Potential of LARC to recover loss in satisfied demand for modern contraception after the COVID-19 pandemic: a case scenario analysis of Brazil and Mexico.

Objectives: To estimate inequalities in demand for family planning satisfied with modern methods among women in Latin America and the Caribbean, with an emphasis on Brazil and Mexico, and to calculate the scenario for recovery of modern contraceptive coverage by expanding access to long-acting contraceptives (LARC) after the COVID-19 pandemic. Methods: National health surveys from 2006 to 2018 were used to estimate the demand for family planning satisfied with modern methods and how it was affected by the COVID-19 pandemic. The scenario included three variables: coverage, health outcomes, and costs. Considering coverage, United Nations Population Fund data were used to estimate the impact of COVID-19 on access to contraception in Latin America and the Caribbean. Health outcomes were assessed with the Impact 2 tool. Direct investment was used to evaluate cost-effectiveness. Results: Substantial inequalities were found in the use of modern contraceptive methods before the pandemic. We showed the potential cost-effectiveness of avoiding maternal deaths by introducing LARCs. Conclusions: In the scenario predicted for Brazil and Mexico, the costs of modern family planning and averted disability-adjusted life years are modest. Governments in Latin America and the Caribbean should consider promoting LARCs as a highly efficient and cost-effective intervention.

Health and economic benefits of achieving contraceptive and maternal health targets in Small Island Developing States in the Pacific and Caribbean.

INTRODUCTION: Reducing unmet need for modern contraception and expanding access to quality maternal health (MH) services are priorities for improving women's health and economic empowerment. To support investment decisions, we estimated the additional cost and expected health and economic benefits of achieving the United Nations targets of zero unmet need for modern contraceptive choices and 95% coverage of MH services by 2030 in select Small Island Developing States. METHODS: Five Pacific (Kiribati, Samoa, Solomon Islands, Tonga and Vanuatu) and four Caribbean (Barbados, Guyana, Jamaica and Saint Lucia) countries were considered based on population survey data availability. For each country, the Lives Saved Tool was used to model costs, health outcomes and economic benefits for two scenarios: business-as-usual (BAU) (coverage maintained) and coverage-targets-achieved, which scaled linearly from 2022 (following COVID-19 disruptions) coverage of evidence-based family planning and MH interventions to reach United Nations targets, including modern contraceptive methods and access to complete antenatal, delivery and emergency care. Unintended pregnancies, maternal deaths, stillbirths and newborn deaths averted by the coverage-targets-achieved scenario were converted to workforce, education and social economic benefits; and benefit-cost ratios were calculated. RESULTS: The coverage-targets-achieved scenario required an additional US$12.6M (US$10.8M-US$15.9M) over 2020-2030 for the five Pacific countries (15% more than US$82.4M to maintain BAU). This additional investment was estimated to avert 126 000 (40%) unintended pregnancies, 2200 (28%) stillbirths and 121 (29%) maternal deaths and lead to a 15-fold economic benefit of US$190.6M (US$67.0M-US$304.5M) by 2050. For the four Caribbean countries, an additional US$17.8M (US$15.3M-US$22.4M) was needed to reach the targets (4% more than US$405.4M to maintain BAU). This was estimated to avert 127 000 (23%) unintended pregnancies, 3600 (23%) stillbirths and 221 (25%) maternal deaths and lead to a 24-fold economic benefit of US$426.2M (US$138.6M-US$745.7M) by 2050. CONCLUSION: Achieving full coverage of contraceptive and MH services in the Pacific and Caribbean is likely to have a high return on investment.

[Alternatives for adopting policies centered on access to medicines]. / Alternativas para la adopción de políticas centradas en el acceso a medicamentos.

Latin America is adopting regulations that bear on medicinal costs and spending. The regulations have four main goals: i) to guarantee a competitive market, ii) to ensure affordability for individual consumers (commercial channel), iii) to contain public spending on medicines (institutional channel), and iv) to guarantee efficient spending on medicines. The experience of Latin America differs from that of countries in developed regions. In the latter, the countries tend to have similar policies, both in promoting generic medicines and in price control strategies, and in optimizing and containing pharmaceutical expense. In contrast, in Latin America, certain institutional weaknesses impede the consolidation and application of an effective regulatory policy. This paper reviews the experience gained through the adoption of economic regulations aimed at reducing spending and improving access to medicines, suggests lessons learned at the international level, and offers recommendations for the countries of Latin America. Its purpose is to offer key elements to decision-makers and the authorities of the countries concerned in pursuing economic regulation of medicines.

