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OBJECTIVE: The goal of this study was to inform public health policy which can reduce Colombia's estimated infant mortality rate (IMR), 17.78 deaths for 1000 live births (2011), by lowering preventable first day mortality (PFDM). STUDY DESIGN: This study combined a time series analysis, using a linear regression method, for the period 2001-2012 with a cross-sectional analysis, using odds ratios and bi-variate methods, for the year 2012 to study first day mortality (FDM) and PFDM classified by biological, socio-economic, and medical correlates. METHODS: The study examined the trends for 2001-2012 in Colombia's infant mortality rate per 1000, and in the relative significance of PFDM by cause. It established the relative odds of PFDM for 2012 by major risk categories, defined by birthweight and gestational age, and within those by biological, sociodemographic risk factors or groups and by potential access to and use of care. Then, the study established the major causes of PFDM within major risk categories and groups. RESULTS: Between 2001 and 2012, the average annual rate of FDM declined by 6.30%, while overall infant mortality only declined by 4.20%. Yet, in 2012, 37.04% of FDM was preventable by using proper pregnancy control (7.00% of total preventable), proper care during childbirth (37.20%), and handling causes associated with late diagnosis and treatment (55.80%). PFDM is primarily a socio-economic phenomenon, even among normal weight and gestational age newborns, who account for 32.73% of PFDM due to improper management of pregnancy and delivery among lower socio-economic and outlying populations, specifically in rural areas and among members of the inferior subsidised social insurance regime. CONCLUSION: From efficacy and probable cost effectiveness perspectives, intervention priority should be given to handling babies with normal gestation age and birthweight, and then to babies with very low gestation age and birthweight. At the same time, more prenatal visits could lead to fewer very high-risk situations at the outset. In view of the Colombian regulation to the contrary, the use of foetal monitoring and echography methods by all general practitioners should be considered. They should be trained accordingly. Policies should focus on members of the underprovided subsidised health insurance regime, rural areas, young, low-educated and single mothers during pregnancy, mainly delivery.

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The reforms that have affected the Russian health care system since the breakup of the Soviet Union, principally those in the general administration of the Russian Federation, have suffered from inconsistency and the absence of a strategy. The various reforms have caused a shift from a national health system characterized by highly centralized management and control, typical of the totalitarian uniform state, to a highly decentralized but fragmented multitude of state systems. Each of these systems is relatively centralized at the local level and run by local administrations with limited government infrastructure and experience. The role of government in the emerging system, and in particular the role of the federal government, remains ill defined. As a result, there is a grave risk that the Russian health care system may disintegrate as a national system. This undermines (a) the prevailing universal and fairly equitable access to care, (b) stabilization of the system following a long period of transition, and (c) the long-term reform that is required to bring the Russian health care system up to par with the health care systems in other developed countries. A rapid transition to a genuine federal health system with well-articulated roles for different levels of government, in tandem with implementation of the 1993 Compulsory Health Insurance System, is essential for the stabilization and reform of the Russian health care system.

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The Russian (1993 amended) health insurance legislation initiated a far-reaching reform in the financing, organization and management of the Russian health system. However, the implementation of the legislation has been slow and unstructured due to a lack of appropriate administrative and financial mechanisms: these concern entitlement, private-public mix, financial responsibilities of government at all levels, investment instruments, reimbursement and compensation systems, and a well-defined role of government. These issues are discussed in this article in the context of the Russian economy, the state of the health system, and the reform effort in the system.

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In 1980 the Government of Indonesia proposed the introduction of a pay-for-performance system, the Functional Position System (FPS), for certain occupational categories of civil servants to provide a career development path and stimulate productivity (Government of Indonesia. Government Ordinance No. 3, 1980 Concerning Appointment to Civil Service Rank. Jakarta, 1980). The FPS, a bold pay concept in the civil service, links pay to skills and performance. In 1987, instructions were issued for doctors to be included in the system (Government of Indonesia, Credit Scores for Doctors. Circular Issued by the Ministry of Health and the Agency for Administration of the Civil Service No. 614/MENKES/E/VIII/1987 and No. 16/SE/1987). In this paper we evaluate how well the system-which in principle could be applicable to both developed and developing economies--can meet its stated objectives for Indonesian doctors working in the community, and for Indonesian health policy objectives as stated in the country's last five-year development plan "Repelita V" (Government of Indonesia. The Fifth Five-year Development Plan (Repelita V) 1989-1994. Jakarta, Indonesia, 1989). The FPS is particularly innovative in the Indonesian environment where wages are low and comparatively uniform, reflecting a philosophy of 'shared poverty', and vary primarily by seniority. The FPS has, however, several conceptual and practical shortcomings. The design of the reward system disregards effort or time inputs, as well as other inputs needed per unit of reward. Consequently, the FPS can not be used as an effective incentive system promoting professional excellence and health policy objectives. Practically, the system hardly provides an effective alternative for career development among community physicians.(ABSTRACT TRUNCATED AT 250 WORDS)

