Essays on health care reform, wealth inequality, and demography

This thesis contains three chapters. The first chapter uses a general equilibrium framework to simulate and compare the long run effects of the Patient Protection and Affordable Care Act (PPACA) and of health care costs reduction policies on macroeconomic variables, government budget, and welfare of individuals. We found that all policies were able to reduce uninsured population, with the PPACA being more effective than cost reductions. The PPACA increased public deficit mainly due to the Medicaid expansion, forcing tax hikes. On the other hand, cost reductions alleviated the fiscal burden of public insurance, reducing public deficit and taxes. Regarding welfare effects, the PPACA as a whole and cost reductions are welfare improving. High welfare gains would be achieved if the U.S. medical costs followed the same trend of OECD countries. Besides, feasible cost reductions are more welfare improving than most of the PPACA components, proving to be a good alternative. The second chapter documents that life cycle general equilibrium models with heterogeneous agents have a very hard time reproducing the American wealth distribution. A common assumption made in this literature is that all young adults enter the economy with no initial assets. In this chapter, we relax this assumption – not supported by the data – and evaluate the ability of an otherwise standard life cycle model to account for the U.S. wealth inequality. The new feature of the model is that agents enter the economy with assets drawn from an initial distribution of assets. We found that heterogeneity with respect to initial wealth is key for this class of models to replicate the data. According to our results, American inequality can be explained almost entirely by the fact that some individuals are lucky enough to be born into wealth, while others are born with few or no assets. The third chapter documents that a common assumption adopted in life cycle general equilibrium models is that the population is stable at steady state, that is, its relative age distribution becomes constant over time. An open question is whether the demographic assumptions commonly adopted in these models in fact imply that the population becomes stable. In this chapter we prove the existence of a stable population in a demographic environment where both the age-specific mortality rates and the population growth rate are constant over time, the setup commonly adopted in life cycle general equilibrium models. Hence, the stability of the population do not need to be taken as assumption in these models.

A eficiência do gasto e da qualidade da saúde pública: uma análise nos municípios do estado do Rio Grande do Norte (2004 e 2008)

The overall objective of this study is to analyze the efficiency in the use of resources and the quality of public health in the municipalities of Rio Grande do Norte, from 2004 to 2008. It also seeks to identify the determinants of municipal inefficiency and measure the productivity of public spending on health. To this end, three methods of analysis are used: the DEA, the Malmquist index and the Tobit regression model. Among other findings, it appears that municipalities considered more inefficient in the measurement of expenditure on health make the largest expense in this function. On the other hand, from 2004 to 2008, only 13 municipalities showed an increase in the productivity of public spending. It is also noted that municipalities considered efficient in quality of health, although having more physical and human resources, offer fewer health services to the population. In all, the major determinants of health spending inefficiencies are the variables: age of the mayor, coalition, population density, literacy race and budget revenues. Regarding the inefficiency of the health quality, variables such as: coalition, literacy race have strong influence on this behavior. Thereby, the hypotheses proposed by the study have been fully accepted. In other words, for the efficiency of the quality and health spending it is needed more than resources, i.e., the expenditure shows itself as essential, but not enough, for political and economic aspects also interfere with the performance of spent and in the quality of health care offered to the population

Segurança do paciente no sistema de medicação: análise de enfermeiros de um hospital de ensino

