Evaluating the 2014 sugar-sweetened beverage tax in Chile: An observational study in urban areas.

BACKGROUND: In October 2014, Chile implemented a tax modification on sugar-sweetened beverages (SSBs) called the Impuesto Adicional a las Bebidas Analcohólicas (IABA). The design of the tax was unique, increasing the tax on soft drinks above 6.25 grams of added sugar per 100 mL and decreasing the tax for those below this threshold. METHODS AND FINDINGS: This study evaluates Chile's SSB tax, which was announced in March 2014 and implemented in October 2014. We used household-level grocery-purchasing data from 2011 to 2015 for 2,836 households living in cities representative of the urban population of Chile. We employed a fixed-effects econometric approach and estimated the before-after change in purchasing of SSBs controlling for seasonality, general time trend, temperature, and economic fluctuations as well as time-invariant household characteristics. Results showed significant changes in purchasing for the statistically preferred model: while there was a barely significant decrease in the volume of all soft drinks, there was a highly significant decrease in the monthly purchased volume of the higher-taxed, sugary soft drinks by 21.6%. The direction of this reduction was robust to different empirical modelling approaches, but the statistical significance and the magnitude of the changes varied considerably. The reduction in soft drink purchasing was most evident amongst higher socioeconomic groups and higher pretax purchasers of sugary soft drinks. There was no systematic, robust pattern in the estimates by household obesity status. After tax implementation, the purchase prices of soft drinks decreased for the items for which the tax rate was reduced, but they remained unchanged for sugary items, for which the tax was increased. However, the purchase prices increased for sugary soft drinks at the time of the policy announcement. The main limitations include a lack of a randomised design, limiting the extent of causal inference possible, and the focus on purchasing data rather than consumption or health outcomes. CONCLUSIONS: The results of subgroup analyses suggest that the policy may have been partially effective, though not necessarily in ways that are likely to reduce socioeconomic inequalities in diet-related health. It remains unclear whether the policy has had a major, overall population-level impact. Additionally, because the present study examined purchasing of soft drinks for only 1 year, a longer-term evaluation-ideally including an assessment of consumption and health impacts-should be conducted in future research. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02926001.

Critical Analysis of Markov Models Used for the Economic Evaluation of Colorectal Cancer Screening: A Systematic Review.

BACKGROUND: The economic evaluation of colorectal cancer screening is challenging because of the need to model the underlying unobservable natural history of the disease. OBJECTIVES: To describe the available Markov models and to critically analyze their main structural assumptions. METHODS: A systematic search was performed in eight relevant databases (MEDLINE, Embase, Econlit, National Health Service Economic Evaluation Database, Health Economic Evaluations Database, Health Technology Assessment database, Cost-Effective Analysis Registry, and European Network of Health Economics Evaluation Databases), identifying 34 models that met the inclusion criteria. A comparative analysis of model structure and parameterization was conducted using two checklists and guidelines for cost-effectiveness screening models. RESULTS: Two modeling techniques were identified. One strategy used a Markov model to reproduce the natural history of the disease and an overlaying model that reproduced the screening process, whereas the other used a single model to represent a screening program. Most of the studies included only adenoma-carcinoma sequences, a few included de novo cancer, and none included the serrated pathway. Parameterization of adenoma dwell time, sojourn time, and surveillance differed between studies, and there was a lack of validation and statistical calibration against local epidemiological data. Most of the studies analyzed failed to perform an adequate literature review and synthesis of diagnostic accuracy properties of the screening tests modeled. CONCLUSIONS: Several strategies to model colorectal cancer screening have been developed, but many challenges remain to adequately represent the natural history of the disease and the screening process. Structural uncertainty analysis could be a useful strategy for understanding the impact of the assumptions of different models on cost-effectiveness results.

[Health technology assessment and its impact on pharmaceutical pricing and reimbursement policies]. / Evaluación de tecnología sanitaria y su impacto en políticas de tarificación y cobertura de medicamentos.

