An assessment of infant mortality rates in Colombia, 1980-2009 / Una evaluación de las tasas de mortalidad infantil en Colombia, 1980-2009

Abstract Purpose: The infant mortality rate is a key indicator of human welfare and development. However, in Colombia, the Departamento Administrativo Nacional de Estadística has set the registered rate for 2009 as 13.69 per 1,000 live births, while the estimated rate is 20.13, suggesting the presence of inconsistencies in the data, as in many other transitional economies. Objective: To set the record straight on Colombia's Infant mortality rate reporting since 1980 by using all available data that have recently become public. Methods: The study analyzes 8,636,510 records of live births (1998-2009) and 443,338 records of deaths (1979-2009), and considers information from all available sources: births and death registries, census data, Departamento Administrativo Nacional de Estadística, and Profamilia surveys. First, following a descriptive analysis, an exponential function is used to estimate the Infant mortality rates in Colombia for 1980-2009 while resolving internal inconsistencies in the data from all sources. The objective is to evaluate the infant mortality rate in Colombia, 1980-2009. Results: The analysis demonstrates that the registered and the estimated rates for 2009 are incompatible since they follow inconsistent long-term rates of decline in Infant mortality rate. While the registered rate underestimates the real situation, the estimated rate appears to grossly overestimate it. Analyses, based on other sources, put the Infant mortality rate between 15.81 and 17.58 in 2009, with rates of decline between 3.0 and 5.0 percent for the period 1980-2009. Conclusions: The study concludes that during the period 1980-2009, the Infant mortality rate for Colombia on average fell from about 54 to about 17, suggesting a long-term annual rate of decline of about 4.0 percent.

Resumen Propósito: La Tasa de Mortalidad Infantil es un indicador clave del bienestar y desarrollo humano. Sin embargo, en Colombia el Departamento Administrativo Nacional de Estadística reporta una tasa de mortalidad infantil registrada para 2009 de 13.69 por cada 1,000 nacidos vivos, mientras que, la tasa estimada es de 20.13 para el mismo año, como en muchas economías de transición, lo que sugiere la presencia de datos inconsistentes. El objetivo fue determinar la tasa de mortalidad infantil de Colombia desde 1980 a 2009, con los datos disponibles y publicados recientemente. Métodos: El estudio analiza 8 636 510 de registros individuales de nacidos vivos (1998-2009) y 443 338 registros individuales de mortalidad (1979-2009). Además, se incluyen todas las fuentes disponibles: nacimientos y defunciones registrados del Departamento Administrativo Nacional de Estadística (DANE), datos censales, y la Encuesta Nacional de Demografía y Salud (ENDS) de Profamilia Colombia. En primer lugar, tras un análisis descriptivo, se utilizó una función exponencial para estimar las tasas de mortalidad infantil en Colombia para 1980-2009 mientras se resuelven las incoherencias internas en los datos de todas las fuentes, con el objetivo de evaluar la tasa de mortalidad infantil en Colombia 1980-2009. Resultados: El análisis mostró que las tasas registradas y estimadas para 2009 eran incompatibles, debido a que la tasa de descenso de los nacimientos y las defunciones a lo largo del tiempo también eran inconsistentes. Si bien la tasa registrada de 13.69, estaba subestimada frente a la situación real, la tasa estimada de 20.13, parecía estar demasiado sobreestimada. Los análisis basados en otras fuentes muestran que la tasa de mortalidad infantil se encuentra entre 15.81 y 17.58 en 2009, con tasas de descenso anual entre un 3.0 y el 5.0 por ciento, para el período 1980-2009. Conclusiones: El estudio concluye que, durante el período 1980-2009 la tasa de mortalidad infantil para Colombia se redujo de 54 a 17 muertes por mil nacidos vivos, lo que sugiere una tasa anual de descenso aproximada para el período de 4.0 por ciento.

Early adolescent childbearing in Colombia: time-trends and consequences.