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On June 15, 1994, the Israeli Parliament voted to enact the National Health Insurance bill (NHI). The bill marks the end of a process that lasted for virtually as long as Israel's almost 50 year history. Israel's attempts at health reform began long before the current spate of reforms in many Western countries. Faced with many of the same problems of access, equity and cost control common to many of its counterparts, Israel initiated a reform process based on the recommendations of a prominent State Commission of Inquiry into the Israeli Health System (the Netanyahu Commission) which reported to the Government in 1990. The Commission's proposals were based on a diagnosis indicating that the major problems of the system stem from the lack of clarity regarding the rights of citizens to health care, the lack of a clear allocation of responsibility and accountability among government, insurance or sick funds, and providers in the system, and undue centralization of system operations. This diagnosis led to three major planks for reform: (1) enactment of national health insurance legislation granting a basic package of care to each citizen and hence bringing most of the system's finance under public auspices; (2) divesting the Government from the organization, management and provision of care; hence integrating the management of preventive and psychiatric services provided by the government with the primary and other services provided by sick funds, and granting financial and operational independence to at least government hospitals; and (3) restructuring the Ministry of Health. As is often the case in public policy, more consensus surrounds the diagnosis than the solutions. As a result, nearly four years of implementation efforts have only recently resulted in a major breakthrough. In this paper we make an effort to outline the inherent weaknesses of the Israeli health care system that have led to the crisis in the mid 1980s, summarize the recommendations of the State Commission for structural change in the system, and review the politics of implementing the recommended reforms.

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This paper outlines some general lessons developing nations can draw from the health system reform experiences of developed nations. Using the experiences of developed countries, developing countries should be better able to anticipate socio-economic changes and choose an optimal path for their health systems development to accompany those changes. Most developed countries have adopted rather common objectives and principles in their health systems because of market failure in health care; developing countries may start adopting those principles because they do not have market conditions in the first place. It is suggested that developing countries strengthen what is probably the most fundamental initial systemic asset they have: public finance. They should do so by attracting democratically, possibly through earmarked taxes, resources otherwise channelled through the private sector, competing with public finance for limited real resources. This effort can be promoted by giving consumers, mainly of high income groups and in urban areas, more say (through institutions performing the OMCC function) in the nature of care these groups have access to under auspices of public finance. Where feasible, private insurance as a major source of finance should be seen as a transitional phenomenon, giving way to the emergence of OMCC institutions which require similar financial and managerial market infrastructure. Private and competitive provision of care may be unrealistic in many developing areas because of both scarcity of real resources, mainly manpower, and health needs. The challenge of government is, as resources grow, to divest itself from the provision of care and stay involved in activities and facilities that are of 'public nature'--under specific circumstances--that foster private competitive provision. In general, the government should play an enabling role also by investing in health promotions and management skills for health systems.

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Despite the wide variety of health care systems in industrialized democracies, a universal paradigm for financing, organization, and macromanagement has been emerging through reforms of the past decade. The policies within this paradigm attempt to promote equity, social efficiency, and consumer satisfaction by combining the advantages of public finance principles--universal access and control of spending--with the advantages of competitive market principles--consumer satisfaction and internal efficiency. This paradigm is characterized by three systemic functions: (1) financing of care, based on public finance principles, not necessarily carried out by government; (2) organization and management of publicly funded care consumption by either competing nongovernmental entities or noncompeting public administrations; and (3) provision of care based on competitive market principles. The institutional arrangement of these functions lends itself to the creation of two internal markets for consumer choice and, of the three, the second function is a key component of the emerging paradigm.

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This study explored the degree to which risks embedded in the social construction of gender roles and personality traits explained gender differences in health perceptions and reporting among mild hypertensive patients (134 women and 104 men) under the same treatment regime. Compared with men, women were less educated, less likely to be employed, less happy, more distressed, less satisfied with family functioning, and had a weaker sense of coherence. Twice as many women as men evaluated their health as 'poor', and on average reported 2.6 more symptoms than men. These gender differences largely disappeared when unhappiness, distress, and sense of coherence were controlled. While education attainment, employment, and satisfaction with family functioning decreased gender differences in some half of the symptoms, multivariate analysis suggested that unhappiness, distress, and the sense of coherence are far better predictors of gender differential health perceptions. It is suggested that beyond biological predispositions, women's health is in double jeopardy by gender role related risks, which affect morbidity both directly through immunology system and indirectly through health perceptions.

