Managed competition in Colombia: convergence of public and private insurance and delivery.

The Colombian health system has made a deep transition into managed competition since a major reform in 1993. A market for insurers was created, the consumer has free choice of insurer and a national-level equalisation fund distributes revenues via a per-capita payment. Fully subsidised insurance for the poor and informal, and a comprehensive standardised benefit package for subsidised and contributory schemes (both schemes covering 98 per cent of the population), has led to a low level of out-of-pocket expenses and high financial protection, as well as to reduced gaps in equity in access. The preconditions for managed competition are largely met, but improving health care providers' organisation towards integrated care, to enable them to deliver more value, is a necessary step to achieve the expected results of managed competition in terms of efficiency and quality. Although the current system is likely to be reformed in the coming months, the nature and extent of those reforms are not defined yet, so our analysis is based on the current system.

Costo-efectividad de la calidad del control prenatal con respecto al bajo peso al nacer en el Cauca / Antenatal control quality cost-effectiveness regarding low birth weight in Cauca

Antecedentes: El departamento del Cauca en Colombia es multiétnico, multicultural y biodiverso, también con grandes diferencias en bajo peso al nacer (BPN), mortalidad perinatal y mortalidad neonatal tardía entre municipios. Objetivo: Determinar la relación de costo-efectividad del control prenatal (CPN) cuando ha tenido buena calidad frente al que ha tenido calidad deficiente con respecto al BPN en el departamento del Cauca entre 2018 y 2020. Método: Evaluación económica con diseño epidemiológico de una cohorte histórica desde la perspectiva de la institución pagadora. Se calculó la razón incremental de costo-efectividad (RICE), análisis de sensibilidad e impacto presupuestal. Resultados: La incidencia de BPN fue del 8,3% (348/4182). La calidad deficiente en el CPN incrementó el riesgo de BPN (OR: 3,38; IC95%: 1,05-8,2) y la buena calidad tuvo una mejor relación de costo-efectividad (RICE: USD 2727,75), con posición dominante frente a la calidad deficiente (6,14 veces el PIB per cápita de ahorro) y con un impacto presupuestal de USD 2.904.392. Conclusiones: La buena calidad del CPN en el departamento del Cauca durante 2018-2020 fue costo-efectiva y dominante por ser de menor costo y mayor efectividad.

Background: The department of Cauca in Colombia is multiethnic, multicultural, and biodiverse, also with large differences in low birth weight (LBW), perinatal mortality, and late neonatal mortality among municipalities. Objective: To determine the cost-effectiveness relationship of antenatal care (ANC) when it has had good quality compared to that which has had poor quality with respect to low birth weight in the department of Cauca between 2018 and 2019. Method: Economic evaluation with epidemiological cohort design historical from the perspective of the payer institution. Incremental cost-effectiveness ratio (RICE), sensitivity analysis, and budgetary impact were calculated. Results: The incidence of LBW was 8.3% (348/4182). Poor quality in ANC increased the risk of LBW (OR: 3.38; CI95%: 1.05-8.2), good quality had a better cost-effectiveness ratio (RICE: USD 2727.75), with dominant position against poor quality (6.14 times the GDP/capita savings) with a budgetary impact of USD 2,904,392. Conclusions: The good quality of the ANC in the department of Cauca during 2018-2020 was cost-effective and dominant because it is lower cost and more effective.

Scarcity in abundance? Spatial inequalities in Rheumatoid Arthritis in a health system with financial equity.

BACKGROUND: This paper estimates spatial inequalities of Rheumatoid Arthritis (RA) in Colombia and explores correlates of those disparities from a health system perspective. METHODS: We apply descriptive epidemiology to healthcare administrative records for estimation of crude and age-standardized prevalences, and health systems thinking for identification of barriers to effective access in RA diagnosis. RESULTS: The crude and age-standardized RA prevalence for Colombia in 2018 is estimated at 0.43% and 0.36%, respectively. In the contributory regime, the binding constraint is effective access to rheumatologists in rural and sparsely populated areas; this constraint in workforce affects service delivery, and ultimately comes from the lack of a differentiated model for effective provision of healthcare in those areas (governance). CONCLUSIONS: There are opportunities for implementation of public health policies and health system interventions that would lead to a better identification of RA patients and the subsequent more precise estimation of RA prevalence, and most importantly, to reduce exposition to risk factors and accurate diagnosis and treatment of RA patients.

[Benefits of the cigarette tax in Mexico, by sex and income quintileBenefícios do imposto sobre cigarros no México: análise por sexo e quintil de renda]. / Beneficios del impuesto a los cigarros en México: análisis por sexo y quintil de ingreso.