Teenage childbearing has been increasing, especially among girls aged 10 to 14 years, slowing the improvements in public health and propelling social marginalization. The objective of this article is to study adolescent pregnancy in Colombia and suggest possible policy interventions. The study comprises univariate and multivariate analyses that examine trends and correlates of teenage childbirth and related infant mortality in Colombia between 2001-2011 using complete vital statistics. The study compares, by relative risk analysis as well, two groups of teenage mothers, aged 10 to 14 years and 15 to 19 years, with a reference group of mothers aged 20 to 34 years. During the study period, the average of annual birth rates increased 2.6% and 0.8% in mothers aged 10 to 14 years, and 15 to 19 years respectively, whereas it declined at an average rate of 0.2% annually for mothers aged 20 to 35 years. Simultaneously, while the overall rate declined, the infant mortality rate (IMR) of the youngest group was consistently higher during the entire period compared to the IMR of older groups. Compared with the other groups, mothers aged from 10 to 14 were more likely to be unmarried, rural, indigenous or afro-descendant, and have less access to health care. The study demonstrates that early teenage childbirth is a growing challenge at least in Colombia. These mothers are at higher risk of losing their babies while being poor and remaining poor. The study suggests the need for policy that targets appropriate education and health care to poor girls as early as age 10 and even younger.

Impact of desertification and land degradation on Colombian children.

OBJECTIVES: Desertification affected more than 24% of Colombia's land mass in 2012. The study aims to establish the singular impact of desertification on under-five mortality in Colombia. METHODS: Descriptive statistics and multivariate logit regressions are applied to the population of live births and under-five deaths in Colombia 2008-2011. RESULTS: Children have a higher probability to die in rural communities and among mothers with low education who also have inferior health insurance. Controlling for those, desertification below about 50% of the land, lowers child mortality and increases it after that percentage. The impact of extraction of hydrocarbons is 12.45, metals 5.73 and others 4.91 times higher in municipalities with more than 50% of desertification territory. Rural areas with high desertification have 2.25 times higher risk of mortality due to malnutrition. CONCLUSIONS: In the short term, when mines have less or no effect on desertification, living conditions may improve and reduce child mortality. In the long term, however, as desertification intensifies affecting the ecosystem, child mortality increases. More research is needed, and policy formulated accordingly.

An assessment of infant mortality rates in Colombia, 1980-2009.

PURPOSE: The infant mortality rate is a key indicator of human welfare and development. However, in Colombia, the Departamento Administrativo Nacional de Estadística has set the registered rate for 2009 as 13.69 per 1,000 live births, while the estimated rate is 20.13, suggesting the presence of inconsistencies in the data, as in many other transitional economies. Objective: To set the record straight on Colombia's Infant mortality rate reporting since 1980 by using all available data that have recently become public. METHODS: . The study analyzes 8,636,510 records of live births (1998-2009) and 443,338 records of deaths (1979-2009), and considers information from all available sources: births and death registries, census data, Departamento Administrativo Nacional de Estadística, and Profamilia surveys. First, following a descriptive analysis, an exponential function is used to estimate the Infant mortality rates in Colombia for 1980-2009 while resolving internal inconsistencies in the data from all sources. The objective is to evaluate the infant mortality rate in Colombia, 1980-2009. RESULTS: The analysis demonstrates that the registered and the estimated rates for 2009 are incompatible since they follow inconsistent long-term rates of decline in Infant mortality rate. While the registered rate underestimates the real situation, the estimated rate appears to grossly overestimate it. Analyses, based on other sources, put the Infant mortality rate between 15.81 and 17.58 in 2009, with rates of decline between 3.0 and 5.0 percent for the period 1980-2009. CONCLUSIONS: The study concludes that during the period 1980-2009, the Infant mortality rate for Colombia on average fell from about 54 to about 17, suggesting a long-term annual rate of decline of about 4.0 percent.

Early adolescent childbearing in Colombia: time-trends and consequences / Maternidad prematura adolescente en Colombia: tendencias temporales y consecuencias / Gravidez precoce na adolescência na Colômbia: tendências temporais e consequências

