Contextual politics of service delivery reforms: Lessons from Delhi, Mexico city and Sao Paulo comparison

Little attention has been given to the contextual politics of service delivery reforms. By focusing on cases of reform in the healthcare sector and, to a lesser extent, in the main policies in the social service sector in India, Mexico and Brazil, this article explores two dimensions of analysis which have enormous relevance in understanding the reach and effectiveness of service delivery reforms: (1) the historical timing of reforms and sectorial baselines, and (2) the degree and institutional locus of local discretion in policy. Findings show that depending on both dimensions, there is an extraordinary variation as to the degree, interests involved and meaning of changes which, in theory, correspond to these countries` commitment to the service delivery reforms, However, consideration of the contextual politics is relevant not for the sake of diversity but for the similarities that this diversity reveals, pointing to underlying analytic dimensions that receive attention in this article.

Streptokinase and Enoxaparin as an Alternative to Fibrin-Specific Lytic-Based Regimens An ExTRACT-TIMI 25 Analysis

Background: Enoxaparin was superior to unfractionated heparin (UFH), regardless of fibrinolytic agent in ST-elevation myocardial infarction (STEMI) patients receiving fibrinolytic therapy in ExTRACT-TIMI 25 (Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment Thrombolysis in Myocardial Infarction 25) trial. Objective: This post hoc analysis compared outcomes with streptokinase plus enoxaparin to the standard regimen of fibrin-specific lytic (FSL) plus UFH and to the newer combination of FSL plus enoxaparin. Methods: In ExTRACT-TIMI 25, STEMI patients received either streptokinase or a FSL (alteplase, reteplase or tenecteplase) at the physician`s discretion and were randomized to enoxaparin or UFH, stratified by fibrinolytic type. Thirty-day outcomes were adjusted for baseline characteristics, region, in-hospital percutaneous coronary intervention (PCI) and a propensity score for the choice of lytic. Results: The primary trial endpoint of 30-day death/myocardial infarction (MI) occurred in fewer patients in the streptokinase-enoxaparin cohort (n = 2083) compared with FSL-UFH (n = 8141) [10.2% vs 12.0%, adjusted odds ratio [OR(adj)] 0.76; 95% CI 0.62, 0.93; p = 0.008]. Major bleeding was significantly increased with streptokinase-enoxaparin compared with FSL-UFH (ORadj 2.74; 95% CI 1.81; 4.14; p < 0.001) but intracranial haemorrhage (ICH) was similar (OR(adj) 0.90; 95% CI 0.40, 2.01; p = 0.79). Net clinical outcomes, defined as either death/MI/major bleeding or as death/MI/ICH tended to favour streptokinase-enoxaparin compared with FSL-UFH (OR(adj) 0.88; 95% CI 0.73, 1.06; p = 0.17; and OR(adj) 0.77; 95% CI 0.63, 0.93; p = 0.008, respectively). Patients receiving FSL-enoxaparin (n = 8142) and streptokinase-enoxaparin therapies experienced similar adjusted rates of the primary endpoint (OR(adj) 1.08; 95% CI 0.87, 1.32; p = 0.49) and net clinical outcomes. Conclusions: Our results suggest that fibrinolytic therapy with the combination of streptokinase and the potent anticoagulant agent enoxaparin resulted in similar adjusted outcomes compared with more costly regimens utilizing a FSL.

Computer technology - A political player in social policy processes

The absence of considerations of technology in policy studies reinforces the popular notion that technology is a neutral tool, Through an analysis of the role played by computers in the policy processes of Australia's Department of Social Security, this paper argues that computers are political players in policy processes, Findings indicate that computers make aspects of the social domain knowable and therefore governable, The use of computers makes previously infeasible policies possible, Computers also operate as bureaucrats and as agents of client surveillance. Increased policy change, reduced discretion and increasingly targeted and complex policies can be attributed to the use of computer technology, If policy processes are to be adequately understood and analysed, then the role of technology in those processes must be considered.

