La présente thèse, organisée en trois volets, poursuivait trois objectifs : i) Estimer les coûts médicaux directs du traitement du DT2 dans 4 pays d’Afrique subsaharienne et dans le cas du Mali, rapprocher ces coûts médicaux directs estimés aux dépenses effectives des patients diabétiques ; ii) Examiner le coût-efficacité des interventions de prévention basées sur la modification du mode de vie chez les sujets à haut risque du DT2; iii) Cerner la perception et les attitudes des acteurs de la santé sur les outils de plaidoyer développés dans le cadre du projet DFN et leur potentiel d’impact sur les décideurs. Dans le premier volet, il s’est agi d’estimer les coûts du DT2 et de ses complications au moyen d’un calculateur et de le mettre à l’épreuve au Bénin, au Burkina- Faso, en Guinée et au Mali. Les composantes de soins pour le DT2 et ses complications avaient été définies au préalable par une équipe de spécialistes, sur la base de leur expérience clinique et des lignes directrices existantes. Les prix ont été relevés dans deux structures hospitalières du secteur public et deux du privé. Les coûts ont été estimés sur une base annuelle pour le DT2 avec ou sans complications chroniques puis par épisode pour les complications aiguës. Dans le cas du Mali, ces coûts ont été rapprochés des dépenses de patients diabétiques d’après une précédente enquête transversale dans ce pays. Cette enquête portait sur 500 sujets diabétiques sélectionnés au hasard dans les registres. Les dépenses pour les soins des trois derniers mois avaient été relevées. Les déterminants des dépenses ont été explorés. Il ressort des différences de coûts dans le même secteur puis entre le secteur privé et le secteur public. Le coût minimum du traitement du DT2 sans complications dans le secteur public représentait entre 21% et 34% de PIB par habitant, puis entre 26% - 47% en présence de la rétinopathie et au-delà de 70% pour la néphropathie, la complication chronique la plus coûteuse. Les dépenses des sujets diabétiques enquêtés au Mali, étaient en deçà des coûts minima estimatifs des différentes complications excepté la rétinopathie et le DT2 sans complication. Les facteurs comme l’insulinothérapie, le nombre de complications et la résidence dans la capitale étaient significativement associés aux dépenses plus élevées des patients. Dans le second volet, la revue systématique a consisté à recenser les études d’évaluation économique des interventions de prévention du DT2 dans des groupes à haut risque par l’alimentation et/ou l’activité physique. Les interventions de contrôle de l’obésité comme facteur de risque majeur de DT2 ont également été considérées. Les études ont été sélectionnées dans les bases de données scientifiques en utilisant les mots clés et des critères prédéfinis. Les études originales publiées entre janvier 2009 et décembre 2014 et conduites en français, anglais ou espagnol étaient potentiellement éligibles. La liste de contrôle de « British Medical Journal » a servi à évaluer la qualité des études. Des 21 études retenues, 15 rapportaient que les interventions étaient coût-efficaces suivant les limites d’acceptabilité considérées. Six études étaient non concluantes, dont quatre destinées à la prévention du DT2 et deux, au contrôle de l’obésité. Dans le troisième volet, les perceptions d’utilisateurs potentiels de ce calculateur et d’un autre outil de plaidoyer, à savoir, l’argumentaire narratif expliquant la nécessité de se pencher sur la lutte contre le DT2 en Afrique, ont été évaluées dans une étude qualitative exploratoire. Les données ont été collectées au cours d’entretiens individuels avec 16 acteurs de la santé de quatre pays d’Afrique subsaharienne et un groupe de discussion avec 10 étudiants de master de nutrition à l’issue d’un atelier de formation sur le plaidoyer faisant appel à ces outils, au Bénin. Les entretiens ont été enregistrés, transcrits et codés à l’aide du logiciel QDA Miner. Les participants ont souligné la pertinence des outils pour le plaidoyer et la convivialité du calculateur de coûts. Il demeure cependant que le contexte politique marqué par la compétition des priorités, l’absence de cohésion entre les décideurs et un défaut de données notamment sur le coût-efficacité des interventions sont des freins à la priorisation du DT2 dans les politiques de santé en Afrique subsaharienne que les répondants ont relevés. L’étude confirme que le traitement du DT2 est financièrement inabordable pour un grand nombre de patients. Elle souligne que les dépenses des patients sont en deçà des coûts estimés pour un traitement approprié avec quelques exceptions. La prévention du DT2 basée le mode de vie est coût-efficace mais devrait être étudiée en Afrique. On peut espérer que la pertinence des outils de ce travail telle que relevée par les acteurs de santé se traduise par leur utilisation. Ceci pour susciter des interventions de prévention afin d’infléchir l’évolution du DT2 et son impact économique en Afrique subsaharienne. / This thesis is organized in three different parts with three objectives: