Academic literature on the topic 'Health policy decisions'

Background. High-quality health decisions are often defined as those that are both evidence informed and values congruent. A values-congruent decision aligns with what matters to those most affected by the decision. Values clarification methods are intended to support values-congruent decisions, but their effects on values congruence are rarely evaluated. Methods. We tested 11 strategies, including the 3 most commonly used values clarification methods, across 6 between-subjects online randomized experiments in demographically diverse US populations ( n1 = 1346, n2 = 456, n3 = 840, n4 = 1178, n5 = 841, n6 = 2033) in the same hypothetical decision. Our primary outcome was values congruence. Decisional conflict was a secondary outcome in studies 3 to 6. Results. Two commonly used values clarification methods (pros and cons, rating scales) reduced decisional conflict but did not encourage values-congruent decisions. Strategies using mathematical models to show participants which option aligned with what mattered to them encouraged values-congruent decisions and reduced decisional conflict when assessed. Limitations. A hypothetical decision was necessary for ethical reasons, as we believed some strategies may harm decision quality. Later studies used more outcomes and covariates. Results may not generalize outside US-based adults with online access. We assumed validity and stability of values during the brief experiments. Conclusions. Failing to explicitly support the process of aligning options with values leads to increased proportions of values-incongruent decisions. Methods representing more than half of values clarification methods commonly in use failed to encourage values-congruent decisions. Methods that use models to explicitly show people how options align with their values offer more promise for helping people make decisions aligned with what matters to them. Decisional conflict, while arguably an important outcome in and of itself, is not an appropriate proxy for values congruence.

Health is greatly influenced by social, economic and political determinants. Accordingly, decisions influencing people's health do not concern only health services or 'health policies', but decisions in many different policy areas have their influence on these health determinants. Health Impact assessment (HIA) is a predictive tool to support decisions in policy-making. The ultimate goal of this framework is to maximize health gains and, as far as possible, to reduce health inequalities. HIA presents a commitment to ensure that the rural dimension is routinely considered as part of the making and implementing of policy. The aim of this paper is to review the use of HIA on rural areas. Conclusions: HIA shows its great potential to contribute to local authority decision making. The use of HIA was identified in 2 key areas: strategic planning (sustainable development, EU Common Agricultural Policy, Federal Farm Bill, land-use planning work); and in specific smaller scale projects (rural health service redesign proposal, accessing healthy food, transport, health care disparities, etc.).

Background. We explored decisional conflict as measured with the 16-item Decisional Conflict Scale (DCS) and how it varies across clinical situations, decision types, and exposure to decision support interventions (DESIs). Methods. An exhaustive scoping review was conducted using backward citation searches and keyword searches. Eligible studies were published between 1995 and March 2015, used an original experimental/observational research design, concerned a health-related decision, and provided DCS data. Dyads independently screened titles/abstracts and full texts, and extracted data. We performed narrative syntheses and calculated average or median DCS scores. Results. We included 246 articles reporting on 253 studies. DCS scores ranged from 2.4 to 79.7 out of 100. Highest baseline DCS scores were for care planning (44.8 ± 8.9, median = 47.0) and treatment decisions (32.5 ± 12.6, median = 31.9), in contexts of primary care (40.6 ± 18.3), and geriatrics (39.8 ± 11.2). Baseline scores were high among decision makers who were ill (33.2 ± 14.1, median = 30.2) or making decisions for themselves (33.4 ± 13.8, median = 32.0). Total DCS scores <25 out of 100 were associated with implementing decisions. Without DESIs, DCS scores tended to increase shortly after decision making (>37.4). After DESI use, DCS scores decreased short-term but increased or remained the same long-term (>6 months). Conclusions. DCS scores were highest at baseline and decreased after decision making. DESIs decreased decisional conflict immediately after decision making. The largest improvements after DESIs were in decision makers who were ill or made decisions for themselves. Further meta-analyses are needed for decision type, contexts, and interventions to inform hypotheses about the expected effects of DESIs, the best timing for measurement, and interpretation of DCS scores.

This article describes the development of health technology assessment (HTA) in Sweden, its influence on decision making, and its link with priority setting. Sweden has a well established governmental HTA body, the Swedish Council on Technology Assessment in Health Care (SBU), and an increasing number of regional/local HTA organizations. HTA has had an impact on clinical practice and is used to some extent in policy decisions. Several initiatives have now been taken to develop processes for open priority setting of health-care services. With the establishment of a new agency to undertake reimbursement decisions on pharmaceuticals, and greater patient and public involvement in decision making, it seems inevitable that HTA will play a more important role in priority setting in the near future.

Introduction. The Ottawa Decision Support Framework (ODSF) has guided practitioners and patients facing difficult decisions for 20 years. It asserts that decision support interventions that address patients’ decisional needs improve decision quality. Purpose. To update the ODSF based on a synthesis of evidence. Methods. We conducted an overview of systematic reviews, searching 9 electronic databases. Eligible reviews included decisional needs assessments, decision support interventions, and decisional outcome measures guided by the ODSF. We extracted data and synthesized results narratively. Eight ODSF developers/expert users from 4 disciplines revised the ODSF. Results. Of 4656 citations, we identified 4 eligible reviews (>250 studies, >100 different decisions, >50,000 patients, 18 countries, 5 continents). They reported current ODSF decisional needs and their most frequent manifestations in the areas of inadequate knowledge/information, unclear values, decisional conflict/uncertainty, and inadequate support. They uncovered 11 new manifestations of 6 decisional needs. Using the Decisional Conflict Scale (DCS) to assess decisional needs, average scores were elevated at baseline and declined shortly after decision making, even without information interventions. Patient decision aids were superior to usual care in reducing total DCS scores and improving decision quality. We revised the ODSF by refining definitions of 6 decisional needs and adding new interventions to address 4 needs. We added a decision process outcome and eliminated secondary outcomes unlikely to improve across a range of decisions, retaining the implementation/continuance of the chosen option and appropriate use/costs of health services. Conclusions. We updated the ODSF to reflect the current evidence and identified implications for practice and further research.