Out-of-pocket spending for contraceptives in Latin America.

Despite progress in increasing the use of modern contraceptives in most Latin American countries over the last few decades, important challenges remain, including the heavy reliance on out-of-pocket spending to access contraceptives, which may expose consumption to macroeconomic fluctuations. Out-of-pocket spending on contraceptives and/or the proportion of women aged 15-49 who received free contraceptives at a public health facility or as part of statutory health insurance were estimated for 13 Latin American countries using the most recently available household budget surveys and demographic and health or similar household surveys. Data on contraceptive retail sales in 12 countries over the 2006-2010 period and publicly available macroeconomic indicators were used to examine the relationship between changes in sales and macroeconomic indicators using multiple regression models. On average, women aged 15-49 spent close to US$1 per month out-of-pocket on contraceptives. However, almost three out of five women received them free of charge. A 1% increase in the percentage of the population living on less than US$ 3.2/day (2011 PPP values), or the percentage unemployed in the labour force, predicted about a 2% decrease in the growth of contraceptive retail sales (measured in couple-years of protection, CYP, per capita) the subsequent year. The analysis revealed the sensitivity of contraceptive retail sales to changes in macroeconomic variables, particularly changes in poverty levels. Achieving universal access to family planning by 2030 will require improving contraceptive financing schemes.

[Lessons learned from drug supplies for primary health care]. / Lecciones aprendidas en la provisión de medicamentos para la atención primaria de la salud.

Drug supply strategies have not been widely included in Latin American health reform programs. National efforts, when they have included such strategies, have focused on supporting drug availability for inpatient treatment and, in some cases, for ambulatory treatment of low prevalence and high-cost diseases. Nevertheless, some innovative drug supply programs for primary health care have been implemented in many countries. This article reviews and systematizes recent experiences with the supply of drugs in Latin American countries. Firstly, this article analyzes four phases of the cycle for managing drugs: selection, procurement, distribution, and use, and; secondly, it identifies lessons learned and some characteristics of efficient drug supply systems. Conclusions emphasize experiences which have not only achieved supply at low costs, but also have increased the productivity, efficiency, and effectiveness of primary health care, improved prescriptions, and strengthened the network.

Potential of LARC to recover loss in satisfied demand for modern contraception after the COVID-19 pandemic: a case scenario analysis of Brazil and Mexico / Potencial de los anticonceptivos de acción prolongada para recuperar las pérdidas en la demanda satisfecha de anticonceptivos modernos después de la pandemia de COVID-19: análisis de escenarios en Brasil y México / Potencial dos métodos contraceptivos reversíveis de longa duração para recuperar a perda de demanda por planejamento familiar atendida por métodos contraceptivos modernos após a pandemia de COVID-19: análise de cenários do Brasil e do México

ABSTRACT Objectives. To estimate inequalities in demand for family planning satisfied with modern methods among women in Latin America and the Caribbean, with an emphasis on Brazil and Mexico, and to calculate the scenario for recovery of modern contraceptive coverage by expanding access to long-acting contraceptives (LARC) after the COVID-19 pandemic. Methods. National health surveys from 2006 to 2018 were used to estimate the demand for family planning satisfied with modern methods and how it was affected by the COVID-19 pandemic. The scenario included three variables: coverage, health outcomes, and costs. Considering coverage, United Nations Population Fund data were used to estimate the impact of COVID-19 on access to contraception in Latin America and the Caribbean. Health outcomes were assessed with the Impact 2 tool. Direct investment was used to evaluate cost-effectiveness. Results. Substantial inequalities were found in the use of modern contraceptive methods before the pandemic. We showed the potential cost-effectiveness of avoiding maternal deaths by introducing LARCs. Conclusions. In the scenario predicted for Brazil and Mexico, the costs of modern family planning and averted disability-adjusted life years are modest. Governments in Latin America and the Caribbean should consider promoting LARCs as a highly efficient and cost-effective intervention.

