A gestão dos resíduos hospitalares e o papel da autoridade de saúde : caso do concelho da Amad

RESUMO O Problema. A natureza, diversidade e perigosidade dos resíduos hospitalares (RH) exige procedimentos específicos na sua gestão. A sua produção depende do número de unidades de prestação de cuidados de saúde (upcs), tipo de cuidados prestados, número de doentes observados, práticas dos profissionais e dos órgãos de gestão das upcs, inovação tecnológica, entre outros. A gestão integrada de RH tem evoluído qualitativamente nos últimos anos. Existe uma carência de informação sobre os quantitativos de RH produzidos nas upcs e na prestação de cuidados domiciliários, em Portugal. Por outro lado, os Serviços de Saúde Pública, abrangendo o poder de Autoridade de Saúde, intervêm na gestão do risco para a saúde e o ambiente associado à produção de RH, necessitando de indicadores para a sua monitorização. O quadro legal de um país nesta matéria estabelece a estratégia de gestão destes resíduos, a qual é condicionada pela classificação e definição de RH por si adoptadas. Objectivos e Metodologias. O presente estudo pretende: quantificar a produção de RH resultantes da prestação de cuidados de saúde, em seres humanos e animais nas upcs, do sistema público e privado, desenvolvendo um estudo longitudinal, onde se quantifica esta produção nos Hospitais, Centros de Saúde, Clínicas Médicas e Dentárias, Lares para Idosos, Postos Médicos de Empresas, Centros de Hemodiálise e Clínicas Veterinárias do Concelho da Amadora, e se compara esta produção em dois anos consecutivos; analisar as consequências do exercício do poder de Autoridade de Saúde na gestão integrada de RH pelas upcs; quantificar a produção média de RH, por acto prestado, nos cuidados domiciliários e, com um estudo analítico transversal, relacionar essa produção média com as características dos doentes e dos tratamentos efectuados; proceder à análise comparativa das definições e classificações de RH em países da União Europeia, através de um estudo de revisão da legislação nesta matéria em quatro países, incluindo Portugal. Resultados e Conclusões. Obtém-se a produção média de RH, por Grupos I+II, III e IV: nos Hospitais, por cama.dia, considerando a taxa de ocupação; por consulta, nos Centros de Saúde, Clínicas Médicas e Dentárias e Postos Médicos de Empresas; por cama.ano, nos Lares para Idosos, considerando a sua taxa de ocupação; e por ano, nas Clínicas de Hemodiálise e Veterinárias. Verifica-se que a actuação da Autoridade de Saúde, produz nas upcs uma diferença estatisticamente significativa no aumento das contratualizações destas com os operadores de tratamento de RH. Quantifica-se o peso médio de resíduos dos Grupos III e IV produzido por acto prestado nos tratamentos domiciliários e relaciona-se esta variável dependente com as características dos doentes e dos tratamentos efectuados. Comparam-se os distintos critérios utilizados na elaboração das definições e classificações destes resíduos inscritas na legislação da Alemanha, Reino Unido, Espanha e Portugal. Recomendações. Apresentam-se linhas de investigação futura e propõe-se uma reflexão sobre eventuais alterações de aspectos específicos no quadro legal português e nos planos de gestão integrada de RH, em Portugal. ABSTRACT The problem: The nature, diversity and hazardousness of hospital wastes (HW) requires specific procedures in its management. Its production depends on the number and patterns of healthcare services, number of patients, professional and administration practices and technologic innovations, among others. Integrated management of HW has been developping, in the scope of quality, for the past few years. There is a lack of information about the amount of HW produced in healthcare units and in the domiciliary visits, in Portugal. On the other hand, the Public Health Services, embracing the Health Authority’s power, play a very important role in managing the risk of HW production to public and environmental health. They need to use some indicators in its monitorization. In a country, rules and regulations define hospital waste management policies, which are confined by the addopted classification and definition of HW. Goals and Methods: This research study aims to quantify the production of HW as a result of healthcare services in human beings and animals, public service and private one. Through a longitudinal study, this production is quantified in Hospitals, Health Centers, Medical and Dental Clinics, Residential Centers for old people, Companies Medical Centers and Veterinary and Haemodyalisis Clinics in Amadora’s Council, comparing this production in two consecutive years. This study also focus the consequences of the Health Authority’s role in the healthcare services integrated