Background: Global aging has increased the reliance on surrogates to make health care decisions for others. We investigated the differences between making health care decisions and predicting health care decisions, self-other differences for made and predicted health care decisions, and the roles of perceived social norms, emotional closeness, empathy, age, and gender. Methods: Participants ( N = 2037) from a nationally representative US panel were randomly assigned to make or to predict a health care decision. They were also randomly assigned to 1 of 5 recipients: themselves, a loved one 60 y or older, a loved one younger than 60 y, a distant acquaintance 60 y or older, or a distant acquaintance younger than 60 y. Hypothetical health care scenarios depicted choices between relatively safe lower-risk treatments with a good chance of yielding mild health improvements versus higher-risk treatments that offered a moderate chance of substantial health improvements. Participants reported their likelihood of choosing lower- versus higher-risk treatments, their perceptions of family and friends’ approval of risky health care decisions, and their empathy. Results: We present 3 key findings. First, made decisions involved less risk taking than predicted decisions, especially for distant others. Second, predicted decisions were similar for others and oneself, but made decisions were less risk taking for others than oneself. People predicted that loved ones would be less risk taking than distant others would be. Third, perceived social norms were more strongly associated than empathy with made and predicted decisions. Limitations: Hypothetical scenarios may not adequately represent emotional processes in health care decision making. Conclusions: Perceived social norms may sway people to take less risk in health care decisions, especially when making decisions for others. These findings have implications for improving surrogate decision making. Highlights People made less risky health care decisions for others than for themselves, even though they predicted others would make decisions similar to their own. This has implications for understanding how surrogates apply the substituted judgment standard when making decisions for patients. Perceived social norms were more strongly related to decisions than treatment-recipient (relationship closeness, age) and decision-maker (age, gender, empathy) characteristics. Those who perceived that avoiding health care risks was valued by their social group were less likely to choose risky medical treatments. Understanding the power of perceived social norms in shaping surrogates’ decisions may help physicians to engage surrogates in shared decision making. Knowledge of perceived social norms may facilitate the design of decision aids for surrogates.

background: Accreditation of local health departments (LHDs) has been identified as a crucial strategy for strengthening the public health infrastructure. This study seeks to identify the role of organizational and structural factors on accreditation-seeking decisions of LHDs. data sets and sources: Data were obtained from the NACCHO 2013 National Profile of Local Health Departments Study. . LHDs were coded as “urban”, “micropolitan”, or “rural” based on Rural/Urban Commuting Area codes. “Micropolitan” includes census tracts with towns of 10,000 - 49,999 population and census tracts tied to these towns through commuting. “Rural” includes census tracts with small towns of fewer than 10,000 population, tracts tied to small towns, and isolated census tracts. analysis: Binary logistic regression analysis was conducted to predict PHAB accreditation decision. Predictors included variables related to rurality, governance, funding, and workforce. findings: From a sample of 448, approximately 6% of LHDs surveyed had submitted their letter of intent or full accreditation application. Over two-thirds were not seeking accreditation or deferring to the state agency. LHDs located in urban communities were 30.6 times (95% CI: 10.1, 93.2) more likely to seek accreditation compared to rural LHDs. LHDs with a local board of health were 3.5 times (95% CI: 1.6, 7.7) more likely to seek accreditation (controlling for rurality). Additionally, employing an epidemiologist (aOR=2.4, 95% CI: 1.2, 4.9), having a strategic plan (aOR=14.7, 95% CI: 6.7, 32.2) were associated with higher likelihood of seeking PHAB accreditation. conclusions: Rural LHDs are less likely to seek accreditation. This lower likelihood of seeking accreditation likely relates to a myriad of challenges. Simultaneously, rural populations experience health disparities related to risky health behaviors, health outcomes, and access to medical care. Through accreditation, rural LHDs can become better equipped to meet the needs of their communities.

Background: Accreditation of local health departments (LHDs) has been identified as a crucial strategy for strengthening the public health infrastructure. Research Objective: To identify the role of organizational and structural factors on accreditation-seeking decisions of LHDs. Of particular interest is the effect of rurality on the likelihood of seeking accreditation through the Public Health Accreditation Board (PHAB). Data Sets and Sources: Data were obtained from the NACCHO 2013 National Profile of Local Health Departments Study (2013 Profile Study). The 2013 Profile Study includes a core questionnaire (core,) that was sent to all LHDs, and two modules, sent to a sample. Variables were selected from the core and module one for this project. LHDs were coded as “urban”, “micropolitan”, or “rural” based on Rural/Urban Commuting Area codes for the zip code of the LHD address. “Micropolitan” includes census tracts with towns of between 10,000 and 49,999 population and census tracts tied to these towns through commuting. “Rural” includes census tracts with small towns of fewer than 10,000 population, tracts tied to small towns, and isolated census tracts. Both “micropolitan” and “rural” categories are considered rural by the Federal Office of Rural Health Policy. Study Design: Cross-sectional. Analysis: Binary logistic regression analysis was conducted to predict PHAB accreditation decision. The variable for PHAB accreditation decision was created from the 2013 Profile Study question, “Which of the following best describes your LHD with respect to participation in the PHAB’s accreditation program for LHDs?” LHDs that selected “My LHD has submitted an application for accreditation” or “My LHD has submitted a statement of Intent” were coded as “Seeking PHAB Accreditation.” LHDs that selected “My LHD has decided NOT to apply for accreditation” or “The state health agency is pursuing accreditation on behalf of my LHD” were coded as “Not Seeking PHAB Accreditation.” Predictors included variables related to rurality, governance, funding, and workforce. Findings: From a sample of 448, approximately 6% of LHDs surveyed had either submitted their letter of intent or full accreditation application. Over two-thirds were either not seeking accreditation or deferring to the state agency. LHDs located in urban communities were 30.6 times (95% CI: 10.1, 93.2) more likely to seek accreditation compared to rural LHDs. LHDs with a local board of health were 3.5 times (95% CI: 1.6, 7.7) more likely to seek accreditation (controlling for rurality). Additionally, employing an epidemiologist (aOR=2.4, 95% CI: 1.2, 4.9), having a strategic plan (aOR=14.7, 95% CI: 6.7, 32.2), and higher per capita revenue (aOR=1.02, 95% CI: 1.01, 1.02) were associated with higher likelihood of seeking PHAB accreditation. Conclusions: Specific geographic, governance, leadership, and workforce factors were associated with intention to seek accreditation. Implications: Rural LHDs are less likely to seek accreditation. This lower likelihood of seeking accreditation likely relates to a myriad of challenges (e.g., lower levels of staffing and funding). Simultaneously, rural populations experience health disparities related to risky health behaviors, health outcomes, and access to medical care. Through accreditation, rural LHDs can become better equipped to meet the needs of their communities.