RESUMEN Objetivos. Estimar las desigualdades en la demanda de planificación familiar satisfecha con métodos anticonceptivos modernos entre las mujeres de América Latina y el Caribe, especialmente en Brasil y México, y analizar el escenario de recuperación de la cobertura de los anticonceptivos modernos mediante la ampliación del acceso a los anticonceptivos de acción prolongada tras la pandemia de COVID-19. Métodos. Se emplearon encuestas nacionales de salud desde el año 2006 hasta el año 2018 para estimar la demanda de planificación familiar satisfecha con métodos modernos y el impacto de la pandemia de COVID-19. El escenario comprendía tres variables: cobertura, resultados en materia de salud y costos. En lo respectivo a la cobertura, se emplearon datos del Fondo de Población de las Naciones Unidas para evaluar la repercusión de la COVID-19 en el acceso a los anticonceptivos en América Latina y el Caribe. Los resultados en materia de salud se examinaron con la herramienta Impact 2. Se empleó la inversión directa para evaluar la costo-efectividad. Resultados. Se encontraron desigualdades sustanciales en el uso de métodos anticonceptivos modernos antes de la pandemia. Se demostró la posible costo-efectividad de evitar muertes maternas mediante la introducción de anticonceptivos de acción prolongada. Conclusiones. De acuerdo con el escenario previsto para Brasil y México, los costos de la planificación familiar moderna y los años de vida ajustados en función de la discapacidad evitados son moderados. Los gobiernos de América Latina y el Caribe deberían considerar la posibilidad de promover los anticonceptivos de acción prolongada como intervención sumamente eficiente y costo-efectiva.

RESUMO Objetivos. Estimar as desigualdades na demanda por planejamento familiar atendida por métodos contraceptivos modernos em mulheres da América Latina e do Caribe, com ênfase no Brasil e no México, e calcular o cenário de recuperação da cobertura por métodos contraceptivos modernos por meio da ampliação do acesso a métodos contraceptivos reversíveis de longa duração (LARC) após a pandemia de COVID-19. Métodos. Foram usadas pesquisas nacionais de saúde de 2006 a 2018 para estimar a demanda por planejamento familiar atendida por métodos contraceptivos modernos e como ela foi afetada pela pandemia de COVID-19. O cenário incluiu três variáveis: cobertura, desfechos de saúde e custos. Para cobertura, os dados do Fundo de População das Nações Unidas foram usados para estimar o impacto da COVID-19 no acesso à contracepção na América Latina e no Caribe. Desfechos de saúde foram avaliados com a ferramenta Impact 2. O investimento direto foi usado para avaliar a relação custo-benefício. Resultados. Foram constatadas desigualdades importantes no uso de métodos contraceptivos modernos antes da pandemia. Demonstramos a potencial relação custo-benefício de evitar mortes maternas mediante a introdução de LARC. Conclusões. No cenário previsto para o Brasil e o México, os custos do planejamento familiar moderno e dos anos de vida ajustados por incapacidade por ele evitados são modestos. Os governos da América Latina e do Caribe devem considerar a promoção dos LARC como uma intervenção altamente eficiente e custo-efetiva.

[Economy of generic drugs in Latin America]. / Economía de los medicamentos genéricos en América Latina.

In terms of economics, implementing generic drug policy is nothing other than consolidating (or even, creating) drug markets that set competitive prices, the result of which favors public access to essential drugs. This article approaches the topic of generic drugs from the economic perspective by examining various regulatory models in order to evaluate and leverage generic drug policy implementation options as a mechanism for battling some of the markets' specific weaknesses. The conclusion is that there is no single unequivocal method for promoting the use of generic drugs, and that the most favorable way to integrate markets may be through a broad combination of alternatives. These alternatives are grouped and analyzed according to the market issues or challenges that must be overcome. Several options are then identified based on the degree of market consolidation to be obtained.

Alternativas para la adopción de políticas centradas en el acceso a medicamentos / Alternatives for adopting policies centered on access to medicines

América Latina está incorporando regulaciones que incidan en el costo y el gasto en medicamentos. Sus objetivos centrales son cuatro: i) garantizar la competitividad en el mercado, ii) asegurar precios asequibles a los consumidores individuales (canal comercial), iii) contener el gasto público en medicamentos (canal institucional) y iv) garantizar la eficiencia del gasto en medicamentos. La experiencia de América Latina difiere de la de los países de regiones desarrolladas. En estas últimas los países tienden a converger en sus políticas, tanto en la promoción de medicamentos genéricos y estrategias de control de precios, como en las medidas de racionalización y contención del gasto farmacéutico. En contraste, en América Latina ciertas debilidades institucionales impiden la consolidación y aplicación de una política regulatoria efectiva. El presente trabajo revisa la experiencia acumulada en la adopción de regulaciones económicas dirigidas a reducir el gasto y mejorar el acceso a los medicamentos, postula lecciones aprendidas a nivel internacional y ofrece recomendaciones para los países de América Latina. Su propósito es aportar elementos clave para los decisores de política y las autoridades de los países interesados en llevar adelante la regulación económica de medicamentos.

