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ResumenObjetivoEvaluar la eficiencia técnica de los hospitales públicos tradicionales sin personalidad jurídica específica y sujetos al derecho administrativo, y de las empresas públicas hospitalarias, sujetos de derecho y regidas parcialmente por el derecho privado del Sistema Sanitario Público de Andalucía, durante el periodo 2005-2008.MétodosEl estudio comprende los 32 hospitales públicos de Andalucía durante el periodo 2005-2008. La metodología consta de dos etapas. Primero se calcularon los índices de eficiencia técnica de los hospitales mediante análisis envolvente de datos, y la evolución de la eficiencia con el índice de Malmquist. Los resultados se compararon por calidad percibida, y se realizó un análisis de sensibilidad mediante un modelo auxiliar y bootstrapping. En la segunda etapa se realizó un análisis bivariado entre la eficiencia de los hospitales y su tipo de organización.ResultadosLas empresas públicas fueron más eficientes que los hospitales tradicionales en todos los años del estudio (más de un 10% de media). Sin embargo, se observa un proceso de convergencia entre ambos tipos de organizaciones, ya que mientras que los hospitales tradicionales aumentaron ligeramente su eficiencia en el periodo, un 0,50%, las empresas públicas sufrieron una disminución en su eficiencia de más de un 2%.DiscusiónLa principal causa de la superior eficiencia de las empresas públicas puede radicar en su mayor flexibilidad laboral y presupuestaria. El proceso de convergencia observado apunta, no obstante, a un proceso de aprendizaje mutuo no necesariamente eficiente.AbstractObjectiveTo assess the technical efficiency of traditional public hospitals without their own legal identity and subject to administrative law, and that of public enterprise hospitals, with their own legal identities and partly governed by private law, all of them belonging to the taxypayer-funded health system of Andalusia during the period 2005 -2008.MethodsThe study included the 32 publicly-owned hospitals in Andalusia during the period 2005-2008. The method consisted of two stages. In the first stage, the indices of technical efficiency of the hospitals were calculated using Data Envelopment Analysis, and the change in total factor productivity was estimated using the Malmquist index. The results were compared according to perceived quality, and a sensitivity analysis was conducted through an auxiliary model and bootstrapping. In the second stage, a bivariate analysis was performed between hospital efficiency and organization type.ResultsPublic enterprises were more efficient than traditional hospitals (on average by over 10%) in each of the study years. Nevertheless, a process of convergence was observed between the two types of organizations because, while the efficiency of traditional hospitals increased slightly (by 0.50%) over the study period, the performance of public enterprises declined by over 2%.DiscussionThe possible reasons for the greater efficiency of public enterprises include their greater budgetary and employment flexibility. However, the convergence process observed points to a process of mutual learning that is not necessarily efficient.

This paper presents a methodology to optimize, using Altman's Z-Score for private companies, the prediction of private companies of the Spanish health sector entering a situation of bankruptcy.The proposed method consists of the application of genetic algorithms (GA) to find the coefficients of the formula of the chain of ratios proposed by Altman in the version of the score for private companies which optimize the prediction for Spanish private health companies, maximizing sensitivity and specificity, and thereby reducing type I and type II errors. For this purpose, a sample of 5,903 companies from the Spanish private health sector obtained from the database of the Iberian Balance Analysis System (SABI) between 2007 and 2015 was used.The results show that the predictive model obtained with the AG presents greater accuracy, sensitivity and specificity than that proposed by Altman for private companies with both test data and all sample data.The most important finding of this study was to establish a methodology that can identify the optimized coefficients for the Altman Z-Score, which allows a more accurate prediction of bankruptcy in Spanish private healthcare companies.

Tobacco control in Colombia is regulated by Law 1335 of 2009. The implementation and monitoring of the provisions of this law require strengthening of intersectorial work at the local level. This field note presents an intersectorial work experience that was carried out in the municipality of Tunja (Colombia) to improve tobacco control. The Respirarte Group was established. This group consists of an intersectorial team composed of 15 institutions. The Respirarte Group achieved the following political and community actions: signing of an agreement on tobacco control by government actors, expedition of a local decree to comply with Law 1335 in the municipality, provision of information and communication, and social mobilization and monitoring. This experience serves as a national and international reference and its lessons could be used in the approach to other public health problems.

This article reviews trends in lifestyle factors and identifies priorities in the fields of prevention and health promotion in the current economic recession. Several information sources were used, including a survey of 30 public health and primary care experts. Between 2006 and 2012, no significant changes in lifestyle factors were detected except for a decrease in habitual alcohol drinking. There was a slight decrease in the use of illegal drugs and a significant increase in the use of psychoactive drugs. Most experts believe that decision-making about new mass screening programs and changes in vaccination schedules needs to be improved by including opportunity cost analysis and increasing the transparency and independence of the professionals involved. Preventive health services are contributing to medicalization, but experts' opinions are divided on the need for some preventive activities. Priorities in preventive services are mental health and HIV infection in vulnerable populations. Most experts trust in the potential of health promotion to mitigate the health effects of the economic crisis. Priority groups are children, unemployed people and other vulnerable groups. Priority interventions are community health activities (working in partnership with local governments and other sectors), advocacy, and mental health promotion. Effective tools for health promotion that are currently underused are legislation and mass media. There is a need to clarify the role of the healthcare sector in intersectorial activities, as well as to acknowledge that social determinants of health depend on other sectors. Experts also warn of the consequences of austerity and of policies that negatively impact on living conditions.