Introduction: Beta-Blocker Evaluation Survival Trial (BEST) sub-analyses indicated a likely interaction between bucindolol and race disadvantaging black heart failure (HF) patients (Domanski J Cardiac Fail 2003); Arg389 homozygotes having adjusted reductions of 38% in mortality and 34% in mortality/hospitalization over other genotypes (Liggett PNAS 2006). Bucindolol is being evaluated in Arg389 genotype patients in the GENETIC-AF trial (NCT01970501). Objective: To conduct parallel (using Domanski et al and Liggett et al) ex ante economic evaluations of Arg389 genetic testing in stage III/IV HF to support bucindolol treatment decisions (if Arg389-positive) and carvedilol (if Arg389-negative) treatment versus no such testing and empirical bucindolol; using Domanski et al and Liggett et al BEST sub-analyses. Methods: In both Domanski et al and Liggett et al analyses, we used a decision tree model with time horizon of 18 months divided into 3 six-month cycles to estimate the cost-effectiveness and cost-utility of Arg389 genetic testing, considering overall survival (OS) from Domanski et al and Liggett et al BEST sub-analyses. Costs and utilities were retrieved from literature except for assumed cost for bucindolol treatment (1.5x cost of carvedilol) and genetic testing ($250). Discount rate was set at 3%/yr. Weibull distributions were fitted to OS data. Life-years (LY) and quality-adjusted life-years (QALY) were used to estimate incremental cost-effectiveness (ICER) and cost-utility ratios (ICUR), and results were validated using probabilistic sensitivity analyses (PSA). Results: In the Domanski et-based analysis, Arg389 genetic testing versus no testing was associated with incremental gains of 0.29LYs and 0.27QALYs at incremental cost of $726; yielding ICER of US$2,503/LY and ICUR of US$2,688/QALY gained. In the Liggett et al-based analysis, Arg-389 genetic testing versus no testing was associated with incremental gains of 0.35LYs and 0.32QALYs at savings of -$1.081; for ICER of -US$3,089/LY and ICUR of -US$3,378/QALY gained. Both analyses were confirmed in PSAs. Conclusion: Arg389 genetic testing to support bucindolol treatment in stage III/IV HF patients prevails economically over bucindolol treatment without genetic testing due to superior OS. If bucindolol is priced at 1.5x the cost of carvedilol. this economic benefit is likely to disappear if bucindolol and/ or genetic testing are priced higher. The clinical and economic benefits of bucindolol treatment with versus without Arg389 genetic testing versus empiric carvedilol remains to be assessed.

A contribuição dos problemas ligados ao álcool para a carga de doenças em África tem sido amplamente negligenciada. Devido a rápidas mudanças no contexto de vários países e a novas evidências científicas relativas a doenças atribuíveis ao álcool, tais como HIV e a incidência de TB, os problemas e carga da doença em África relacionados com o consumo de álcool podem ser maiores do que o que foi previamente estimado. Ao mesmo tempo existe pouca informação sob a forma como os países estão a gerir o consumo de álcool e as consequências ligadas a esse consumo, o que sugere que uma avaliação das políticas nacionais é necessária nesta região. O objetivo geral desta tese é o de rever as evidências relacionadas com o consumo de álcool em África e analisar as políticas do álcool existentes, contribuindo assim para a melhoria das decisões políticas relacionadas com esse consumo na região. Em particular, a tese concentra-se nos quatro objetivos específicos seguintes: I) estimar a mortalidade e morbilidade atribuídas ao álcool em África; II) identificar os fatores que podem afetar a magnitude e os padrões de consumo de álcool em África; III) avaliar as respostas políticas nacionais relacionadas com o consumo de álcool em 46 países e sua eficácia para reduzir os malefícios relacionados com esse consumo; IV) documentar as diferentes etapas e atores envolvidos no desenvolvimento de uma política relativa ao consumo de álcool num país Africano (Malawi). A investigação utilizou diferentes tipos de métodos. Os resultados mostram que o consumo de álcool tem um grande impacto sobre a carga de doença e mortalidade nos países africanos, com o álcool sendo responsável, em 2012, por 6.4% de todas as mortes e 4.7% de todos os DALYs na Região (estudo I). A nossa análise identificou sete fatores que estão intimamente ligados a possíveis mudanças no consumo de álcool em África. Impulsionada em grande parte pela globalização, a convergência potencial desses fatores é suscetível de se associar a um crescimento contínuo no consumo de álcool bem como ao aumento da morbilidade e mortalidade relacionada ao álcool em todo o continente (estudo II). Os países têm vindo a utilizar diferentes tipos de medidas de política para controlar o consumo de álcool. A avaliação dos níveis atuais de restrição das políticas existentes, mostra que os países atingiram uma pontuação média de 44,1 de 100 pontos possíveis, variando entre 9,1 (São Tomé e Príncipe) e 75,0 pontos (Argélia). De acordo com nossos resultados, os níveis de restrição das políticas existentes estão negativamente correlacionados com o consumo de álcool em consumidores atuais (rs = -.353, p = 0,005) (Estudo III). O estudo IV reflete as dificuldades e complexidade dos processos políticos e sociais na elaboração de políticas de álcool no Malawi. Apesar da influência da indústria do álcool no estabelecimento da agenda politica e no processo de consulta, o nosso estudo demonstra que as organizações da sociedade civil, quando devidamente financiadas e apoiadas, podem desempenhar um papel importante e decisivo na evolução da política do governo com vista a defesa do interesse público. As frações de mortalidade e morbilidade atribuídas ao álcool em muitos países africanos são consideráveis e, portanto, o álcool não pode ser deixado de fora das agendas de saúde e desenvolvimento desses países. Os governos africanos precisam de ter um papel mais ativo na proteção da saúde da população. Embora os países tenham adotado algum tipo de medidas de políticas para controlar o consumo de álcool, os nossos resultados mostram que há uma necessidade de uma resposta política mais forte para reduzir a carga relacionada com o consumo de álcool no continente. Finalmente, devido às dificuldades inerentes ao desenvolvimento de políticas do álcool, os governos devem considerar fortemente o aumento da participação das organizações da sociedade civil para apoiar uma direção no sentido da defesa do interesse público.
Alcohol-related problems and burden of disease in Africa has been largely neglected. Due to the rapidly changing context in several countries and new scientific evidences of alcohol-attributablediseases, such as HIV and TB incidence, alcohol-related problems and burden of disease in Africa might be higher than what has previously been estimated.At the same time there is little information on the extent to which African countries are addressing alcohol consumption and alcohol-related harm, which suggests that evaluations of national alcohol policies are needed in this region.The overall aim of this thesis is to reviewevidence about alcohol consumption and analyse alcohol-related policies in Africa, thus contributingto the improvement of alcohol-related policy decisions in this region. In particular the thesis concentrates on followingfour objectives: I) estimate alcohol-attributablemortality and morbidityin Africa; II) identifyfactors that might affect magnitude and patterns of alcohol consumption in Africa; III)evaluatenational alcohol policy responses in 46 countries and their effectiveness to reduce alcohol-related harm; IV) document the different stages and actors involved in the development of alcohol policy in one African country (Malawi).The research used different type of methods. Our results show thatalcohol consumption has a large impact on burden of disease and mortality in African countries, withalcohol being responsible, in 2012, for 6.4% of all deaths and 4.7% of all DALYs in the Region(study I). Our analysis identified seven factors which are closely tied to potential changes in alcohol consumption in Africa. Driven largely by globalization, a potential convergence of these factors is likely to be associated with continued growth in alcohol consumption and alcohol-related morbidity and mortality across the continent(study II).Countries have been using different types of policy measuresto control alcohol consumption. When evaluating current policy restrictiveness, countries attained a mean score of 44.1 of 100 points possible, ranging from 9.1 (Sao Tomé and Principe) to 75.0 (Algeria). According to our results, actual policy restrictiveness scores were negatively correlated with and APC among drinkers (rs = -.353, p = 0.005) (Study III). Study IV reflects the difficulties and complexityof alcohol policy development in Malawi. Despite the influence of the alcohol industry in the agenda-settingand consultative process, when adequately resourced and supported, civil society organizations were found toplay an ximportant and decisiverole in steering policy developments in a sound public-interest direction. Alcohol-attributable fractions of mortality and morbidity in many African countries are considerable and therefore alcohol cannot be left out of countries health and development agendas. African governments need to take a more active role in protecting the public’s health. Although countries have adopted some type of policy measures to control alcohol consumption, our results show that there is a need for a strongerpolicy response to reduce alcohol-related burden in the continent. Finally, due to the inherent difficulties in alcohol policydevelopment, governments should strongly consider increasing the involvement of civil society organisations to support sound public-interest direction.