Latin America is adopting regulations that bear on medicinal costs and spending. The regulations have four main goals: i) to guarantee a competitive market, ii) to ensure affordability for individual consumers (commercial channel), iii) to contain public spending on medicines (institutional channel), and iv) to guarantee efficient spending on medicines. The experience of Latin America differs from that of countries in developed regions. In the latter, the countries tend to have similar policies, both in promoting generic medicines and in price control strategies, and in optimizing and containing pharmaceutical expense. In contrast, in Latin America, certain institutional weaknesses impede the consolidation and application of an effective regulatory policy. This paper reviews the experience gained through the adoption of economic regulations aimed at reducing spending and improving access to medicines, suggests lessons learned at the international level, and offers recommendations for the countries of Latin America. Its purpose is to offer key elements to decision-makers and the authorities of the countries concerned in pursuing economic regulation of medicines.

[How do we heal the Argentine health care system?]. / Cómo curar al sistema de salud argentino?

This article proposes a set of measures to reform the Argentine health care system and turn the country's current crisis into an opportunity for progressive, sustainable change. The proposal consists of a model for the intergovernmental division of health responsibilities. The national government would be responsible for strengthening its leadership role and for developing national insurance for low-prevalence high-cost diseases. With the provincial governments, the insurance role would be strengthened, with public health insurance making certain that there is universal coverage. Public hospitals would function as autonomous entities financed by social insurance, private insurance, and provincial public insurance. Municipalities would have an active role in disease prevention and health promotion, principally through primary care.

Lecciones aprendidas en la provisión de medicamentos para la atención primaria de la salud: [revisión] / Lessons learned from drug supplies for primary health care: [review]

En las reformas de salud que se llevaron a cabo en América Latina, la provisión de medicamentos no adquirió protagonismo. Cuando fue incluida, se dio prioridad a los medicamentos para internación, así como para enfermedades de baja prevalencia y alto costo. Sin embargo, en los últimos años un conjunto de programas han realizado innovaciones en la gestión de suministros para el primer nivel de atención. Aquí se abordan estas experiencias en América Latina, primero analizándolas a través de cuatro momentos del ciclo de gestión de medicamentos: selección, compra, distribución y utilización. Después, se busca identificar las lecciones aprendidas y las condiciones de un buen sistema de provisión. Las conclusiones destacan experiencias que lograron no sólo disponibilidad a costos bajos, sino también aumentos en la productividad y resolutividad del primer nivel, además de mejoras en la prescripción y el fortalecimiento del funcionamiento en red.

Drug supply strategies have not been widely included in Latin American health reform programs. National efforts, when they have included such strategies, have focused on supporting drug availability for inpatient treatment and, in some cases, for ambulatory treatment of low prevalence and high-cost diseases. Nevertheless, some innovative drug supply programs for primary health care have been implemented in many countries. This article reviews and systematizes recent experiences with the supply of drugs in Latin American countries. Firstly, this article analyzes four phases of the cycle for managing drugs: selection, procurement, distribution, and use, and; secondly, it identifies lessons learned and some characteristics of efficient drug supply systems. Conclusions emphasize experiences which have not only achieved supply at low costs, but also have increased the productivity, efficiency, and effectiveness of primary health care, improved prescriptions, and strengthened the network.

Economía de los medicamentos genéricos en América Latina / Economy of generic drugs in Latin America

In terms of economics, implementing generic drug policy is nothing other than consolidating (or even, creating) drug markets that set competitive prices, the result of which favors public access to essential drugs. This article approaches the topic of generic drugs from the economic perspective by examining various regulatory models in order to evaluate and leverage generic drug policy implementation options as a mechanism for battling some of the markets’ specific weaknesses. The conclusion is that there is no single unequivocal method for promoting the use of generic drugs, and that the most favorable way to integrate markets may be through a broad combination of alternatives. These alternatives are grouped and analyzed according to the market issues or challenges that must be overcome. Several options are then identified based on the degree of market consolidation to be obtained.

Cómo curar al sistema de salud argentino? / How do we heal the Argentine health care system?

