Submitted by Cristiane Shirayama (cristiane.shirayama@fgv.br) on 2011-06-03T15:03:41Z No. of bitstreams: 1 66080100246.pdf: 513399 bytes, checksum: 58504e64a230abc4e45c758f6c0e2d7a (MD5) / Approved for entry into archive by Vera Lúcia Mourão(vera.mourao@fgv.br) on 2011-06-03T16:44:39Z (GMT) No. of bitstreams: 1 66080100246.pdf: 513399 bytes, checksum: 58504e64a230abc4e45c758f6c0e2d7a (MD5) / Approved for entry into archive by Vera Lúcia Mourão(vera.mourao@fgv.br) on 2011-06-03T16:59:26Z (GMT) No. of bitstreams: 1 66080100246.pdf: 513399 bytes, checksum: 58504e64a230abc4e45c758f6c0e2d7a (MD5) / Made available in DSpace on 2011-06-03T18:44:20Z (GMT). No. of bitstreams: 1 66080100246.pdf: 513399 bytes, checksum: 58504e64a230abc4e45c758f6c0e2d7a (MD5) Previous issue date: 2011-01-19 / One of the most important guidelines regarding Sistema Único de Saúde (SUS) is the health services management descentralization which allows decision makers to be closer to local population. On the other hand, one of the arguments against descentralization is that it can imply in considerable scale losses. The main objective of this analysis is to investigate existence of economy of scale in public health segment in Brasil. Some national empirical studies already founded evidences of economies of scale in public services, including the specific case in health segment, like Souza, Cribari-Neto and Stosic (2005) and Mattos et al. (2009). This study seeks to add new evidences to this theme, based on a new investigation that differs from the others in terms of methodology. Initially, an efficiency score (using DEA method – Data envelopment analysis) based on three input variables (health public spending, sewer covering and canalized water supply) and three output variables (infantil mortality, infectious illness hopitalization and health system access rate). After having this score calculated, we analyze the relation between population size, demographic variables and the municipality eficiency to provide health services. To achieve it, it was applied a panel data regression including 537 of 645 municipalities in São Paulo state for the period of 2002-2007, which allowed to consider fixed effects of the them and to control specific characteristics as income, violence, education and others. The results confirm what was concluded before using different methodologies, proving that the size of a municipality population is an important determinant of its efficiency in health area. Finally, possible explanations are investigated to justify the strong impact of scale in the efficiency regarding spending in health. The question we seek to answer is regarding the factors that determine this economy of scale, which can be considered as infra-strutucture expenses (hospital and beds) or expenses in human resources, equipments, materials or medicines. This question is partially analyzed estimating a SUR (Seemingly Unrelated Regressions) in which relevant differences in intensity of different inputs categories usage are different according to population size. / Uma das mais importantes diretrizes do Sistema Único de Saúde (SUS) é a descentralização da gestão dos serviços de saúde, visando uma maior proximidade dos agentes tomadores de decisão com a população local. Contudo, um dos argumentos contrários à descentralização é de que esta pode implicar em consideráveis perdas de escala. Este trabalho tem como objetivo investigar a existência de economias de escala no setor de saúde pública no Brasil. Alguns estudos empíricos nacionais já encontraram evidências de economias de escala na provisão de serviços públicos em geral, incluindo o caso específico do setor de saúde, como os trabalhos de Souza, Cribari-Neto e Stosic (2005) e Mattos et al. (2009). Este estudo busca acrescentar novas evidências a esse tema, a partir de uma nova investigação que difere das anteriores em metodologia. Inicialmente é calculado um score de eficiência (através do método DEA - Data envelopment analysis) com base em três variáveis de insumo (gastos em saúde, cobertura de esgoto e de abastecimento de água encanada) e três variáveis de produto (mortalidade infantil, internação por doenças infecciosas e taxa de acesso ao sistema de saúde). Após o cálculo deste score, analisa-se a relação entre tamanho da população e outras variáveis demográficas e a eficiência dos municípios na provisão de saúde. Para isso foi feita uma regressão usando dados de painel que inclui 537 dos 645 municípios do Estado de São Paulo ao longo do período 2002-2007, o que permite o controle do efeito fixo dos municípios, além do controle de características como renda per capita, violência, educação, entre outros. Os resultados confirmam aqueles já encontrados por outros pesquisadores a partir de outras metodologias, revelando que o tamanho do município é um importante determinante de sua eficiência na área de saúde. Assim sendo, por fim, investigam-se possíveis explicações para o forte impacto da escala na eficiência de gastos em saúde. A questão que surge é a identificação dos fatores que determinam essas economias de escala, que podem vir, por exemplo, dos gastos em infra-estrutura – como quantidade de leitos e estabelecimentos – ou de gastos com recursos humanos, equipamentos, materiais ou remédios. Parte desta questão é analisada ao se estimar um modelo de regressões aparentemente não correlacionadas, no qual se identificam diferenças relevantes na intensidade de utilização de diferentes categorias de insumos de acordo com o tamanho da população.

The Public health insurance system in the Czech Republic was established more than 20 years ago. During this period, the public health insurance system has gone through many transformations. A lot of reform proposals have been submitted with the aim of keeping the increase of healthcare expenses under control but simultaneously not limiting the quality and the accessibility of healthcare. The introduction of the regulatory fees was a part of the healthcare reformation and its purpose was to reduce the demand for healthcare and thus regulate the consumption of health services. Secondarily, the regulatory fees should bring private funds into healthcare system. In the theoretical part of the research, the author describes healthcare systems of several European countries mainly from the point of view of cost sharing by patients. The funding of healthcare in the Czech Republic is then evaluated in more detail. The research characterises all the types of regulatory fees including all the legal changes they have undergone prior to their implementation. The author summarizes the amounts of funds received from the different types of fees which patients have paid since the introduction of regulatory fees in 2012 on the basis of data received from health insurance companies. In the practical part of the research, the author analyses and statistically processes data which were taken from one specific bureau of employee health insurance company. On the basis of this data, the author maps the development of average visits of healthcare institutions per patient in the chosen fields of ambulant care specializations. The author compares the number of average visits in 2007, which is the year before the introduction of regulatory fees, with the number of average visits after the regulations implementation that means during the 2008-2013 period. The aim was to discover whether the fees had any effect on the amount of healthcare services and whether they led to decrease in the number of patients´ visits (at the doctor). The development of the number of patients´ visits was studied in 22 different fields of ambulatory specialization in total. The collected results have been statistically processed using one sample, one-tailed T test. Furthermore, the influence of fees on the healthcare expenses was surveyed in the respective ambulatory fields. In the similar manner as with the patients´ visits, the author compares the average expenses per one patient before the introduction of regulatory fees in 2007 with the average value after the implementation of regulatory fees to the healthcare system. The research offers a comprehensive overview of these issues and can be used as a basic material for further research about regulatory fees and patient cost sharing in healthcare.