Health, economic and social burden of tobacco in Latin America and the expected gains of fully implementing taxes, plain packaging, advertising bans and smoke-free environments control measures: a modelling study.

OBJECTIVE: To investigate the tobacco-attributable burden on disease, medical costs, productivity losses and informal caregiving; and to estimate the health and economic gains that can be achieved if the main tobacco control measures (raising taxes on tobacco, plain packaging, advertising bans and smoke-free environments) are fully implemented in eight countries that encompass 80% of the Latin American population. DESIGN: Markov probabilistic microsimulation economic model of the natural history, costs and quality of life associated with the main tobacco-related diseases. Model inputs and data on labour productivity, informal caregivers' burden and interventions' effectiveness were obtained through literature review, surveys, civil registrations, vital statistics and hospital databases. Epidemiological and economic data from January to October 2020 were used to populate the model. FINDINGS: In these eight countries, smoking is responsible each year for 351 000 deaths, 2.25 million disease events, 12.2 million healthy years of life lost, US$22.8 billion in direct medical costs, US$16.2 billion in lost productivity and US$10.8 billion in caregiver costs. These economic losses represent 1.4% of countries' aggregated gross domestic products. The full implementation and enforcement of the four strategies: taxes, plain packaging, advertising bans and smoke-free environments would avert 271 000, 78 000, 71 000 and 39 000 deaths, respectively, in the next 10 years, and result in US$63.8, US$12.3, US$11.4 and US$5.7 billions in economic gains, respectively, on top of the benefits being achieved today by the current level of implementation of these measures. CONCLUSIONS: Smoking represents a substantial burden in Latin America. The full implementation of tobacco control measures could successfully avert deaths and disability, reduce healthcare spending and caregiver and productivity losses, likely resulting in large net economic benefits.

[Health technology assessment in Ecuador's ministry of public health as a tool for drug purchasing from 2012 to 2015]. / La evaluación de tecnologías sanitarias en el Ministerio de Salud Pública de Ecuador como herramienta para la compra de medicamentos entre 2012 y 2015.

OBJECTIVE: Learn how the Ministry of Public Health (MSP, the Spanish acronym) of Ecuador uses health technology assessment (HTA) in decision-making on the purchase of drugs that are not on the National List of Essential Medicines (NLEM). METHODS: Information from databases of the Health Intelligence Directorate (DIS, the Spanish acronym) and the National Directorate of Drugs and Medical Devices (DNMDM, the Spanish acronym), was used to compare decisions made by both entities, to learn about the use and consistency of HTA reports in decisions on purchasing drugs not included in the NLEM. RESULTS: From 2012 to 2015, 227 reports were issued, of which 87 cover drugs; 36, devices; 29: medical procedures; 34: health programs; and 41: other medical technologies. The DNMDM requested 59 of the reports on drugs. There was 80% agreement in decisions made by the two directorates that participate in the process. CONCLUSIONS: The MSP, through the DIS, began using HTA in 2012. Given that the majority of reports evaluate drugs, it is essential that reports be prepared for other types of medical technologies and that they be prepared and used as widely as possible. Despite a high level of agreement in decisions, it is important to continue to improve the reports' scope and quality, and to monitor adoption and dissemination of authorized and funded technologies to learn the effectiveness and impact of HTA in Ecuador.

[Payment mechanisms and financial resources management for consolidation of Ecuador's health system]. / Mecanismos de pago y gestión de recursos financieros para la consolidación del Sistema de Salud de Ecuador.

OBJECTIVE: Analyze the proposal by the Ministry of Public Health to reform the public financing model in Ecuador with regard to pooling of funds and payment mechanisms. METHOD: A literature review was done of the financing model, the current legal framework, and the budgetary bases in Pubmed, SciELO, LILACS Ecuador, and regional LILACS using the key words health financing, health financing systems, capitation, pooling of funds, health system reform Ecuador, health system Ecuador, and health payment mechanisms. Books and other documents suggested by health systems experts were also included. RESULTS: Review of the financing model enabled identifying the historical segmentation of Ecuador's health system; out of this, the Ministry of Public Health conceived its proposal to reform the financing model. The Ministry's proposed solutions are pooling of funds and payment of services at the first level of care through payment per capita adjusted for socioeconomic and demographic risks. Progress made in reforming the financing model includes design of the proposals and their implementation mechanisms, and discussions with stakeholders. CONCLUSIONS: Implementation of these changes may produce improvements for the health system in efficiency, spreading of risks, incentives for meeting health objectives, as well as contribute to its sustainability and advance toward universal health coverage. Nevertheless, legal, political, and operational constraints are hampering their implementation.