Factors Related to the Selection of Surgical Versus Percutaneous Revascularization in Diabetic Patients With Multivessel Coronary Artery Disease in the BARI 2D (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes) Trial

Objectives We evaluated demographic, clinical, and angiographic factors influencing the selection of coronary artery bypass graft (CABG) surgery versus percutaneous coronary intervention (PCI) in diabetic patients with multivessel coronary artery disease (CAD) in the BARI 2D (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes) trial. Background Factors guiding selection of mode of revascularization for patients with diabetes mellitus and multivessel CAD are not clearly defined. Methods In the BARI 2D trial, the selected revascularization strategy, CABG or PCI, was based on physician discretion, declared independent of randomization to either immediate or deferred revascularization if clinically warranted. We analyzed factors favoring selection of CABG versus PCI in 1,593 diabetic patients with multivessel CAD enrolled between 2001 and 2005. Results Selection of CABG over PCI was declared in 44% of patients and was driven by angiographic factors including triple vessel disease (odds ratio [OR]: 4.43), left anterior descending stenosis >= 70% (OR: 2.86), proximal left anterior descending stenosis >= 50% (OR: 1.78), total occlusion (OR: 2.35), and multiple class C lesions (OR: 2.06) (all p < 0.005). Nonangiographic predictors of CABG included age >= 65 years (OR: 1.43, p = 0.011) and non-U.S. region (OR: 2.89, p = 0.017). Absence of prior PCI (OR: 0.45, p < 0.001) and the availability of drug-eluting stents conferred a lower probability of choosing CABG (OR: 0.60, p = 0.003). Conclusions The majority of diabetic patients with multivessel disease were selected for PCI rather than CABG. Preference for CABG over PCI was largely based on angiographic features related to the extent, location, and nature of CAD, as well as geographic, demographic, and clinical factors. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305) (J Am Coll Cardiol Intv 2009;2:384-92) (C) 2009 by the American College of Cardiology Foundation

Algumas notas sobre o problema da «corrupção», sobretudo no seio do Direito penal económico e social, quer de um ponto de vista do Direito penal, quer a partir de uma perspectiva criminológica: o caso da empresa

Resumo: 1 – Introdução; 2 – Breve nota de Criminologia e Política Criminal no que diz respeito ao papel das polícias perante a teoria da discricionariedade no contexto do problema da corrupção, igualmente económica e social; 3 - O problema da «corrupção», sobretudo no seio do Direito penal económico e social: o caso da importância da empresa; 4 – Algumas pré-conclusões sobre a dificuldade de imputar crimes, nomeadamente crimes de corrupção, às «empresas»; 5 – Conclusão. § Abstract: 1 - Introduction 2 - a brief note of Criminology and Criminal Policy in relation to the role of the police before the theory of discretion in the context of the problem of corruption, also economic and social development; 3 - the problem of the «corruption», especially within the social and economic criminal law: the case of the importance of the company; 4 - Some pre-conclusions about the difficulty of attributing crimes, including crimes of corruption, the «companies», 5 - Conclusion.

Norma contabilística e de relato financeiro 10 – custos de empréstimos obtidos

Dissertação de Mestrado submetida ao Instituto Superior de Contabilidade e Administração do Porto para a obtenção do grau de Mestre em Auditoria Trabalho efetuado sob a orientação do Mestre Carlos Martins

Health and psychosocial effects of flexible working hours

OBJECTIVE: To examine whether any impairments in health and social lives can be found under different kinds of flexible working hours, and whether such effects are related to specific characteristics of these working hours. METHODS: Two studies - a company based survey (N=660) and an internet survey (N=528) - have been conducted. The first one was a questionnaire study (paper and pencil) on employees working under some 'typical' kinds of different flexible working time arrangements in different companies and different occupational fields (health care, manufacturing, retail, administration, call centres). The second study was an internet-based survey, using an adaptation of the questionnaire from the first study. RESULTS: The results of both studies consistently show that high variability of working hours is associated with increased impairments in health and well-being and this is especially true if this variability is company controlled. These effects are less pronounced if variability is self-controlled; however, autonomy does not compensate the effects of variability. CONCLUSIONS: Recommendations for an appropriate design of flexible working hours should be developed in order to minimize any impairing effects on health and psychosocial well-being; these recommendations should include - besides allowing for discretion in controlling one's (flexible) working hours - that variability in flexible working hours should be kept low (or at least moderate), even if this variability is self-controlled.