Teenage childbearing has been increasing, especially among girls aged 10 to 14 years, slowing the improvements in public health and propelling social marginalization. The objective of this article is to study adolescent pregnancy in Colombia and suggest possible policy interventions. The study comprises univariate and multivariate analyses that examine trends and correlates of teenage childbirth and related infant mortality in Colombia between 2001-2011 using complete vital statistics. The study compares, by relative risk analysis as well, two groups of teenage mothers, aged 10 to 14 years and 15 to 19 years, with a reference group of mothers aged 20 to 34 years. During the study period, the average of annual birth rates increased 2.6% and 0.8% in mothers aged 10 to 14 years, and 15 to 19 years respectively, whereas it declined at an average rate of 0.2% annually for mothers aged 20 to 35 years. Simultaneously, while the overall rate declined, the infant mortality rate (IMR) of the youngest group was consistently higher during the entire period compared to the IMR of older groups. Compared with the other groups, mothers aged from 10 to 14 were more likely to be unmarried, rural, indigenous or afro-descendant, and have less access to health care. The study demonstrates that early teenage childbirth is a growing challenge at least in Colombia. These mothers are at higher risk of losing their babies while being poor and remaining poor. The study suggests the need for policy that targets appropriate education and health care to poor girls as early as age 10 and even younger.

La maternidad prematura se ha visto incrementada, especialmente entre niñas con edades comprendidas entre los 10 a 14 años, aminorando mejoras en la salud pública y propagando la marginalización social. El objetivo de este artículo es estudiar los embarazos adolescentes en Colombia y sugerir posibles políticas de intervención. El estudio abarca análisis univariados y multivariados que examinan tendencias y correlacionan el parto en la adolescencia y la mortalidad infantil relacionada, en Colombia, durante el periodo de 2001 a 2011, usando estadísticas vitales completas. El estudio compara, también, mediante un análisis de riesgos relativos, a dos grupos de madres adolescentes, con edades de 10 a 14 y edades de 15 a 19 años, con un grupo de referencia, madres con edades de 20 a 34. Durante el período de estudio, la media anual de la tasa de natalidad se incrementó un 2,6% y un 0,8% en madres con edades de 10 a 14 años, y edades de 15 a 19 años, respectivamente, mientras que decreció a una tasa media de 0,2% anualmente en madres con 20-35 años de edad. Simultáneamente, mientras disminuía en general, la tasa de mortalidad infantil (TMI) del grupo más joven fue consistentemente más alta durante todo el período que la TMI de los grupos con mayor edad. Comparadas con otros grupos, las madres con edades entre 10 a 14 años eran más propensas a no estar casadas, ser procedentes del ámbito rural, indígenas o afro-mulatas, y contar con menor acceso a servicios de salud. El estudio demuestra que la maternidad prematura en adolescentes es un desafío creciente, al menos en Colombia. Estas madres tienen un riesgo más alto de perder a sus bebés mientras están en situación de pobreza. El estudio indica la necesidad de políticas que tengan como objetivo una educación apropiada y cuidados de salud, dirigidos a niñas pobres, desde una edad tan temprana como los 10 años o incluso más jóvenes.

A gravidez na adolescência tem crescido, especialmente na faixa etária de 10 a 14 anos, freando avanços na saúde pública e impulsionando a marginalização social. O objetivo deste artigo é estudar a gravidez na adolescência na Colômbia e sugerir possíveis intervenções de políticas públicas. O estudo consiste em análises univariadas e multivariadas que examinam tendências e correlativos da gravidez na adolescência e da mortalidade infantil associada na Colômbia no período de 2001 a 2011 usando estatísticas vitais completas. O estudo compara, também por meio de análise de risco relativo, dois grupos de mães adolescentes, com idade entre 10 e 14 anos e entre 15 e 19 anos, com um grupo de referência, mães com idade entre 20 e 34 anos. Durante o período do estudo, as taxas médias anuais de natalidade aumentaram em 2,6% e 0,8% entre as mães com idade entre 10 e 14 e entre 15 e 19 anos, respectivamente, ao mesmo tempo em que sofreram uma redução, a uma taxa média anual de 0,2%, entre as mães com idade entre 20 e 35 anos. Ao mesmo tempo, a taxa de mortalidade infantil (TMI) do grupo mais jovem foi consistentemente mais alta do que a dos grupos mais velhos, ainda que tenha sofrido uma redução. Quando comparadas aos outros grupos, mães com idade entre 10 e 14 anos tinham maior probabilidade de serem solteiras, indígenas ou Afro-mulatas, viverem em áreas rurais e terem menos acesso a serviços de saúde. Este estudo demonstra que a gravidez precoce na adolescência é um desafio crescente, pelo menos na Colômbia. Essas mães têm risco maior de perderem seus bebês e, simultaneamente, de serem e permanecerem pobres. O estudo sugere a necessidade de políticas dirigidas à educação e serviços de saúde apropriados para meninas pobres a partir dos 10 anos e até mais jovens.