This study aimed to identify and describe the factors related to Patient Safety in a medication system according to the nurses analysis in a teaching hospital from the photographic analysis method. This was a cross-sectional, descriptive study with mixed approach in a teaching hospital in Rio Grande do Norte. The population consisted of 42 nurses from inpatient units, of which 34 composed the study sample. As eligibility criteria, we defined nurses from public service and nurses who agreed to participate. Ethical determinations were observed, the study was submitted to the Ethics and Research of the University Hospital Onofre Lopes, obtaining the assent with ethical assessment certificate (CAAE 0098.0.051.294-11). For data collection, we used the photographic method (Photographic Analysis Technique) by Patricia Marck (Canada). It was developed in two phases: at first, we randomly captured photos from the medication system, resulting in 282 images; then we selected/processed the photographs, which were reduced to 10 images in Microsoft Excel 2010; in the second phase, the nurses answered the questionnaire divided into socio-professional profile and Digital Photography Scoring Tool (questions a and b ). For analysis of the question a , we used the content analysis technique, and for b , we used the Statistical Package for the Social Sciences 20.0 (temporary license). The socio-professional profile revealed the predominance of females; age group 34-43 years; professionals with specialization; 10-18 years of length of service; and nurses working exclusively in the hospital and who know the Patient Safety. The photographic analysis in relation to Patient Safety resulted in specific categories for each stage of the medication system. Regarding disposal, we identified Proper verification ; Improper verification ; Correct identification ; Disposal in single doses ; and Improper Environment , with predominance of that last category. As for storage: Proper storage ; Improper storage ; Risk of exchange/disappearance ; and Poor hygiene , with special reference to improper storage. In preparation: Risk of exchanging medication/patient ; Inappropriate physical space ; and Inadequate 9 preparation of controlled drugs , highlighting the first category. In drug administration: Lack of Personal Protective Equipment ; Use of Personal Protective Equipment ; Improper administration technique ; Proper administration technique ; Correct drug identification ; Incorrect drug identification ; and Peripheral venous access without identification . From the safety assessment of 10 photographs, by adapting the scores (1-10) to the Likert Scale, we identified three Totally Unsafe (Level 1), three Unsafe (Level 2), three Partially Safe (Level 3), one Safe (Level 4), and no photograph considered Totally Safe. This study identified the prevalence of unsafety in the medication system in the nurses opinion. We were also able to understand that, although nurses identify safety aspects, the most prevalent categories characterize an unsafe assessment. Nursing needs to reflect on its practice, identifying gaps in the medication system in order to achieve a proper and safe care

Gestão pública em saúde mental: um estudo em CAPS com gerência pública e privada do Rio Grande Do Norte

Currently, several models of management services from the public administration are in operation in Brazil following a global trend. Besides the traditional public management operated in SUS, there are ongoing experiments of privately management in the public health services. Accordingly, we have developed an investigation into two Psychosocial Care Centers operating between these two forms of financial resources management: the first is the CAPS II - PAR situated in the municipality of Parnamirim whose form is private and the second is the CAPS II West Christmas is that the municipal government. We seek to know the workings of services, planning forms and criteria for use of financial resources, identify differences between departments on ways to run and see how technicians and users participate in the planning and management of these resources. Documentary Research was conducted by the municipal Christmas and the financial administration of the CAPS service in Parnamirim. Were conducted an interview with manager (mental health coordinator of Natal) and another interview with an employee of planning department in the Health Department of Natal, an interview with the coordinator and financial administrator of CAPS - PAR and two groups of discussion taped conversation with semi structured script interviews with six technicians in CAPS PAR and six professionals crowded in CAPS - West.Differences were observed in the management of resources funded from four blocks of discussion and analysis of results, where the privately-run service for the direct management and bureaucracy without being discussed and planned spending on staff, as well as through meetings with users, the use of the financial resources available in box; already in service with municipal public administration there is a hierarchy, this answering the coordination of mental health and the local health department that centralizes resources and defines their spending. There are meetings with patients and families, but the demands are limited as to what can be sued because of the manager s authorization. Such differentiation would be related to differences in the articulation of public management with the different types of possible management in public services, where from the implementation of new public administration in the Brazilian s State Management Reform initiated in the second half of the 1990s, benefit management services with private regime, with autonomy and direct transfer of resources

Serviço Social Audit Saúde no SUS/RN: projeto ético político profissional e de reforma sanitária