Mecanismos de pago y gestión de recursos financieros para la consolidación del Sistema de Salud de Ecuador / Payment mechanisms and financial resources manage¬ment for consolidation of Ecuador’s health system

Objetivo. El objetivo de este artículo es analizar la propuesta planteada por el Ministerio de Salud Pública para la reforma del modelo de financiamiento público en Ecuador referente a mancomunación de fondos y mecanismos de pago. Método. Se realizó una revisión documental sobre el modelo de financiamiento, el marco legal vigente y las bases presupuestarias por medio de Pubmed, Scielo, LILACS Ecuador y LILACS regional utilizando como palabras clave financiamiento de la salud, sistemas de financiamiento en salud, capitación, mancomunación de fondos, reforma de salud Ecuador, sistema de salud Ecuador y mecanismos de pago en salud. Se incluyeron, además, libros y otros documentos referidos por expertos en sistemas de salud. Resultados. La revisión del modelo de financiamiento permitió identificar la segmentación histórica del sistema de salud ecuatoriano, a partir de la cual nace la propuesta del Ministerio de Salud Pública para reformar el modelo de financiamiento. El Ministerio ha planteado como soluciones la mancomunación de fondos y el pago de servicios en el primer nivel de atención mediante una cápita ajustada por riesgos socioeconómicos y demográficos. Los avances en la reforma del modelo de financiamiento incluyen el diseño de los planteamientos, sus mecanismos de implementación y el debate con los actores. Conclusiones. La implementación de estas modificaciones puede generar mejoras para el sistema de salud en la eficiencia, dispersión de riesgos, incentivos para el cumplimiento de objetivos sanitarios, así como contribuir a su sostenibilidad y avanzar hacia la cobertura universal de salud. No obstante, existen limitaciones legales, políticas y operativas que dificultan su implantación.

Objective. Analyze the proposal by the Ministry of Public Health to reform the public financing model in Ecuador with regard to pooling of funds and payment mechanisms. Method. A literature review was done of the financing model, the current legal framework, and the budgetary bases in Pubmed, SciELO, LILACS Ecuador, and regional LILACS using the key words health financing, health financing systems, capitation, pooling of funds, health system reform Ecuador, health system Ecuador, and health payment mechanisms. Books and other documents suggested by health systems experts were also included. Results. Review of the financing model enabled identifying the historical segmentation of Ecuador’s health system; out of this, the Ministry of Public Health conceived its proposal to reform the financing model. The Ministry’s proposed solutions are pooling of funds and payment of services at the first level of care through payment per capita adjusted for socioeconomic and demographic risks. Progress made in reforming the financing model includes design of the proposals and their implementation mechanisms, and discussions with stakeholders. Conclusions. Implementation of these changes may produce improvements for the health system in efficiency, spreading of risks, incentives for meeting health objectives, as well as contribute to its sustainability and advance toward universal health coverage. Nevertheless, legal, political, and operational constraints are hampering their implementation.

La evaluación de tecnologías sanitarias en el Ministerio de Salud Pública de Ecuador como herramienta para la compra de medicamentos entre 2012 y 2015 / Health technology assessment in Ecuador’s ministry of public health as a tool for drug purchasing from 2012 to 2015

Objetivo. Conocer el uso de la evaluación de tecnologías sanitarias (ETS) en la toma de decisiones del Ministerio de Salud Pública (MSP) del Ecuador para la compra de medicamentos que no se encuentran en el Cuadro Nacional de Medicamentos Básicos (CNMB). Métodos. Con la información de las bases de datos de la Dirección de Inteligencia de la Salud (DIS) y la Dirección Nacional de Medicamentos y Dispositivos Médicos (DNMDM), se compararon las decisiones tomadas por ambas instancias, para conocer el uso y la congruencia de los informes de ETS en las decisiones de compra de los medicamentos no incluidos en el CNMB. Resultados. Entre 2012 y 2015, se han elaborado 227 informes, de los cuales 87 corresponden a medicamentos, 36 a dispositivos, 29 a procedimientos médicos, 34 a programas sanitarios, y 41 a otras tecnologías médicas. De los informes de medicamentos, 59 fueron solicitados por la DNM. La concordancia entre las decisiones tomadas por las dos direcciones que participan en el proceso alcanzó 80%. Conclusiones. La ETS se inició en el MSP en 2012 a través de la DIS. Considerando que la mayoría de informes evalúan medicamentos, es indispensable que se desarrollen informes para otros tipos de tecnologías médicas y que se difunda al máximo su desarrollo y uso. A pesar de que el nivel de concordancia entre las decisiones es elevado, es importante seguir mejorando el alcance y la calidad de los informes, así como monitorizar la incorporación y difusión de las tecnologías autorizadas y financiadas para conocer la efectividad y el impacto de la ETS en Ecuador.

Objective. Learn how the Ministry of Public Health (MSP, the Spanish acronym) of Ecuador uses health technology assessment (HTA) in decision-making on the purchase of drugs that are not on the National List of Essential Medicines (NLEM). Methods. Information from databases of the Health Intelligence Directorate (DIS, the Spanish acronym) and the National Directorate of Drugs and Medical Devices (DNMDM, the Spanish acronym), was used to compare decisions made by both entities, to learn about the use and consistency of HTA reports in decisions on purchasing drugs not included in the NLEM. Results. From 2012 to 2015, 227 reports were issued, of which 87 cover drugs; 36, devices; 29: medical procedures; 34: health programs; and 41: other medical technologies. The DNMDM requested 59 of the reports on drugs. There was 80% agreement in decisions made by the two directorates that participate in the process. Conclusions. The MSP, through the DIS, began using HTA in 2012. Given that the majority of reports evaluate drugs, it is essential that reports be prepared for other types of medical technologies and that they be prepared and used as widely as possible. Despite a high level of agreement in decisions, it is important to continue to improve the reports’ scope and quality, and to monitor adoption and dissemination of authorized and funded technologies to learn the effectiveness and impact of HTA in Ecuador.