To identify and describe the responsibilities attributed to health administrations in preventing and addressing violence against women in the international legislation on this issue.We carried out a content analysis of the laws on violence against women collected in the following legal databases: the Annual Review of Law of Harvard University, the United Nations' Secretary-General's database on Violence against Women, the International Digest of Health Legislation and Stop Violence against Women. All legal documents explicitly mentioning the participation of the health sector in interventions against violence against women were identified. Subsequently, the interventions selected were classified into primary, secondary and tertiary prevention, as defined by the World Health Organization in its first World Report on Violence and Health (2002).Of the 115 countries analyzed, 55 have laws on violence against women that include the participation of the health sector in interventions concerning this phenomenon. In most of these countries, this participation focusses on reporting detected cases and on providing healthcare and assistance to women referred from police services. We identified 24 laws that explicitly mention the interventions developed by the health sector, mainly consisting of tertiary prevention. The laws of Mexico, Colombia, Argentina, El Salvador, Spain and the Philippines include interventions involving the three levels of prevention.One-fourth of the laws concerning violence against women studied incorporate specific interventions in the health sector, suggesting that a comprehensive approach to the problem is still required. Greater utilization of the potential of this sector is required in interventions to prevent violence against women.

The object of this short paper is to present the results of Spanish public health care expenditures projections until 2013 according to the expected impact of the main demographic and technological health cost drivers.Future annual health expenditures are estimated using a simple method based on the decomposition of the past main growth factors in two scenarios. The main cost drivers considered were the following: demography, which includes the increasing number of people and the impact of population ageing; the increase in the price of health care inputs above the general price level; and the impact of changes in medical practice related with expanding medical technology.In 2013, public health care expenditure may be around 5.7% and 6% of gross domestic product (GDP); that is, at least, between 0.24 and 0.53 additional GDP points will be spent on public health care. The main factor responsible for the future expenditure increase will continue to be the increase in the average health service intensity, followed by demographic factors. In the base-case scenario, public expenditure increase until 2013 will be compatible with a real 2.5% annual increase in consumption of non-health goods and services. In order to finance the future costs, the Spanish population will have to devote to public health expenditure less than 7% of income increase until 2013.Despite being important, the expected Spanish GDP growth until 2013 may be enough to finance the increase in public health expenditure as a result of the impact of demographic changes. Expanding medical technology is expected to continue being the main driver of future costs.

In this paper, the policy-sensitive imbalances in the health professional markets are discussed. In Spain, the current staffing levels are still the result of unforeseen demographic and socio-economic developments. In some specialties and areas, there are selective shortages which in all likelihood will become more serious in the coming years due to the objective causes analyzed in this text. We propose a gradual increase in the medical schools numerus clausus and in the number of residents positions, the use of a variety of incentives to attract professionals to specific positions and, particularly, to increase the standing and quality of primary care.

Due to the economic importance of the service sector and its trade potential, in 1995 the World Trade Organization (WTO) launched the General Agreement on Trade in Services with the objective of liberalizing trade in services worldwide and of establishing rules and disciplines to regulate it. Until now, the Agreement has produced few case laws on its rules and some of them are in the process of being developed, which makes the Agreement ambiguous and hampers accurate forecasting of its implications. Nevertheless, some analysts consider that certain characteristics and rules represent a threat to the funding mechanisms of public services and to the sovereignty of governments to generate their own rules. Moreover, the Agreement would lead to irreversible formalization of commitments, without the possibility of returning to previous conditions in the case of failure of the market and/or private participation. In addition, the Agreement acts against exclusive monopolies and providers and to a certain extent this will affect subsidies to local providers. The ability of the European Communities Court of Justice to enforce the implementation of competitive measures in public services has produced uncertainty because of the implications for health services. The Spanish Agreement with the WTO contains many questions that remain open, representing an opportunity for the participation of the health sector in the next negotiation rounds.

In recent years, changes in the organization of healthcare institutions and the increased number of medical malpractice claims have revealed the need to study the concept of medical responsibility and the repercussion of these changes on healthcare provision. To date, discussion has focussed on legal aspects and economic implications have been largely ignored.The present article reviews studies that have performed an economic analysis the subject. Firstly, we examine studies that gradually introduce the concepts of uncertainty, risk aversion and moral hazard. Secondly, in the healthcare environment, we pay particular attention to models that include new arguments on professionals' objective duties or to bargaining models when there is asymmetric information. Finally, we consider the medical malpractice insurance market and investigate how reputation and the possibilities of exercising defensive medicine influence healthcare provision. Our analysis suggests that, due to the characteristics of the healthcare market, the models proposed by the economy of information are very useful for performing economic analyses of liability in medical malpractice. However, alternative hypotheses also need to be formulated so that these models can be adapted to the specific characteristics of different health systems.

To assess the level of agreement in positive questions, and policy-value questions in Health Economics of the members of the Spanish Health Economics Association (AES).A survey was made among the members of the AES (42 academic health economists, 196 health managers, and 34 practising physicians). The survey included 20 positive questions, 11 policy questions, 4 value questions, and 5 socio-demographic questions. An analysis of the average absolute differences between percentage agreeing and percentage disagreeing by type of question was performed.Two main results can be identified. First, there are no significant differences in the level of agreement between health economists, health care managers and practising physicians with respect to positive and policy-value questions. Second, there is no significant difference in the level of agreement in the three identified groups between type of questions (positive versus policy-value questions).There are no significant differences in the agreement about the positive questions between the three identified groups in the AES (academic health economists, health care managers and practising physicians.

En este articulo se aportan razones para concluir que la economia de la salud esta entre las disciplinas que lideran el «cambio de paradigma» en economia, el cual necesita extenderse cuanto antes al resto de la economia. Esta conclusion se obtiene a partir de considerar como la economia puede ser aplicada a temas que a primera vista no parecen economicos, como puede ser intentar responder a cual es el mejor tratamiento que un sistema nacional de salud deberia proporcionar a un paciente con una enfermedad concreta.