Health policies in Brazil, the decentralization of SUS management responsibilities for the three spheres of government has driven the creation and regulation of the audits of health services in the National Audit Office, this is a trend of neoliberal policies imposed by international bodies like the World Bank and IMF to peripheral countries characterized by productive restructuring and reforming the state focuses on the presence of two competing projects in the area of health: Health Sector Reform Project which is based on the democratic rule of law with the assumption of health as social right and duty of the State in defending the extension of the conquest of rights and democratization of access to health care guaranteed through the public financing strategies and the effective decentralization of decisions pervaded by social control and privatized Health Project which is based on the state minimum, with a reduction in social spending or in partnerships and privatization, stronger nonprofit sector, subject to capitalist interests, is made effective through strategies targeting health policy and refilantropização actions. In this context, the present study is an analysis on the work of social audits of public health in infants from a qualitative and quantitative approach, embodied by the critical method of dialectical Marxist social theory that enabled us to unveil the characterization, the demands, challenges and outline the profile of Social Work in teams inserted audits of SUS in RN, but also provided evidence to demonstrate the prospects and possibilities of this area of activity of social workers. It was also found that through the audit work that the state fulfill its role as bureaucratic and regulator of health services with efficiency, effectiveness and economy. Yet, paradoxically, the audits of SUS may provide a vehicle for enforcing rights and ensuring the fundamental principles contained in the project of health reform, because it can be configured in a space of political struggle as representing a new field of knowledge production that needs to be appropriate for a theoretical critic able to redirect the social interests in favor of the user. From this perspective, it is concluded that the work of social audits of public health in infants despite the social relevance that prints, as they constitute an activity study of reality and its transformation proposition requires a transformative political action guided the discussion Marxist theory holds that the ethical project professional politician of Social Work

Care cost for pregnant and parturient women with diabetes and mild hyperglycemia

OBJETIVO: Comparar custos de hospitalização e de atenção ambulatorial em gestantes/parturientes diabéticas e com hiperglicemia leve. MÉTODOS: Estudo observacional, prospectivo, quantitativo descritivo realizado em centro de diabete perinatal em Botucatu, SP, entre 2007 e 2008. Foram estimados os custos por absorção diretos e indiretos disponíveis na instituição e os custos específicos para a doença (medicamentos e exames). As 30 gestantes diabéticas tratadas com dieta foram acompanhadas em ambulatório e 20 tratadas com dieta mais insulina foram hospitalizadas. RESULTADOS: O custo da doença diabete (para a assistência pré-natal e parto) foi de US$ 3,311.84 para as gestantes hospitalizadas e de US$ 1,366.04 para as acompanhadas em ambulatório. CONCLUSÕES: Os custos diretos e indiretos e o custo total da assistência pré-natal foram mais elevados nas gestantes diabéticas hospitalizadas enquanto os custos da assistência ao parto e hospitalização para parto e puerpério foram semelhantes. Os custos da assistência pré-natal como no parto/puerpério foram superiores aos valores pagos pelo Sistema Único de Saúde.

Quality of life and its association with cardiovascular risk factors in a community health care program population

OBJECTIVE: To evaluate quality of life in a population that attended a specific community event on health care education, and to investigate the association of their quality of life with the presence of cardiovascular risk factors INTRODUCTION: Interest in health-related quality of life is growing worldwide as a consequence of increasing rates of chronic disease. However, little is known about the association between quality of life and cardiovascular risk factors. METHODS: This study included 332 individuals. Demographics, blood pressure, body mass index, and casual glycemia were evaluated. The brief version of the World Health Organization Quality of Life questionnaire on quality of life was given to them. The medians of the scores obtained for the physical, psychological, emotional, and environmental domains were used as cutoffs to define higher and lower scores. A multinomial logistic regression model was used to define the parameters associated with lower scores. RESULTS: Diabetes mellitus, dyslipidemia, and obesity were associated with lower scores in the physical domain. Dyslipidemia was also associeted with lower scores in the psychological domain. Male gender and regular physical activity had protective effects on quality of life. Aging was inversely associated with decreased quality of life in the environmental domain. CONCLUSION: The presence of cardiovascular risk factors is related to a decreased quality of life. Conversely, male gender and regular physical activity had protective effects on quality of life. These findings suggest that exercising should be further promoted by health-related public programs, with a special focus on women.

Health surveys and use of maternal and child health care services in three municipalities within the São Paulo metropolitan area