Despite the growing concerns about routine prostate-specific antigen (PSA) screening in men, little is known about the societal and economic impact of screening among the African American population. The purpose of this qualitative case study was to explore beliefs among African American men about PSA screening, funding for screening, and the role of the United States Preventive Service Task Force in addressing the problem. Guided by rational choice theory, data collection consisted of completion of a health beliefs survey, face-to-face interviews, field notes taken during interview, and interview audio recording. The population for the study included African American men residing in a large metropolitan Midwestern city, who are between the ages of 45 and 65, and who have not been diagnosed with prostate cancer disease. Data were analyzed using NVivo10-© to identify themes and patterns. Results from the study show that the decision to participate in prostate screening for African American men is hindered due to concerns about access, cost, and affordability. These three factors should be further evaluated in a larger setting for a greater understanding of their roles in more effective screening programs and policies. Insights gained from this study may positively impact future policy by providing a deeper understanding of the beliefs held by African American men on the issue of prostate cancer screening that may eventually lead to developing and successfully implementing policies that can be cost effective.

Policies mandating HIV status disclosure to decrease incidence create ethical challenges for physicians on whether to breach or maintain infected patients' confidentiality. In Sub-Saharan Africa where HIV incidence is high, there is a need for clear guidelines/policies on making confidentiality decisions. The purpose of this quantitative quasi experiment was to determine whether the gender, gender orientation, and sexual relationship of an infected patient and physicians' demographics predicted physicians' decisions to breach confidentiality. In Plateau State, Nigeria, 222 physicians were given vignette questionnaires containing 6 different descriptions of gender, gender orientation, and sexual relationships of a hypothetical patient. Each physician decided to maintain or breach a patient's confidentiality in a variant. The utilitarian framework was applied, and data were analyzed using logistic regression models. A majority of the participants (70%) indicated a breach by directly informing sex partners or informing or referring to the health department. Only physicians' feature of previous confidentiality breach significantly predicted the decision to breach [p =.028, Exp (B) =.1.345, 95%CI (1.032, 1.753)]. The results suggested that regardless of patients' characteristics, physicians will breach confidentiality to protect sex partners potentially at risk of HIV infection. These findings may bring about positive social change by clarifying reasons for physicians' breach decisions, by informing the development of physicians' decision guidelines that would enhance physicians' practices in managing discordant couples, which could reduce HIV transmission among discordant couples leading to better and longer lives.