Objective: Estimate economic and health benefits, by sex and income quintile, of tax-based cigarette price increases in Mexico. Methods: An extended cost-effectiveness analysis (ECEA) model was used to estimate distributional benefits for women and men in the scenario of a 44% increase in the price of cigarettes (from 56.4 Mexican pesos [MX$] to MX$81.2 per pack), as a result of tripling the current specific excise tax (from MX$0.49/cigarette to MX$1.49/cigarette). The model was calibrated with official national information sources. Results: With a tax increase of one peso per cigarette, about 1.5 million smokers would quit (351 300 women and 1.1 million men). This would prevent approximately 630 000 smoking-attributable premature deaths. Reducing the burden of disease would save the health sector close to MX$42.8 billion and prevent more than 250 000 people (including 50 200 women smokers) from falling into poverty. It would also result in an additional MX$16.2 billion in revenue per year, of which the lowest income quintile would contribute less than 3% (1% for low-income women). Conclusions: The tobacco epidemic has clearly differentiated patterns between women and men, reflecting a gender component. While the tobacco tax in Mexico would have great benefits with respect to the current state of the epidemic, this could also contribute to the broader goal of social justice by reducing gender inequities.

Objetivo: Estimar os benefícios econômicos e de saúde, por sexo e quintil de renda, do aumento dos preços dos cigarros por meio de impostos no México. Métodos: Com um modelo de análise ampliada de custo-efetividade (ECEA, na sigla em inglês), foram estimados os benefícios distributivos em mulheres e homens com um cenário de aumento de 44% no preço dos cigarros (de 56,4 pesos mexicanos [MX$] para MX$ 81,2 por maço), como resultado da triplicação do imposto específico atual (de MX$ 0,49/cigarro para MX$ 1,49/cigarro). O modelo foi calibrado com fontes oficiais de informação nacional. Resultados: Com o aumento do imposto de um MX$ por cigarro, cerca de 1,5 milhão de fumantes abandonariam o consumo (351.300 mulheres e 1,1 milhão de homens). Assim, seriam evitadas aproximadamente 630.000 mortes prematuras atribuíveis ao tabaco. A redução da carga de doenças permitiria uma economia para o setor da saúde de cerca de MX$ 42,8 bilhões e evitaria que mais de 250.000 pessoas (incluindo 50.200 mulheres fumantes) caíssem na pobreza. Além disso, seriam arrecadados MX$ 16,2 bilhões adicionais por ano, dos quais o quintil mais baixo contribuiria com menos de 3% (1% no caso de mulheres de baixa renda). Conclusões: A epidemia de tabagismo tem padrões claramente diferenciados entre mulheres e homens e reflete um componente de gênero. Embora os benefícios do imposto sobre o tabaco no México tenham importância relativa no atual estado da epidemia em cada caso, poderiam contribuir para um objetivo mais amplo de justiça social ao reduzir as desigualdades de gênero.

Beneficios del impuesto a los cigarros en México: análisis por sexo y quintil de ingreso

[RESUMEN]. Objetivo. Estimar los beneficios económicos y en salud, por sexo y por quintil de ingreso, del incremento de los precios de los cigarros mediante impuestos en México. Métodos. Con un modelo de costo-efectividad extendido (ECEA, por su sigla en inglés) se estimaron los beneficios distributivos en mujeres y hombres con un escenario de incremento del precio de los cigarros de 44% (de 56,4 pesos mexicanos [MX$] a MX$81,2 por cajetilla), como resultado de triplicar el impuesto especí- fico actual (de MX$0,49/cigarro a MX$1,49/cigarro). El modelo se calibró con fuentes oficiales de información nacional Resultados. Con el incremento del impuesto de un peso por cigarro, cerca de 1,5 millones de fumadores abandonarían el consumo (351 300 mujeres y 1,1 millón de hombres). Así, se evitarían aproximadamente 630 000 muertes prematuras atribuibles al tabaco. La reducción de la carga de enfermedad permitiría ahorros para el sector salud cercanos a MX$42 800 millones y evitaría que más de 250 000 personas (entre ellas, 50 200 mujeres fumadoras) cayeran en situación de pobreza. Además, se recaudarían MX$16 200 millones adicionales por año, de los cuales el quintil más bajo aportaría menos de 3% (1% en el caso de las mujeres de menores ingresos). Conclusiones. La epidemia de tabaquismo tiene patrones claramente diferenciados entre mujeres y hom- bres y reflejan un componente de género. Si bien los beneficios del impuesto al tabaco en México tendrían magnitudes relativas al estado actual de la epidemia en cada caso, estos podrían contribuir a un objetivo más amplio de justicia social mediante la reducción de las inequidades de género.

[ABSTRACT]. Objective. Estimate economic and health benefits, by sex and income quintile, of tax-based cigarette price increases in Mexico. Methods. An extended cost-effectiveness analysis (ECEA) model was used to estimate distributional benefits for women and men in the scenario of a 44% increase in the price of cigarettes (from 56.4 Mexican pesos [MX$] to MX$81.2 per pack), as a result of tripling the current specific excise tax (from MX$0.49/cigarette to MX$1.49/cigarette). The model was calibrated with official national information sources. Results. With a tax increase of one peso per cigarette, about 1.5 million smokers would quit (351 300 women and 1.1 million men). This would prevent approximately 630 000 smoking-attributable premature deaths. Reducing the burden of disease would save the health sector close to MX$42.8 billion and prevent more than 250 000 people (including 50 200 women smokers) from falling into poverty. It would also result in an additional MX$16.2 billion in revenue per year, of which the lowest income quintile would contribute less than 3% (1% for low-income women). Conclusions. The tobacco epidemic has clearly differentiated patterns between women and men, reflecting a gender component. While the tobacco tax in Mexico would have great benefits with respect to the current state of the epidemic, this could also contribute to the broader goal of social justice by reducing gender inequities.

