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BACKGROUND: Drug insurance schemes are systems that provide access to medicines on a prepaid basis and could potentially improve access to essential medicines and reduce out-of-pocket payments for vulnerable populations. OBJECTIVES: To assess the effects on drug use, drug expenditure, healthcare utilisation and healthcare outcomes of alternative policies for regulating drug insurance schemes. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers between November 2014 and September 2020, including a citation search for included studies on 15 September 2021 using Web of Science. We screened reference lists of all the relevant reports that we retrieved and reports from the Background section. Authors of relevant papers, relevant organisations, and discussion lists were contacted to identify additional studies, including unpublished and ongoing studies. SELECTION CRITERIA: We planned to include randomised trials, non-randomised trials, interrupted time-series studies (including controlled ITS [CITS] and repeated measures [RM] studies), and controlled before-after (CBA) studies. Two review authors independently assessed the search results and reference lists of relevant reports, retrieved the full text of potentially relevant references and independently applied the inclusion criteria to those studies. We resolved disagreements by discussion, and when necessary by including a third review author. We excluded studies of the following pharmaceutical policies covered in other Cochrane Reviews: those that determined how decisions were made about which conditions or drugs were covered; those that placed restrictions on reimbursement for drugs that were covered; and those that regulated out-of-pocket payments for drugs. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from the included studies and assessed risk of bias for each study, with disagreements being resolved by consensus. We used the criteria suggested by  Cochrane Effective Practice and Organisation of Care (EPOC)  to assess the risk of bias of included studies. For randomised trials, non-randomised trials and controlled before-after studies, we planned to report relative effects. For dichotomous outcomes, we reported the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For interrupted time series and controlled interrupted time-series studies, we computed changes along two dimensions: change in level; and change in slope. We undertook a structured synthesis following the EPOC guidance on this topic, describing the range of effects found in the studies for each category of outcomes. MAIN RESULTS: We identified 58 studies that met the inclusion criteria (25 interrupted time-series studies and 33 controlled before-after studies). Most of the studies (54) assessed a single policy implemented in the United States (US) healthcare system: Medicare Part D. The other four assessed other drug insurance schemes from Canada and the US, but only one of them provided analysable data for inclusion in the quantitative synthesis. The introduction of drug insurance schemes may increase prescription drug use (low-certainty evidence). On the other hand, Medicare Part D may decrease drug expenditure measured as both out-of-pocket spending and total drug spending (low-certainty evidence). Regarding healthcare utilisation, drug insurance policies (such as Medicare Part D) may lead to a small increase in visits to the emergency department. However, it is uncertain whether this type of policy increases or decreases hospital admissions or outpatient visits by beneficiaries of the scheme because the certainty of the evidence was very low. Likewise, it is uncertain if the policy increases or reduces health outcomes such as mortality because the certainty of the evidence was very low. AUTHORS' CONCLUSIONS: The introduction of drug insurance schemes such as Medicare Part D in the US health system may increase prescription drug use and may decrease out-of-pocket payments by the beneficiaries of the scheme and total drug expenditures. It may also lead to a small increase in visits to the emergency department by the beneficiaries of the policy. Its effects on other healthcare utilisation outcomes and on health outcomes are uncertain because of the very low certainty of the evidence. The applicability of this evidence to settings outside US healthcare is limited.

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[ABSTRACT]. Overweight and obesity are a global epidemic with rates having risen to alarming levels in both developed and developing countries. Chile has been no exemption, with sharp increases in obesity prevalence, especially among school-age children. This paper describes the policy actions and strategies implemented to tackle this major public health concern in Chile over the last 10 years, and highlights the main challenges and nuances of the process. Chile has taken policy action that includes front-of-package labelling, advertising regulations, and school-food restrictions. New policies focus on the social determinants of health as they relate to food environments and people’s behavior. These actions are not only suitable to the current context in Chile, but are also supported by the best available scientific evidence. Moreover, the implementation of these policies has produced a broad debate involving public institutions and the food industry, with discussions issues ranging from property rights to trade barriers. Despite some differences among stakeholders, a valuable political consensus has been achieved, and several international organizations are eager to evaluate the impact of these pioneer initiatives in Latin America.