A judicialização da saúde é uma expressão cada vez mais presente nos cenários de assistência à saúde no Brasil materializada, principalmente, pelos mandados judiciais para a realização de procedimentos diagnósticos e terapêuticos, consultas, internações e dispensação de insumos médico-cirúrgicos. Como objetivo geral o estudo visa analisar o processo de judicialização da saúde no Brasil, no âmbito do SUS, a partir dos profissionais de saúde envolvidos nesse processo. Foram definidos como objetivos específicos descrever a estrutura e os conteúdos das representações sociais da judicialização da saúde no âmbito do SUS para gestores, reguladores e profissionais de saúde envolvidos no processo de atendimento às demandas geradas pela prática da ação judicial; comparar as Representações Sociais sobre a judicialização da saúde destes grupos sociais; discutir os conteúdos dessas representações no processo de judicialização da saúde compreendendo o campo social no qual esta questão se insere, as relações de poder que as perpassam e as construções simbólicas que as especificam. Trata-se de um estudo qualitativo, desenvolvido à luz da Teoria das Representações Sociais, realizado com 152 profissionais, em um hospital universitário e na central de regulação de procedimentos e leitos na cidade do Rio de Janeiro. Aplicou-se a Técnica de Evocação Livre através do termo indutor judicialização da saúde, sendo essas analisadas com a técnica de quadro de quatro casas e 40 entrevistas semiestruturadas analisadas através da análise de conteúdo temático-categorial instrumentalizada pelo software NVivo. Na análise estrutural foram evocadas 761 palavras, com média das ordens médias de evocação de três, com frequência máxima de 17 e mínima de 10, já a análise processual resultou em seis categorias, com 2257 unidades de registro, distribuídas em 85 temas. Identificou-se que os profissionais de saúde apresentam um posicionamento negativo diante da realidade imposta pela judicialização, entretanto reconhecem esse recurso como necessário mediante a crise da saúde pública brasileira. Os profissionais de saúde trabalham sob a pressão do poder judiciário, com a ameaça de prisão levando a um cotidiano estressante de suas práticas profissionais decorrente de uma ação ineficaz do Estado na execução da política de saúde. Conclui-se que a representação social encontra-se em fase final de consolidação. Considerando a representação social como determinante de práticas, concluímos também que as representações que emergiram deste estudo podem contribuir para a mudança das práticas dos profissionais de saúde que operacionalizam esse sistema. Espera-se desta forma, que ocorra a promoção de melhorias no resultado final da assistência direta aos usuários que buscam as instituições públicas de saúde para serem atendidos em suas necessidades de saúde, caracterizando-se dessa forma um desafio maior que caminha no sentido de fazer avançar a democracia e a cidadania.
The health litigation is an expression increasingly present in the public institutions of health care in Brazil materialized mainly by warrants for performing diagnostic and therapeutic procedures, consultations, hospitalizations and dispensation of medical and surgical supplies. The study aims to analyze the process of legalization of health in Brazil, under the Unified Health System, from the health professionals involved in this process. Were defined as specific goals the description of the structure and content of the social representations of litigation of health activities and services within the managers, regulators and health professionals involved in the process of legalization of health; the comparison of the social representations about the legalization of that social group and the discussion of the contents of these representations in the legalization of health process. This is a qualitative study, based on the Theory of Social Representations, conducted with 152 subjects in a university hospital and the central of regulation of procedures and beds in the city of Rio de Janeiro. We applied the free word association technique by the inducing term "health litigation", that were analyzed with the technique of four-digit chart and also 40 semi-structured interviews that were analyzed through thematic content analysis, instrumentalized by NVivo software. 761 words were evoked with average sized orders recall of 3, with maximum and minimum frequency of 17 and 10. The procedural analysis resulted in six categories, with 2257 units of analysis, distributed in 85 themes. It was identified that health professionals have a negative position towards the reality imposed by the l health litigation, however they recognize this feature as required by the Brazilian public health crisis. Health professionals are working under the pressure of the judiciary, with the threat of arrest leading to a stressful routine of their professional practices due to an ineffective action of the State in the implementation of health policy. It is concluded that social representation is in the final stages of consolidation. Considering the social representation as a determinant of practices, we also concluded that the representations that have emerged from this study may contribute to the changing practices of health professionals that operationalize this system. It is expected therefore, that the promotion of improvements occur on the outcome of direct assistance to users seeking the public health institutions to be cared for in their health needs, characterizing thereby a greater challenge that goes towards making advancing democracy and citizenship.

The advancement in technology mandates the extensive use of computerized healthcare devices making Electronic Health Records (EHRs) the way to store the patient details. The EHR systems have high availability and security requirements for the storage database. DIGHT is a distributed key-value store architecture being developed at SICS addressing the problems of high availability and scalability, data integrity and confidentiality, accountability, EHR versioning and extensibility. This Master thesis addresses the authorization requirements of the EHR systems. eXtensible Access Control Markup Language (XACML) is a OASIS standard for general purpose access control policy language designed for managing the access for resources. All of the available open source implementation of Policy Decision Point(PDP) conforms to XACML version 2.0 and retrieves the policies from the traditional file systems. Sun open source implementation of PDP conforming to XACML 2.0 was evaluated. It was upgraded to conform with XACML 3.0 standards. The XACML Admin Profile for delegation was also implemented. The testing was carried out with a prototype application which accepts text sms from registered doctors through an sms gateway. The application was designed for adding new patient record, medical record to an existing patient and retrieving existing patient and medical records. The application generates the XACML Request and send it to the PDP for evaluation. The XACML policies for authorizing the doctors were stored in MySQL database clusters. The PDP evaluates the request and send the XACML Response back to the application. The application processes the response and send appropriate reply to the sender. Performance evaluation was carried out with policies stored in database clusters. The thesis also discusses about the possible future enhancements like implementing XACML profile for SAML assertions, implementing the Policy Information Point to fetch attributes.

AbstractThe utility of political science insight and methodology for public health has become increasingly apparent in discussions over policy implementation. However, prior to coronavirus 2019 (COVID-19), public health analyses undertaken within a political science paradigm focused primarily on how to mobilize decision-makers in order to bring about particular kinds of legislation or policy initiatives (policies on tobacco, alcohol, urban design, etc.). This chapter, written before the onset of COVID-19, suggested that it would be useful to use the lens of political science to understand pandemic planning, as the evidence-policy-politics nexus in public health differs substantially between the fields of health promotion and disease surveillance and response. Using the case of H1N1 in Nova Scotia, the chapter notes some of the political tensions that arose when decisions had to be made in the face of limited information, public pressure, and rapidly-changing circumstances.

Abstract In this chapter, I outline some key patient-centred medical virtues and several community-centred medical virtues, and I consider what sorts of antimicrobial prescribing decisions such virtues would lead physicians to make. I argue that practically-intelligent virtuous physicians should also have an awareness of the sorts of cognitive biases that are especially likely to distort their antimicrobial prescribing decisions, and I urge physicians to develop ways of avoiding or counteracting such biases. Further, I argue that effectively addressing the impact of these biases and other countervailing factors that inhibit virtuous prescribing practices is the responsibility not only of individual physicians, but also of institutions and regulators. I outline some strategies that individual physicians, institutions, and healthcare policymakers could develop to help physicians hit the targets of those patient-centred and community-centred medical virtues, and to thereby play their part in redressing the problems of antimicrobial resistance.