[Determinants of infant mortality in Colombia. Path Analysis]. / Determinantes de la mortalidad infantil en Colombia. Path Análisis.

OBJECTIVE: To disentangle the singular effects of biological, environmental, socioeconomic, and medical factors on the probability for infants to die. MATERIALS AND METHODS: Apply a Path Analysis to Colombia's complete records of infant births and deaths, and the availability of maternal and child health services, during 2003-2009. RESULTS: From a biological perspective, a high birth weight resulting from a normal gestational age is the most important variable to ensure the infant's survival. Prenatal care is key to reduce infant mortality. From a socioeconomic perspective, high levels of education and relative access to high quality care in the contributory social health insurance regime for maternal residence, contribute to higher chances of infant survival. CONCLUSIONS: Related findings suggest that augmenting access to maternal, child and intensive care beds supported by the subsidized regime can reduce infant mortality.

OBJETIVO: Separar y analizar los efectos de los factores biológicos, ambientales, socioeconómicos, de atención médica y servicios de salud; y su probabilidad de generar una muerte infantil. MATERIALES Y MÉTODOS: Se aplica el Path análisis utilizando las características del niño y de la madre en los registros individuales de nacimiento y defunción infantil, y la disponibilidad de camas materno infantil entre 2003 y 2009. RESULTADOS: El efecto biológico más importante para asegurar la supervivencia infantil fue el peso al nacer cerca de las 37 semanas de gestación. La principal intervención para reducir la mortalidad infantil fue el control prenatal. Variables socioeconómicas para la supervivencia infantil fueron la educación de la madre, acceso a servicios materno infantil para el régimen contributivo en el mismo municipio de residencia, el cual se encontró asociado a la calidad de los servicios de salud. CONCLUSIONES: El estudio sugiere que, además de participar en acciones de promoción de la salud, las madres del régimen subsidiado deben tener acceso a camas de cuidado intensivo neonatal, disponibles en el mismo departamento de residencia, para contribuir a reducir la mortalidad infantil.

Encuestas de Satisfacción del Paciente en Colombia: Una Oportunidad para Mejorar / Patient Satisfaction Surveys in Colombia: Scope for Improvement

Resumen Objetivo: Este artículo espera ayudar con el reto de alinear las encuestas colombianas con las mejores prácticas internacionales. Método: Se analiza si las tres principales encuestas colombianas cumplen los ocho criterios de receptividad planteados por la Organización Mundial de la Salud. Este es un estándar internacional que responde a la necesidad de evaluar la satisfacción del paciente. Resultados: Las encuestas colombianas se centran en evaluar la percepción de calidad que tiene el paciente. Son escasas las preguntas equivalentes a las ocho dimensiones propuestas por la organización mundial de la salud. Conclusiones: Las tres principales encuestas colombianas, que evalúan salud y atención médica, no hacen una medición adecuada. Este artículo sugiere que la situación se puede compensar tomando la ventaja que ofrece la infraestructura actual de encuesta a hogares, así como los requerimientos administrativos para estimar la satisfacción del paciente.

Abstract Objetive: The study reviews whether the three major Colombian surveys meet the eight World Health Organization responsiveness criteria. The responsiveness framework is an internationally acknowledged standard that meets the challenge of evaluating patient satisfaction. Method: After exploring patient evaluations practices that are internationally recognized, this study makes a comparative analysis of the Colombian surveys. Results: Colombian surveys are concerned on evaluating patients' perception of quality. There are only few questions that have an equivalent assessment to the eight dimensions suggested by the World Health Organization. Conclusion: By using this framework, the three major Colombian surveys, which deal with health and medical care, do not make accurate evaluation of patient satisfaction. This article suggests how to ameliorate the situation by taking advantage of Colombia's celebrated household survey infrastructure as well as its administrative requirements.

