Harnessing Health Technology Assessment in Latin America and the Caribbean: Keeping the Region on Course.

Latin America and the Caribbean has made significant progress toward universal health coverage (UHC), but health spending efficiency, equity, and sustainability remain major challenges-and progress is hindered by the difficult macroeconomic context. Health technology assessment (HTA) can make resource allocation more efficient and equitable when systematically used to inform coverage decisions. We highlight five considerations that need to be taken into account to realize the full potential of HTA in the LAC region: i) explicitly link HTA to decision-making and anchor it in legal frameworks, ii) systematically incorporate the opportunity cost as a core principle into HTA activities informing coverage decisions, iii) make the internationally available evidence more fit for purpose for low- and middle-income countries (LMICs), iv) incorporate pragmatism as a key principle of HTA activities in the region, and v) institutionalize the monitoring of HTA processes and results.

Defining a Health Benefits Package: What Are the Necessary Processes?

Abstract-There is immense interest worldwide in the notion of universal health coverage (UHC). A major policy focus in moving toward UHC has been on the key policy question: what services should be made available and under what conditions? In this article we are concerned with how a feasible set of UHC services can be explicitly defined to create what is commonly known as a "health benefits package" (HBP), a set of services that can be feasibly financed and provided under the actual circumstances in which a given country finds itself. We explain why an explicit statement of the HBP is important and then describe a framework that includes ten core elements that are indispensable if a coherent and sustainable process for setting the HBP is to be established.

Priority setting for health in emerging markets.

The use of health technology assessment research in emerging economies is becoming an increasingly important tool to determine the uses of health spending. As low- and middle-income countries' gross domestic product grows, the funding available for health has increased in tandem. There is growing evidence that comparative effectiveness research and cost-effectiveness can be used to improve health outcomes within a predefined financial space. The use of these evaluation tools, combined with a systematized process of priority setting, can help inform national and global health payers. This review of country institutions for health technology assessment illustrates two points: the efforts underway to use research to inform priorities are widespread and not confined to wealthier countries; and many countries' efforts to create evidence-based policy are incomplete and more country-specific research will be needed. Further evidence shows that there is scope to reduce these gaps and opportunity to support better incorporation of data through better-defined priority-setting processes.

Priority-setting institutions in health: recommendations from a center for global development working group.

The rationing problem is common to all health systems-the challenge of managing finite resources to address unlimited demand for services. In most low- and middle-income countries, rationing occurs as an ad hoc, haphazard series of nontransparent choices that reflect the competing interests of governments, donors, and other stakeholders. Yet in a growing number of countries, more explicit processes, with strengths and limitations, are under development that merit better support. Against this background, the purpose of the Center for Global Development Working Group, which is to examine how priorities are set currently, and to propose institutional arrangements that promote country ownership and improve health outcomes by more systematically managing this complex process of politics and economics, is discussed. Current global and national priority-setting practices in low- and middle-income countries, the potential for strengthened national institutions, and increased global support are reviewed. Recommendations for action are provided.

Colombia's universal health insurance system.

By insuring more than 80 percent of its population, Colombia provides a valuable opportunity to gather evidence on a hotly debated health policy issue. Results from three studies evaluating the impact of universal health insurance in Colombia show that it has greatly increased access to and use of health services, even those that are free for all, and has reduced the incidence of catastrophic health spending. The impact has been more dramatic among those most vulnerable to health shocks: those living in rural areas, the poorest, and the self-employed.

