RESUMO
The Spanish National Health System (SNHS) has sustainability problems resulting from weaknesses in institutional design and governance compounded by the economic crisis it faces. The global economic crisis has had a particularly virulent impact in Spain, characterized by high levels of unemployment and public and private debt. Fiscal adjustment policies implemented may significantly compromise the SNHS. Along with general funding problems, the strong territorial decentralization of health jurisdictions in the Autonomous Communities has not been backed up by efficient State-level health coordination. The SNHS suffers from problems in its rules of governance, its autonomous financing system, human resource policies and diversity of direct and indirect management models in different Autonomous Communities. A reform strategy in Spanish healthcare governancemust be articulated within the context of a broader review of public policies to stabilize the lines of defense of the welfare state. Within the scope of the health sector, the financing system must be improved and institutional changes to increase efficiency must be implemented.
Assuntos
Atenção à Saúde/organização & administração , Atenção à Saúde/economia , Gastos em Saúde , EspanhaRESUMO
El Sistema Nacional de Salud (SNS) español presenta problemas de sostenibilidad derivados de deficiencias en su diseño institucional y de gobierno, agravadas por la crisis económica que padece. La crisis económica mundial ha tenido una repercusión especialmente virulenta en España, caracterizada por altos niveles de desempleo y de deuda pública y privada. Las políticas de ajuste fiscal emprendidas pueden deteriorar el SNS significativamente. Junto a problemas de financiación general, la fuerte descentralización territorial de competencias sanitarias en las Comunidades Autónomas no ha sido acompañada de un marco eficaz de coordinación sanitaria a nivel de Estado. El SNS adolece de problemas en sus reglas de gobierno, su sistema de financiación autonómica, las políticas de recursos humanos y la diversidad de formas de gestión directa e indirecta que funcionan en las distintas Comunidades Autónomas. Una estrategia de reformas en el gobierno de la sanidad española debe articularse en el marco de una revisión más amplia de las políticas públicas que permita estabilizar las líneas de defensa del Estado del Bienestar. En el ámbito del sector sanitario se debe mejorar su sistema de financiación y desarrollar cambios institucionales para aumentar la eficiencia.
The Spanish National Health System (SNHS) has sustainability problems resulting from weaknesses in institutional design and governance compounded by the economic crisis it faces. The global economic crisis has had a particularly virulent impact in Spain, characterized by high levels of unemployment and public and private debt. Fiscal adjustment policies implemented may significantly compromise the SNHS. Along with general funding problems, the strong territorial decentralization of health jurisdictions in the Autonomous Communities has not been backed up by efficient State-level health coordination. The SNHS suffers from problems in its rules of governance, its autonomous financing system, human resource policies and diversity of direct and indirect management models in different Autonomous Communities. A reform strategy in Spanish healthcare governancemust be articulated within the context of a broader review of public policies to stabilize the lines of defense of the welfare state. Within the scope of the health sector, the financing system must be improved and institutional changes to increase efficiency must be implemented.
Assuntos
Atenção à Saúde/organização & administração , Atenção à Saúde/economia , Gastos em Saúde , EspanhaRESUMO
OBJECTIVE: To assess the cost-effectiveness of two diagnostic strategies for prostate cancer in men with prostate-specific antigen (PSA) levels of 4-10 ng/ml and normal digital rectal examination (DRE). DESIGN: Cost-effectiveness analysis was performed using a decision tree model. Data collection and a systematic review of patients at the Urology Department (Carlos Haya Hospital) were made. 101 patients over the age of 40 with PSA levels of 4-10 ng/ml and normal DRE were selected. Transrectal ultrasound-guided prostate biopsy (TRUS-Bx) and percent free PSA testing prior to TRUS-Bx were performed. The outcome measures used were the incremental cost-effectiveness ratio, and costs were calculated through activity-based costing. The effectiveness was measured by means of the number of detected cases, test utility and actual cases (detected cases minus lost cases). RESULTS: Using base-case analysis, the strategy of percent free PSA + TRUS-Bx was found to be the most cost-effective. The incremental cost-effectiveness ratio for free PSA + TRUS-Bx compared with TRUS-Bx was EUR 2,277.40. Strategy 2 (TRUS-Bx) would be more cost-effective if the cost of percent free PSA increased to EUR 21.64 or if prostate cancer prevalence increased to 26%. CONCLUSIONS: The use of percent free PSA prior to TRUS-Bx is the most cost-effective diagnostic strategy. However, this result is very sensitive and strategy 2 (TRUS-Bx) would be more cost-effective if the cost of the percent free PSA increased to EUR 21.64 or if the prevalence of prostate cancer increased to above 26%.
