The aim of this thesis was to examine the cost-effectiveness of specific advanced home care and home rehabilitation interventions and to improve economic evaluation methods when applied to advanced home care. This included a comparison of two alternative ways of administering oxygen at home to patients with chronic hypoxaemia, as well as a review of scientific evidence on costs and effects of home rehabilitation after stroke. Also included were studies on prominent methodological issues in advanced home care - the redistribution of care efforts among caregivers and costing of informal care efforts. For patients with chronic hypoxaemia, a randomised, controlled trial showed that mobile liquid oxygen was considerably more costly compared to concentrator treatment. However, the treatment effects showed that liquid oxygen had a better impact on patient quality of life. The literature review revealed that the outcomes and costs of home rehabilitation after stroke are equal to those of alternative treatment strategies. Similar results were obtained in a study comparing hospital-based and home-based stroke rehabilitation, which also showed that there is a considerable redistribution of costs between health care providers and social welfare providers. Studies of patients in advanced home care in the county of Östergötland, Sweden, showed that the cost of informal care constitutes a considerable part of the care effort in all costing approaches used. Also, informal care costs were higher among patients who were men, who were younger, who had their own housing and had a cancer diagnosis. This thesis reveals that advanced home care interventions can differ regarding costs as well as effects, and thus comparisons between alternative home care interventions must also be performed. Further, redistribution effects are important to consider in evaluations. The cost of informal care is substantial in advanced home care. These costs must be included in evaluations with a societal perspective or else the comparisons will be biased.

This dissertation examines heterogeneity in the value of a statistical life (henceforth VSL) stemming from employer-provided health insurance (henceforth EHI) and worker sorting. The dissertation consists of three essays. In the first essay (Chapter 2), I investigate the effect of health-driven productivity on the wage compensation for mortality risk, and how EHI influences VSL using the US labor market data. In this chapter I build a framework showing that the level of job risks influences the incentive of employers to provide EHI. The basic notion of the framework is that health insurance is an investment in health and health is a form of general human capital. Employers are willing to invest in employees' health and pay the associated costs as long as they can recoup the costs of health investment. Occupational hazards, however, are harmful to health; productivity gains from health tend to decline as risk increases, resulting in lower health investment made by employers. As a result, the workers in risky jobs have to contribute more to their health investment in the form of lower wages than do workers in safe jobs. This behavioral response pushes down the wage offer curve of the insured in high risk occupations. Consequently, workers with health insurance, on average, accept a lower risk premium, leading to a lower VSL. Empirical findings from this dissertation suggest evidence of heterogeneity in VSL due to health insurance status: the estimated VSL for workers with health insurance is lower than those without one. In the second essay (Chapter 3), I extend the framework of the second chapter into the United Kingdom (the UK) labor market. Different from the US, the UK has universal health care system in which all eligible individuals (almost all the UK citizens) are covered by publicly-provided health care. This chapter also provides evidence that private medical insurance in the universal health care system affects the risk premium. Despite the fact that the UK and the US have different institutional settings in health coverage, findings from the UK are, to some extent, qualitatively similar to the US. A major issue in estimates of VSL is that people are not randomly assigned to jobs. That is, heterogeneous people would sort into jobs based on their preferences on risk and safety-related skills. Thus, failure to account for heterogeneity in both risk preferences and safety-related skills will bias the estimated VSL. In the third essay (Chapter 4), I discuss worker sorting and how it may affect the mortality risk premium. In this chapter, I focus on the role of personality traits in safety-related skill and their influence on worker sorting based on job risk. I use Five-Factor Model of personality or also known as the ‘’Big Five” personality traits. The big 5 personality traits are extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience. In my framework, these personality traits are inputs and the technology of skill formation transforms the traits into safety-related skill.