[RESUMO]. Objetivo. Estimar os benefícios econômicos e de saúde, por sexo e quintil de renda, do aumento dos preços dos cigarros por meio de impostos no México. Métodos. Com um modelo de análise ampliada de custo-efetividade (ECEA, na sigla em inglês), foram esti- mados os benefícios distributivos em mulheres e homens com um cenário de aumento de 44% no preço dos cigarros (de 56,4 pesos mexicanos [MX$] para MX$ 81,2 por maço), como resultado da triplicação do imposto específico atual (de MX$ 0,49/cigarro para MX$ 1,49/cigarro). O modelo foi calibrado com fontes oficiais de informação nacional. Resultados. Com o aumento do imposto de um MX$ por cigarro, cerca de 1,5 milhão de fumantes abando- nariam o consumo (351.300 mulheres e 1,1 milhão de homens). Assim, seriam evitadas aproximadamente 630.000 mortes prematuras atribuíveis ao tabaco. A redução da carga de doenças permitiria uma economia para o setor da saúde de cerca de MX$ 42,8 bilhões e evitaria que mais de 250.000 pessoas (incluindo 50.200 mulheres fumantes) caíssem na pobreza. Além disso, seriam arrecadados MX$ 16,2 bilhões adicionais por ano, dos quais o quintil mais baixo contribuiria com menos de 3% (1% no caso de mulheres de baixa renda). Conclusões. A epidemia de tabagismo tem padrões claramente diferenciados entre mulheres e homens e reflete um componente de gênero. Embora os benefícios do imposto sobre o tabaco no México tenham impor- tância relativa no atual estado da epidemia em cada caso, poderiam contribuir para um objetivo mais amplo de justiça social ao reduzir as desigualdades de gênero.

Tobacco industry pricing strategies for single cigarettes and multistick packs after excise tax increases in Colombia.

INTRODUCTION: Taxes on tobacco products are an efficient way of reducing consumption. However, they are only effective if passed on to consumers with higher prices. This study aims to examine tobacco industry (TI) pricing strategies in response to tax increases, and whether they differ by price segments or presentation (packs or individual sticks) in Colombia. This is the first such academic study in Latin America and the first anywhere to include the market for single sticks. METHODS: Using data on cigarette pricing/taxation from a survey of smokers (2016-2017) and official government data on pricing (2007-2019), the TI's pricing strategies were examined, split by brand, price segments, different sized packs and single cigarettes. RESULTS: The TI employed targeted pricing strategies in Colombia: differentially shifting taxes; and launching new brands/brand variants. The industry overshifted taxes when increases were smaller and predictable, but used undershifting more when there was a larger increase in 2017, after which it mostly overshifted on budget and premium (but undershifted mid-priced) brands. The prices for single sticks increased more than the tax increase in 2017 when their consumption also increased. CONCLUSION: The pricing strategies identified suggest excise taxes can be increased further, particularly the specific component, to reduce the price gap between brand segments. Brands should be restricted to a single variant along with prohibitions on launching new brands/brand variants. Lastly, since the pricing of single sticks does not match the pattern of packs, more monitoring of their sales and distribution is required, especially since they promote consumption and hinder effective implementation of tobacco tax policies.

Tobacco Taxes as the Unsung Hero: Impact of a Tax Increase on Advancing Sustainable Development in Colombia.

Objective: Tobacco taxes are a well-established cost-effective policy to prevent Noncommunicable Diseases. This paper evaluates the expected effects of a tobacco tax increase on the Sustainable Development Goals in Colombia. Methods: We use microsimulation to build an artificial society that mimics the observed characteristics of Colombia's population, and from there we simulate the behavioral response to a tax increase of COP$4,750 (an increase that has been discussed by policy makers and legislators) and the subsequent effects in all SDGs. Results: The tobacco tax hike reduces the number of smokers (from 4.51 to 3.45 MM smokers) and smoking intensity, resulting in a drop in the number of cigarettes smoked in Colombia (from 332.3 to 215.5 MM of 20-stick packs). Such reduction is expected to decrease premature mortality, healthcare costs, poverty and people facing catastrophic expenditure on healthcare, to increase health, income and gender equity, and to strengthen domestic resource mobilization even in the presence of illicit cigarettes. Conclusion: Tobacco taxes are an effective intervention for public health and a powerful instrument to advance on the 2030 Sustainable Development Agenda. Relevance: A comprehensive analysis of the impact of tobacco taxes on all areas of Sustainable Development is missing in the empirical literature. Such perspective is needed to break the barriers for further tobacco tax increases by gathering wider societal support, especially from stakeholders and key decision makers from development areas other than health. SDG Nr: SDG3 (health), SDG 1 (no poverty), SDG 4 (education), SDG 5 (gender equality), SDG6 (water), SDG10 (inequality), SDG12 (responsible production and consumption), SDG17 (partnerships).

The distributional effects of tobacco tax increases across regions in Mexico: an extended cost-effectiveness analysis.