management of HW. The middle production of HW in the domiciliary treatments is also quantified and, with a transversal analytic study, its association with patients and treatments’ characteristics is enhanced. Finally, the definitions and classifications in the European Union Countries are compared through a study that revises this matter’s legislation in four countries, including Portugal. Results and Conclusions: We get the middle production of Groups I+II, III and IV: HW: in Hospitals, by bed.day, bearing the occupation rate; by consultation, in Health Centers, Medical and Dental Clinics and Companies Medical Centers; by bed.year in Residential Centers for old people, considering their occupation rate; by year, in Veterinary and Haemodyalisis Clinics. We verify that the Health Authority’s role produces a significative statistical difference in the rise of the contracts between healthcare services and HW operators. We quantify the Groups III and IV’s wastes middle weight, produced by each medical treatment in domiciliary visits and relate this dependent variable with patients and treatments’ characteristics. We compare the different criteria used in the making of definitions and classifications of these wastes registered in German, United Kingdom, Spain and Portugal’s laws. Recommendations: Lines of further investigation are explaned. We also tender a reflexion about potential changes in rules, in regulations and in the integrated plans for managing hospital wastes in Portugal. RÉSUMÉ Le Problème. La gestion des déchets d'activités hospitalières (DAH) et de soins de santé (DSS) exige des procédures spécifiques en raison de leur nature, diversité et dangerosité. Leur production dépend, parmi d’autres, du nombre d’unités de soins de santé (USS), du type de soins administrés, du nombre de malades observés, des pratiques des professionnels et des organes de gestion des USS, de l’innovation technologique. La gestion intégrée des DAH et des DSS subit une évolution qualitative dans les dernières années. Il existe un déficit d’information sur les quantitatifs de DAH et de DSS provenant des USS et de la prestation de soins domiciliaires, au Portugal. D’autre part les Services de Santé Publique, y compris le pouvoir de l’Autorité de Santé, qui interviennent dans la gestion du risque pour la santé et pour l’environnement associé à la production de DAH et de DSS, ont besoin d’indicateurs pour leur surveillance. Dans cette matière le cadre légal établit la stratégie de gestion de ces déchets, laquelle est conditionnée par la classification et par la définition des DAH et des DSS adoptées par le pays. Objectifs et Méthodologie. Cet étude prétend: quantifier la production de DAH et de DSS provenant de la prestation de soins de santé, en êtres humains et animaux dans les USS du système public et privé. À travers un étude longitudinal, on quantifie cette production dans les Hôpitaux, Centres de Santé, Cliniques Médicales et Dentaires, Maisons de Repos pour personnes âgées, Cabinets Médicaux d’ Entreprises, Centres d’Hémodialyse et Cliniques Vétérinaires du municipe d’ Amadora, en comparant cette production en deux ans consécutifs; analyser les conséquences de l’exercice du pouvoir de l’Autorité de Santé dans la gestion intégrée des DAH et des DSS par les USS; quantifier la production moyenne de DAH et de DSS dans la prestation de soins domiciliaires et, avec un étude analytique transversal, rapporter cette production moyenne avec les caractéristiques des malades et des soins administrés; procéder à l’ analyse comparative des définitions et classifications des DAH et des DSS dans des pays de l’Union Européenne, à travers un étude de révision de la législation relative à cette matière dans quatre pays, Portugal y compris. Résultats et Conclusions. On obtient la production moyenne de DAH et des DSS, par Classes I+II, III et IV: dans les hôpitaux, par lit.jour, en considérant le taux d’occupation; par consultation, dans les Centres de Santé, Cliniques Médicales et Dentaires et Cabinets Médicaux d’ Entreprises par lit.an dans les Maisons de Repos pour personnes âgées en considérant le taux d’occupation; et par an, dans les Cliniques d’Hémodialyse et Vétérinaires. On constate que l’actuation de l’Autorité de Santé produit dans les USS une différence statistiquement significative dans l’accroissement de leurs contractualisations avec les opérateurs de traitement de DAH et de DSS. On quantifie le poids moyen des déchets des Classes III et IV produit par acte de prestation de soins à domicile et on rapporte cette variable dépendante avec les caractéristiques des malades et des soins administrés. On compare les différents critères utilisés dans l’élaboration des définitions et des classifications de ces déchets inscrites dans la légis