[RESUMEN]. El sobrepeso y la obesidad son una epidemia mundial, en la que se registran tasas que han aumentado hasta niveles alarmantes tanto en los países desarrollados como en los países en desarrollo. Chile no ha sido una excepción, con aumentos pronunciados de la prevalencia de la obesidad, especialmente en los niños en edad escolar. En este documento se describen las políticas y estrategias aplicadas para luchar contra este grave problema de salud pública en Chile durante los 10 últimos años, y se resaltan los principales retos y matices del proceso. Chile ha tomado medidas de política que incluyen el etiquetado frontal de los envases, la reglamentación de la publicidad y restricciones en cuanto a la alimentación en las escuelas. Las nuevas políticas se centran en los determinantes sociales de la salud pues guardan relación con el entorno en cuanto a la alimentación y el comportamiento de las personas. Estas medidas no solo son apropiadas para el contexto actual de Chile, sino que también se basan en las mejores pruebas científicas de que se dispone. Por otro lado, la aplicación de estas políticas ha generado un amplio debate con las instituciones públicas y la industria alimentaria, cuyos temas de discusión abarcan desde derechos de propiedad hasta barreras comerciales. A pesar de algunas diferencias entre los interesados directos, se ha logrado un valioso consenso político y varias organizaciones internacionales están dispuestas a evaluar la repercusión de estas iniciativas pioneras en América Latina.

[RESUMO]. O sobrepeso e a obesidade constituem uma epidemia global atingindo níveis alarmantes nos países desenvolvidos e em desenvolvimento. O Chile não é exceção: o país tem registrado uma elevação acentuada da prevalência de obesidade, sobretudo em crianças em idade escolar. Este artigo descreve as medidas envolvendo políticas e estratégias implantadas no Chile na última década para combater este importante problema de saúde pública e destaca os principais desafios e as particularidades do processo. O país adotou políticas para rotulagem nutricional na parte da frente da embalagem dos produtos alimentícios, regulamentação da publicidade e restrições aos alimentos servidos em escolas. As novas políticas são direcionadas aos determinantes sociais da saúde por estarem associados aos ambientes e aos comportamentos alimentares da população. Além de serem adaptadas ao contexto atual do Chile, estas medidas se embasam nas melhores evidências científicas. A execução destas políticas deu início a um amplo debate entre as instituições públicas e a indústria de produtos alimentícios envolvendo de questões sobre direitos de propriedade às barreiras comerciais. Apesar das suas posições divergentes sobre alguns aspectos, os interessados diretos chegaram a um consenso político importante. As organizações internacionais esperam agora conhecer o resultado da avaliação do impacto dessas iniciativas pioneiras na América Latina.

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BACKGROUND: Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, as well as the involvement of stakeholders in decision-making. Changes in governance arrangements can affect health and related goals in numerous ways, generally through changes in authority, accountability, openness, participation and coherence. A broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems and improving the governance of their health systems. OBJECTIVES: To provide an overview of the available evidence from up-to-date systematic reviews about the effects of governance arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview. METHODS: We searched Health Systems Evidence in November 2010 and PDQ Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of governance arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out-of-pocket payments, cost-effectiveness), healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment) and that were published after April 2005. We excluded reviews with limitations that were important enough to compromise the reliability of the findings of the review. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries. MAIN RESULTS: We identified 7272 systematic reviews and included 21 of them in this overview (19 primary reviews and 2 supplementary reviews). We focus here on the results of the 19 primary reviews, one of which had important methodological limitations. The other 18 were reliable (with only minor limitations).We grouped the governance arrangements addressed in the reviews into five categories: authority and accountability for health policies (three reviews); authority and accountability for organisations (two reviews); authority and accountability for commercial products (three reviews); authority and accountability for health professionals (seven reviews); and stakeholder involvement (four reviews).Overall, we found desirable effects for the following interventions on at least one outcome, with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Decision-making about what is covered by health insurance- Placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate-certainty evidence). Stakeholder participation in policy and organisational decisions- Participatory learning and action groups for women probably improve newborn survival (moderate-certainty evidence).- Consumer involvement in preparing patient information probably improves the quality of the information and patient knowledge (moderate-certainty evidence). Disclosing performance information to patients and the public- Disclosing performance data on hospital quality to the public probably encourages hospitals to implement quality improvement activities (moderate-certainty evidence).- Disclosing performance data on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate-certainty evidence). AUTHORS' CONCLUSIONS: Investigators have evaluated a wide range of governance arrangements that are relevant for low-income countries using sound systematic review methods. These strategies have been targeted at different levels in health systems, and studies have assessed a range of outcomes. Moderate-certainty evidence shows desirable effects (with no undesirable effects) for some interventions. However, there are important gaps in the availability of systematic reviews and primary studies for the all of the main categories of governance arrangements.