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Data obtained with the passive-avoidance task are usually presented as the median values of the latencies to respond. In an earlier publication we described a better way of presenting such data based on the observation that the complement of the cumulative distribution of step-through latencies can be closely fitted by a simple exponential function. Thus the "step-through rate constant" (STRC) is concise and accurate quantitative description of population behavior in this test. In this paper we present two examples of the application of this procedure. In the first, variation in the interval between training and testing in rats changes the STRCs of the different groups. In the second (based on data published by Flood et al.) administration of cycloheximide is seen to partition the experimental population of mice into two subgroups with different STRCs.

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Low concentrations of trifluoperazine (TFP) reversibly inhibited vegetative growth of Saccharomyces cerevisiae. The cell cycle was analysed by flow cytometry using haploid a cells synchronized by alpha-factor arrest and several temperature-sensitive cell division cycle mutants (cdc). Cells were pulse-labelled with fluorescein-labelled concanavalin A (ConA-FITC) to determine cell division or stained with propidium iodide to determine the stage of cell cycle arrest by TFP. Cell growth was estimated from the changes in the relative intensity of scattered light, and budding was determined microscopically. When TFP was added before Start on release from alpha-factor arrest, after release of cdc28-arrested cells, and at transition from stationary phase to vegetative growth, cell growth, budding and DNA synthesis were inhibited. When TFP was added after execution of spindle pole body duplication, cell growth, bud emergence and DNA synthesis were not inhibited but cell division was inhibited and the cells arrested with buds at G2M Using cdc mutants, the second stage of arrest by TFP was determined to be just before medial-nuclear division.

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The time-course of 45Ca2+ influx into yeast cells was measured under non-steady-state conditions obtained by preincubating the cells in a Ca2+-free medium containing glucose and buffer. Two components were distinguished: a saturable component which reached a steady-state after about 40 s of 45Ca2+ uptake and a linear increase in cellular 45Ca2+ starting after 60-90 s. Using differential extraction methods it was determined that after 20 s of uptake, 45Ca2+ was localized in the cytoplasmic pool and in bound form with no 45Ca2+ in the vacuole. After 3 min most of the cellular 45Ca2+ was concentrated in the vacuole and in bound form. The initial rate of 45Ca2+ uptake under non-steady-state conditions thus measured 45Ca2+ transport across the plasma membrane without interference by vacuolar uptake. The effect of membrane potential (delta psi) on this transport was investigated in cells depleted of ATP. A high delta psi was produced by preincubating the cells with trifluoperazine (TFP) and subsequently washing the cells free from TFP. Substantial 45Ca2+ influx was measured in the absence of metabolic energy in cells with a high delta psi. Below a threshold value of -69.5 mV the logarithms of the initial rate of 45Ca2+ influx and of the steady-state level of the first component were linear with respect to delta psi. It is suggested that 45Ca2+ influx across the plasma membrane is mediated by channels which open when delta psi is below a threshold value. The results indicated that Ca2+ influx across the plasma membrane was driven electrophoretically by delta psi.

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Two phenothiazine compounds, trifluoperazine and chlorpromazine, inhibited growth in vitro of the five most common pathogenic yeasts, with MICs ranging from 10 to 40 micrograms/ml. Daily intraperitoneal injections of trifluoperazine (4 to 7 mg/kg of body weight) increased the survival of mice experimentally infected with Candida albicans or Cryptococcus neoformans. The potential use of these drugs against fungal meningitis is discussed.

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In the extensive literature dealing with the one-trial passive-avoidance task the data are usually represented by the median latency to respond. We propose here a novel representation and analysis of passive-avoidance data which is based on the observation that the complement of the cumulative distribution of step-through latencies (i.e., the fraction of animals remaining in the safe compartment) decays exponentially with time from the onset of the trial. A remarkably close fit of this complementary distribution is seen when the best-fitting straight line is drawn through the data points plotted on semilog coordinates. The slope of this line k, which we call "the step-through rate constant," (or alternatively, the T1/2 which is equal to 0.69/k) provides an accurate description of the population behavior as a whole in most cases. In view of the exponential distribution of passive-avoidance data this treatment appears to be more appropriate than the widely-used measures of central tendency, the median and mean. It is applicable to research on the effects of drugs on passive-avoidance memory, and probably appropriate to other behavioral paradigms and species.

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The paper suggests a hedonic prices approach to estimate the cost of hospital services. It applies this approach to Israeli data as a first approximation of hospitalization costs in that country. In the absence of accounting data, this approach enables us to estimate the relative cost of basic hospital services, how hospital characteristics affect cost and how cost changes with time. Moreover, it provides for a standardized measure to view the relative efficiency of a cross section of hospitals. Several findings based on Israeli data demonstrate the potential of the approach and may be of general interest. First, controlling for department mix, bigger hospitals, which are usually also teaching hospitals and may have a different case-mix, incur higher cost per admission than smaller hospitals. Second, by institution, General Sick Fund hospitals are more expensive, but also experience, in terms of budget allocations, less discrimination than Government hospitals. Hence, provision of equitable service may be less efficient than in services where there is budgetary discrimination to induce specialization, etc. Third, hospitals have been subject to inflationary pressures over and above the general inflation level in Israel, as may be the case in most other western countries. Fourth, a comparison of cost per admission across hospitals and over time shows that cost has been consistently increasing in particular hospitals and falling in others, beyond the average increases warranted by growth in size, changes in composition, and hospitalization-specific inflation. More research is needed in order to explain these unexplained but consistent trends.