BACKGROUND: Several studies have shown the beneficial effects of tobacco fiscal policy, but distributional effects have been less examined, especially at the subnational level. The objective of this study is to analyse the distributional effects of a one-peso tobacco tax increase (roughly equivalent to tripling the current excise tax) on health, poverty, and financial outcomes at the subnational level in Mexico. METHODS: We employ an extended cost-effectiveness analysis that estimates life-years gained, smoking attributable deaths averted, treatment costs averted, number of persons avoiding poverty and catastrophic health expenditures, and additional tax revenues by income group across five regions. RESULTS: With the one-peso tax increase (or 44% price increase), about 1.5 million smokers would quit smoking across the five regions, resulting in nearly 630 thousand premature deaths averted and 12.6 million life years gained. The bottom income quintile would gain three times more life years gains than the top quintile (ratio 3:1), and the largest gain for the most deprived would occur in the South (ratio 19:1), the region with the highest poverty incidence. Costs averted and additional tax revenues would reach 44.6 and 16.2 billion pesos, respectively. Moreover, 251 thousand individuals would avoid falling into poverty, including 53.2 in the lowest income quintile, and 563.9 thousand would avoid catastrophic health expenditures. Overall, the bottom income group would obtain 26% of the life years gained and 24% of the cost averted, while only paying 3% of the additional tax revenue. CONCLUSIONS: The most significant gains from a substantial cigarette price increase would be for the poorest 20%, especially in the South, the most impoverished region of Mexico. Therefore, tobacco taxes are an opportunity for governments to advance in equity and towards the achievement of sustainable development goals on non-communicable diseases.

Beneficios del impuesto a los cigarros en México: análisis por sexo y quintil de ingreso / Benefits of the cigarette tax in Mexico, by sex and income quintile / Benefícios do imposto sobre cigarros no México: análise por sexo e quintil de renda

RESUMEN Objetivo. Estimar los beneficios económicos y en salud, por sexo y por quintil de ingreso, del incremento de los precios de los cigarros mediante impuestos en México. Métodos. Con un modelo de costo-efectividad extendido (ECEA, por su sigla en inglés) se estimaron los beneficios distributivos en mujeres y hombres con un escenario de incremento del precio de los cigarros de 44% (de 56,4 pesos mexicanos [MX$] a MX$81,2 por cajetilla), como resultado de triplicar el impuesto específico actual (de MX$0,49/cigarro a MX$1,49/cigarro). El modelo se calibró con fuentes oficiales de información nacional Resultados. Con el incremento del impuesto de un peso por cigarro, cerca de 1,5 millones de fumadores abandonarían el consumo (351 300 mujeres y 1,1 millón de hombres). Así, se evitarían aproximadamente 630 000 muertes prematuras atribuibles al tabaco. La reducción de la carga de enfermedad permitiría ahorros para el sector salud cercanos a MX$42 800 millones y evitaría que más de 250 000 personas (entre ellas, 50 200 mujeres fumadoras) cayeran en situación de pobreza. Además, se recaudarían MX$16 200 millones adicionales por año, de los cuales el quintil más bajo aportaría menos de 3% (1% en el caso de las mujeres de menores ingresos). Conclusiones. La epidemia de tabaquismo tiene patrones claramente diferenciados entre mujeres y hombres y reflejan un componente de género. Si bien los beneficios del impuesto al tabaco en México tendrían magnitudes relativas al estado actual de la epidemia en cada caso, estos podrían contribuir a un objetivo más amplio de justicia social mediante la reducción de las inequidades de género.

ABSTRACT Objective. Estimate economic and health benefits, by sex and income quintile, of tax-based cigarette price increases in Mexico. Methods. An extended cost-effectiveness analysis (ECEA) model was used to estimate distributional benefits for women and men in the scenario of a 44% increase in the price of cigarettes (from 56.4 Mexican pesos [MX$] to MX$81.2 per pack), as a result of tripling the current specific excise tax (from MX$0.49/cigarette to MX$1.49/cigarette). The model was calibrated with official national information sources. Results. With a tax increase of one peso per cigarette, about 1.5 million smokers would quit (351 300 women and 1.1 million men). This would prevent approximately 630 000 smoking-attributable premature deaths. Reducing the burden of disease would save the health sector close to MX$42.8 billion and prevent more than 250 000 people (including 50 200 women smokers) from falling into poverty. It would also result in an additional MX$16.2 billion in revenue per year, of which the lowest income quintile would contribute less than 3% (1% for low-income women). Conclusions. The tobacco epidemic has clearly differentiated patterns between women and men, reflecting a gender component. While the tobacco tax in Mexico would have great benefits with respect to the current state of the epidemic, this could also contribute to the broader goal of social justice by reducing gender inequities.