Objectives. To describe the changes in the use of maternal and child health care services by residents of three municipalities-Embu, Itapecerica da Serra, and Taboao da Serra-in the São Paulo metropolitan area, 12 years after the implementation of the Unified Health System (SUS) in Brazil, and to analyze the potential of population-based health care surveys as sources of data to evaluate these changes.Methods. Two population-based, cross-sectional surveys were carried out in 1990 and 2002 in municipalities located within the São Paulo metropolitan area. For children under 1 year of age, the two periods were compared in terms of outpatient services utilization and hospital admission; for the mothers, the periods were compared in terms of prenatal care and deliveries. In both surveys, stratified and multiple-stage conglomerate sampling was employed, with standardization of interview questions.Results. The most important changes observed were regarding the location of services used for prenatal care, deliveries, and hospitalization of children less than 1 year of age. There was a significant increase in the use of services in the surrounding region or hometown, and decrease in the utilization of services in the city of São Paulo (in 1990, 80% of deliveries and almost all admissions for children less than 1 year versus 32% and 46%, respectively, in 2002). The use of primary care units and 24-hour walk-in clinics also increased. All these changes reflect care provided by public resources. In the private sector, there was a decrease in direct payments and payments through company-paid health insurance and an increase in payments through self-paid health insurance.Conclusions. The major changes observed in the second survey occurred simultaneous to the changes that resulted from the implementation of the SUS. Population-based health surveys are adequate for analyzing and comparing the utilization of health care services at different times.

Childbirth care: contributing to the debate on human development

Com a finalidade de subsidiar gestores da área de saúde da mulher, na formulação de políticas públicas, voltadas ao desenvolvimento humano, realizou-se esta investigação, cujo objetivo foi avaliar a estrutura e o processo da atenção ao parto e ao neonato desenvolvido em região do interior paulista. Estudo epidemiológico, voltado para avaliação dos serviços de saúde, baseou-se na observação da assistência prestada pelo Sistema Único de Saúde em 12 maternidades e 134 partos, adotando-se padrões estabelecidos pelo Ministério da Saúde ou Organização Mundial de Saúde para comparação. Os resultados apontam problemas relacionados à estrutura em algumas maternidades, mostrando que práticas úteis ao parto normal ainda são pouco utilizadas, enquanto que outras prejudiciais ou ineficazes ainda são utilizadas rotineiramente. Reverter esse quadro será essencial para oferecer atendimento de qualidade às mulheres, com conseqüente redução nas taxas de mortalidade materna e neonatal, para que a região atinja as metas estabelecidas para ampliação do desenvolvimento humano no milênio.

Evaluation of pre-natal care from the perspective of different models in primary care

OBJETIVOS: avaliar a qualidade do cuidado pré-natal desenvolvido na atenção primária, comparando os modelos tradicional e Estratégia Saúde da Família. MÉTODO: estudo de avaliação de serviço, pautado nas políticas públicas de saúde. Os dados foram obtidos por meio de entrevista com gerentes, observação nas unidades de saúde e análise de prontuários de gestantes, selecionados aleatoriamente. Diferenças nos indicadores de estrutura e processo foram avaliadas pelo teste qui-quadrado, adotando-se p<0,05 como nível crítico, cálculo dos odds ratio e intervalos de confiança de 95%. RESULTADOS: foram evidenciadas estruturas semelhantes em ambos os modelos de atenção. Indicadores-síntese de processo, criados neste estudo, e os indicados pelas políticas públicas apontaram situação mais favorável nas Unidades de Saúde da Família. Para o conjunto de atividades preconizadas para o pré-natal, o desempenho foi deficiente em ambos os modelos, embora pouco melhor nas Unidades de Saúde da Família. CONCLUSÃO: os resultados indicam a necessidade de ações para melhoria da atenção pré-natal nos dois modelos de atenção básica no município avaliado.

Fungemia by yeasts in Brazil: occurrence and phenotypic study of strains isolated at the Public Hospital, Botucatu, São Paulo

Objective. - In this study strains of yeasts isolated from the blood of human patients were analyzed taxonomically, their virulence factors were determined and compared, and phenotypic markers were used to compare the samples with respect to phenotypic differences across the range of patients as well as between samples isotated from the same patient.Methods. - the study involved a total of 75 strains of yeast isolated from the blood of in-patients of the Public Hospital, Botucatu, S (a) over tildeo Paulo, Brazil, with a clinical profile of fungemia. The hospital wards with the largest number of fungemias were neonatal intensive care units (ICUs) (32%) followed by gastric surgery (13.4%) and pediatric wards (10.7%). After identification, the samples were analyzed for the production of phospholipase and proteinase enzymes, and biotyped according to their susceptibility to killer toxins.Results. - the most frequent species found was Candida albicans (38.7%) followed by C. parapsilosis (30.7%). In terms of enzyme production, 98.7% of the 75 samples of yeast presented a strongly positive activity for proteinase; however, 78.7% did not present any phospholipasic activity. Six different biotypes were identified, the most frequent being 511 and 888.Conclusion. In association with phenotypic methods, genetic analyses should also be made of the samples under study to help in the rational development of a wider range of preventive measures and better control of hospital-contracted infections. (c) 2005 Published by Elsevier SAS.