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BACKGROUND: A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low-income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness. OBJECTIVES: To provide an overview of the available evidence from up-to-date systematic reviews about the effects of implementation strategies for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview. METHODS: We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries. MAIN RESULTS: We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high-income countries. There were no studies from low-income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories - strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient-centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in-service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self-management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community-based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support. AUTHORS' CONCLUSIONS: Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence-based interventions in low-income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process-based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.

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Informing the health policymaking process with the best available scientific evidence has become relevant to health systems globally. Knowledge Translation Platforms (KTP), such as the World Health Organization’s Evidence Informed Policy Networks (EVIPNet), are a recognized strategy for linking research to action. This report describes the experience of implementing EVIPNet in Chile, from its objectives, organizational structure, strategy, activities, and main outputs, to its evolution over the course of its first year. Lessons learned are also covered. Of the activities initiated by EVIPNet-Chile, the Rapid Response Service proved to be a good starting point for engaging policymakers. Capacity building workshops and policy dialogues with relevant stakeholders were also successful. Additionally, EVIPNet-Chile developed a model for engaging academic institutions in policymaking through a network focused on preparing evidence briefs. A number of challenges, such as changing methods for producing rapid evidence syntheses, were also identified. This KTP implementation model located in a Ministry of Health could contribute to the development of similar initiatives in other health systems.

Fundamentar o processo de formulação de políticas de saúde com as melhores evidências científicas disponíveis tornou-se indispensável nos sistemas de saúde em todo o mundo. As plataformas de tradução de conhecimento, como as Redes de Políticas Informadas por Evidências (EVIPNet) da Organização Mundial da Saúde (OMS), são parte de uma estratégia comprovada para vincular a pesquisa à ação. Este informe descreve a experiência de implantação da EVIPNet no Chile: dos objetivos, estrutura organizacional, estratégia, atividades e principais resultados à evolução ao longo do primeiro ano de atividade. As lições aprendidas são também apresentadas. Das atividades iniciadas pela EVIPNet-Chile, o Serviço de Resposta Rápida mostrou ser um bom ponto de partida para atrair a participação dos formuladores de políticas. Os seminários de capacitação e os colóquios sobre políticas com os interessados relevantes renderam bons resultados. Além disso, a EVIPNet-Chile elaborou um modelo para atrair a participação das instituições acadêmicas na formulação de políticas com uma rede dedicada ao preparo de resumos de evidências. Um dos muitos desafios identificados é modificar os métodos para produzir sínteses rápidas de evidências. Este modelo de implantação da plataforma de tradução de conhecimento sediado em um ministério da saúde poderia contribuir para a elaboração de iniciativas semelhantes em outros sistemas de saúde.