RESUMO Objetivo. Estimar os benefícios econômicos e de saúde, por sexo e quintil de renda, do aumento dos preços dos cigarros por meio de impostos no México. Métodos. Com um modelo de análise ampliada de custo-efetividade (ECEA, na sigla em inglês), foram estimados os benefícios distributivos em mulheres e homens com um cenário de aumento de 44% no preço dos cigarros (de 56,4 pesos mexicanos [MX$] para MX$ 81,2 por maço), como resultado da triplicação do imposto específico atual (de MX$ 0,49/cigarro para MX$ 1,49/cigarro). O modelo foi calibrado com fontes oficiais de informação nacional. Resultados. Com o aumento do imposto de um MX$ por cigarro, cerca de 1,5 milhão de fumantes abandonariam o consumo (351.300 mulheres e 1,1 milhão de homens). Assim, seriam evitadas aproximadamente 630.000 mortes prematuras atribuíveis ao tabaco. A redução da carga de doenças permitiria uma economia para o setor da saúde de cerca de MX$ 42,8 bilhões e evitaria que mais de 250.000 pessoas (incluindo 50.200 mulheres fumantes) caíssem na pobreza. Além disso, seriam arrecadados MX$ 16,2 bilhões adicionais por ano, dos quais o quintil mais baixo contribuiria com menos de 3% (1% no caso de mulheres de baixa renda). Conclusões. A epidemia de tabagismo tem padrões claramente diferenciados entre mulheres e homens e reflete um componente de gênero. Embora os benefícios do imposto sobre o tabaco no México tenham importância relativa no atual estado da epidemia em cada caso, poderiam contribuir para um objetivo mais amplo de justiça social ao reduzir as desigualdades de gênero.

Tobacco taxes and illicit cigarette trade in Colombia.

This paper estimates the short-term impact of a twofold increase of the tobacco excise tax on consumption of illicit cigarette trade in Colombia. Using data collected before and after the tax increase from a novel smoker survey (DEICS-Col), the impact is estimated as the change in the probability that a smoker has illicit cigarettes. The methodology follows a difference-in-differences strategy, measuring the year-to-year variation of the proportion of illicit cigarettes between smokers who report buying low-priced cigarettes (the highest treatment intensity) and those who bought high-priced cigarettes (lowest treatment intensity). Estimations of the impact show an average increase of 4-5 percentage points on the proportion of illicit cigarettes relative to an initial penetration of low-priced illicit cigarettes of nearly 5.1 %.

Smoke signals: monitoring illicit cigarettes and smoking behaviour in Colombia to support tobacco taxes.

BACKGROUND: A street cross-sectional survey in 2016 with a representative sample of 1697 smokers in five Colombian cities was used to estimate the penetration of illicit cigarettes (PIC). The first wave was collected 3 months before a 100% increase in tobacco excise tax, and a second wave collected data 9 months after tax reform was effective. OBJECTIVE : Analyse changes after a cigarette tax increase in PIC, prices and smoking behaviour patterns for five Colombian cities (63% of the market). Smoking behaviour includes consumption intensity, presentation (stick/pack) and place of purchase. METHODS : Repeated street cross-sectional survey with smokers' self-report on smoking behaviour, last purchase information and direct observation of smokers' packs. Sampling frame: smokers, men and women, aged 12 years or older, all income levels, resident in the five cities with the highest number of smokers representing 63% of cigarette market share (Bogotá, Medellín, Cali, Cartagena and Cúcuta) with 1 733 316 smokers in 2013. Sample size was 1697 per wave, with confidence level 95%, margin of error 3.5% for Bogotá and Medellín and 5% for the other three cities. Smokers in second wave match first wave's location, sex and age group. Illicit cigarettes were identified based on brand, health warnings and price. RESULTS : After the tax hike, the average real price of a 20-stick pack increased by 28.2% and by 23.1% for loose cigarettes. Illicit cigarettes represented 3.4% of total cigarette consumption in 2016 and increased to 6.4% in 2017, lower than the current industry estimate of 18%. Consumption intensity decreased: the proportion of heavy smokers (more than 10 cigarettes per day) wentdown from 37% in 2016 to 26% in 2017. CONCLUSION: After the tax increase, Colombia's PIC remained at low levels, and there is enough space for new tobacco tax hikes.

How much for a broken heart? Costs of cardiovascular disease in Colombia using a person-based approach.

The shift of the Noncommunicable Diseases (NCDs) epidemic, including cardiovascular disease, from developed to Low and Middle Income Countries (LMIC), creates new challenges in contexts where there is poor information on healthcare costs. Clearly this information is essential for planning, and its relevance is even more valuable as a driver for prevention and control of NCDs. This paper begins to address that handicap by estimating the healthcare cost of Cardiovascular Disease (Coronary Heart Disease and Stroke) in Colombia, using a person-based approach. Results show that the annual healthcare cost of a person with Coronary Heart Disease is between INT$ 4,277 and INT$ 4,846, while the cost for a person with Stroke varies between INT$5,816 and INT$6,616. The expansion of the NCDs epidemic combined with such high costs threatens the financial sustainability of health systems; primary prevention and policies targeting structural and intermediate determinants of health are a promising way to make health systems financially sustainable.