i) To estimate the direct medical costs of treatment of T2D in four sub-Saharan African countries and in the case of Mali, compare the direct medical costs estimated from prices used in the health system to the real expenditures of diabetic patients, ii) To evaluate the perceptions of health professionals on advocacy tools for T2D including the cost calculator used to estimate medical costs and a narrative argument developed under the Double Burden Nutritional project, iii) To examine the cost effectiveness of economic evaluation of lifestyle interventions for primary prevention of T2D. In the first part of the study, we estimated the costs of T2D and its complications in Benin, Burkina - Faso, Guinea and Mali. The care components for T2D and its complications were defined by a team of specialists, based on their clinical experience and current guidelines. Prices were collected from two public healthcare facilities and two private facilities. The costs were estimated on an annual basis for T2D with or without chronic complications and per episode for acute complications. The estimated annual costs in Mali were compared to diabetic patients’ expenditures based on data from a cross-sectional survey conducted earlier in that country. The survey covered 500 diabetic subjects randomly selected from the registry of known diabetics. Data on expenditures for care in the last three months were collected. Determinants of expenditures were examined. The results showed cost disparities within countries, within and between the private and the public sector. The minimum cost of treatment of T2D without complications in the public sector amounted to 21% - 34% of the country’s Gross National Income per capita; 26% - 47% in the presence of retinopathy - the cheapest complication -, and above 70 % for nephropathy, the most costly complication. According to Mali survey, diabetic subjects’ expenditures were below the estimated minimum cost, except for diabetes without complications or only with retinopathy. Insulin therapy, the number of complications and residing in the capital were significantly associated with higher expenditures. The second part of the thesis consists of the systematic review of economic evaluation studies of T2D prevention interventions in high-risk groups through diet and physical activity. Interventions to control obesity as a major risk factor for T2D were also considered. The studies were extracted from scientific databases using keywords and predefined criteria. Original studies published between January 2009 and December 2014 and conducted in French, English or Spanish were potentially eligible. The "British Medical Journal" checklist was used to assess the quality of studies. Of the 21 studies included, 15 reported that the interventions were cost-effective as per the acceptability limits considered. Six studies were inconclusive, including four for T2D prevention and two for obesity control. In the third second part, the perceptions of potential users of the cost calculator and another advocacy tool, namely, the narrative set of arguments explaining the need to address T2D in Africa, were evaluated in an exploratory qualitative study. Data were collected through individual interviews of 16 health professionals from four sub-Saharan countries and a focus group with 10 Master’s students in nutrition during a training workshop on advocacy using these tools, in Benin. The questions pertained to the two tools and to factors involved in the prioritization of health policy, with a focus on T2D. Interviews were recorded, transcribed and coded using the QDA Miner software. Participants underlined the relevance of the tools for advocacy. They considered the cost calculator as user – friendly. It remains that the political context characterized by competing priorities, lack of cohesion between policy makers, and lack of data, especially the cost - effectiveness of interventions, are challenges for positioning T2D as a priority in public policies in sub-Saharan African countries. The studies confirmed that treatment of T2D is unaffordable for many patients. It highlighted the fact that expenses of patients were below the estimated costs for minimal treatment with some exceptions. Prevention of T2D based on lifestyle modification appears cost-effective but studies should be conducted in Africa. We hope that the tools, which were found relevant by health actors of the four countries, will be helpful in stimulating preventive interventions in order to reduce the trend of T2D and its economic burden in sub-Saharan Africa.