Para los sistemas de salud a nivel mundial se ha vuelto cada vez más importante contar con la mejor evidencia disponible como información para el proceso de formulación de políticas de salud. Las plataformas de traducción del conocimiento, como la Red de Políticas Informadas por la Evidencia (EVIPNet, por su sigla en inglés) de la Organización Mundial de la Salud, son estrategias reconocidas para vincular la investigación a la acción. En este informe se describe la experiencia de la utilización de EVIPNet en Chile, sus objetivos, estructura orgánica, estrategia, actividades y resultados principales de su evolución en el curso de su primer año. Se incluyen asimismo las enseñanzas extraídas. De las actividades iniciadas por EVIPNet en Chile, el servicio de respuesta rápida resultó ser un buen punto de partida para interesar a los responsables de las políticas. También fueron exitosos los talleres que se llevaron a cabo sobre creación de capacidades y los diálogos de política con los interesados directos pertinentes. Además, EVIPNet en Chile elaboró un modelo para invitar a instituciones académicas a participar en el proceso de formulación de políticas por medio de una red centrada en la preparación de resúmenes de datos científicos. Se encontraron también varios retos, como el cambio de métodos para producir síntesis rápidas de datos científicos. Este modelo de aplicación de plataformas de traducción del conocimiento, ubicado en un Ministerio de Salud, podría contribuir al desarrollo de iniciativas similares en otros sistemas de salud.

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INTRODUCTION: Chile implemented a generic substitution policy in 2014 to improve access to medicines. This study aims to measure if the generic substitution policy had an effect on the sales volume and prices of referent and the branded generic products with demonstrated bioequivalence (BEQ) in the private pharmaceutical market. METHODS: The volume and total private sales of medicines sold at private sector retail outlets between November 2011 and October 2016 were considered in the analysis. We calculated the total number of daily defined doses (DDD) by adding up the number of DDDs of different presentations with the active pharmaceutical ingredient (API). We determined the ratio of the median prices of all BEQ per DDD presentations compared with the median price of the corresponding referent presentations per DDD in 2011 and 2016. Sixteen APIs representing 231 different conventional-release presentations were included in the analysis. RESULTS: Overall, the volume of sales of the referent products decreased over time after the intervention. However, this reduction was not mirrored by an increase in the corresponding branded generic BEQ volumes overall. In all cases, the median price per DDD of the referent was higher than its BEQ counterpart in 2011 and 2016. CONCLUSION: Since referent products are more costly than branded BEQ generic products, reducing their consumption-and increasing the BEQ availability-should improve access to medicines in Chile. However, this must be accompanied by promotion of BEQ products to ensure savings for consumers in the long term. Future research should focus on identifying facilitating and inhibiting factors of generic substitution.

RESUMO

Informing the health policymaking process with the best available scientific evidence has become relevant to health systems globally. Knowledge Translation Platforms (KTP), such as the World Health Organization's Evidence Informed Policy Networks (EVIPNet), are a recognized strategy for linking research to action. This report describes the experience of implementing EVIPNet in Chile, from its objectives, organizational structure, strategy, activities, and main outputs, to its evolution over the course of its first year. Lessons learned are also covered. Of the activities initiated by EVIPNet-Chile, the Rapid Response Service proved to be a good starting point for engaging policymakers. Capacity building workshops and policy dialogues with relevant stakeholders were also successful. Additionally, EVIPNet-Chile developed a model for engaging academic institutions in policymaking through a network focused on preparing evidence briefs. A number of challenges, such as changing methods for producing rapid evidence syntheses, were also identified. This KTP implementation model located in a Ministry of Health could contribute to the development of similar initiatives in other health systems.

Para los sistemas de salud a nivel mundial se ha vuelto cada vez más importante contar con la mejor evidencia disponible como información para el proceso de formulación de políticas de salud. Las plataformas de traducción del conocimiento, como la Red de Políticas Informadas por la Evidencia (EVIPNet, por su sigla en inglés) de la Organización Mundial de la Salud, son estrategias reconocidas para vincular la investigación a la acción.En este informe se describe la experiencia de la utilización de EVIPNet en Chile, sus objetivos, estructura orgánica, estrategia, actividades y resultados principales de su evolución en el curso de su primer año. Se incluyen asimismo las enseñanzas extraídas.De las actividades iniciadas por EVIPNet en Chile, el servicio de respuesta rápida resultó ser un buen punto de partida para interesar a los responsables de las políticas. También fueron exitosos los talleres que se llevaron a cabo sobre creación de capacidades y los diálogos de política con los interesados directos pertinentes. Además, EVIPNet en Chile elaboró un modelo para invitar a instituciones académicas a participar en el proceso de formulación de políticas por medio de una red centrada en la preparación de resúmenes de datos científicos. Se encontraron también varios retos, como el cambio de métodos para producir síntesis rápidas de datos científicos. Este modelo de aplicación de plataformas de traducción del conocimiento, ubicado en un Ministerio de Salud, podría contribuir al desarrollo de iniciativas similares en otros sistemas de salud.