Factores de riesgo y enfermedades cardiometabólicas en Risaralda 2017 proyectada a 2050 / Risk factors and cardiometabolic disease in Risaralda 2017 to 2050

Resumen Objetivo: Proyectar el comportamiento de factores de riesgo y de la incidencia de dos enfermedades cardiometabólicas, en una población colombiana entre 2017 y 2050. Metodología: Diseño de cohorte abierta basado en un modelo de microsimulación dinámica para la población adulta de Risaralda, Colombia. Los factores de riesgo analizados son tabaquismo, obesidad global, obesidad central y colesterol total. Se creó una población sintética que replica las características demográficas y de salud de Risaralda en 2010, utilizando algoritmos de emparejamiento e imputación estadística. La evolución a lo largo del curso de vida se simuló basada en reglas derivadas de la literatura, con ecuaciones estocásticas y modelos econométricos. Se calcula la incidencia de diabetes tipo II y de eventos cerebrovasculares isquémicos de 2017 a 2050. Resultados: En 2050, 16.7 % serán fumadores, la tercera parte de ellos presentarán obesidad global y más de la mitad presentarán obesidad central. El promedio de colesterol total aumentará 5 mg/dL. Adicionalmente, se espera que entre 2017 y 2050 se presenten 204.966 casos nuevos de diabetes y 65.758 eventos cerebrovasculares isquémicos. Conclusiones: Los estilos de vida y el envejecimiento poblacional, llevarán a mayor exposición a riesgo y aumentarán la velocidad a la que los risaraldenses se enfermarán de Diabetes y experimentarán eventos cerebrovasculares. La obesidad global y central son factores que explicarían esta tendencia. Se requieren intervenciones intersectoriales que protejan a la población y reduzcan cargas fiscales por condiciones evitables.

Abstract Objective: predict the behavior of the risk factors and the incidence of two cardiometabolic diseases in a population from Colombia between 2017 and 2050. Methodology: Follow up of individual's cohort of an artificial society of Risaralda, Colombia, based on a microsimulation model. The risk factors analyzed in this study are tobacco use, obesity, central obesity and total cholesterol. A synthetic population was created to replicate demographic and health characteristics of Risaralda in 2010, using pairing algorithms and statistical imputation. The evolution along the life course was simulated based on rules from scientific literature, with stochastic equations and econometric estimates. The incidence of type II diabetes and ischemic stroke is calculated for the adult population between 2017 to 2050. Results: 16.7% of the adults by 2050 is expected to be smokers, a third of them will have global obesity and more than half will have central obesity. The average level of serum total cholesterol would increase by 5 mg/dL. Additionally, is expected that between 2017 and 2050 there will be 204.966 incident cases of diabetes and 65.758 first-ever ischemic stroke events. Conclusions: Lifestyles and expected population aging will lead to greater risk of disease and will increase the rate at which local people will get diabetes and ischemic stroke. Risk factors like global and central obesity explain this trend. Effective intersectoral interventions are needed to protect the population and reduce tax burden due to preventable conditions.

Measuring illicit cigarette trade in Colombia.

BACKGROUND: By 2016, tobacco industry provided the only illicit trade estimates in Colombia and used these to discourage tax increases since the 1990s. To establish the viability of a threefold hike in the excise tax, policy makers needed unbiased estimates of the illicit cigarette. OBJECTIVE: To estimate the size of illicit cigarette trade in five Colombian cities (63% of the market), analyse characteristics of smokers of illicit cigarettes and compare market share results with one industry-funded survey. METHODS: Street cross-sectional survey with smokers' self-report on consumption pattern, last purchase information and direct observation of smoker's packs. Sampling frame: smokers, men and women, 12 years old or older, all income levels, resident in five Colombian cities (Bogotá, Medellín, Cali, Cartagena and Cúcuta) with 1 733 316 smokers in 2013. Sample size 1697, simple random sample by city, sampling weights based on age groups and cities. Confidence level 95%, margin of error 3.5% for Bogotá and Medellín and 5% for the other three cities. Data collection period: 24 August-14 September 2016. RESULTS: Illicit cigarettes represent 3.5% of consumption in the five cities, a much lower estimate than the industry data. There are significant differences across cities, with Bogotá at the bottom (1.5%) and Cúcuta at the top (22.8%). CONCLUSION: The low overall penetration of illicit cigarettes in Colombia indicates that the industry's warnings against tax increases are not justified. The limited importance of tax levels as determinant of consumption of illicit cigarettes is also suggested by the differences across cities, all of them with the same tax regime.

Symptom burden profile in myelofibrosis patients with thrombocytopenia: Lessons and unmet needs.

Myelofibrosis is a myeloproliferative neoplasm associated with progressive cytopenias and high symptom burden. MF patients with thrombocytopenia have poor prognosis but the presence of thrombocytopenia frequently precludes the use of JAK2 inhibitors. In this study, we assessed quality of life and symptom burden in 418 MF patients with (n=89) and without (n=329) thrombocytopenia using prospective data from the MPN-QOL study group database, including the Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) and Total Symptom Score (MPN10). Thrombocytopenia, defined as platelet count <100×109/L (moderate 51-100×109/L; severe ≤50×109/L), was associated with anemia (76% vs. 45%, p<0.001), leukopenia (29% vs. 11%, p<0.001), and need for red blood cell transfusion (35% vs. 19%, p=0.002). Thrombocytopenic patients had more fatigue, early satiety, inactivity, dizziness, sad mood, cough, night sweats, itching, fever, and weight loss; total symptom scores were also higher (33 vs. 24, p<0.001). Patients with severe thrombocytopenia were more likely to have anemia (86% vs. 67%, p=0.04), leukopenia (40% vs. 20%, p=0.04), and transfusion requirements (51% vs. 20%, p=0.002) but few differences in symptoms when compared to patients with moderate thrombocytopenia. These results suggest that MF patients with thrombocytopenia experience greater symptomatic burden than MF patients without thrombocytopenia and may benefit from additional therapies.