Territorial hypothesis predicts the trade-off between reproductive opportunities and parental care in three species of damselfishes (Pomacentridae: Actinopterygii)

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Variability on red blood cell transfusion practices among Brazilian neonatal intensive care units

BACKGROUND:Guidelines for red blood cell (RBC) transfusions exist; however, transfusion practices vary among centers. This study aimed to analyze transfusion practices and the impact of patients and institutional characteristics on the indications of RBC transfusions in preterm infants.STUDY DESIGN and METHODS:RBC transfusion practices were investigated in a multicenter prospective cohort of preterm infants with a birth weight of less than 1500 g born at eight public university neonatal intensive care units of the Brazilian Network on Neonatal Research. Variables associated with any RBC transfusions were analyzed by logistic regression analysis.RESULTS:Of 952 very-low-birth-weight infants, 532 (55.9%) received at least one RBC transfusion. The percentages of transfused neonates were 48.9, 54.5, 56.0, 61.2, 56.3, 47.8, 75.4, and 44.7%, respectively, for Centers 1 through 8. The number of transfusions during the first 28 days of life was higher in Center 4 and 7 than in other centers. After 28 days, the number of transfusions decreased, except for Center 7. Multivariate logistic regression analysis showed higher likelihood of transfusion in infants with late onset sepsis (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.8-4.4), intraventricular hemorrhage (OR, 9.4; 95% CI, 3.3-26.8), intubation at birth (OR, 1.7; 95% CI, 1.0-2.8), need for umbilical catheter (OR, 2.4; 95% CI, 1.3-4.4), days on mechanical ventilation (OR, 1.1; 95% CI, 1.0-1.2), oxygen therapy (OR, 1.1; 95% CI, 1.0-1.1), parenteral nutrition (OR, 1.1; 95% CI, 1.0-1.1), and birth center (p < 0.001).CONCLUSIONS:The need of RBC transfusions in very-low-birth-weight preterm infants was associated with clinical conditions and birth center. The distribution of the number of transfusions during hospital stay may be used as a measure of neonatal care quality.

Care arrangements for people with dementia in developing countries

Background: Rapid demographic ageing will soon lead to large increases in the numbers of persons with dementia in developing countries. This study is the first comprehensive assessment of care arrangements for people with dementia in those regions. Methods: A descriptive and comparative study of dementia care; caregiver characteristics, the nature of care provided, and the practical, psychological (Zarit Burden Interview, General Health Questionnaire) and economic impact upon the caregiver in 24 centres in India, China and South East Asia, Latin America and the Caribbean and Africa. Results: We interviewed 706 persons with dementia, and their caregivers. Most caregivers were women, living with the person with dementia in extended family households. One-quarter to one-half of households included a child. Larger households were associated with lower caregiver strain, where the caregiver was co-resident. However, despite the traditional apparatus of family care, levels of caregiver strain were at least as high as in the developed world. Many had cutback on work to care and faced the additional expense of paid carers and health services. Families from the poorest countries were particularly likely to have used expensive private medical services, and to be spending more than 10% of the per capita GNP on health care. Conclusions: Older people in developing countries are indivisible from their younger family members. The high levels of family strain identified in this study feed into the cycle of disadvantage and should thus be a concern for policymakers in the developing world. Copyright © 2004 John Wiley & Sons, Ltd.

Botucatu, Brazil: A Regional Community Palliative Care Model

The Pain Management and Palliative Care Service in the Department of Anesthesia at Botucatu Medical School, UNESP is a pioneer in Brazil. Based on an interdisciplinary team that provides specialized inpatient, ambulatory outpatient, and home care to patients in Botucatu and the surrounding region, the service is also able to provide extensive educational opportunities in pain management and palliative care for medical students, anesthesia residents, practicing anesthetists, and nurses. © 2007 U.S. Cancer Pain Relief Committee.