Household catastrophic health expenditures: a comparative analysis of twelve Latin American and Caribbean Countries / Gastos catastróficos en salud de los hogares: un análisis comparativo de doce países en América Latina y el Caribe

OBJETIVO: Comparar los patrones de gastos catastróficos en salud en 12 países de América Latina y el Caribe. MATERIAL Y MÉTODOS: Se estimó la prevalencia de gastos catastróficos de manera uniforme para doce países usando encuestas de hogares. Se emplearon dos tipos de indicadores para medir la prevalencia basados en el gasto de bolsillo en salud: a) en relación con una línea de pobreza internacional; y b) en relación con la capacidad de pago del hogar en términos de su propia canasta alimentaria. Se estimaron razones para comparar el nivel de gastos catastróficos entre subgrupos poblacionales definidos por variables económicas y sociales. RESULTADOS: El porcentaje de hogares con gastos catastróficos variaron de 1 a 25 por ciento en los 12 países. En general, la residencia rural, el bajo nivel de ingresos, la presencia de adultos mayores, y la carencia de aseguramiento en salud de los hogares se asocian con mayor propensión a sufrir gastos catastróficos en salud. Sin embargo, existe una marcada heterogeneidad por país. CONCLUSIONES: Los estudios comparativos entre países pueden servir para examinar cómo los sistemas de salud contribuyen a la protección social de los hogares en América Latina.

OBJECTIVE: Compare patterns of catastrophic health expenditures in 12 countries in Latin America and the Caribbean. MATERIAL AND METHODS: Prevalence of catastrophic expenses was estimated uniformly at the household level using household surveys. Two types of prevalence indicators were used based on out-of-pocket health expense: a) relative to an international poverty line, and b) relative to the household's ability to pay net of their food basket. Ratios of catastrophic expenditures were estimated across subgroups defined by economic and social variables. RESULTS: The percent of households with catastrophic health expenditures ranged from 1 to 25 percent in the twelve countries. In general, rural residence, lowest quintile of income, presence of older adults, and lack of health insurance in the household are associated with higher propensity of catastrophic health expenditures. However, there is vast heterogeneity by country. CONCLUSIONS: Cross national studies may serve to examine how health systems contribute to the social protection of Latin American households.

Decentralization and equity of resource allocation: evidence from Colombia and Chile.

OBJECTIVE: To investigate the relation between decentralization and equity of resource allocation in Colombia and Chile. METHODS: The "decision space" approach and analysis of expenditures and utilization rates were used to provide a comparative analysis of decentralization of the health systems of Colombia and Chile. FINDINGS: Evidence from Colombia and Chile suggests that decentralization, under certain conditions and with some specific policy mechanisms, can improve equity of resource allocation. In these countries, equitable levels of per capita financial allocations at the municipal level were achieved through different forms of decentralization--the use of allocation formulae, adequate local funding choices and horizontal equity funds. Findings on equity of utilization of services were less consistent, but they did show that increased levels of funding were associated with increased utilization. This suggests that improved equity of funding over time might reduce inequities of service utilization. CONCLUSION: Decentralization can contribute to, or at least maintain, equitable allocation of health resources among municipalities of different incomes.

Equitable financing, out-of-pocket payments and the role of health care reform in Colombia.

For a health care system to be considered equitable in its financing, the financial burden of contributions has to be progressive or at least proportional. Out-of-pocket financing takes a larger proportion of poor than of non-poor households' income. To remedy this regressive burden, among other goals, Colombia launched a health care reform based on social insurance as a means to reduce health care financing through out-of-pocket payments, and to reduce financial barriers to access. This paper analyzes the evolution of regressivity in out-of-pocket financing from 1984 to 1997, in order to detect if the 1993 health care reform had an impact on such regressivity. The Kakwani index of progressivity was estimated using three national household surveys. Kakwani indices showed a constant trend towards more regressivity (-0.126 in 1984, to -0.3498 in 1997) when using income to build the index, but a trend towards progressivity (-0.0092 in 1984, to 0.0026 in 1997) when using expenses. Our findings suggest that there was a progressive impact of the reform on out-of-pocket financing when household expenses are used to build the Kakwani index; however, due to issues of comparability between surveys, the findings are not conclusive.