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-06-15T14:03:39Z No. of bitstreams: 1 paulacamilarodriguespinto.pdf: 1768488 bytes, checksum: df991e2e2165a0de75151462b2b03622 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-07-13T14:12:09Z (GMT) No. of bitstreams: 1 paulacamilarodriguespinto.pdf: 1768488 bytes, checksum: df991e2e2165a0de75151462b2b03622 (MD5) / Made available in DSpace on 2016-07-13T14:12:09Z (GMT). No. of bitstreams: 1 paulacamilarodriguespinto.pdf: 1768488 bytes, checksum: df991e2e2165a0de75151462b2b03622 (MD5) Previous issue date: 2016-03-11 / O diabetes mellitus é considerado uma epidemia mundial pela Organização Mundial de Saúde. Tanto a prevalência, quanto a incidência dos dois tipos principais (1 e 2) têm aumentado a cada ano. No Brasil, observa-se o fenômeno da judicialização para conseguir medicamentos e insumos para o tratamento de diabetes. Há material gratuito, dispensado pelo Sistema Único de Saúde e programas como Farmácia Popular e Aqui Tem Farmácia Popular. No entanto, alguns pacientes recorrem à Justiça para ter acesso ao tratamento prescrito. O estudo tem o objetivo de avaliar o impacto econômico e os custos médicos diretos envolvidos nos processos impetrados pelos pacientes contra o município de Juiz de Fora, Minas Gerais, para conseguir insulinas, medicamentos, insumos descartáveis, insumos permanentes e dietas para tratamento de diabetes mellitus. Foram estudadas cópias de processos judiciais deferidos ou deferidos parcialmente, impetrados entre 2009 e 2014 contra a Prefeitura de Juiz de Fora, arquivados na Secretaria de Saúde e na Procuradoria Geral do Município. Analisaram-se 125 processos, com custo médio de R$5.944,44 por paciente, considerando os custos médicos diretos. De acordo com a simulação dos custos, em 2014, foram gastos R$743.055,57 com esses tratamentos de diabetes, ou 9,29% dos R$8 milhões destinados para gastos com judicialização da saúde no município, ou seja, os tratamentos de diabetes mellitus solicitados por via judicial causam impacto econômico para o orçamento de saúde. Os insumos descartáveis e as insulinas foram os maiores custos médicos diretos, respectivamente R$344.818,09 e R$159.410,88. 54,4% das receitas anexadas aos processos são provenientes do SUS; 51,2% dos processos foram representados por um órgão público; 47,2% dos processos continham pedidos em que nenhum dos itens é dispensado gratuitamente; 53,6% dos impetrantes têm diabetes tipo 1; 60,8% são do sexo feminino; 29,6% são adultos; 24,8% são menores; 22,4% são idosos. / Diabetes mellitus is considered a global epidemic by the World Health Organization. Both the prevalence and the incidence of the two main types (1 and 2) have increased each year. In Brazil it is observed a phenomenon called judicialization to achieve drugs and supplies for the treatment of diabetes. There is free material for diabetes treatment in Brazil distributed by the Public Health System and by some assistance programs such as Farmácia Popular and Aqui Tem Farmácia Popular. However, some patients go to court to have access to the treatment prescribed. The study aims to calculate the economic impact and the direct medical costs involved in lawsuits filed by patients against the city of Juiz de Fora, Minas Gerais, to get insulin, drugs, disposable supplies, permanent suppliet and diet goods for the treatment of diabetes mellitus. Copies of granted or granted in part lawsuits filed between 2009 and 2014 against Juiz de Fora City Council have been studied. They were stored in Municipal Health Department and City Attorneys Office. 125 cases were analyzed with an average cost of R$5,944.44 per patient considering direct medical costs. According to the simulation of costs expenditures were R$743,055.57 with these diabetes treatments or 9.29% of R$ 8 million allocated to spending on health judicialization in Juiz de Fora in 2014, having economic impact on the health budget. Disposable supplies and insulin were the highest direct medical costs, respectively R$344,818.09 and R$159,410.88. 54.4% of prescriptions attached to lawsuits were from SUS; 51.2% of the lawsuits had a public defender in charge; 47.2% of the lawsuits required items that are not available free of charge in the public health system; 53.6% of plaintiffs have type 1 diabetes; 60.8% are female; 29.6% are adults; 24.8% aged 0-17; 22.4% are elderly people.

Выпускная квалификационная работа (магистерская диссертация) посвящена исследованию финансирования здравоохранения населения в Сингапуре. Предметом исследования являются медицинские накопительные счета Сингапура, которые играют основную роль в финансировании здравоохранения страны. Основной целью магистерской диссертации является рассмотрение успешного опыта финансирования здравоохранения в Сингапуре, которой возможно применить в отечественной системе здравоохранения. В заключении обозначены рекомендации по совершенствованию дальнейшего улучшения отечественной системы финансирования здравоохранения. / The final qualifying work (master's thesis) is devoted to the study of the financing of public health in Singapore. The subject of study is Singapore's medical savings accounts, which play a major role in financing the country's health care. The main purpose of the master's thesis is to consider the successful experience of financing health care in Singapore, which can be applied in the domestic health care system. In the conclusion, recommendations for improving the further improvement of the domestic system of health care financing are indicated.