Gestão sustentável da água em empreendimentos turísticos

O presente documento enquadra-se no âmbito do trabalho final do mestrado (TFM) do curso de Engenharia Civil, na área de especialização de Hidráulica, do Instituto Superior de Engenharia de Lisboa, sob a forma de um projeto na fase de estudo prévio com o título ―Gestão Sustentável da Água no empreendimento turístico Parque de Campismo da Ilha do Pessegueiro situado em Porto Covo - Região de Turismo do Alentejo‖. Este trabalho é constituído essencialmente por 5 partes. Sendo a primeira uma breve introdução às questões a abordar, a segunda corresponde à discrição teórica do uso eficiente da água baseando-se no PNEUA (Programa nacional para o uso eficiente da água). Já a terceira parte é relativa ao atual sistema de utilização da água no Parque de campismo da ilha do pessegueiro (PCIP), sendo a quarta o estudo do desenvolvimento do projecto para a gestão eficiente da água no empreendimento e a quinta parte o estudo de viabilidade económica e financeira a implementar no projecto. Para além da implementação de medidas de poupança são também objetivos principais deste trabalho a reutilização da água através da recolha, o tratamento e armazenamento das águas residuais e aproveitamento das águas pluviais para posterior abastecimento do sistema de utilização em descargas sanitárias, lavagem de pavimentos e regas de espaços verdes. São, portanto, três os subsistemas de gestão eficiente da água que se pretende implementar. Dá-se importância ao estudo de viabilidade económica do projeto, cujo período de retorno do capital investido em capitais próprios e alheios é de seis anos. Este projeto pretende dar apoio técnico ao uso eficiente da água no PCIP, de forma a conseguir por um lado obter vantagens económicas e por outro proteger o ambiente. As vantagens económicas são interessantes para orientar os recursos financeiros para outros investimentos e as questões ambientais são a base de uma campanha, já em curso, para obtenção de certificação energética, em conjunto com outras práticas já em curso, nomeadamente a recolha seletiva de resíduos sólidos para recircular e aproveitamento de energia solar.

Sistema de suporte à negociação numa empresa de prestação de serviços médicos

Nesta dissertação foram estudados métodos de apoio à negociação com o objectivo de encontrar o melhor modelo de negociação para uma empresa prestadora de serviços médicos. O modelo utilizado foi o WinWin e para testar o modelo foi desenvolvido um sistema de apoio à negociação com os clientes. A aplicação foi desenvolvida com o objectivo de conseguir optimizar percursos e reduzir custos, dentro de certas condições, da forma mais eficiente possível, e que fosse de acordo aos interesses do processo de negociação e do contrato com o cliente. Com isto, a aplicação foi testada com 70 contratos, tendo conseguido simular vários grafos que conseguiam alocar todas as consultas dos contratos de forma a respeitar os objectivos impostos por este, e sendo eficientes no sentido de reduzir os custos e tempo de deslocação, diminuindo consequentemente os custos do contrato para o cliente. A redução dos custos para o cliente permite à empresa prestadora de serviços médicos ser mais competitiva face aos seus concorrentes, assim como possuir uma maior margem de manobra face ao processo de negociação, pois também através das simulações conseguem ter uma noção mais precisa dos custos totais de um contrato, diminuindo assim possíveis riscos de um contrato mal estimado.

Cross-cultural validity of the demand-control questionnaire: Swedish and Brazilian workers

OBJECTIVE To evaluate the cross-cultural validity of the Demand-Control Questionnaire, comparing the original Swedish questionnaire with the Brazilian version. METHODS We compared data from 362 Swedish and 399 Brazilian health workers. Confirmatory and exploratory factor analyses were performed to test structural validity, using the robust weighted least squares mean and variance-adjusted (WLSMV) estimator. Construct validity, using hypotheses testing, was evaluated through the inspection of the mean score distribution of the scale dimensions according to sociodemographic and social support at work variables. RESULTS The confirmatory and exploratory factor analyses supported the instrument in three dimensions (for Swedish and Brazilians): psychological demands, skill discretion and decision authority. The best-fit model was achieved by including an error correlation between work fast and work intensely (psychological demands) and removing the item repetitive work (skill discretion). Hypotheses testing showed that workers with university degree had higher scores on skill discretion and decision authority and those with high levels of Social Support at Work had lower scores on psychological demands and higher scores on decision authority. CONCLUSIONS The results supported the equivalent dimensional structures across the two culturally different work contexts. Skill discretion and decision authority formed two distinct dimensions and the item repetitive work should be removed.