Fundamentar o processo de formulação de políticas de saúde com as melhores evidências científicas disponíveis tornou-se indispensável nos sistemas de saúde em todo o mundo. As plataformas de tradução de conhecimento, como as Redes de Políticas Informadas por Evidências (EVIPNet) da Organização Mundial da Saúde (OMS), são parte de uma estratégia comprovada para vincular a pesquisa à ação.Este informe descreve a experiência de implantação da EVIPNet no Chile: dos objetivos, estrutura organizacional, estratégia, atividades e principais resultados à evolução ao longo do primeiro ano de atividade. As lições aprendidas são também apresentadas.Das atividades iniciadas pela EVIPNet-Chile, o Serviço de Resposta Rápida mostrou ser um bom ponto de partida para atrair a participação dos formuladores de políticas. Os seminários de capacitação e os colóquios sobre políticas com os interessados relevantes renderam bons resultados. Além disso, a EVIPNet-Chile elaborou um modelo para atrair a participação das instituições acadêmicas na formulação de políticas com uma rede dedicada ao preparo de resumos de evidências. Um dos muitos desafios identificados é modificar os métodos para produzir sínteses rápidas de evidências. Este modelo de implantação da plataforma de tradução de conhecimento sediado em um ministério da saúde poderia contribuir para a elaboração de iniciativas semelhantes em outros sistemas de saúde.

RESUMO

Overweight and obesity are a global epidemic with rates having risen to alarming levels in both developed and developing countries. Chile has been no exemption, with sharp increases in obesity prevalence, especially among school-age children. This paper describes the policy actions and strategies implemented to tackle this major public health concern in Chile over the last 10 years, and highlights the main challenges and nuances of the process. Chile has taken policy action that includes front-of-package labelling, advertising regulations, and school-food restrictions. New policies focus on the social determinants of health as they relate to food environments and people's behavior. These actions are not only suitable to the current context in Chile, but are also supported by the best available scientific evidence. Moreover, the implementation of these policies has produced a broad debate involving public institutions and the food industry, with discussions issues ranging from property rights to trade barriers. Despite some differences among stakeholders, a valuable political consensus has been achieved, and several international organizations are eager to evaluate the impact of these pioneer initiatives in Latin America.

El sobrepeso y la obesidad son una epidemia mundial, en la que se registran tasas que han aumentado hasta niveles alarmantes tanto en los países desarrollados como en los países en desarrollo. Chile no ha sido una excepción, con aumentos pronunciados de la prevalencia de la obesidad, especialmente en los niños en edad escolar. En este documento se describen las políticas y estrategias aplicadas para luchar contra este grave problema de salud pública en Chile durante los 10 últimos años, y se resaltan los principales retos y matices del proceso. Chile ha tomado medidas de política que incluyen el etiquetado frontal de los envases, la reglamentación de la publicidad y restricciones en cuanto a la alimentación en las escuelas. Las nuevas políticas se centran en los determinantes sociales de la salud pues guardan relación con el entorno en cuanto a la alimentación y el comportamiento de las personas. Estas medidas no solo son apropiadas para el contexto actual de Chile, sino que también se basan en las mejores pruebas científicas de que se dispone. Por otro lado, la aplicación de estas políticas ha generado un amplio debate con las instituciones públicas y la industria alimentaria, cuyos temas de discusión abarcan desde derechos de propiedad hasta barreras comerciales. A pesar de algunas diferencias entre los interesados directos, se ha logrado un valioso consenso político y varias organizaciones internacionales están dispuestas a evaluar la repercusión de estas iniciativas pioneras en América Latina.