A Public Health Observatory (PHO) is a platform to provide “health intelligence” as a service for a specific population. The World Health Organization (WHO) identifies the primary purposes of PHOs as “monitoring health situations and trends, including assessing progress toward agreed-upon health-related targets; producing and sharing evidence; and, supporting the use of such evidence for policy and decision making” For the purposes of the PULSE project, create an observatory to function as a unique point of access to the PULSE technology for people both inside and outside the project consortium.Specifically, we create a platform for e-learning and knowledge sharing that it can be easily navigated by lay persons that are interested in learning about or participating in the PULSE project. We targeted specifically policymakers, clinicians, as well as leaders and citizens in other cities. As a concept, it reflects the principles participation, sustainability, and collaboration across sectors and levels of government The Observatory leverages on the Health in All Policies (HiAP) framework. HiAP is a cross-sectoral approach to public policy that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity.

ExpressDecision2 is a general-purpose web application designed to support the individual in making difficult decisions under uncertainty, which are emotionally driven and typically solved by using rational intuition. This web app is based on the self-regulation model of the thinking process developed within the framework of the systemic-structural activity theory. This paper demonstrates the application of two customized versions of ExpressDecision2: 1. ED2StatinChoice – for making a patient-centered and shared-with-clinician decision about taking statins for cholesterol reduction to prevent a heart attack or stroke. The two primary resources regarding taking statins for cholesterol reduction are The 2018 AHA/ACC Cholesterol Guideline and Mayo Clinic Statin Choice Decision-Aid tool. These and other guidelines and decision aids, as well as information derived from a health professional, provide the patient with essential information regarding the pros and cons of using statins, while also empowering the patient to make the ultimate decision regarding whether they should take statins. Overall, such a problem is both uncertain and difficult for the patient and so requires them to establish both short- and long-term goals, as well as relevant options for selection. ED2StatinChoice is designed specifically to help the patient make the best choice in such a difficult scenario. ED2StatinChoice complements existing decision-support tools, such as the Mayo Clinic Statin Choice Decision Aid. Its method of assistance involves clarifying the goal and various choices with subsequent aggregation of all pros and cons, thus helping make a motivated decision regarding which statin therapy is most preferable. 2. ED2InsuranceChoice – for making a client-centered and potentially shared-with-agent decision about buying an insurance policy in order to reduce financial uncertainty and make accidental loss more manageable. People buy health, car, life, home and other types of insurance to protect themselves from financial loss in the event of illness, car damage, house fire and other accidents, respectively. For example, they make decisions when choosing from among liability, comprehensive and collision insurance types. This decision-making process is guided by tangible statistical factors regarding people’s risks of accidental losses and by non-tangible factors, such as “peace of mind” due to being protected against financial loss in the event of an accident. It is important to note that peace of mind is an essential and decisive factor when selecting an insurance policy. It reflects subjective justification of rate adequacy for the premium: the premium should be reasonable and coverage must be sufficient. Unfortunately, such non-tangible factors as peace of mind from being protected against financial loss in an accident, as well as anxiety from losing money while paying an insurance premium for coverage that doesn’t get used unless you have an accident are not sufficiently reflected in existing models of insurance choice.

The article is devoted to the problems of human resource management in the modern environment in the context of sustainable development of the region. The authors of the study suggest the need for a socio-economic policy in the North Ossetia-Alania and the Russian Federation, which will help to reduce the adverse effects of various environmental factors on human resources, demographics and health of the region. In conducting the study, the authors found that anthropogenic impacts lead to environmental problems of various kinds. The consequence of this is an increase in morbidity and natural loss of population characteristic of several regions of the country. The authors had taken account of the provisions that a decent quality of life, a healthy population, and thus a high level of human development can be ensured only if the natural environment is preserved and maintained at an appropriate quality. The main provisions of the article and the results presented are interesting for further theoretical substantiation, research and practical recommendations in the field of human resource management strategy development, their development and use. Allow to develop strategic decisions on the problems of formation and consistent implementation of a unified state and regional policy in the field of preservation of human resources, to implement the most ambitious programs aimed at improving public health and the environmental situation.

Management accounting theory aims to contribute to manag­ers using accounting reports for supporting their management decisions. During the COVID-19 pandemic, such insights would be essential for sup­porting decisions during lockdowns and other policy makers’ rules imposed by this health crisis. To unveil how academic literature addresses manage­ment accounting challenges arising from the COVID-19 specific context, this study conducts an automated computer analysis of the bibliometric data addressing financial issues related to the COVID-19 pandemic.

Policy decisions regarding commercial harvesting of aquatic species by (typically governmental) regulatory agencies are often based in part upon field data, simulation results, and mathematical models. Regulatory agencies may limit or expand seasons, determine total harvest allowed, increase or decrease licensure fees, and raise or lower taxation rates in response to the state of the ecological system. Ultimately, the regulatory agency uses such measures to ensure viable populations in an attempt to balance ecosystem health and benefits for society. Such decisions impact commercial fishing ventures affecting the nature of harvesting efforts and their intensity. Conclusions drawn from mathematical models of ecological systems, and derived simulation results which affect this reality are highly dependent upon the validity of information available. Knowledge or estimates of critical parameters such as intrinsic growth rate, carrying capacity, etc. and dynamic variables such as biomass levels dictate the usefulness of analytical and numerical analyses. The purpose of this treatment is to illustrate that control laws applied to mathematical models of species dynamics may be used to discern estimates of parameters that inherently exist in such models in an effort to provide more valuable information upon which to base policy decisions. Dynamic models of both single-species evolution and predator-prey interactions are examined.

