 times higher among the poorest and 4.17 times higher among the least educated.CONCLUSIONS There was an increase in catastrophic health expenditure among Brazilian families, principally among the poorest and those headed by the least-educated individuals, contributing to an increase in social inequality.

Insecticide treated mosquito nets for malaria control in India-experience from a tribal area on operational feasibility and uptake

The study assessed the operational feasibility and acceptability of insecticide-treated mosquito nets (ITNs) in one Primary Health Centre (PHC) in a falciparum malaria endemic district in the state of Orissa, India, where 74% of the people are tribes and DDT indoor residual spraying had been withdrawn and ITNs introduced by the National Vector Borne Disease Control Programme. To a population of 63,920, 24,442 ITNs were distributed free of charge through 101 treatment centers during July-August 2002. Interview of 1,130, 1,012 and 126 respondents showed that the net use rates were 80%, 74% and 55% in the cold, rainy and summer seasons, respectively. Since using ITNs, 74.5-76.6% of the respondents observed reduction of mosquito bites and 7.2-32.1% reduction of malaria incidence; 37% expressed willingness to buy ITNs if the cost was lower and they were affordable. Up to ten months post-treatment, almost 100% mortality of vector mosquitoes was recorded on unwashed and washed nets (once or twice). Health workers re-treated the nets at the treatment centers eight months after distribution on a cost-recovery basis. The coverage reported by the PHC was only 4.2%, mainly because of unwillingness of the people to pay for re-treatment and to go to the treatment centers from their villages. When the re-treatment was continued at the villages involving personnel from several departments, the coverage improved to about 90%.Interview of 126 respondents showed that among those who got their nets re-treated, 81.4% paid cash for the re-treatment and the remainder were reluctant to pay. Majority of those who paid said that they did so due to the fear that if they did not do so they would lose benefits from other government welfare schemes. The 2nd re-treatment was therefore carried out free of charge nine months after the 1st re-treatment and thus achieved coverage of 70.4%. The study showed community acceptance to use ITNs as they perceived the benefit. Distribution and re-treatment of nets was thus possible through the PHC system, if done free of charge and when personnel from different departments, especially those at village level, were involved.

The generation and re-generation of social capital and enterprises in multi-stakeholders social cooperative enterprises: a system dynamic approach

Theories on social capital and on social entrepreneurship have mainly highlighted the attitude of social capital to generate enterprises and to foster good relations between third sector organizations and the public sector. This paper considers the social capital in a specific third sector enterprise; here, multi-stakeholder social cooperatives are seen, at the same time, as social capital results, creators and incubators. In the particular enterprises that identify themselves as community social enterprises, social capital, both as organizational and relational capital, is fundamental: SCEs arise from but also produce and disseminate social capital. This paper aims to improve the building of relational social capital and the refining of helpful relations drawn from other arenas, where they were created and from where they are sometimes transferred to other realities, where their role is carried on further (often working in non-profit, horizontally and vertically arranged groups, where they share resources and relations). To represent this perspective, we use a qualitative system dynamic approach in which social capital is measured using proxies. Cooperation of volunteers, customers, community leaders and third sector local organizations is fundamental to establish trust relations between public local authorities and cooperatives. These relations help the latter to maintain long-term contracts with local authorities as providers of social services and enable them to add innovation to their services, by developing experiences and management models and maintaining an interchange with civil servants regarding these matters. The long-term relations and the organizational relations linking SCEs and public organizations help to create and to renovate social capital. Thus, multi-stakeholder cooperatives originated via social capital developed in third sector organizations produce new social capital within the cooperatives themselves and between different cooperatives (entrepreneurial components of the third sector) and the public sector. In their entrepreneurial life, cooperatives have to contrast the "working drift," as a result of which only workers remain as members of the cooperative, while other stakeholders leave the organization. Those who are not workers in the cooperative are (stake)holders with "weak ties," who are nevertheless fundamental in making a worker's cooperative an authentic social multi-stakeholders cooperative. To maintain multi-stakeholder governance and the relations with third sector and civil society, social cooperatives have to reinforce participation and dialogue with civil society through ongoing efforts to include people that provide social proposals. We try to represent these processes in a system dynamic model applied to local cooperatives, measuring the social capital created by the social cooperative through proxies, such as number of volunteers and strong cooperation with public institutions. Using a reverse-engineering approach, we can individuate the determinants of the creation of social capital and thereby give support to governance that creates social capital.

Knowledge of the Portuguese population on Basic Life Support and availability to attend training

OBJECTIVETo evaluate the level of knowledge and the availability of the Portuguese population to attend training in Basic Life Support (BLS) and identify factors related to their level of knowledge about BLS.METHODObservational study including 1,700 people who responded to a questionnaire containing data on demography, profession, training, interest in training and knowledge about BLS.RESULTSAmong 754 men and 943 women, only 17.8% (303) attended a course on BLS, but 95.6% expressed willingness to carry out the training. On average, they did not show good levels of knowledge on basic life support (correct answers in 25.9 ± 11.5 of the 64 indicators). Male, older respondents who had the training and those who performed BLS gave more correct answers, on average (p<0.01).CONCLUSIONThe skill levels of the Portuguese population are low, but people are available for training, hence it is important to develop training courses and practice to improve their knowledge.