The expectations of patients have dramatically changed since the introduction of the first public health services more than a decade ago, as have the surrounding conditions a health system has to tackle. The grown health systems of the industrialised countries counter the challenges of an ageing society, technological advancement and chronic disease by a state of constant reform, which has been present for the last few years, without the abolition of the basic principles of affordability, accessibility and solidarity. One solution to answer all these expectations and requirements is so-called "integrated care", a patient-centred model, which propagates better processes, coordination and cooperation between the different service providers and sectors in health care. Based on a comprehensive discussion of the existing theories on health systems analysis, decision making and performance measurement in health as well as the trade-offs emerging therefrom, the first part of this thesis examines the changing conditions and expectations as well as problem areas of organisation and restructuring in health care systems. This analysis serves as a foundation for the introduction of the integrated care concept, an international expert questionnaire on the decision making in integrated care and conclusions on priority setting of decision makers in health. The analysis of the results demonstrates the high value that is placed on a clear political framework and incentives for the promotion of integrated care, as well as the substantive demand for improved communication, coordination and information structures. (author's abstract)

There is a growing realisation from the Australian government that new models of health care will need to be developed to address the disparity of access, increasing demand and escalating cost of traditional means of delivering health care. There is growing evidence showing health care services can be delivered safely and efficiently by email. Despite this body of evidence the clinical utility of email is occurring at a much slower rate than in other business areas. Technological barriers and privacy risks are often cited as cause of the fragmented adoption and utilisation of email-based telemedicine. In addressing these impediments, the service-delivery application needs to be considered. The service-delivery applications used in email-based telemedicine can be divided into two distinct categories. The first is ordinary email applications — such as the commercial products used for personal communication — and the second is where the health care provider undertakes the development of an email application purpose-written to support their telemedicine service. This aim of this research was to develop a decision support model (DSM) to address the complex issues in choosing the service-delivery application most appropriate for an email service. Three areas which would influence a provider’s decision were identified — i) privacy and security ii) economics and ii) quality of service — and investigated. Most emails are sent in plain text across the Internet and pose a privacy risk. Encryption of the email message is used to mitigate the risk. Two means of encryption were investigated: public key infrastructure (PKI) used in conjunction with ordinary email and secure web-mail applications, which require the development of a purpose-written application. Decisive factors in choosing the most appropriate privacy-enhancing technology for an email-based service were identified by a number of means including: technical assessment of encryption models, literature review, survey of users of an email-based telemedicine service and analysis of client applications used in a telemedicine service. This investigation established that correspondent’s perception to privacy risk, email client application support of PKI, risk tolerance to human error and the technical skill are decisive factors in choosing privacy-enhancing technology. The survey respondents considered a privacy breach during email communication was either likely or very unlikely regardless of whether the communication was encrypted or not. Indicating correspondents are unlikely to comply with encryption especially if the technology is cumbersome. Although the population was of a limited demographic, there was a large proliferation (around 87%) of web-mail clients — for example, Hotmail and Gmail — amongst the users of email-based telemedicine services. Web-mail clients cannot be secured with PKI. Hence, assessment of client-email applications used by correspondents in telemedicine will influence the type of privacy-enhancing technology. Technical assessment of privacy-enhancing technology has identified human-error as a risk when using PKI. Secure web-mail obviates human-error. Therefore, tolerance to human-error risk will be decisive in choice of privacy-enhancing technology. PKI has received criticism for being user-unfriendly and requiring technical proficiency to use. This investigation has established the usability of secure web-mail is comparable to ordinary, unencrypted email. Indicating secure communication is feasible when services are not supported by technical expertise. The cost of providing an email-based service is influenced by the service-delivery application. To develop a purpose-written application will cost the heath care provider but staff may be able to work more efficiently because the resultant application contains telemedicine specific functionality that meet the exact requirements of the service. Staff resources to run an email-based telemedicine service using ordinary email were compared to staff resources to run the same service using a purpose-written application. The purpose-written application afforded a reduction of 3% in time for clinical staff. Ancillary staff savings were more pronounced with a 33% reduction in administrative staff time and a 21% reduction in supervisory staff time. A cost-minimisation analysis established at a workload of up to 5000 email consultations per annum it is more economical to the run the service with ordinary email. For higher workload volumes it is cheaper to run the service with a purpose-written application. The threshold of 5000 emails consultations is the point at which the higher initial development cost of a purpose- written application are offset by staff efficiencies. A sensitivity analysis established the most influential factor in the economic model was workload volume — development costs and variable costs had little influence on the threshold. Response time was established as a quality of service metric after investigation demonstrated increases in response time were strongly correlated with a decrease in utilisation rate. The response time to maximise the utilisation rate was 32h or less. Pre- and post- studies demonstrated a purpose-written application can reduce response times. Telemedicine specific functionality in a purpose-written application was also investigated. Conditions for a purpose-written application — for example, use of multi-disciplinary staff, a priority service model and continuum of care over multiple email exchanges — to be efficacious at reducing response times were established. The conditions identified in the privacy and security, economic and quality of service investigation were amalgamated into a DSM. The DSM was retrospectively tested by comparing the output of the model to a gold-standard of the actual service-delivery used by a number of subject organisations. When used to identify services that required a purpose-written application the DSM was 92% sensitive and 92% specific. The model was also tested prospectively and demonstrated 85% concordance from testers in the choosing the service-delivery application. Testing the DSM identified strengths for both ordinary email and purpose-written applications under different circumstances — indicating both are valid alternatives for email-based telemedicine. The individual requirements of a telemedicine service — for example, privacy requirements, participants, the workload volume, number of staff disciplines, mode of service — will dictate the choice of the most appropriate service-delivery application. Informed decision on when and why to use a service-delivery application has implications for the successful delivery of email-based telemedicine services because the choice of service-delivery application will affect: - The staff resources needed to run the service; - The capital cost of implementing a service; - The operating costs of running a service; - The response times to client emails which in turn, influences the utilisation of the service; - The privacy-enhancing technology which in turn, influences the usability and compliance to legislative and statutory requirements.