Sistema de pago para la atención de la población pobre no afiliada al sistema general de seguridad social en salud en la ciudad de Bogotá / Payment system for the care of the poor population not affiliated to the general social security health system in the city of Bogota

Antecedentes: a A finales de 1999, la Secretaría Distrital de Salud de Bogotá (SDS), sustituyó la facturación Fee For Service (presupuestación histórica) por un nuevo mecánismo de pago llamado "Pago Fijo Global Prospectivo por actividad final en salud", para financiar la atención de la población pobre no afiliada al Sistema de Seguridad Social en Salud. La SDS decidió contratar un estudio que tuviera como fin la disminución de la variabilidad de cada uno de los paquetes. Objetivos: redefinir unidades homogéneas para el sistema de pago por actividades finales a las Empresas Sociales del Estado adscritas a la Secretaría Distrital de Salud de Bogotá, de tal forma que se disminuya la variabilidad en los paquetes de servicios. Metodología:se utilizó la información de facturación que los hospitales enviaron a la SDS en el período comprendido entre mayo de 1999 y junio de 2000, el procedimiento principal de atención y el nivel del hospital; con esta información se desarrollaron los procesos estadísticos y el ajuste de modelos de regresión múltiple. Resultados: Se buscó aumentar la homogeneidad de los paquetes evaluando la influencia de los valores extremos (Outliers) y discriminando los paquetes con base en las variables relacionadas anteriormente. Al obtener una disminución importante de la variabilidad al separarse las actividades finales en valores Outliers y valores normales, se estructuró un pago diferencial para los primeros y se definieron las nuevas tarifas para los segundos, disminuyendo el riesgo financiero de los hospitales para el conjunto de las actividades finales. Conclusión: esta forma de pago estimula en los prestadores el control de costos y la eficiencia en la prestación de los servicios, lo cual es fundamental en un escenario de restricción de recursos financieros y costos ascendentes en el sector de la salud.

Background: a At the end of 1999, the District Health Secretariat of Bogota (SDS) replaced Fee For Service billing (historical budgeting) with a new payment mechanism called "Prospective Global Fixed Payment for final health activity" to finance the care of the poor population not affiliated with the Social Security Health System. The SDS decided to contract a study aimed at reducing the variability of each of the packages. Objectives: to redefine homogeneous units for the final activity-based payment system for the State Social Enterprises attached to the District Health Secretariat of Bogota, in order to reduce variability in the service packages. Methodology: We used the billing information that the hospitals sent to the SDS between May 1999 and June 2000, the main procedure of care and the hospital level; with this information we developed the statistical processes and the adjustment of multiple regression models. Results: We sought to increase the homogeneity of the packages by evaluating the influence of the extreme values (outliers) and discriminating the packages based on the variables listed above. By obtaining a significant decrease in variability when separating the final activities into Outliers and normal values, a differential payment was structured for the former and new rates were defined for the latter, reducing the hospitals' financial risk for the final activities as a whole. Conclusion: this form of payment stimulates providers to control costs and efficiency in the provision of services, which is essential in a scenario of financial resources restriction and rising costs in the health sector.

Medición de la eficiencia económica y de gestión en los hospitales públicos del Distrito Capital / Economic efficiency and management assessment in the public hospitals from Capital District

Lograr niveles adecuados de eficiencia en la producción y gestión en los hospitales del Distrito Capital es fundamental para continuar y fortalecer el proceso de desarrollo institucional; esto requiere de una actividad permanente y coherente que contribuya a solucionar los principales problemas que enfrentan estas instituciones. Con el fin de evaluar el estado de los hospitales del Distrito Capital en términos de su eficiencia económica y del rendimiento de su capital físico y humano, así como de su gestión, se realizó una investigación que buscaba hacer una aproximación a los niveles de eficiencia y de gestión en dichas instituciones. Este libro presenta los resultados de dicha investigación, la cual formula, además, una serie de recomendaciones que combinadas con el análisis de otros elementos de tipo estructural y coyuntural propios del sector salud en el Distrito premitirán lograr niveles adecuados de eficiencia en la producción y en la gestión en los hospitales distritales