Direcção e gestão de obra – obra de arte – Ponte sobre o Rio Lombe – Angola

Este relatório diz respeito ao trabalho desenvolvido em ambiente de estágio académico numa empreitada de Obra Pública, compreendendo a construção da nova ponte sobre o rio Lombe, na EN230, Estrada N’Dalatando – Malanje, Província de Malanje, República de Angola. O estágio foi realizado na CONDURIL – Engenharia, S.A. – Sucursal Angola, empresa dedicada à execução de obras de engenharia civil e obras públicas, com uma vasta experiencia profissional nesta área de actividade. O objectivo deste relatório, para além da descrição de todos os trabalhos práticos de execução da obra, é de transcrever os conhecimentos adquiridos ao longo do estágio, nomeadamente no que concerne aos dos processos de ‘Gestão, Coordenação e Planeamento’, imputáveis as funções da ‘Direcção Técnica de Obra’ durante toda a fase de execução da empreitada, estando o principal foco na descrição das actividades referentes ao controlo da obra.

Relatório de estágio Direcção e gestão de obra - Obra de Arte Ponte sobre o rio Lombe – Angola

Mestrado em Engenharia Civil - Tecnologia e Gestão das Construções

Tifo Murino em Portugal

Murine typhus or endemic typhus is a wide spread infectious disease, with a low prevalence in developed countries, but surely underdiagnosed. Its relative benignity, the similarity to other infectious diseases and the discretion of its epidemiologic chain, as well as the usual unexpectedness of its existence, makes its diagnosis more difficult. The clinical presentation and evolution of this case illustrate the necessity of being aware of this nosological entity.

Adjusting to external imbalances within the EMU, the case of Portugal

From 1995 to 2010 Portugal has accumulated a negative international asset position of 110 percent of GDP. In a developed and aging economy the number is astonishing and any argument to consider it sustainable must rely on extremely favorable forecasts on growth. Portuguese policy options are reduced in number: no autonomous monetary policy, no currency to devaluate, and limited discretion in changing fiscal deficits and government debt. To start the necessary deleveraging a remaining possible policy is a budget-neutral change of the tax structure that increases private saving and net exports. An increase in the VAT and a decrease in the employer’s social security contribution tax can achieve the desired outcome in the short run if they are complemented with wage moderation. To obtain a substantial improvement in competitiveness and a large decrease in consumption, the changes in the tax rates have to be large. While a precise quantitative assessment is difficult, the initial increase in the effective VAT rate needed to allow the social security tax to decrease by 16 percentage points (pp) is approximately 10 pp. Such a large increase in the effective VAT rate could be obtained by raising most of the reduced VAT rates to the new general VAT rate of 23 percent. The empirical analysis shows that over time the suggested tax swap could generate surpluses and improve the trade balance. A temporary version of the suggested tax-swap has the attractiveness to achieve a sharper increase in the private saving rate maintaining the short run gains in competitiveness. Finally, the temporary version of the fiscal devaluation could be the basis for an automatic stabilizer to external imbalances within a monetary union.Portugal has been running large current account deficits every year since 1995. These deficits have accumulated to an astonishing 110 percent of GDP negative external asset position. The sustainability of such a large external position is questionable and must rely on fantastic productivity growth expectations. The recent global financial crisis appears to have anticipated the international investors reality check on those future expectations with the result of a large increase in the cost of external financing. Today the rebalancing of the current account through an increase in national savings and an improvement in competitiveness must be at the top of the Portuguese authorities “to do” list as the cost of a pull out from international investors is of the order of 10% of GDP. The external rebalancing is difficult as the degrees of freedom of the Portuguese authorities are limited in number: they have no autonomous monetary policy, no currency to devaluate, and little discretion in fiscal policy as deficit limits and debt targets are set by the Stability Growth Pact and the postcrisis consensus on medium-term fiscal consolidation. One possibility that remains is to change the fiscal policy mix for a given budget deficit. The purpose of this paper is to explore the effects of a “fiscal devaluation”1 obtained through a tax swap between employers’ social security contributions and taxes on consumption2. The paper begins by illustrating Portugal’s current account evolution during the euro period. The second section section lays out a model to offer a qualitative assessment of the dynamic outcomes of the the tax swap. I show that the suggested tax swap can in theory achieve the desired outcomes in terms of competitiveness and consumption if complemented with moderation (stickiness) in wages. I also study the effects of a temporary version of the tax swap and show that it achieves a sharper improvement in the current account that accelerate the rebalancing. The third section moves to the empirical analysis and estimates the likely effects of the tax swap for the Portuguese economy. The fourth section concludes.