Esta dissertação é composta por dois ensaios sobre economia da saúde. O primeiro ensaio tem como objetivo analisar o ambiente regulatório no mercado de medicamentos para doenças raras. Essas doenças são caracterizadas por afetar um pequeno número de indivíduos em uma determinada população e por serem crônicas, progressivas, degenerativas, 80% são de origem genética, 50% afetam as crianças, das quais 30% morrem antes dos 5 anos de idade. Elas representam risco de morte e um custo socioeconômico alto para o paciente e sua família. Devido à raridade, a indústria farmacêutica tem não demonstra interesse em desenvolver novos medicamentos órfãos. Apesar de individualmente raras, estima-se que o número de casos de alcançar 420 a 560 milhões de pessoas. Para a referida análise foi utilizado o modelo econômico desenvolvido por DeBrock (1985), que consiste na determinação simultânea de esforço de inovação e extensão de patentes, estabelecendo a trajetória ótima de proteção como resultado de um jogo não cooperativo entre o regulador e a empresa inovadora. Foram identificados individualmente os principais incentivos e instrumentos de regulação econômica. Eles são compostos por assistência à protocolos, procedimento centralizado de análise, reduções de taxas, o acesso de pesquisa financiado e exclusividade de mercado. Conclui-se que o instrumento regulatório mais importante foi a exclusividade de mercado, pois garante lucros extraordinários para a empresa inovadora, tornando o desenvolvimento de novas drogas tornou-se economicamente viável. No entanto, ressalta-se que todos os mecanismos tem um papel importante no sistema de incentivos e que cada um deles deve ser considerado para o desenvolvimento de políticas públicas para doenças raras. O segundo ensaio tem como objetivo medir o impacto do Diabete Melito nos rendimentos dos trabalhadores brasileiros no ano de 2008. Essa doença é caracterizada pelo elevado nível de glicose no sangue, problema que pode desencadear desencadeia má cicatrização, ataque cardíaco, acidente vascular cerebral, insuficiência renal, problemas de visão e amputação de membros. Dados do Ministério da Saúde indicam que, no Brasil, em 2010, havia cerca de 10 milhões de casos da doença, sendo a quarta principal causa de morte no país. Dados da WHO estimam que a prevalência da doença no Brasil é de 10,2% da população, cerca de 20 milhões de pessoas. A hipótese a ser testada é que o estado de saúde interfere nos rendimentos por meio de três mecanismos distintos: (i) na decisão de participar no mercado de trabalho, mensurado por meio de um Probit binário, (ii) na quantidade de horas trabalhadas e (iii) a produtividade por hora, ambos mensurados por meio do método de dois estágios de Heckman. Cada modelo é estimado separadamente para indivíduos com e sem doenças, sendo tomada a diferença do valor esperado de ambos para capturar o efeito contrafactual. Os resultados obtidos indicaram a existência de perdas progressivas, que incidem com maior intensidade entre a população feminina e que, no agregado, podem chegar ao valor de R$ 8.064.408.441.99 (USD 3.450.709.518,02 e EUR 2.490.436.905,56), correspondendo a cerca de 0,54% dos rendimentos totais e 0,20% do PIB do referido ano. Concluiu-se que o Diabete Melito gera perdas significativas na renda dos trabalhadores brasileiros, especialmente em relação à sua participação no mercado de trabalho. Os resultados indicam que as políticas públicas devem ser direcionadas para a prevenção da doença, uma vez que o desenvolvimento de comorbidades amplifica o efeito de perdas. Por fim, visando a manter a inter-relação entre os temas e a estabelecer a unidade do trabalho, foram abordadas na última seção as conclusões a respeito da dissertação. / This dissertation consists of two essays on health economics. The aim of the first essay is to analyze the regulatory environment for medicinal products for rare diseases. These diseases are characterized by to affect a small number of individuals in a given population and to be chronic, progressive, degenerative, 80% are genetic in origin, 50% affect children, of which 30% die before the age of 5. They represent death risk and a high socioeconomic cost to the patient and his family. Due to the rarity, pharmaceutical industry has not shown interest in developing new orphan drugs. Although individually rare, estimatives show that the number of cases to reach 420 million to 560 million people. For this analysis the economic model developed by DeBrock (1985), which consists of the simultaneous determination of innovation effort and extension of patents, establishing the optimal path protection as a result of a non-cooperative game between the regulator and the innovator was used. The main incentives and instruments of economic regulation were individually identified. They are protocols assistance, centralized analysis procedure, fee reductions, access to funded research and market exclusivity. We conclude that the most important regulatory tool was market exclusivity, because it ensures extraordinary profits for the innovator, making the development of new drugs become economically viable. However, it is noteworthy that all the mechanisms have an important role in the incentive system and that each of them should be considered for the development of public policies for rare diseases. The second essay aims to measure the impact of diabetes mellitus on the income of Brazilian workers in 2008. The main disease characteristic is high blood glucose, a problem that can trigger scarring troubles, heart attack, stroke, failure kidney, vision problems and limbs amputation. Ministry of Health data indicate that, in Brazil, in 2010, there were about 10 million cases of the disease, making it the fourth leading cause of death in the country. WHO data estimate that the disease prevalence is 10.2% of the Brazilian population, about 20 million people. The hypothesis to be tested is that the health status interfere in worker income through three distinct mechanisms: (i) in the decision to participate in the labor market, measured by means of a binary Probit, (ii) in the amount of hours worked and (iii) in the productivity per hour, both measured by the Heckman two-stage method. Each model is estimated separately for individuals with and without disease, and taking the difference of the expected value of both to capture the counterfactual effect. The results indicated the existence of progressive losses, which focus more strongly among women and that, in the aggregate, may reach R$ 8.064.408.441.99 (3,450,709,518.02 USD and EUR 2,490,436,905, 56), corresponding to about 0.54% of the total income and 0.20% of GDP in that year. It was concluded that diabetes mellitus causes significant losses in Brazilian workers income, especially in relation to their participation in the labor market. The results indicate that public policies should be directed to the prevention of disease, since the development of comorbidities amplifies the losses effect. Finally, to keep the inter-relationship between the issues and to establish the unity of the work, have been addressed in the last section the conclusions regarding the dissertation.