Determinantes de la mortalidad infantil en Colombia: path análisis / Determinants of infant mortality in Colombia: path analysis

RESUMEN Objetivo Separar y analizar los efectos de los factores biológicos, ambientales, socioeconómicos, de atención médica y servicios de salud; y su probabilidad de generar una muerte infantil. Materiales y Métodos Se aplica el Path análisis utilizando las características del niño y de la madre en los registros individuales de nacimiento y defunción infantil, y la disponibilidad de camas materno infantil entre 2003 y 2009. Resultados El efecto biológico más importante para asegurar la supervivencia infantil fue el peso al nacer cerca de las 37 semanas de gestación. La principal intervención para reducir la mortalidad infantil fue el control prenatal. Variables socioeconómicas para la supervivencia infantil fueron la educación de la madre, acceso a servicios materno infantil para el régimen contributivo en el mismo municipio de residencia, el cual se encontró asociado a la calidad de los servicios de salud. Conclusiones El estudio sugiere que, además de participar en acciones de promoción de la salud, las madres del régimen subsidiado deben tener acceso a camas de cuidado intensivo neonatal, disponibles en el mismo departamento de residencia, para contribuir a reducir la mortalidad infantil.(AU)

ABSTRACT Objective To disentangle the singular effects of biological, environmental, socioeconomic, and medical factors on the probability for infants to die. Materials and Methods Apply a Path Analysis to Colombia's complete records of infant births and deaths, and the availability of maternal and child health services, during 2003-2009. Results From a biological perspective, a high birth weight resulting from a normal gestational age is the most important variable to ensure the infant's survival. Prenatal care is key to reduce infant mortality. From a socioeconomic perspective, high levels of education and relative access to high quality care in the contributory social health insurance regime for maternal residence, contribute to higher chances of infant survival. Conclusions Related findings suggest that augmenting access to maternal, child and intensive care beds supported by the subsidized regime can reduce infant mortality.(AU)

Demand-side strategies to deal with moral hazard in public insurance for long-term care.

Moral hazard in public insurance for long-term care may be counteracted by strategies influencing supply or demand. Demand-side strategies may target the patient or the insurer. Various demand-side strategies and how they are implemented in four European countries (Germany, Belgium, Switzerland and the Netherlands) are described, highlighting the pros and cons of each strategy. Patient-oriented strategies to counteract moral hazard are used in all four countries but their impact on efficiency is unclear and crucially depends on their design. Strategies targeted at insurers are much less popular: Belgium and Switzerland have introduced elements of managed competition for some types of long-term care, as has the Netherlands in 2015. As only some elements of managed competition have been introduced, it is unclear whether it improves efficiency. Its effect will depend on the feasibility of setting appropriate financial incentives for insurers using risk equalization and the willingness of governments to provide insurers with instruments to manage long-term care.

Brechas regionales de la mortalidad infantil en Colombia / Regional disparities in infant mortality in Colombia

Objetivos. Estudiar las variaciones de la tasa de mortalidad infantil (TMI) en los departamentos de Colombia durante el período 2003-2009, examinar la persistencia de las variaciones entre los departamentos sobre el tiempo y relacionarlas con el impacto de las condiciones socioeconómicas y la disponibilidad de servicios de salud, sobre la mortalidad infantil. Materiales y métodos. Utilizando estadísticas vitales y relacionando datos socioeconómicos y de servicios de salud, se analizaron tres aspectos: la variación de la TMI departamental (2003-2009), la relación entre la TMI departamental y determinantes claves en el tiempo, y las líneas de causalidad e impacto relativo de los diferentes factores. Se emplearan ecuaciones estructurales. Resultados. Se encontró una razón de 4,7 entre la mayor y menor TMI departamental (2009), esta podría estar subestimada principalmente por el subregistros en departamentos de bajos ingresos. Hay una relación negativa entre la TMI departamental con el tiempo y variables altamente correlacionadas, como educación de la madre, ingreso per cápita, cobertura de aseguramiento y acceso a servicios. Conclusiones. El efecto del aseguramiento, disponibilidad de camas privadas y atención médica, es superior al impacto de mejores condiciones socioeconómicas sobre la TMI. La oferta de servicios no parece estar influenciada por una política racional, los recursos no se asignan de acuerdo con las necesidades, sino con el desarrollo general. Las camas privadas se hacen disponibles donde hay mejor aseguramiento en salud y menor TMI.