This article proposes a set of measures to reform the Argentine health care system and turn the country's current crisis into an opportunity for progressive, sustainable change. The proposal consists of a model for the intergovernmental division of health responsibilities. The national government would be responsible for strengthening its leadership role and for developing national insurance for low-prevalence high-cost diseases. With the provincial governments, the insurance role would be strengthened, with public health insurance making certain that there is universal coverage. Public hospitals would function as autonomous entities financed by social insurance, private insurance, and provincial public insurance. Municipalities would have an active role in disease prevention and health promotion, principally through primary care

Estratégia e construção de políticas sociais: o caso da Secretaria de Assistência Social do município de São Paulo / Strategy and design of social policies: the case of the Departement of Social Services of the city of São Paulo, Brazil

Este artigo apresenta a experiência inovadora de reorganização dos serviços sociais implementada pela Secretaria de Assistência Social da cidade de São Paulo a partir de 2002. A partir do "triângulo estratégico" postulado por Mark Moore e da "teoria do negócio" desenvolvida por Peter Drucker, o artigo analisa os aspectos envolvidos nas gestões política, programática e operacional da assistência social. Nos três níveis de gestão foram registrados empreendimentos inovadores que estabeleceram uma lógica sinérgica.

Herramientas para el análisis del sector salud / Tools for health sector analysis

Este artículo asume como objetivo precisar algunos conceptos e hipótesis que funcionarán como dispositivos teórico-conceptuales para el análisis sectorial. Primero plantea un esquema analítico para el sector salud. Luego, se consideran los aspectos de la organización del sistema, entendiendo por la misma al conjunto de actores que los integran y los roles que asumen. En tercer lugar, se presenta un esquema para desagregarlos en sus componentes y subsistemas. Entre los primeros se presenta aquí un modelo de análisis que distingue tres grandes componentes dentro de todo sistema y servicio de salud, su modelo de gestión, su modelo de financiación y su modelo de atención. Para el análisis de los subsistemas se despliegan dos de las taxonomías más utilizadas a nivel mundial para el análisis de los sistemas de salud: por un lado, la clasificación tradicional de los tipos ideales de sistemas de salud y por otro lado el modelo de Evans

Alternativas para la financiación hospitalaria en Argentina / Choices in argentine hospitals financing

La problemática del financiamiento hospitalario puede ser caracterizada a través de un conjunto de interrogantes: ¿cuánto debe gastarse en atención hospitalaria?, ¿de dónde deben provenir los recursos?, ¿cómo asignar los recursos?. Este documento consta de dos secciones. En la primera se realiza un análisis de estos tres interrogantes centrándose en el caso de los establecimientos públicos de internación en Argentina. En la segunda se realiza un breve análisis de los que podrían constituir modelos e instrumentos alternativos para la financiación hospitalaria en nuestro país

La investigación en economía y gestión en salud en Argentina / Research in health economy and management in Argentina

El presente documento examina la investigación en economía de la salud en Argentina. Para ello se han recolectado y analizado los principales trabajos de investigación desarrollados en las dos últimas décadas. En primer lugar se presenta un conjunto de hipótesis en relación al estado del arte de la economía de la salud. Se incluye, también, una descripción de los aspectos relacionados con la reproducción del conocimiento en el área, tales como docencia y actividades de intercambio científico. Por último se presentan un conjunto de conclusiones en relación a las fortalezas y debilidades de la investigación en economía de la salud en el país

Estrategias económicas y financiamiento del medicamemnto / Economics strategies and medicament finanancing

Los esfuerzos por regular el mercado de medicamentos se incrementaron durante la última década, y en especial en los países desarrollados. El presente artículo analiza las experiencias obtenidas en aquellos esfuerzos regulatorios y presenta un conjunto de herramientas y estrategias útiles para la formulación de políticas de regulación del mercado de medicamentos. Las medidas de política son presentadas distinguiéndose sus objetivos, su operación y sus mecanismos de implemetación. Aunque el abanico de alternativas remite mayormente a la experienciade países desarrollados como Estados Unidos y países de Europa, se intenta también una síntesis del estado actual de la cuestión en países de America Latina

Modelos de pago en servicios de salud / Paid models in health services

Los modelos de pagos son poderosas herramientas de gestion ya que permiten operar sobre el gasto y sobre las conductas de las personas. El estudio y diseño de los modelos de contratación y pago más adecuados para cada situación se ha transformado en una especie de nueva alquimia que promete dar respuesta a gran parte de los desafios de la gestión en salud. Este documento se propopne presentar de forma sistemática las principales caracdterísticas de los instrumentos o modelos de pago a prestadores. El texto está estructurado en tres secciones. La primera parte aborda a los modelos de pago en su carácter de acción socvial y económica y examina sus posibles clasificaciones. En la segunda parte se identifican un conjunto de variables y se formulan algunas hipótesis. Luego se describe un modelo análitico para el estudio de los modelos.La tercera parte proppone una evaluación de los modelos de pago a los profecionales y a establecimientos. El análisis desarrollados en esta última sección se basa en el modelo propuesto enla sección anterior y apunta a identificar las ventajas y desventajas de cada modalidad