Contexto: O diabetes mellitus (DM) é uma causa importante de morbimortalidade nas sociedades ocidentais devido à carga de sofrimento, incapacidade, perda de produtividade e morte prematura que provoca. No Brasil, seu impacto econômico é desconhecido. Objetivos: Dimensionar a participação do DM nas hospitalizações da rede pública brasileira (1999-2001), colaborando na avaliação dos custos diretos. Especificamente, analisar as hospitalizações (327.800) e os óbitos hospitalares (17.760) por DM como diagnóstico principal (CID-10 E10-E14 e procedimento realizado) e estimar as hospitalizações atribuíveis ao DM, incluindo as anteriores e aquelas por complicações crônicas (CC) e condições médicas gerais (CMG). Métodos: A partir de dados do Sistema de Informação Hospitalar do Sistema Único de Saúde (SIH/SUS) (37 milhões de hospitalizações), foram calculados indicadores por região de residência do paciente e sexo (ajustados por idade pelo método direto, com intervalos de confiança de 95%), faixas etárias, médias de permanência e de gastos por internação e populacional em US$. Realizou-se regressão logística múltipla para o desfecho óbito. As prevalências de DM foram combinadas aos riscos relativos de hospitalização por CC e CMG (metodologia do risco atribuível) e somadas às internações por DM como diagnóstico principal. Utilizou-se análise de sensibilidade para diferentes prevalências e riscos relativos. Resultados: Os coeficientes de hospitalizações e de óbitos hospitalares e a letalidade por DM como diagnóstico principal atingiram respectivamente 6,4/104hab., 34,9/106hab. e 5,4%. As mulheres apresentaram os coeficientes mais elevados, porém os homens predominaram na letalidade em todas as regiões. O gasto médio (US$ 150,59) diferiu significativamente entre as internações com e sem óbito, mas a média de permanência (6,4 dias) foi semelhante. O gasto populacional equivaleu a US$ 969,09/104hab. As razões de chances de óbito foram maiores para homens, pacientes ≥75 anos, e habitantes das regiões Nordeste e Sudeste. As hospitalizações atribuíveis ao DM foram estimadas em 836,3 mil/ano (49,3/104hab.), atingindo US$ 243,9 milhões/ano (US$ 14,4 mil/104hab.). DM como diagnóstico principal (13,1%), CC (41,5%) e CMG (45,4%) responderam por 6,7%, 51,4% e 41,9% respectivamente dos gastos. O valor médio das internações atribuíveis (US$ 292) situou-se 36% acima das não-atribuíveis. As doenças vasculares periféricas apresentaram a maior diferença no valor médio entre hospitalizações atribuíveis e não-atribuíveis (24%), porém as cardiovasculares destacaram-se em quantidade (27%) e envolveram os maiores gastos (37%). Os homens internaram menos (48%) que as mulheres, porém com gasto total maior (53%). As internações de pacientes entre 45-64 anos constituíram o maior grupo (45%) e gastos (48%) enquanto os pacientes com ≥75, os maiores coeficientes de hospitalização (350/104hab.) e de despesa (US$ 93,4 mil/104hab.). As regiões mais desenvolvidas gastaram o dobro (/104hab.) em relação às demais. Considerações Finais e Recomendações: As configurações no consumo de serviços hospitalares foram semelhantes às de países mais desenvolvidos, com importantes desigualdades regionais e de sexo. O gasto governamental exclusivamente com hospitalizações atribuíveis ao DM foi expressivo (2,2% do orçamento do Ministério da Saúde). A ampliação de atividades preventivas poderia diminuir a incidência do DM, reduzir a necessidade de internações, minimizar as complicações e minorar a severidade de outras condições médicas mais gerais. / Background: Diabetes mellitus (DM) is one of the main causes of morbi/mortality in western societies due to the burden of suffering, disabilities, loss of productivity and premature death that encompasses. Its economic impact is unknown in Brazil. Objectives: To dimension the share of DM hospitalizations on the Brazilian national health system (1999-2001), helping on evaluating direct costs. Specifically, to analyze hospitalizations (327.800) and hospitalization deaths (17.760) caused by DM as first-listed diagnosis (ICD-10 E10-E14 and procedure done) and to estimate the magnitude of DM attributable hospitalizations, including DM itself, chronic complications (CC) and general medical conditions (GMC). Methods: Data from the Hospital Information System of the National Health System (SIH/SUS) (37 millions of hospitalizations). Indicators were calculated by residence region of the patients and sex (adjusted by direct method for age with 95% confidence intervals), age intervals, average length of stay and expenditure by admission and population in US$. Multiple logistic regression was performed for death as outcome. Combinations of DM prevalence and hospitalization relative risks for CC and GMC were added to DM first-listed hospitalizations (attributable risk methodology). Sensitivity analyze was used for different prevalences and relative risks. Results: Hospitalizations and hospitalization deaths coefficients and lethality by DM as first-listed diagnosis were 6.4/104inhab., 34.9/106inhab. and 5.4% respectively. Coefficients were higher for women, although lethality was for men in every five region. Average expenditure (US$150,59) differed significantly between those with/without death but presented equal average length of stay (6.4). Population expenditure was US$ 969.09/104inhab. Odds-ratio for dying were larger for men, patients 75 