Background: Cannabis is the most commonly used drug during pregnancy in the United States and use during pregnancy is increasing along with greater legal and social acceptance. Methods: We conducted a qualitative content analysis of 23 in-depth interviews with pregnant and lactating people in Massachusetts, a state that legalized cannabis for adult use in 2016. Our aim was to explore how policy constrains or facilitates people’s ability to make informed decisions about cannabis use during pregnancy and lactation. Our analysis was conducted using an ecosocial approach, recognizing that the implementation and interpretation of cannabis policy can be understood at multiple levels, which interact with each other and shape the health and experiences of individuals. Additionally, this analysis was informed by a harm reduction approach in which we acknowledge the complexity surrounding cannabis use during pregnancy and lactation, while attempting to identify ways to reduce potentially harmful consequences. Results: Findings revealed that, despite the legal status of cannabis, there continues to be a lack of clarity for pregnant and lactating people regarding the legal implications of cannabis use. Inconsistent state and institutional policies about drug testing of mothers and newborns leave a cloud of fear hanging over the experiences of cannabis users and inhibit their ability to obtain expert advice from healthcare providers. Conclusion: Decision makers in public and institutional policy should work to clarify and update policies regarding substance use during pregnancy following legalization of a new substance, and ensure that pregnant and lactating people are afforded the same legal protections as the general population.

Current requirements for site remediation and closure are standards-based and are often overly conservative, costly, and in some cases, technically impractical. Use of risk-informed alternate endpoints provides a means to achieve remediation goals that are permitted by regulations and are protective of human health and the environment. Alternate endpoints enable the establishment of a path for cleanup that may include intermediate remedial milestones and transition points and/or regulatory alternatives to standards-based remediation. A framework is presented that is centered around developing and refining conceptual models in conjunction with assessing risks and potential endpoints as part of a system-based assessment that integrates site data with scientific understanding of processes that control the distribution and transport of contaminants in the subsurface and pathways to receptors. This system-based assessment and subsequent implementation of the remediation strategy with appropriate monitoring are targeted at providing a holistic approach to addressing risks to human health and the environment. This holistic approach also enables effective predictive analysis of contaminant behavior to provide defensible criteria and data for making long-term decisions. Developing and implementing an alternate endpoint-based approach for remediation and waste site closure presents a number of challenges and opportunities. Categories of these challenges include scientific and technical, regulatory, institutional, and budget and resource allocation issues. Opportunities exist for developing and implementing systems-based approaches with respect to supportive characterization, monitoring, predictive modeling, and remediation approaches.

The Covid-19 crisis has impressively raised the general awareness that our social coexistence and political decisions are essentially based on data, the weighing of risks and thus on probability estimates. This places high demands on the ability of health authorities, policy makers and the media to communicate statistical information as well as on the ability of citizens to understand these messages. In this paper we reflect on the role of scientific evidence in democratic societies and analyze selected illustrative examples of communicating evidence via visualizations and simulation, media reports, and expert’s statements. We identify venues and formats of communicating statistical information about the pandemics to the public that seems to be effective contrasting less helpful formats. We conclude by presenting recommendations for stakeholders in politics, media and statistics agencies on how to communicate empirical evidence to the public efficiently, released by the Deutsche Arbeitsgemeinschaft Statistik, an umbrella organization of statistical associations in Germany.

The ‘reinstatement’ of children within the planning discourse reflects a scholarly and professional recognition of the interdependencies between urban space and critical health issues of specific social groups (Gleeson & Sipe, 2006). This research paper interrogates the international policy concept of child-friendly cities, defined as “any system of local governance committed to fulfilling child rights as articulated in the Convention on the Rights of the Child. It is a city or community where the voices, needs, priorities and rights of children are an integral part of public policies, programmes and decisions” (UNICEF, 2018: 10). It considers the conceptual limitation of the policy concept when children’s ability to survive, grow and thrive are increasingly threatened by extreme weather events and environmental degradation. The research paper looks specifically at the urban challenges faced by mega-delta cities in Asia (e.g. Bangkok, Dhaka, Hanoi, Ho Chi Minh City, Kolkata, Shenzhen, Yangon) where children make up a sizeable demographic group. Utilizing the uneven spatial development of Dhaka, Bangladesh (Ganges-Brahmaputra Delta) as case study, the paper explores how the conceptual limitation of CFCs shapes its implementation gaps. Lastly, this research paper considers the long-term impact of the COVID-19 pandemic on children living in the mega-deltas cities of Asia.

The Social Protection and Health (SPH) Division of the Inter-American Development Bank (IDB) held its annual Regional Policy Dialogue (RPD) Digital Health for All: Latin America and the Caribbeans golden opportunity to improve the efficiency, quality and equity of sector on September 12-14th 2022 in Panama City, Panama. The RPD brought together over 120 participants, including leaders from over 20 countries, vice-ministers of health and directors of technology and communications, and regional and global experts in digital health. The meeting sought to provide a setting to discuss what the IDB and different countries have learned in the past four years of implementation of digital health, structural challenges to scale digital health, and the measures needed to ensure that decisions made today are both sustainable and transformational. The meetings objectives broadly included discussing three topics: 1) how to ensure that digital health adds value in terms of improved efficiency, quality, and equity;2) policy considerations for linking digital health to health outcomes; and3) the future state of our region in terms of digital transformation of the health sector.This report provides an overview of the meeting, its main findings, and the steps that lie ahead on this journey.

Complex systems modelling is already implemented in critical policy areas such as climate change and health. It could also play an important role in the nuclear weapons sphere – by opening alternative pathways that may help mitigate risks of confrontation and escalation – but such modelling has yet to be fully embraced by policymakers in this community. By applying a complexity lens, policy- and decision-makers at all stages along the nuclear chain of command might better understand how their actions could have significant consequences for international security and peace. Nuclear decision-making is shaped by, and interacts with, the ever-changing international security environment and nuclear weapons policy. Tackling problems in the nuclear weapons policy field requires the implementation of ‘system of systems’ design principles, mathematical modelling approaches and multidisciplinary analysis. This research paper presents nuclear weapons decision-making as a complex endeavour, with individual decisions being influenced by multiple factors such as reasoning, intuition (gut feeling), biases and system-level noise. At a time of crisis, these factors may combine to cause risks of escalation. The authors draw on past examples of near nuclear use to examine decision-making in the nuclear context as a ‘wicked problem’, with multi-layered, interacting and constantly fluctuating elements.