The purpose of this study is to demonstrate that within the United States health care system, a number of institutions have evolved which have given rise to a perverse set of incentives that direct technological change. As a result of these incentives, the diffusion and utilization of new and existing technologies is carried out in a random and indiscrete fashion, subsequently placing upward pressure on the costs of health care. This analysis relies on the empirical work, observations, and writings of a large number of physicians, social scientists, hospital administrators, and federal bureaucrats.

Submitted by Luiz Eduardo Gapanowicz (lgapanowicz@rededor.com.br) on 2012-08-21T13:24:33Z No. of bitstreams: 1 Dissertação Mex 2a 12 corrigida Ricardo BIBLIOTECA ajust parte numerada_R02 08 2012.docx: 371539 bytes, checksum: 0623ddaae545be40dced1a298d937001 (MD5) / Approved for entry into archive by Janete de Oliveira Feitosa (janete.feitosa@fgv.br) on 2012-08-24T15:51:42Z (GMT) No. of bitstreams: 1 Dissertação Mex 2a 12 corrigida Ricardo BIBLIOTECA ajust parte numerada_R02 08 2012.docx: 371539 bytes, checksum: 0623ddaae545be40dced1a298d937001 (MD5) / Approved for entry into archive by Marcia Bacha (marcia.bacha@fgv.br) on 2012-08-28T14:21:51Z (GMT) No. of bitstreams: 1 Dissertação Mex 2a 12 corrigida Ricardo BIBLIOTECA ajust parte numerada_R02 08 2012.docx: 371539 bytes, checksum: 0623ddaae545be40dced1a298d937001 (MD5) / Made available in DSpace on 2012-08-28T14:22:09Z (GMT). No. of bitstreams: 1 Dissertação Mex 2a 12 corrigida Ricardo BIBLIOTECA ajust parte numerada_R02 08 2012.docx: 371539 bytes, checksum: 0623ddaae545be40dced1a298d937001 (MD5) Previous issue date: 2012-06-26 / The health practice in the country has been going through big and difficult challenges. Concerning funds, the public sector is still in need of a better sizing and strategy. The private sector has its crisis by the lack of more analysis of its costs and variations. The regulation of the supplementary sector is still crude. The immense health challenges and the searches for solution are a constant for better sizing and handling the process. Several factors are pressuring the model, increasing expenses in a vicious unforeseeable situation, without any foresight. There is an urgent need of understanding the outflow model involved and above all the factors that most interfere in the variation of these expenses. The followed work searches a better understanding of the variation costs of the problem of the services given, through the analysis of three medical cases of high relevancy: appendicectomy, hysterectomy, colecistectomy, observing the prices variation practiced in historical 05 years’ time, comparing with the economic and inflationary indexes as IPCA, variation of the Health Insurance Plans by ANS and the variation of hospital/ medical expenses. As results, we observed that for these classics and isolated events, there isn’t a clear pattern of prices linked to any of these indexes, neither a linear variation that allows a better and big analysis. At the same time when the volume of the attending increase, in the mix of these three events we observe a very close relation to the IPCA that is, by the way, very close do the readjustment of the index authorized by ANS in this period. There is a lot to do and study for better understanding of these prices and costs model, as well as its variations. / A prática de saúde no país passa por grandes e difíceis desafios. No que tange a financiamento o setor público ainda carece de um melhor dimensionamento e proposta estratégica. Já o setor privado tem sua crise pela falta de maios análise dos seus custos e suas variações. A regulação do setor suplementar ainda é muito jovem. Os grandes desafios da saúde e a busca de solução são uma constante para melhor dimensionar e gerir o processo. Vários são os fatores pressionam o modelo aumentando seus gastos e ainda em uma situação mais perversa sem nenhuma previsão. Há a necessidade urgente de se entender o modelo de gastos envolvidos e acima de tudo os fatores que mais interferem na variação desses gastos. O trabalho que segue busca entender melhor o problema de variação de custos destes serviços prestados, através da análise de três casos médicos de alta relevância: apendicectomia; histerectomia; e colecistectomia, observando a variação dos preços praticados em uma série histórica de 5 anos, comparando com índices econômicos e inflacionários como IPCA, variação dos preços dos planos de saúde pela ANS e variação dos custos médicos hospitalares. Como resultados observamos que para estes eventos clássicos e isolados eventos não há um padrão nítido de preços atrelados a qualquer destes índices, nem uma variação linear que permita uma maior e melhor análise. Ao mesmo tempo quando se aumenta o volume dos atendimentos, no mix dos três eventos passamos a observar uma relação bem próxima ao IPCA que por sua vez é muito próxima do índice de reajustes autorizado pela ANS no período. Muito há o que ser feito e estudado como forma de melhor entender este modelo de preços e custos, bem como suas variações.