yrs, and inhabitants of northeast and southeast. Hospitalizations attributable to DM were estimated at 836.3 thousand/year (49.3/104inhab.) reaching US$ 243.9 millions/year (US$ 14.4 thousand/104inhab.). DM as fist-list diagnosis (13.1%), CC (41.5%) and GMC (45.4%) depicted 6.7%, 51.4% e 41.9% respectively of annual expenditures. Average value of attributable hospitalizations (US$ 292) was 36% higher than non-attributable. Peripheral vascular diseases posed the largest excess based on average values (24%) although cardiovascular ones represented the major quantity (27%) and expenditure group (37%). Men were less admitted (48%) than women, but incurred more expenditure (53%). People 45-64 years old consisted the largest (45%) and most expensive (48%) group while 75+ generated the highest coefficients of hospitalization (350/104inhab.) and expenditure (US$ 93.4 thousands/104inhab.). Most developed regions accounted for nearly twice expenses than other regions. Conclusions and Recommendations: Patterns of hospitalization were similar to those most developed countries. Important regional and gender inequalities did exist. Governmental expenditures related exclusively to DM attributable hospitalizations was meaningful (2.2% of the budget of the Ministry oh Health). Broadening preventive health care actions could diminish the incidence of DM, reduce the need for hospitalizations, minimize complications and minors the severity of general medical conditions.

A esclerose múltipla (EM) é considerada doença rara no país, porém tem um grande impacto econômico na sociedade, pois é uma das causas mais importantes de incapacidade em adultos jovens. A doença manifesta-se através de surtos, ou seja, pioras neurológicas agudas, com sintomas instalando-se em horas ou poucos dias. O tratamento do surto é altamente eficaz, podendo reverter o déficit neurológico estabelecido. A única forma regulamentada de tratamento é através da internação em hospital, porém poderia ser realizado em regime de hospital-dia que, contudo, não é previsto pelo Sistema Único de Saúde. Este é um estudo de custo-minimização, desenvolvido com o objetivo de comparar os custos do tratamento do surto de EM à base de corticóide, em regime de internação e regime de hospital-dia, com o objetivo de confirmar a economia deste último. Verificaram-se todos os materiais, medicamentos e profissionais necessários ao tratamento de pulsoterapia com metilprednisolona em pacientes com EM. Esta lista foi orçada tomando-se como referência os valores praticados pelo Hospital de Clínicas de Porto Alegre em sua última compra. Além disto, os valores salariais foram baseados no piso salarial das categorias de profissionais envolvidos no tratamento. Idealizou-se um hospital-dia com 12 leitos, respeitando todas as recomendações do Ministério da Saúde. Os custos do tratamento completo em regime de internação e em hospital-dia foram respectivamente R$ 564,23 e R$ 172,41 - uma redução absoluta de R$ 391,82 e relativa de 69,44%. O levantamento do número de Autorizações de Internação Hospitalar (AIHs) para tratamento de surto de esclerose múltipla em todo o país foi de 10.157 no período de 2002 a 2006. Considerando todo este período, o número de diárias hospitalares (pacientes-dia) que poderiam ter estado disponíveis para ocupação por outras patologias foi de 93.816. Concluiu-se que o tratamento do surto da esclerose múltipla em hospital-dia é bem mais econômico que o regime de internação, promovendo uma potencial relevante economia à sociedade, permitindo melhor utilização dos leitos hospitalares. / Multiple sclerosis is considered a rare disease in Brazil; however has a great economical impact in our society, and is known as one of the most important causes of disability among young adults. Multiple sclerosis is characterized by neurological relapses, occurring in a period of hours or a few days. The treatment of relapses with corticosteroids in high doses is highly effective in relieving the neurological deficit. It can be administered as inpatient or outpatient basis, the last not authorized by the Brazilian Public Health System. This is a cost-minimization analysis in order to compare the costs of this treatment as inpatient to outpatient. We checked the costs of all materials, medications and professionals necessary for this procedure, based in the reference prices practiced at Hospital de Clínicas de Porto Alegre. Moreover, the costs of the professionals involved in this procedure were based on those practiced and suggested by the health labor union in our district. We planned an ideal day-hospital for the outpatient basis treatment, characterized by “twelve simultaneous armchairs”, following all the recommendations from the Brazilian Ministry of Health. The estimated costs of treatment were R$ 564,23 and R$ 172,41, for inpatient and outpatient basis, respectively. This represented a saving of R$ 391,82, meaning a relative reduction of 69,44% in total costs. The number of inpatient basis treatment from 2002 through 2006 in Brazil as a whole, was 10.157. If those patients could have been submitted to an outpatient basis treatment, it would have saved of 93.816 hospital beds. The treatment of relapses of multiple sclerosis as outpatient basis is less expensive than inpatient treatment, promoting an economy for the society, and allowing a better and more rational utilization of hospital beds.