O sobrepeso e a obesidade constituem uma epidemia global atingindo níveis alarmantes nos países desenvolvidos e em desenvolvimento. O Chile não é exceção: o país tem registrado uma elevação acentuada da prevalência de obesidade, sobretudo em crianças em idade escolar. Este artigo descreve as medidas envolvendo políticas e estratégias implantadas no Chile na última década para combater este importante problema de saúde pública e destaca os principais desafios e as particularidades do processo. O país adotou políticas para rotulagem nutricional na parte da frente da embalagem dos produtos alimentícios, regulamentação da publicidade e restrições aos alimentos servidos em escolas. As novas políticas são direcionadas aos determinantes sociais da saúde por estarem associados aos ambientes e aos comportamentos alimentares da população. Além de serem adaptadas ao contexto atual do Chile, estas medidas se embasam nas melhores evidências científicas. A execução destas políticas deu início a um amplo debate entre as instituições públicas e a indústria de produtos alimentícios envolvendo de questões sobre direitos de propriedade às barreiras comerciais. Apesar das suas posições divergentes sobre alguns aspectos, os interessados diretos chegaram a um consenso político importante. As organizações internacionais esperam agora conhecer o resultado da avaliação do impacto dessas iniciativas pioneiras na América Latina.

RESUMO

Overweight and obesity are a global epidemic with rates having risen to alarming levels in both developed and developing countries. Chile has been no exemption, with sharp increases in obesity prevalence, especially among school-age children. This paper describes the policy actions and strategies implemented to tackle this major public health concern in Chile over the last 10 years, and highlights the main challenges and nuances of the process. Chile has taken policy action that includes front-of-package labelling, advertising regulations, and school-food restrictions. New policies focus on the social determinants of health as they relate to food environments and people's behavior. These actions are not only suitable to the current context in Chile, but are also supported by the best available scientific evidence. Moreover, the implementation of these policies has produced a broad debate involving public institutions and the food industry, with discussions issues ranging from property rights to trade barriers. Despite some differences among stakeholders, a valuable political consensus has been achieved, and several international organizations are eager to evaluate the impact of these pioneer initiatives in Latin America.

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OBJECTIVE:: To analyze the differences in health outcomes by hospital characteristics, focusing on ownership: public, private not-for-profit (PNFP) and private for-profit (PFP). MATERIALS AND METHODS:: We used a discharged patient dataset of Chilean hospitals for the period 2001-2010 with a total of 16 205 314 discharges in 20 public, six PNFP and 15 PFP hospitals.We selected a subsample of two medical conditions: myocardial infarction and stroke.We used probit regression analyses with mortality rates as dependent variable, ownership status as the key explanatory variable, and control variables which included patients' health status and socioeconomic level, and hospital characteristics. RESULTS:: Private hospitals showed lower risk of death relative to public hospitals: 1.3% in PNFP, 0.7% in PFP and 3.5% in public hospitals. CONCLUSIONS:: The analysis shows the inequities that exist between public hospitals and the private sector.

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Resumen: Objetivo: Analizar las diferencias en los resultados en salud según condiciones observadas de los hospitales, en particular su tipo de propiedad: hospitales públicos, privados sin fines de lucro (PSL) y privados con fines de lucro (PCL). Material y métodos: Se utilizó información de egresos hospitalarios en Chile entre 2001 y 2010 con un total de 16 205 314 altas de 20 hospitales públicos, 6 de PSL y 15 de PCL. Se seleccionó una muestra de pacientes con infarto al miocardio (IAM) y accidente cerebrovascular (ACV). Se estimó una regresión probit utilizando como variable dependiente la mortalidad intrahospitalaria y controlando por variables como estado de salud, nivel socioeconómico y características del hospital. Resultados: Los hospitales privados tienen menor riesgo de mortalidad intrahospitalaria: 1.3% en PSL y 0.7% en PCL, mientras que en los hospitales públicos el riesgo llega a 3.5%. Conclusiones: Este análisis muestra las inequidades que el sector público tiene respecto de los demás sectores.