A Dynamic Estimation of Obesity Using Nhanes Data: A Pseudo-Panel Approach.

In this analysis, we examine the effect of wages on obesity by constructing pseudo-panels to conduct a dynamic estimation of Grossman's human capital model. The results indicate that wages have an increasing effect on obesity status. After accounting for past health status, the protective effect of wages commonly disseminated in the literature reverses on obesity status. The results may also indicate possible asymmetric consumption behavior between foods/nutrients that improve diet quality versus those that degrade it. Individuals may be more keen to adhere to prophylactic diet strategies that abate consumption of unhealthy food/nutrients rather than measures which increase healthy nutrient consumption. Additionally, wages have an increasing effect on overall total calories consumed. These findings suggest that higher wage earners may focus their diet efforts on reducing consumption of specific nutrients but compensate by overconsuming other types of nutrients increasing overall calorie intake. Copyright © 2017 John Wiley & Sons, Ltd.

Associations between gender, disease features and symptom burden in patients with myeloproliferative neoplasms: an analysis by the MPN QOL International Working Group.

The myeloproliferative neoplasms, including polycythemia vera, essential thrombocythemia and myelofibrosis, are distinguished by their debilitating symptom profiles, life-threatening complications and profound impact on quality of life. The role gender plays in the symptomatology of myeloproliferative neoplasms remains under-investigated. In this study we evaluated how gender relates to patients' characteristics, disease complications and overall symptom expression. A total of 2,006 patients (polycythemia vera=711, essential thrombocythemia=830, myelofibrosis=460, unknown=5) were prospectively evaluated, with patients completing the Myeloproliferative Neoplasm-Symptom Assessment Form and Brief Fatigue Inventory Patient Reported Outcome tools. Information on the individual patients' characteristics, disease complications and laboratory data was collected. Consistent with known literature, most female patients were more likely to have essential thrombocythemia (48.6% versus 33.0%; P<0.001) and most male patients were more likely to have polycythemia vera (41.8% versus 30.3%; P<0.001). The rate of thrombocytopenia was higher among males than females (13.9% versus 8.2%; P<0.001) and males also had greater red-blood cell transfusion requirements (7.3% versus 4.9%; P=0.02) with shorter mean disease duration (6.4 versus 7.2 years, P=0.03). Despite there being no statistical differences in risk scores, receipt of most therapies or prior complications (hemorrhage, thrombosis), females had more severe and more frequent symptoms for most individual symptoms, along with overall total symptom score (22.8 versus 20.3; P<0.001). Females had particularly high scores for abdominal-related symptoms (abdominal pain/discomfort) and microvascular symptoms (headache, fatigue, insomnia, concentration difficulties, dizziness; all P<0.01). Despite complaining of more severe symptom burden, females had similar quality of life scores to those of males. The results of this study suggest that gender contributes to the heterogeneity of myeloproliferative neoplasms by influencing phenotypic profiles and symptom expression.

[Cigarette taxes and demand in Colombia]. / Impuestos y demanda de cigarrillos en Colombia.

OBJECTIVE: Estimate price and income elasticities of aggregate demand for cigarettes in Colombia, by controlling for structural market changes since the late 1990s, to identify policy opportunities for taxes that could improve public health and increase tax revenues. METHODS: Measurement of aggregate demand for cigarettes using gross income reported on value-added tax returns submitted to Colombia's National Tax and Customs Office (DIAN is the acronym in Spanish) by the tobacco product manufacturing industry, subtracting exports. A quarterly time series was obtained for the period 1994-2014. The econometric estimation using two-stage least squares controls for price endogeneity and uses a set of dummy variables to control for structural changes in the market and in its regulation. RESULTS: Demand is, from a statistical standpoint, sensitive to price and to income. Price elasticity of demand is -0.78 and income elasticity is 0.61. CONCLUSIONS: Inelastic demand implies that it is possible, through cigarette excise taxes, to meet public health targets and increase revenues simultaneously. The results also suggest that the considerable increase in household income in Colombia in the first decade of the 21st century increased purchasing power, which, lacking an accompanying tax increase, promoted cigarette consumption, with negative effects on public health, and wasted an opportunity to increase tax revenues.

