Decentralization Can Improve Equity, but Can It Be Sustained?

A major theoretical issue about health system reform involving decentralization has been whether it promotes equity of health system funding. An article by the principal author and others in 2003 showed that, under certain conditions and policies, decentralization improved the equity of allocation of financial resources to different income levels of municipalities in Colombia and Chile. Another recurring issue has been whether reforms can be sustained over time. In a follow-up study in 2015, we found that the equity of national allocations was sustained even though the allocation rules for intergovernmental transfers and insurance funding sources had changed, as long as per capita allocation rules were retained. Nevertheless, the wealthier municipalities in Chile were able to increase their own source funding contributing to a larger gap between wealthy and poor municipalities, suggesting that in order to assure continued equity some compensation for these funds be included in intergovernmental transfer rules or that local source funding be restricted by national policy. These reforms may be more likely to be sustained if they become embedded in existing financial systems and if they receive support of status quo constituencies.

[Levels of glycosylated hemoglobin and the difference in the cost of health care for diabetic patients: an econometric study]. / Niveles de hemoglobina glicosilada y diferencia en el gasto en salud de pacientes diabéticos: un estudio econométrico.

BACKGROUND: Complications increase treatment costs of diabetes mellitus (DM). An adequate metabolic control of the disease could reduce these costs. AIM: To evaluate the costs of medical care for a cohort of patients with DM, according to their degree of metabolic compensation. MATERIAL AND METHODS: All diabetic patients attended in a regional hospital from 2005 to 2010 were analyzed. A correlational study between costs of individual healthcare and levels of glycosylated hemoglobin (HbA1c), was performed in a series of annual cross-sectional measurements. RESULTS: The study comprised 1,644 diabetic patients. During the study period the average cost of healthcare per patient increased from $878,000 to more than $1,000,000 Chilean pesos (CLP) during the study period. The percentage of patients with HbA1c levels below 7.0% varied between 43.0% and 54.9%. Costs for patients with HbA1c levels between 7 and 8.9% were 1.3 to 1.5 times greater. For the group of patients with HbA1c levels between 9 and 10.9% the costs increased 1.4 to 1.6 times. For patients with HbA1c levels greater than 11.0%, healthcare costs doubled. CONCLUSIONS: Healthcare expenditure varied according to metabolic control, which is consistent with international findings. This study was limited by its selected population, incomplete information on health expenditures, and the inclusion of only direct costs to the health system. If all patients would achieve metabolic compensation, the yearly savings would be CLP $308,000,000 (or USD $657,000).

Niveles de hemoglobina glicosilada y diferencia en el gasto en salud de pacientes diabéticos: un estudio econométrico / Levels of glycosylated hemoglobin and the difference in the cost of health care for diabetic patients: an econometric study

Background: Complications increase treatment costs of diabetes mellitus (DM). An adequate metabolic control of the disease could reduce these costs. Aim: To evaluate the costs of medical care for a cohort of patients with DM, according to their degree of metabolic compensation. Material and Methods: All diabetic patients attended in a regional hospital from 2005 to 2010 were analyzed. A correlational study between costs of individual healthcare and levels of glycosylated hemoglobin (HbA1c), was performed in a series of annual cross-sectional measurements. Results: The study comprised 1,644 diabetic patients. During the study period the average cost of healthcare per patient increased from $878,000 to more than $1,000,000 Chilean pesos (CLP) during the study period. The percentage of patients with HbA1c levels below 7.0% varied between 43.0% and 54.9%. Costs for patients with HbA1c levels between 7 and 8.9% were 1.3 to 1.5 times greater. For the group of patients with HbA1c levels between 9 and 10.9% the costs increased 1.4 to 1.6 times. For patients with HbA1c levels greater than 11.0%, healthcare costs doubled. Conclusions: Healthcare expenditure varied according to metabolic control, which is consistent with international findings. This study was limited by its selected population, incomplete information on health expenditures, and the inclusion of only direct costs to the health system. If all patients would achieve metabolic compensation, the yearly savings would be CLP $308,000,000 (or USD $657,000).

Dificultades en la prescripción racional de insulina: la percepción de los médicos tratantes de enfermos diabético de atención primaria de salud / Perceived difficulties among primary care physicians for the prescription of insulin for diabetic patients

Background: Type 2 Diabetes Mellitus is not always treated successfully, in part due to the difficulties perceived by the medical community about the use of insulin. Aim: To identify the constraints perceived by primary care physicians (PCPs) in the prescription and use of insulin. Material and Methods: Six PCPs were subjected to a semi-structured interview about self-perceived management difficulties, behaviors and beliefs on the use of insulin among diabetics. According to their responses a questionnaire about the subject was devised and PCPs were invited by e-mail to answer it. Results: There were 88 replies and 48 percent of respondents recognized to have management deficiencies in at least one aspect of insulin prescription. The most common deficiencies were determining the type of insulin and treatment of complications. The perceived difficulties were lack of training (58.0 percent), lack of medical hours (46.6 percent), lack of communication with specialists (46.6 percent), lack of reactive strips for capillary blood glucose determination (43.2 percent) and rotation of doctors (40.9 percent). The most common behaviors towards patients reluctant to use insulin were persuasion (83.0 percent), education and supervisión (63.6 percent) and signature ofan ad-hoc document (38.6 percent). Ninety percent considered that timely use of insulin is more beneficial  than its prescription as a last resort and 94.3 percent did not consider that insulin should be prescribed by a specialist. Conclusions: A significant percentage of physicians do not trust their own knowledge about insulin prescription. These professionals should receive training in not only technical aspects of prescribing insulin, but also in the psychological and persuasión strategies. There is willingness among PCPs to prescribe insulin.