The article conceptualizes the pharmaceutical pricing and reimbursement policies related to financial coverage in the context of health systems. It introduces the pharmaceutical market as an imperfect one, in which appropriate regulation is required. Moreover, the basis that guide the pricing and reimbursement processes are defined and described in order to generate a categorization based on whether they are intended to assess the 'added value' and if the evaluation is based on cost-effectiveness criteria. This framework is used to review different types of these policies applied in the international context, discussing the role of the Health Technology Assessment in these processes. Finally, it briefly discusses the potential role of these types of policies in the Chilean context.

Trends in socioeconomic inequalities in life expectancy and lifespan variation in Chile.

Background: Socioeconomic disparities in life expectancy are well-documented in various contexts, including Chile. However, there is a lack of research examining trends in life expectancy inequalities and lifespan variation over time. Addressing these gaps can provide crucial insights into the dynamics of health inequalities. Methods: This study utilizes data from census records, population surveys, and death certificates to compare the life expectancy and the lifespan variation at age 26 of individuals according to their rank in the distribution of years of education within their own birth cohort. The analysis spans three periods (1991, 2002, and 2017) and focuses on two educational groups: individuals in the first (lowest) quintile and tenth (highest) decile of educational attainment. Changes in life expectancy are disaggregated by major causes of death to elucidate their contributions to overall trends. Results: Consistent with existing literature, our findings confirm that individuals with lower education levels experience lower life expectancy and higher lifespan variation compared to their more educated counterparts. Notably, by 2017, life expectancy for individuals in the lowest quintile of education has caught up with that of the top decile in 1991, albeit with contrasting trends between genders. Among women, the gap has reduced, while it has increased for males. Moreover, lifespan variation decreased (increased) over time for individuals in the tenth decile (first quintile). The leading causes of death that explain the increase in life expectancy in women and men in the tenth decile as well as women in the first quintile are cardiovascular, cancer, respiratory and digestive diseases. In the case of males in the first quintile, few gains have been made in life expectancy resulting from cancer and a negative contribution is associated with digestive conditions. Conclusions: This study underscores persistent socioeconomic disparities in life expectancy in Chile, emphasizing the importance of ongoing monitoring of health inequalities across different demographic segments. The gender-specific and educational gradient trends highlight areas for targeted interventions aimed at reducing health disparities and improving overall population health outcomes. Further research is warranted to delve into specific causes of death driving life expectancy differentials and to inform evidence-based policy interventions.

Effects of a sugar-sweetened beverage tax on prices and affordability of soft drinks in Chile: A time series analysis.

Chile is one of several countries that recently implemented a fiscal policy to reduce soft drink (SD) intake and obesity. In 2014 the government increased the existing ad-valorem tax on high-sugar SD by 5% and decreased by 3% the tax on low-sugar SD, based on a 6.25gr/100 ml sugar threshold. This study aims to evaluate the tax modification passed-on to consumers through prices, and to calculate changes in affordability of SDs. We analysed nationally representative consumer price index data of 41 soft drinks within 6 beverage categories between 2009 and 2016. Price change post-tax implementation was estimated for different categories (carbonates, juices, concentrates, waters and energy-sport drinks), using time-series analyses. In addition, changes in affordability were evaluated by estimating the changes in prices relative to wages. The price of carbonates increased by 5.60% (CI 95% 3.18-8.03%) immediately after the tax was implemented. A sustained increase in the prices of concentrates was observed after the implementation. Unexpectedly, a smaller increase was also seen for the price of bottled water - a category that saw no tax change. There were no effects for juices and energy-sports drinks. There was a reduction in affordability for carbonates, concentrates and waters. Overall, the fiscal policy was effective in increasing prices and there are some signs of reduced affordability. Results varied substantially among categories directly affected by the tax policy. While for carbonates the price increase exceeded the tax change ('over-shifting'), in other categories subject to a tax cut, a price reduction was expected but the opposite occurred. As the effect of the tax on prices differed between categories, the effects of the tax policy on consumption patterns are likely to be mixed. Our findings underline the need to better understand and anticipate price setting behaviour of firms in response to a tax.

Impact of the application of the Value Added Tax to imaging tests on out-of-pocket health expenses of households in Chile.