Impuestos y demanda de cigarrillos en Colombia / Cigarette taxes and demand in Colombia

Objetivo. Estimar elasticidades precio e ingreso de la demanda agregada de cigarrillos para Colombia mediante el control de cambios estructurales en el mercado desde finales de los años 90, para identificar espacios de política de impuestos que mejoren la salud pública y aumenten los recaudos fiscales. Métodos. La medición de la demanda agregada de cigarrillos utiliza los ingresos brutos reportados en la declaración del impuesto al valor agregado (IVA) a la Dirección de Impuestos y Aduanas Nacionales de Colombia (DIAN) por la industria de fabricación de productos de tabaco, con descuento de las exportaciones. Se obtuvo una serie de tiempo trimestral para el período 1994–2014. La estimación econométrica por mínimos cuadrados en dos etapas (2SLS) controla por la endogeneidad del precio y utiliza un conjunto de variables dummy para controlar por cambios estructurales en el mercado y en su regulación. Resultados. La demanda es, desde el punto de vista estadístico, sensible al precio y al ingreso. La elasticidad precio de la demanda es -0,78 y la elasticidad ingreso es 0,61. Conclusiones. La demanda inelástica implica que es posible, a través de impuestos al consumo de cigarrillo, alcanzar metas de salud pública y aumentar el recaudo de manera simultánea. Los resultados también sugieren que el aumento considerable del ingreso de los hogares de Colombia en la primera década del siglo xxi generó aumento del poder de compra. Este, al no ir acompañado de un aumento en el impuesto, impulsó el consumo de cigarrillo, con efectos negativos en salud pública, y se desperdició una oportunidad para aumentar el recaudo fiscal.

Objective. Estimate price and income elasticities of aggregate demand for cigarettes in Colombia, by controlling for structural market changes since the late 1990s, to identify policy opportunities for taxes that could improve public health and increase tax revenues. Methods. Measurement of aggregate demand for cigarettes using gross income reported on value-added tax returns submitted to Colombia’s National Tax and Customs Office (DIAN is the acronym in Spanish) by the tobacco product manufacturing industry, subtracting exports. A quarterly time series was obtained for the period 1994-2014. The econometric estimation using two-stage least squares controls for price endogeneity and uses a set of dummy variables to control for structural changes in the market and in its regulation. Results. Demand is, from a statistical standpoint, sensitive to price and to income. Price elasticity of demand is –0.78 and income elasticity is 0.61. Conclusions. Inelastic demand implies that it is possible, through cigarette excise taxes, to meet public health targets and increase revenues simultaneously. The results also suggest that the considerable increase in household income in Colombia in the first decade of the 21st century increased purchasing power, which, lacking an accompanying tax increase, promoted cigarette consumption, with negative effects on public health, and wasted an opportunity to increase tax revenues.

Impuestos y demanda de cigarrillos en Colombia / Cigarette taxes and demand in Colombia

RESUMEN Objetivo Estimar elasticidades precio e ingreso de la demanda agregada de cigarrillos para Colombia mediante el control de cambios estructurales en el mercado desde finales de los años 90, para identificar espacios de política de impuestos que mejoren la salud pública y aumenten los recaudos fiscales. Métodos La medición de la demanda agregada de cigarrillos utiliza los ingresos brutos reportados en la declaración del impuesto al valor agregado (IVA) a la Dirección de Impuestos y Aduanas Nacionales de Colombia (DIAN) por la industria de fabricación de productos de tabaco, con descuento de las exportaciones. Se obtuvo una serie de tiempo trimestral para el período 1994–2014. La estimación econométrica por mínimos cuadrados en dos etapas (2SLS) controla por la endogeneidad del precio y utiliza un conjunto de variables dummy para controlar por cambios estructurales en el mercado y en su regulación. Resultados La demanda es, desde el punto de vista estadístico, sensible al precio y al ingreso. La elasticidad precio de la demanda es -0,78 y la elasticidad ingreso es 0,61. Conclusiones La demanda inelástica implica que es posible, a través de impuestos al consumo de cigarrillo, alcanzar metas de salud pública y aumentar el recaudo de manera simultánea. Los resultados también sugieren que el aumento considerable del ingreso de los hogares de Colombia en la primera década del siglo xxi generó aumento del poder de compra. Este, al no ir acompañado de un aumento en el impuesto, impulsó el consumo de cigarrillo, con efectos negativos en salud pública, y se desperdició una oportunidad para aumentar el recaudo fiscal.

ABSTRACT Objective Estimate price and income elasticities of aggregate demand for cigarettes in Colombia, by controlling for structural market changes since the late 1990s, to identify policy opportunities for taxes that could improve public health and increase tax revenues. Methods Measurement of aggregate demand for cigarettes using gross income reported on value-added tax returns submitted to Colombia’s National Tax and Customs Office (DIAN is the acronym in Spanish) by the tobacco product manufacturing industry, subtracting exports. A quarterly time series was obtained for the period 1994-2014. The econometric estimation using two-stage least squares controls for price endogeneity and uses a set of dummy variables to control for structural changes in the market and in its regulation. Results Demand is, from a statistical standpoint, sensitive to price and to income. Price elasticity of demand is –0.78 and income elasticity is 0.61. Conclusions Inelastic demand implies that it is possible, through cigarette excise taxes, to meet public health targets and increase revenues simultaneously. The results also suggest that the considerable increase in household income in Colombia in the first decade of the 21st century increased purchasing power, which, lacking an accompanying tax increase, promoted cigarette consumption, with negative effects on public health, and wasted an opportunity to increase tax revenues.