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This paper examines the utilization patterns of traditional and modern health services in Indonesia, using household sample survey socio-economic data in conjunction with community-level data on availability of services. The results strongly suggest that low household income is a barrier to the utilization of modern health services, even where they are publicly provided. The relatively well-to-do use the services of trained practitioners and physicians more and spend more on these services than do the poor. That is, income has a qualitative effect shown as a shift to more expensive and sophisticated practitioners and services rather than increased expenditures on the same type of services. Nevertheless, public facilities do make a difference; where they are available people prefer them to indigenous practitioners. Despite limitations of data and method of estimation, it is clear that both income and availability of services matter and hence that public services are more important to the poor than to the rich. The results further suggest that exposure to modern services that may involve health education brings about the right kinds of substitutions from an efficiency viewpoint: paramedics for traditional practitioners as well as physicians.

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PIP: The cross-sectional picture of urban and rural fertility which emerges from recently published Indonesian national level data from the 1976 Intercensal Survey are described. The data reveal only small differences in the average numbers of children ever born or children surviving of ever married women (or mothers) in urban and rural areas of Indonesia. In urban areas, ever married mothers had a standardized average of 3.4 children ever born, and in rural areas 3.3 These averages cannot reveal any differences in past and present childbearing levels. The fertility of urban women, as opposed to rural women, appeared more highly associated with indicators which tend to directly or indirectly depress the average number of children ever born: a higher age at 1st marriage; a higher level of "sterility;" a higher survival ratio of children born; and a higher level of educational attainment. At least some of these factors might be regarded as associated with modernizing trends in the urban areas: increased accessibility to educational facilities; the opening of female opportunities outside the home so that marriage occurs later in life; and a better health environment so that there is less pregnancy wastage and time spent in bearing children. These factors help to provide an incentive to women to limit their fertility; knowledge of contraception methods provides a means. The depressing factors most highly associated with average rural fertility do not appear associated with modernization but with traditional folk customs regarding acceptable behavior. The inflating effects of early marriage are offset by a greater prevalence of marital disruption. This may reflect a cultural acceptability. The reasons may include adolescent or true sterility leading to disunion, the outmigration of a partner, or some other form of disharmony. Female labor force participation is more prevalent in rural than urban areas. There are both traditional and modern aspects to be seen in its restraining effect on average fertility. Both traditional and modern sector jobs have a negative association with fertility. Those jobs which take a woman away from the home were the most forceful in their association with lower fertility. Also noticed was what might be an overriding direct effect of the government's family planning program on the compatibility of agricultural occupations with childbearing, through its promotion of birth control. When stratified, the data yield variations in urban and rural fertility behavior which speak of change occurring in the traditional rural society.^ieng

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PIP: By studying intergenerational benefits from children, this paper shows that the economic analysis of fertility behavior in developing economics can provide a systematic discussion of this behavior. The major hypotheses set forth are: 1) the effect of income on fertility depends on the source and timing of income; 2) in a lifetime context, parents, or would-be parents, who have higher incomes at young ages compared with the income they anticipate at old age, are expected to have a higher demand for children; and 3) the reverse of the latter is predicted for parents who anticipate relatively higher incomes at old age. These hypotheses follow the idea that, in the absence of other appropriate means for intertemporal transfers of wealth, parents even out the lifetime welfare through fertility behavior. Under these circumstances, fertility rates are expected to increase in communities where children abandon their traditional commitments to their aging parents, as may happen during periods of economic and cultural transition. A decline in mortality rates will induce lower fertility. This model suggests that a tax-financed social security scheme along with family planning will be conducive to a reduction in fertility. A test on data from an Indian village in 1968-69 suggests that in a traditional setting there is a correlation between household welfare, measured by income or assets, and the presence of grown children. Income has a positive effect on fertility when the parents' incomes comes from labor rather than human and nonhuman capital which provides income at later stages of life. Longitudinal data depicting income, savings, and fertility patterns over time should prove more promising in exploring the issues discussed.^ieng

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PIP: The author examines the interrelationship between economic factors and fertility behavior at the family level in the relatively underdeveloped Northeast Region of Brazil. Data are from a sample of 176 rural households in the region. Factors examined include age of mother, age of wife at marriage, size of land worked, ownership of land, literacy of husband, education of mother, and infant mortality.^ieng

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