O objetivo principal desta dissertação foi analisar a relação existente entre os eventos de poluição, causados por CO, PM10, NO2, SO2 e O3 – incluindo as variáveis meteorológicas, tais como temperatura e umidade relativa, dentre outras – e seus efeitos sobre a saúde humana. Conceitos microeconômicos foram usados, no intuito de discutir-se, principalmente sobre o papel do Estado/mercados na problemática ambiental, quais sejam: bens públicos, externalidades, ótimo de Pareto, taxas pigouvianas e o teorema de Coase. Estes conceitos permitiram fazer a ponte entre dois capítulos essenciais para a estruturação da dissertação, isto é, economia da saúde e a economia do meio ambiente, respectivamente, ao investigar a existência de causa/efeito entre poluição e saúde. Fizemos uma breve introdução sobre o que é a atmosfera, para depois investigarmos como tais poluentes agem sobre o meio ambiente, e quais as suas relações com o fenômeno das mudanças climáticas e a chuva ácida. No capítulo sobre a economia da saúde fizemos uma perspectiva história e breve discussão sobre os principais instrumentos da avaliação econômica, quais sejam: custo-benefício, custoefetividade, custo-utilidade e custo-minimização. O debate entre a economia da saúde e economia do meio ambiente permitiu que fizéssemos a introdução de um novo conceito, o que chamamos de Economia da Saúde Ambiental, no qual discutimos sobre os padrões e índices de qualidade ambiental, e alguns estudos que investigam a relação entre poluição e doenças respiratórias. Desta forma, elaborou-se um problema que englobasse tanto as dimensões da economia da saúde, quanto às dimensões da economia do meio ambiente e um modelo de regressão binomial negativo que permitiu observar a correlação existente entre poluição e saúde humana. / The main objective of this thesis was to analyze the relationship between pollution events caused by CO, PM10, NO2, SO2, and O3 - including meteorological variables such as temperature and humidity, among others - and their effects on human health. Microeconomic concepts were used in order to discuss mainly about the role of State/markets in environmental issues, namely: public goods, externalities, Pareto optimality, Pigouvian rates and Coase´s theorem. These concepts have enabled a bridge between two key chapters in the structuring of the thesis, ie, health economics and environment economics, respectively, to investigate the existence of cause/effect relationship between pollution and health. We made a brief introduction about what is the atmosphere, and then investigate how such pollutants act on the environment and its relationship with the phenomenon of climate change and acid rain. In the chapter on health economics we did a historical and a brief discussion of the main tools of economic evaluation, namely: cost-benefit, cost-effectiveness, cost-utility and costminimization. The debate between health economics and environment economics allowed us to introduce a new concept, what we call Environmental Health Economics, where we discussed the standards and levels of environmental quality, and some studies investigating the relationship between pollution and respiratory diseases. Thus we, produced a problem that encompasses both dimensions of health economics, about the size of the economy of the environment, and a model of negative binomial regression that allowed us to observe the correlation between pollution and human health.

Esta dissertação é composta por dois ensaios sobre economia da saúde. O primeiro ensaio tem como objetivo analisar o ambiente regulatório no mercado de medicamentos para doenças raras. Essas doenças são caracterizadas por afetar um pequeno número de indivíduos em uma determinada população e por serem crônicas, progressivas, degenerativas, 80% são de origem genética, 50% afetam as crianças, das quais 30% morrem antes dos 5 anos de idade. Elas representam risco de morte e um custo socioeconômico alto para o paciente e sua família. Devido à raridade, a indústria farmacêutica tem não demonstra interesse em desenvolver novos medicamentos órfãos. Apesar de individualmente raras, estima-se que o número de casos de alcançar 420 a 560 milhões de pessoas. Para a referida análise foi utilizado o modelo econômico desenvolvido por DeBrock (1985), que consiste na determinação simultânea de esforço de inovação e extensão de patentes, estabelecendo a trajetória ótima de proteção como resultado de um jogo não cooperativo entre o regulador e a empresa inovadora. Foram identificados individualmente os principais incentivos e instrumentos de regulação econômica. Eles são compostos por assistência à protocolos, procedimento centralizado de análise, reduções de taxas, o acesso de pesquisa financiado e exclusividade de mercado. Conclui-se que o instrumento regulatório mais importante foi a exclusividade de mercado, pois garante lucros extraordinários para a empresa inovadora, tornando o desenvolvimento de novas drogas tornou-se economicamente viável. No entanto, ressalta-se que todos os mecanismos tem um papel importante no sistema de incentivos e que cada um deles deve ser considerado para o desenvolvimento de políticas públicas para doenças raras. O segundo ensaio tem como objetivo medir o impacto do Diabete Melito nos rendimentos dos trabalhadores brasileiros no ano