Patologias na Superestrutura da Ferrovia Balastrada

Nesta dissertação de Mestrado, pretende-se contribuir para o conhecimento no âmbito das patologias da ferrovia, nomeadamente no que se refere a patologias em carril, balastro, travessas e elementos de fixação, tendo sido coletado neste trabalho as mais variadas patologias da ferrovia balastrada bem como a sua catalogação socioeconómica, permitindo com essa enumeração tomadas de decisão coerentes e assertivas no que respeita a recomendações a efetuar tanto como diagnostico como para manutenção. O trabalho inicia-se por uma introdução relativa ao aparecimento da ferrovia num contexto internacional, particularizando posteriormente o caso de Portugal até ao estado da arte atual, com um pequeno desenvolvimento a nível socie-económico com as grandes obras e projetos para os próximos anos. Para além da síntese de conhecimentos referida, apresentou-se um pouco da atualidade ferroviária de alguns países com relevância, quer por associação fronteiriça quer por desenvolvimento tecnológico. Apresenta-se brevemente os componentes mais importantes da ferrovia balastrada com especial destaque para os elementos da superestrutura de via, nos quais se engloba o carril, as travessas, os elementos de fixação e o balastro. Por fim esta dissertação apresenta um trabalho exaustivo na recolha e investigação das várias patologias associadas ao carril, as travessas, aos elementos de fixação e ao balastro, bem como o sistema de código, recomendações e correções associadas, fornecendo assim uma fácil interpretação do tipo de patologia e defeitos associados ao desenvolvimento desses fenómenos.

Amener à l'existence : la fragile naissance des nanosystèmes

En partant d'une étude ethnographique dans un laboratoire engagés dans la conception et la réalisation de micro et nanosystèmes, l'article rend compte de la manière dont ces objets sont amenés à l'existence, mais aussi de la fragilité de cette existence d'être technologique. Confronté à de nombreux échecs, les chercheurs en viennent à douter de leur faisabilité technologique, de leur capacité à maintenir l'intérêt des industriels pour ces objets, voire même du sens de l' histoire technologique. Cette histoire, qu' ils croyaient évoluer inéluctablement des microsystèmes vers les nanosystèmes, semble brutalement s'arrêter, voir s'inverser. Les nanosystèmes ne seraient alors qu'un leurre, une illusion plutôt qu'une nouvelle catégorie de technologie. L'existence-même de l'objet est devenue problématique. En suivant les chercheurs, ingénieurs et techniciens au travail, l'article rend compte de la technogénèse comme exploration des modes d'existence des êtres technologiques.

Vertical R&D Sprillovers, Cooperation, Market Structure, and Innovation.

This paper studies vertical R&D spillovers between upstream and downstream firms. The model incorporates two vertically related industries, with horizontal spillovers within each industry and vertical spillovers between the two industries. Four types of R&D cooperation are studied : no cooperation, horizontal cooperation, vertical cooperation, and simultaneous horizontal and vertical cooperation. Vertical spillovers always increase R&D and welfare, while horizontal spillovers may increase or decrease them. The comparison of cooperative settings in terms of R&D shows that no setting uniformly dominates the others. Which type of cooperation yields more R&D depends on horizontal and vertical spillovers, and market structure. The ranking of cooperative structures hinges on the signs and magnitudes of three competitive externalities (vertical, horizontal, and diagonal) which capture the effect of the R&D of a firm on the profits of other firms. One of the basic results of the strategic investment literature is that cooperation between competitors increases (decreases) R&D when horizontal spillovers are high (low); the model shows that this result does not necessarily hold when vertical spillovers and vertical cooperation are taken into account. The paper proposes a theory of innovation and market structure, showing that the relation between innovation and competition depends on horizontal spillovers, vertical spillovers, and cooperative settings. The private incentives for R&D cooperation are addressed. It is found that buyers and sellers have divergent interests regarding the choice of cooperative settings and that spillovers increase the likelihood of the emergence of cooperation in a decentralized equilibrium.

Information Sharing and the Stability of Cooperation in Research Joint Ventures.

The model studies information sharing and the stability of cooperation in cost reducing Research Joint Ventures (RJVs). In a four-stage game-theoretic framework, firms decide on participation in a RJV, information sharing, R&D expenditures, and output. An important feature of the model is that voluntary information sharing between cooperating firms increases information leakage from the RJV to outsiders. It is found that it is the spillover from the RJV to outsiders which determines the decision of insiders whether to share information, while it is the spillover affecting all firms which determines the level of information sharing within the RJV. RJVs representing a larger portion of firms in the industry are more likely to share information. It is also found that when sharing information is costless, firms never choose intermediate levels of information sharing : they share all the information or none at all. The size of the RJV is found to depend on three effects : a coordination effect, an information sharing effect, and a competition effect. Depending on the relative magnitudes of these effects, the size of the RJV may increase or decrease with spillovers. The effect of information sharing on the profitability of firms as well as on welfare is studied.