Objectives. To study the variations in infant mortality rate (IMR) across Colombia’s 33 administrative departments over the period 2003-2009, examine persistency of variations across departments over time, and relate those variations to the impact of socio-economic conditions and availability of care on IMR. Materials and methods. Using vital statistics and related socio-economic data we establish three types of analysis according to: (a) the variation of the departmental IMR (2003-2009), (b) the association between the departmental IMR and its key determinants over time, and (c) the lines of causality and relative impact of different factors, by using structural equations. Results. The 4.7 fold ratio between the highest and lowest departmental IMR (2009) may be underestimated considering underreporting, especially in low-income departments. There is a negative association between the departmental IMR with time and a set of highly correlated variables, such as the mother education, income per capita, health insurance level and access to services. Conclusions. The effect of better insurance, availability of private beds, and having doctors attending mothers, eclipse the impact of better socioeconomic conditions. The range of services does not appear to be influenced by a rational policy; resources are not allocated according to the need, but with the general development. Private beds are made available where there is better health insurance.

Reforms are needed to increase public funding and curb demand for private care in Israel's health system.

Historically, the Israeli health care system has been considered a high-performance system, providing universal, affordable, high-quality care to all residents. However, a decline in the ratio of physicians to population that reached a modern low in 2006, an approximate ten-percentage-point decline in the share of publicly financed health care between 1995 and 2009, and legislative mandates that favored private insurance have altered Israel's health care system for the worse. Many Israelis now purchase private health insurance to supplement the state-sponsored universal care coverage, and they end up spending more out of pocket even for services covered by the entitlement. Additionally, many publicly paid physicians moonlight at private facilities to earn more money. In this article I recommend that Israel increase public funding for health care and adopt reforms to address the rising demand for privately funded care and the problem of publicly paid physicians who moonlight at private facilities.

[Regional disparities in infant mortality in Colombia]. / Brechas regionales de la mortalidad infantil en Colombia.

OBJECTIVES: To study the variations in infant mortality rate (IMR) across Colombia's 33 administrative departments over the period 2003-2009, examine persistency of variations across departments over time, and relate those variations to the impact of socio-economic conditions and availability of care on IMR. MATERIALS AND METHODS: Using vital statistics and related socio-economic data we establish three types of analysis according to: (a) the variation of the departmental IMR (2003-2009), (b) the association between the departmental IMR and its key determinants over time, and (c) the lines of causality and relative impact of different factors, by using structural equations. RESULTS: The 4.7 fold ratio between the highest and lowest departmental IMR (2009) may be underestimated considering underreporting, especially in low-income departments. There is a negative association between the departmental IMR with time and a set of highly correlated variables, such as the mother education, income per capita, health insurance level and access to services. CONCLUSIONS: The effect of better insurance, availability of private beds, and having doctors attending mothers, eclipse the impact of better socioeconomic conditions. The range of services does not appear to be influenced by a rational policy; resources are not allocated according to the need, but with the general development. Private beds are made available where there is better health insurance.

Long-term care in Israel: challenges and reform options.

OBJECTIVES: This paper has two objectives. The first is to examine the Israeli long-term care (LTC) system that is marked by rapidly increasing demands, and a multitude of public and private LTC arrangements. The second is to propose a reform to improve the system's efficiency and equity. METHODS: The paper studies the LTC services in Israel, and the private-public composition in funding, fund holding, and provision of LTC. It focuses on structural deficiencies in the organization of each of these functions separately, and in combination. RESULTS: In many countries LTC has evolved in a patchwork fashion that at some point in time needs rethinking and rationalization. Israel is a case in point. In spite of numerous LTC arrangements supported by the state, in the absence of a comprehensive strategy, these have not generated a coherent system that can deal efficiently and equitably with existing and fast growing LTC needs, on the one hand, and the resources available to it, on the other. The current system is fragmented. It provides limited coverage and insufficient benefits in a troublesome fashion to public. The findings suggest that Israel can achieve at least in the short term, universal entitlement to LTC at lower financial and social cost, than the current costs of the system. In the medium and long term, the country will need to consider the trade between the burden of direct care on households or the tax burden of publicly supported and organized care. CONCLUSIONS: To remedy the situation the paper suggests a two-planked reform. The first is integration of the current fragmented publicly supported system while deciding on LTC either as a "social endeavor" under a separate authority responsible for implementing the public LTC budget, or as a "medical endeavor", putting this responsibility under the Israeli sickness funds. The second plank, building on the first, comprises extension of universal entitlement to LTC. Such an extension would increase public spending in the long term; simultaneously, it would relieve the tax-paying population of a substantial privately borne burden of a fast aging population.

Integrating public health and personal care in a reformed US health care system.