Abstract: Objective: To analyze the differences in health outcomes by hospital characteristics, focusing on ownership: public, private not-for-profit (PNFP) and private for-profit (PFP). Materials and methods: We used a discharged patient dataset of Chilean hospitals for the period 2001-2010 with a total of 16 205 314 discharges in 20 public, six PNFP and 15 PFP hospitals.We selected a subsample of two medical conditions: myocardial infarction and stroke.We used probit regression analyses with mortality rates as dependent variable, ownership status as the key explanatory variable, and control variables which included patients' health status and socioeconomic level, and hospital characteristics. Results: Private hospitals showed lower risk of death relative to public hospitals: 1.3% in PNFP, 0.7% in PFP and 3.5% in public hospitals. Conclusions: The analysis shows the inequities that exist between public hospitals and the private sector.

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UNLABELLED: Public, private not-for-profit (PNFP) and private for-profit (PFP) hospitals may have different behaviour and performance in different indicators such as health outcomes, cost-efficiency and quality. Chile has a mixed healthcare system both in financing and service delivery. The public National Health Fund (Fondo Nacional de Salud) covers 76% of the population-poorer and with higher health risks-whereas private health insurers cover 16% of the population-richer and with lower health risks. The aim of the study was to analyse the in-patient mortality outcomes by hospital ownership in Chile. METHODS: We use hospital discharge data in Chile for the period 2001-10 with a total of 16,205,314 discharges in 20 public, 6 PNFP and 15 PFP hospitals. We analyse in-patient mortality considering all diagnoses and a subsample considering only myocardial infarction and stroke diagnoses. Using a probit regression, we estimate how hospital ownership explains in-patient mortality controlling for other confounding variables like health and socioeconomic status, and hospital characteristics. RESULTS: The discharge condition was reported as death in 3.5% of the public hospitals' discharges, 1.3% in PNFP and 0.7% in PFP. PNFP and PFP hospitals show a lower risk of in-hospital mortality for all diagnoses, myocardial infarction and stroke in comparison with public hospitals. DISCUSSION: The question about which type of hospital ownership performs better in Chile remains open. Policy decisions regarding health service provision requires more evidence explaining differences by ownership. Better controls for health risk and hospital characteristics are suggested to address these differences in hospital performance.

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INTRODUCTION: Ownership of healthcare providers has been considered as one factor that might influence their health and healthcare related performance. The aim of this article was to provide an overview of what is known about the effects on economic, administrative and health related outcomes of different types of ownership of healthcare providers--namely public, private non-for-profit (PNFP) and private for-profit (PFP)--based on the findings of systematic reviews (SR). METHODS AND FINDINGS: An overview of systematic reviews was performed. Different databases were searched in order to select SRs according to an explicit comprehensive criterion. Included SRs were assessed to determine their methodological quality. Of the 5918 references reviewed, fifteen SR were included, but six of them were rated as having major limitations, so they weren't incorporated in the analyses. According to the nine analyzed SR, ownership does seem to have an effect on health and healthcare related outcomes. In the comparison of PFP and PNFP providers, significant differences in terms of mortality of patients and payments to facilities have been found, both being higher in PFP facilities. In terms of quality and economic indicators such as efficiency, there are no concluding results. When comparing PNFP and public providers, as well as for PFP and public providers, no clear differences were found. CONCLUSION: PFP providers seem to have worst results than their PNFP counterparts, but there are still important evidence gaps in the literature that needs to be covered, including the comparison between public and both PFP and PNFP providers. More research is needed in low and middle income countries to understand the impact on and development of healthcare delivery systems.

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Training of postgraduate medical specialty program managers (PMSPM) is essential for the proper development of their programs. Aim: To identify the main training needs of PMSPM at a medical school. Material and Methods: A mixed-methodology approach was implemented including focus group/interviews and the administration of the Program Managers Training Needs Assessment Questionnaire (PROMANAQ) developed by an expert panel with 59 items (with two sections: relevance/performance-self-perception). Higher priority was assigned to items with high relevance and low performance. Results: Forty five PMSPM completed the PROMANAQ (81.8% response rate). Both sections of PROMANAQ were highly reliable (Cronbach alpha of 0.95/0.97 for relevance/performance-self-perception, respectively). The items with higher priority value were evaluation of clinical educators, evaluation of teaching programs and accreditation of programs. Ten PMSPM were included in the focus group (18.2% of the universe). The findings of the qualitative component were concordant with the areas explored in the questionnaire. Conclusions: The PROMANAQ is valid and reliable to identify the training needs of PMSPM. The views of PMSPM must be taken into account for faculty development planning.