Religion and Economic Growth: Was Weber Right?

Evidence of falling wages in Catholic cities and rising wages in Protestant cities between 1500 and 1750, during the spread of literacy in the vernacular, is inconsistent with most theoretical models of economic growth. In The Protestant Ethic, Weber suggested an alternative explanation based on culture. Here, a theoretical model confirms that a small change in the subjective cost of cooperating with strangers can generate a profound transformation in trading networks. In explaining urban growth in early-modern Europe, specifications compatible with human-capital versions of the neoclassical model and endogenous-growth theory are rejected in favor of a “small-world” formulation based on the Weber thesis.

Statistical Inference for Computable General Equilibrium Models with Application to a Model of the Moroccan Economy

We study the problem of measuring the uncertainty of CGE (or RBC)-type model simulations associated with parameter uncertainty. We describe two approaches for building confidence sets on model endogenous variables. The first one uses a standard Wald-type statistic. The second approach assumes that a confidence set (sampling or Bayesian) is available for the free parameters, from which confidence sets are derived by a projection technique. The latter has two advantages: first, confidence set validity is not affected by model nonlinearities; second, we can easily build simultaneous confidence intervals for an unlimited number of variables. We study conditions under which these confidence sets take the form of intervals and show they can be implemented using standard methods for solving CGE models. We present an application to a CGE model of the Moroccan economy to study the effects of policy-induced increases of transfers from Moroccan expatriates.

Explaining the Great Divergence: Medium and Message on the Eurasian Land Mass, 1700-1850

Between 1700 and 1850, per-capita income doubled in Europe while falling in the rest of Eurasia. Neither geography nor economic institutions can explain this sudden divergence. Here the consequences of differences in communications technology are examined. For the first time, there appeared in Europe a combination of a standardized medium (national vernaculars with a phonetic alphabet) and a non-standardized message (competing religious, political and scientific ideas). The result was an unprecedented fall in the cost of combining ideas and burst of productivity-raising innovation. Elsewhere, decreasing standardization of the medium and increasing standardization of the message blocked innovation.

Directed Technical Change and International Trade

Recent changes in comparative advantage in the largest OECD economies differ significantly from the predictions of Heckscher-Ohlin-Vanek theory. Japan's rising share of OECD machinery exports and the improvement in the comparative advantage of the USA and Germany in heavy industry were accompanied by growing scarcities of the factors used intensively in the favored sector of each country. Here we examine Acemoglu's (1998, 2002) hypothesis that technical change may be directed toward raising the marginal productivity of abundant factors. Testing this hypothesis with 1970-1992 export data from 14 OECD countries, we find evidence that international comparative advantage was reshaped by innovation biased toward the abundant factors in the largest economies.

Economic Development under Alternative Trade Regimes

How does openness affect economic development? This question is answered in the context of a dynamic general equilibrium model of the world economy, where countries have technological differences that are both sector-neutral and specific to the investment goods sector. Relative to a benchmark case of trade in credit markets only, consider (i) a complete restriction of trade, and (ii) a full liberalization of trade. The first change decreases the cross-sectional dispersion of incomes only slightly, and produces a relatively small welfare loss. The second change, instead, decreases dispersion by a significant amount, and produces a very large welfare gain.

Communication and Economic Growth.

Overs the past millennium, each of the three centuries of most rapid demographic growth in the West Coincided with the diffusion of a new communications technology. This paper examines the hypothesis of Harold Innis (1894-1952) that there is two-way feeback between such innovations and economic growth.

How Prescribed Policy Can Mislead when Data Are Defective: a Follow-Up to Srinivasan (1994) Using General Equilibrium.

We highlight an example of considerable bias in officially published input-output data (factor-income shares) by an LDC (Turkey), which many researchers use without question. We make use of an intertemporal general equilibrium model of trade and production to evaluate the dynamic gains for Turkey from currently debated trade policy options and compare the predictions using conservatively adjusted, rather than official, data on factor shares.

Production Linkages Between Informal and Formal Activities Considering Domestic and Imported Inputs: an Application of the Minimal-Flow-Analysis Method to Senegal.

We apply to the Senegalese input-output matrix of 1990, disagregated into formal and informal activities, a recently designed structural analytical method (Minimal-Flow-Analysis) which permits to depict the direct and indirect production likanges existing between activities.