de 2008. Essa doença é caracterizada pelo elevado nível de glicose no sangue, problema que pode desencadear desencadeia má cicatrização, ataque cardíaco, acidente vascular cerebral, insuficiência renal, problemas de visão e amputação de membros. Dados do Ministério da Saúde indicam que, no Brasil, em 2010, havia cerca de 10 milhões de casos da doença, sendo a quarta principal causa de morte no país. Dados da WHO estimam que a prevalência da doença no Brasil é de 10,2% da população, cerca de 20 milhões de pessoas. A hipótese a ser testada é que o estado de saúde interfere nos rendimentos por meio de três mecanismos distintos: (i) na decisão de participar no mercado de trabalho, mensurado por meio de um Probit binário, (ii) na quantidade de horas trabalhadas e (iii) a produtividade por hora, ambos mensurados por meio do método de dois estágios de Heckman. Cada modelo é estimado separadamente para indivíduos com e sem doenças, sendo tomada a diferença do valor esperado de ambos para capturar o efeito contrafactual. Os resultados obtidos indicaram a existência de perdas progressivas, que incidem com maior intensidade entre a população feminina e que, no agregado, podem chegar ao valor de R$ 8.064.408.441.99 (USD 3.450.709.518,02 e EUR 2.490.436.905,56), correspondendo a cerca de 0,54% dos rendimentos totais e 0,20% do PIB do referido ano. Concluiu-se que o Diabete Melito gera perdas significativas na renda dos trabalhadores brasileiros, especialmente em relação à sua participação no mercado de trabalho. Os resultados indicam que as políticas públicas devem ser direcionadas para a prevenção da doença, uma vez que o desenvolvimento de comorbidades amplifica o efeito de perdas. Por fim, visando a manter a inter-relação entre os temas e a estabelecer a unidade do trabalho, foram abordadas na última seção as conclusões a respeito da dissertação. / This dissertation consists of two essays on health economics. The aim of the first essay is to analyze the regulatory environment for medicinal products for rare diseases. These diseases are characterized by to affect a small number of individuals in a given population and to be chronic, progressive, degenerative, 80% are genetic in origin, 50% affect children, of which 30% die before the age of 5. They represent death risk and a high socioeconomic cost to the patient and his family. Due to the rarity, pharmaceutical industry has not shown interest in developing new orphan drugs. Although individually rare, estimatives show that the number of cases to reach 420 million to 560 million people. For this analysis the economic model developed by DeBrock (1985), which consists of the simultaneous determination of innovation effort and extension of patents, establishing the optimal path protection as a result of a non-cooperative game between the regulator and the innovator was used. The main incentives and instruments of economic regulation were individually identified. They are protocols assistance, centralized analysis procedure, fee reductions, access to funded research and market exclusivity. We conclude that the most important regulatory tool was market exclusivity, because it ensures extraordinary profits for the innovator, making the development of new drugs become economically viable. However, it is noteworthy that all the mechanisms have an important role in the incentive system and that each of them should be considered for the development of public policies for rare diseases. The second essay aims to measure the impact of diabetes mellitus on the income of Brazilian workers in 2008. The main disease characteristic is high blood glucose, a problem that can trigger scarring troubles, heart attack, stroke, failure kidney, vision problems and limbs amputation. Ministry of Health data indicate that, in Brazil, in 2010, there were about 10 million cases of the disease, making it the fourth leading cause of death in the country. WHO data estimate that the disease prevalence is 10.2% of the Brazilian population, about 20 million people. The hypothesis to be tested is that the health status interfere in worker income through three distinct mechanisms: (i) in the decision to participate in the labor market, measured by means of a binary Probit, (ii) in the amount of hours worked and (iii) in the productivity per hour, both measured by the Heckman two-stage method. Each model is estimated separately for individuals with and without disease, and taking the difference of the expected value of both to capture the counterfactual effect. The results indicated the existence of progressive losses, which focus more strongly among women and that, in the aggregate, may reach R$ 8.064.408.441.99 (3,450,709,518.02 USD and EUR 2,490,436,905, 56), corresponding to about 0.54% of the total income and 0.20% of GDP in that year. It was concluded that diabetes mellitus causes significant losses in Brazilian workers income, especially in relation to their participation in the labor market. The results indicate that public policies should be directed to the prevention of disease, since the development of comorbidities amplifies the losses effect. Finally, to keep the inter-relationship between the issues and to establish the unity of the work, have been addressed in the last section the conclusions regarding the dissertation.