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BACKGROUND: Training of postgraduate medical specialty program managers (PMSPM) is essential for the proper development of their programs. AIM: To identify the main training needs of PMSPM at a medical school. MATERIAL AND METHODS: A mixed-methodology approach was implemented including focus group/interviews and the administration of the Program Managers Training Needs Assessment Questionnaire (PROMANAQ) developed by an expert panel with 59 items (with two sections: relevance/performance-self-perception). Higher priority was assigned to items with high relevance and low performance. RESULTS: Forty five PMSPM completed the PROMANAQ (81.8% response rate). Both sections of PROMANAQ were highly reliable (Cronbach alpha of 0.95/0.97 for relevance/performance-self-perception, respectively). The items with higher priority value were evaluation of clinical educators, evaluation of teaching programs and accreditation of programs. Ten PMSPM were included in the focus group (18.2% of the universe). The findings of the qualitative component were concordant with the areas explored in the questionnaire. CONCLUSIONS: The PROMANAQ is valid and reliable to identify the training needs of PMSPM. The views of PMSPM must be taken into account for faculty development planning.

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Background: The Postgraduate Hospital Education Environment Measure (PHEEM) questionnaire, is a valid and reliable instrument to measure the educational environment (EE) in postgraduate medical education. Aim: To evaluate the EE perceived by the residents of a postgraduate training program using the PHEEM. Material and Methods: The PHEEM was applied in 2010-2011 in 35 specialty programs. We calculated their individual results and compared means of both global and individual domain scores of the PHEEM, by gender, university of origin and nationality. Cronbach's alpha coefficients and D study (Generalizability theory) were performed for reliability. Results: Three hundred eighteen residents were surveyed (75.7% of the total universe). The mean score of the PHEEM was 105.09 ± 22.46 (65.7% of the maximal score) which is considered a positive EE. The instrument is highly reliable (Cronbach's alpha = 0.934). The D study found that 15 subjects are required to obtain reliable results (G coefficient = 0.813). There were no significant differences between gender and university of origin. Foreigners evaluated better the EE than Chileans and racism was not perceived. The programs showed a safe physical environment and teachers with good clinical skills. The negative aspects perceived were a lack of information about working hours, insufficient academic counseling, and scanty time left for extracurricular activities. Conclusions: This questionnaire allowed us to identify positive aspects of the EE, and areas to be improved in the specialty programs. The PHEEM is a useful instrument to evaluate the EE in Spanish-speaking participants of medical specialty programs.

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BACKGROUND: The Postgraduate Hospital Education Environment Measure (PHEEM) questionnaire, is a valid and reliable instrument to measure the educational environment (EE) in postgraduate medical education. AIM: To evaluate the EE perceived by the residents of a postgraduate training program using the PHEEM. MATERIAL AND METHODS: The PHEEM was applied in 2010-2011 in 35 specialty programs. We calculated their individual results and compared means of both global and individual domain scores of the PHEEM, by gender, university of origin and nationality. Cronbach's alpha coefficients and D study (Generalizability theory) were performed for reliability. RESULTS: Three hundred eighteen residents were surveyed (75.7% of the total universe). The mean score of the PHEEM was 105.09 ± 22.46 (65.7% of the maximal score) which is considered a positive EE. The instrument is highly reliable (Cronbach's alpha = 0.934). The D study found that 15 subjects are required to obtain reliable results (G coefficient = 0.813). There were no significant differences between gender and university of origin. Foreigners evaluated better the EE than Chileans and racism was not perceived. The programs showed a safe physical environment and teachers with good clinical skills. The negative aspects perceived were a lack of information about working hours, insufficient academic counseling, and scanty time left for extracurricular activities. CONCLUSIONS: This questionnaire allowed us to identify positive aspects of the EE, and areas to be improved in the specialty programs. The PHEEM is a useful instrument to evaluate the EE in Spanish-speaking participants of medical specialty programs.

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