INTRODUCTION: Out-of-pocket healthcare expense represents a challenge for health systems for it constitutes a barrier to health care, impacting the equality of access to healthcare systems, something particularly important in the Chilean health system. In this context, the Government recently raised the possibility of incorporating a tax on imaging tests, creating debate over its potential consequences. OBJECTIVE: To explore the impact on household out-of-pocket healthcare expense by the implementation of a value added tax to imaging tests in Chile. METHODS: Cross-sectional study using data of household expenditures from the VII Household Budget Survey. Out-of-pocket healthcare expense and catastrophic household expenses are calculated comparing two scenarios, with and without the inclusion of the proposed tax. Analyses are presented by income deciles to explore the differential equality impact. RESULTS: 42.8% of diagnostic test expense on household corresponds to imaging studies. Under a scenario of tax implementation, a relative increase of 1.1% of out-of-pocket expenses and 2.2% of catastrophic household expenses is observed. The groups that suffer the greatest impact are those with lower income levels, concentrating in the first fifth deciles. CONCLUSIONS: We conclude that, although the increase in the average out-of- pocket spending is moderate, this policy may involve a significant increase in the catastrophic expense of the population with the lowest incomes, thereby increasing health inequalities. Considering the challenges of health system financing in Chile, it appears that such fiscal policy would only worsen the possibility of moving towards lower levels of out-of-pocket of household expenses.

INTRODUCCIÓN : Los gastos de bolsillo en salud representan un desafío para los sistemas sanitarios, en tanto suponen una barrera a la atención sanitaria, impactando la equidad de acceso a los sistemas de salud. Esto constituye un problema particularmente importante en el sistema de salud chileno. En este contexto, se ha planteado recientemente por parte del Gobierno la posibilidad de incorporar un impuesto al consumo de los exámenes imagenológicos, despertando debate por sus posibles consecuencias. OBJETIVO: Explorar el impacto en el gasto de bolsillo de los hogares, con la aplicación de un Impuesto al Valor Agregado a los exámenes imagenológicos en Chile. MÉTODOS: Estudio transversal, utilizando datos de la VII Encuesta de Presupuestos Familiares relacionado al gasto de los hogares. Se calculan las medias de gasto de bolsillo en salud y gasto catastrófico de los hogares comparando dos escenarios, con y sin incorporación del impuesto. Se presentan análisis por deciles de ingresos para explorar los impactos de equidad. RESULTADOS: Un 42,8% del gasto en exámenes de los hogares corresponden a estudios imagenológicos. Bajo un escenario de incorporación del impuesto se observa un incremento relativo de un 1,1% del gasto de bolsillo y un 2,2% del gasto catastrófico de los hogares. Los grupos que más impacto sufrirían son aquellos con niveles más bajos de ingresos, concentrándose en los primeros cinco deciles. CONCLUSIONES: Es posible concluir que, si bien el aumento en el gasto de bolsillo promedio es moderado, esta política podría implicar un aumento importante en el gasto catastrófico de la población con menor nivel de ingresos, aumentando por tanto las desigualdades en salud. Dados los desafíos del financiamiento del sistema de salud en Chile, todo indica que una política fiscal de este tipo sólo empeoraría la posibilidad de avanzar hacia menores niveles de gasto de bolsillo de los hogares.

Evaluación de Tecnología Sanitaria y su impacto en políticas de tarificación y cobertura de medicamentos / Health technology assessment and its impact on pharmaceutical pricing and reimbursement policies

The article conceptualizes the pharmaceutical pricing and reimbursement policies related to financial coverage in the context of health systems. It introduces the pharmaceutical market as an imperfect one, in which appropriate regulation is required. Moreover, the basis that guide the pricing and reimbursement processes are defined and described in order to generate a categorization based on whether they are intended to assess the 'added value' and if the evaluation is based on cost-effectiveness criteria. This framework is used to review different types of these policies applied in the international context, discussing the role of the Health Technology Assessment in these processes. Finally, it briefly discusses the potential role of these types of policies in the Chilean context.