Compared with other developed countries, the United States has an inefficient and expensive health care system with poor outcomes and many citizens who are denied access. Inefficiency is increased by the lack of an integrated system that could promote an optimal mix of personal medical care and population health measures. We advocate a health trust system to provide core medical benefits to every American, while improving efficiency and reducing redundancy. The major innovation of this plan would be to incorporate existing private health insurance plans in a national system that rebalances health care spending between personal and population health services and directs spending to investments with the greatest long-run returns.

Reforming "developing" health systems: Tanzania, Mexico, and the United States.

OBJECTIVE: Tanzania, Mexico, and the United States are at vastly different points on the economic development scale. Yet, their health systems can be classified as "developing": they do not live up to their potential, considering the resources available to them. The three, representing many others, share a common structural deficiency: a segregated health care system that cannot achieve its basic goals, the optimal health of its people, and their possible satisfaction with the system. Segregation follows and signifies first and foremost the lack of financial integration in the system that prevents it from serving its goals through the objectives of equity, cost containment and sustainability, efficient production of care and health, and choice. METHOD: The chapter contrasts the nature of the developing health care system with the common goals', objectives, and principles of the Emerging Paradigm (EP) in developed, integrated--yet decentralized--systems. In this context, the developing health care system is defined by its structural deficiencies, and reform proposals are outlined. FINDINGS: In spite of the vast differences amongst the three countries, their health care systems share strikingly similar features. At least 50% of their total funding sources are private. The systems comprise exclusive vertically integrated, yet segregated, "silos" that handle all systemic functions. These reflect and promote wide variations in health insurance coverage and levels of benefits--substantial portions of their populations are without adequate coverage altogether; a considerable lack of income protection from medical spending; an inability to formalize and follow a coherent health policy; a lack of financial discipline that threatens sustainability and overall efficiency; inefficient production of care and health; and an dissatisfied population. These features are often promoted by the state, using tax money, and donors. POLICY IMPLICATIONS: The situation can be rectified by (a) "centralizing"--at any level of development and resource availability--health system finance around a set package of core medical benefits that is made available to the entire population and (b) "decentralizing" consumption and provision of care. The first serves equity and cost containment and sustainability. The second supports efficiency and client satisfaction. ORIGINALITY/VALUE OF CHAPTER: The chapter views commonly discussed problems of the health care system--a lack of insurance coverage and income protection--as symptoms of a large problem: health system segregation.

The Jewish-Arab divide in life expectancy in Israel.

Life expectancy at birth in Israel in 2001 was 77.7 years for males and 81.6 years for females among Jews, and 74.5 and 77.8 years for males and females, respectively, among Israeli Arabs. In spite of vast improvements in health conditions of the two populations since Israel's statehood in 1948, persistent disparities in life expectancy between the two groups have challenged the Israeli socialized health care system. These disparities are influenced primarily by differences between the two population groups in infant and child mortality rates. This early study suggests that the distribution of life expectancy across localities in Israel reflects the distribution of those localities' socio-economic condition index (not including health and medical care), and the distribution of medical services. The positive association between life expectancy and the index is pronounced, however, only within the Jewish population but not among Arabs. While there may be no significant difference in life expectancy among Jews and Arabs living in poorer communities, there are fewer Arabs living in relatively affluent communities. Thus, persistent higher concentration of poverty among Arabs than among Jews has sufficed to maintain the gap in life expectancy between them. In addition, however, there are population-specific effects: wealth and education are more protective among Jews than among Arabs, while medical services are more protective among Arabs.

Aging and aggregate costs of medical care: conceptual and policy issues.

The conventional wisdom says that because the cost of health care for the aged is more than that of the young at any time, there is a positive relationship between the aging or higher life expectancy of the population and aggregate health care spending. It is difficult, however, to find evidence to support this argument. We present a simple framework that shows how aging of the population may not necessarily increase the total cost of medical care over time or be observed across nations. This follows because numerous other factors that change with aging affect cost of care in ways that are not age-neutral. Such factors include age-specific shifts in morbidity and mortality, growth in income and insurance coverage, rising levels of education and changing technology. Consequently, the relative medical costs of the aged may indeed increase, at least for demographic reasons. Simultaneously, however, the costs of the young may decrease for the same reasons. The Israeli experience, used as a basis for a cursory empirical discussion of the issues, supports the line of reasoning presented in the paper.