Trata-se de um estudo de Avaliação Econômica Parcial cujo objeto é os custos diretos do protocolo assistencial da Casa de Parto David Capistrano Filho/RJ. O objetivo geral é realizar analise dos custos diretos assistenciais destinados ao ciclo gravídico puerperal na Casa de Parto David Capistrano Filho (CPDCF), situada no município do Rio de Janeiro. Os objetivos específicos deste estudo são: estimar o tipo e a quantidade dos recursos consumidos na execução do cuidado ao ciclo gravídico puerperal de acordo com o protocolo assistencial da CPDCF; analisar os custos diretos relacionados ao protocolo assistencial da CPDCF; comparar os custos avaliados no período da pesquisa ao orçamento municipal destinado a assistência das gestantes de baixo risco no mesmo período. O método utilizado foi a Avaliação de Economia em Saúde, a perspectiva adotada foi o Sistema Único de Saúde (SUS) como órgão gestor, foram avaliados os prontuário das gestantes que realizaram o pré-natal na CPDCF no ano de 2010, excluindo destes as que não pariram na unidade, computando um total de 161 prontuários. Na análise foi realizada a descrição dos custos diretos envolvidos na assistência ao ciclo gravídico puerperal, para isso, foram relacionados e contados os recursos utilizados, definidos como unidades de custo, para a assistência na CPDCF durante o pré-natal, trabalho de parto/parto e pós-parto, e posteriormente esses recursos foram valorados de acordo com as tabelas do Sistema de Gerência da Tabela de Procedimentos (SIGTAP), Medicamentos, Próteses e Materiais Especiais do Sistema Único de Saúde/Ministério da Saúde do Banco de Preços em Saúde (BPS) e da Secretaria Municipal de Saúde Defesa Civil/Rio de Janeiro (SMSDC/RJ). Os resultados apontaram que o custo do pré-natal por gestante foi de R$ 271,91, com prevalência de custos para os exames realizados no pré-natal. Em relação ao trabalho de parto e parto, os custos foram de R$ 352,50 por gestante, neste item os maiores custos foram com os recursos humanos. A pesquisa demonstrou que a CPDCF apresentou menor valor que o orçamento municipal destinado para o parto de acordo com a tabela do SIGTAP (R$ 443,40 a R$ 475,16). Apesar desses dados, e de acordo com o relato das diretoras, a CPDCF é ociosa, e esta influência pode ser negativa para os custos do parto. Em relação ao pós-parto foi avaliado o custo por binômio com uma média de custo de R$ 269,94, os maiores custos de pós-parto foram com os recursos humanos. O custo geral da assistência na CPDCF foi de R$ 894,36 por gestante, desse valor, 39,42% correspondeu aos custos com o parto, 30,40% correspondeu ao custo com o pré-natal e 30,18% com a assistência pós-natal. Para afirmar a eficiência e eficácia das ações na CPDCF, é preciso a realização de uma avaliação de economia em saúde completa; o trabalho de parto/parto foram os que mais representaram os custos; o custo do parto é menor que o valor orçado para o parto de baixo risco, mas medidas de ação sobre a ociosidade são necessárias, pois esta pode influenciar nos custos do parto. / This is a partial Economic Evaluation which object is the direct costs of care protocol of the Casa de Parto David Capistrano Filho / RJ. The overall goal is to perform analysis of the direct care costs of care for the pregnancy and childbirth in the Casa de Parto David Capistrano Filho (CPDCF), located in the municipality of Rio de Janeiro. The specific objectives of this study are: to estimate the type and amount of resources consumed in the implementation of care in pregnancy, childbirth and postpartum in accordance with the CPDCF protocol; analyze the direct costs related to the CPDCF protocol; compare costs assessed during the search the municipal budget for the assistance of low risk pregnant women in the same period. The method used was the Assessment of Health Economics, the adopted perspective was the Brazilian Public Health System as a managing agency, the medical records of pregnant women who underwent prenatal CPDCF in the year 2010 were evaleuted, excluding those who did not deliver at the unit, reaching a total of 161 records. The analysis was performed to describe the direct costs involved in pregnancy, childbirth and postpartum care, to that, the resources used were counted and assessed, defined as cost units for assistance in CPDCF during the prenatal, labor / delivery and postpartum, and then these resources were valued in accordance to the tables in the Table Management System Procedures, Drugs, Materials Prosthetics and Special Health System / Department of Health, Bank of Prices in Health and the Municipal Civil Defense Health / Rio de Janeiro. The results pointed that the cost of prenatal care for pregnant women was R$ 271.91, with a prevalence of costs for exams done along prenatal. In relation to labor and delivery costs were R$ 352.50 per pregnant woman, the highest costs associated with childbirth were human resources. The research demonstrated that CPDCF showed a lower value than the municipal budget allocated for delivery according to the Table Management System Procedures, Drugs, Materials Prosthetics and Special Health System / Department of Health (R$ 443.40 to R $ 475.16). Despite these data, and in accordance with the report of the directors, the CPDCF is idle, and this influence can be negative for the cost of delivery. Regarding postpartum the binomial cost was assessed at an average cost of R$ 269.94, the highest costs with postpartum were human resources. The overall cost of care in CPDCF was R$ 894.36 per pregnant woman, from that amount, 39.42% corresponded to the cost of labor, 30.40% corresponded to the cost prenatal and 30.18% with the postpartum care. To assert the efficiency and effectiveness of actions in CPDCF is necessary to carry out an economic assessment of the overall health. Labor / delivery were the most extensive costs. The cost of labor is less than the amount budgeted for low risk delivery, but action measures are necessary on idleness, as this can influence the cost of delivery.