In the Philippines, demand for family planning (FP) is high, and the government is committed to helping the population achieve universal access to quality FP information and services. Reach Health Assessing Cost-Effectiveness for Family Planning (RACE-FP) is a decision support tool designed to estimate the impact FP interventions have on averting unintended pregnancies and on downstream maternal and neonatal health (MNH) outcomes. This report provides technical details of the RACE-FP model. RACE-FP is organized by objectives: improve postpartum FP, improve public sector and private sector provision of FP, improve demand for FP, reduce contraceptive stockouts, and introduce a modern contraceptive method. Although other models have been developed to estimate the impact of contraceptive use on averting unintended pregnancy at the national level for the Philippines, RACE-FP is the only model to provide estimates at national and regional levels, include intervention and commodity costs, disaggregate outcomes by age group and setting (public, private, community), and estimate the broader impact of modern contraceptive prevalence on MNH outcomes. RACE-FP can be an important resource to determine the relative benefit of FP interventions in the Philippines and could support policy decisions globally.

Review question / Objective: The study aims to synthesize, through a review of existing scientific literature, the Health State Utility Value (HSUV) of patients with herpes zoster or postherpetic neuralgia. Condition being studied: Herpes zoster is caused by the reactivation of a primary varicella zoster virus infection. Postherpetic neuralgia is the most common complication, which is defined as pain in a dermal distribution that is maintained for at least 90 days after the rash. The pain caused by postherpetic neuralgia is often debilitating and affects physical functioning, psychological and well-being. Thus, the postherpetic neuralgia has a profound negative impact on functional status and quality of life, and generally results in substantial utilization of health services. An increase in the incidence of post-herpetic neuralgia and herpes zoster is expected, due to the increase in life expectancy, therefore, the result of this review may be important for public policy decisions.

Just over a decade ago, several forest agency leaders from around the world met in Beijing, China at a conference convened by the Rights and Resources Initiative (RRI), the State Forestry Administration (SFA) of China and the Chinese Center for Agriculture Policy (CCAP). As leaders—from Brazil, China, Mexico and the USA—we reflected on how few opportunities existed to learn from one another to discuss forest issues in an informal atmosphere outside of the protocol-laden, jurisdictionally-defined sessions we commonly attended. We wondered whether there was a better way—whether it was possible to have safe conversations where difficult issues, struggles and mistakes could be raised, acknowledged and learned from. From this first conversation, MegaFlorestais was created: a self-governing group of public forest agency leaders with RRI serving as the Secretariat and main funder. The period of 2005-2015 brought changes in forest governance, the status of forest ownership, the health of the world’s forests and the global context within which forestry decisions are made. But much has remained the same. Was MegaFlorestais a factor? What can be learned from reflecting on these changes in a decade?

A number of interventions aiming to increase the use of systematic review evidence in decision making are currently in use. These include summaries of systematic reviews designed to improve the accessibility of the findings (“information products”) and changes to organisational structures, such as employing specialist groups to synthesise evidence in order to inform local decision making.

This report supports an evidence-based approach to the prevention and education objective of the National Strategy to Reduce Harm from Gambling. Applying a public health policy lens, it considers three levels of measures: universal (for the benefit of the whole population), selective (for the benefit of at-risk groups), and indicated (for the benefit of at-risk individuals). Six measures are reviewed by drawing upon a range of evidence in the academic and grey literature. The universal level measures are “Regulatory restriction on how gambling is provided” and “Population-based safer gambling/responsible gambling efforts.” Selective measures focus on age cohorts in a chapter entitled, “Targeted safer gambling campaigns for children, youth, and older adults.” The indicated measures are “Brief internet delivered interventions for gambling,” “Systems and tools that produced actual (‘hard’) barriers and limit access to funds,” and “Self-exclusion.” Since the quantity and quality of the evidence base varied by measure, appropriate review methods were selected to assess publications using a systematic, scoping, or narrative approach. Some measures offered consistent findings regarding the effectiveness of interventions and initiatives, while others were less clear. Unintended consequences were noted since it is important to be aware of unanticipated, negative consequences resulting from prevention and education activities. After reviewing the evidence, authors identified knowledge gaps that require further research, and provided guidance for how the findings could be used to enhance the prevention and education objective. The research evidence is supplemented by consultations with third sector charity representatives who design and implement gambling harm prevention and education programmes. Their insights and experiences enhance, support, or challenge the academic evidence base, and are shared in a separate chapter. Overall, research evidence is limited for many of the measures. Quality assessments suggest that improvements are needed to support policy decisions more fully. Still, opportunities exist to advance evidence-based policy for an effective gambling harm prevention and education plan.

This publication presents six case studies of public policies that promote the development and use of geospatial technologies and applications, which can be categorized in five layers: institutions, tools, data, skills and industry. The evolution of these technologies and applications over the past decade has been driven by the understanding that where people and things are located is central to smart decision making. As a result of low-cost launch vehicles, increasing numbers of satellites in orbit, new sensor technologies, machine learning algorithms, advances in cloud computing, and the emergence of other technologies such as drones and high-altitude platforms, the geospatial economy is now expanding into many new geographies and sectors. This expansion calls for the development of innovative applications that benefit government in areas such as agriculture, environment, energy, aviation, maritime, transport, health, education, business, and society.

1.1 Macroeconomic summary Economic recovery has consistently outperformed the technical staff’s expectations following a steep decline in activity in the second quarter of 2020. At the same time, total and core inflation rates have fallen and remain at low levels, suggesting that a significant element of the reactivation of Colombia’s economy has been related to recovery in potential GDP. This would support the technical staff’s diagnosis of weak aggregate demand and ample excess capacity. The most recently available data on 2020 growth suggests a contraction in economic activity of 6.8%, lower than estimates from January’s Monetary Policy Report (-7.2%). High-frequency indicators suggest that economic performance was significantly more dynamic than expected in January, despite mobility restrictions and quarantine measures. This has also come amid declines in total and core inflation, the latter of which was below January projections if controlling for certain relative price changes. This suggests that the unexpected strength of recent growth contains elements of demand, and that excess capacity, while significant, could be lower than previously estimated. Nevertheless, uncertainty over the measurement of excess capacity continues to be unusually high and marked both by variations in the way different economic sectors and spending components have been affected by the pandemic, and by uneven price behavior. The size of excess capacity, and in particular the evolution of the pandemic in forthcoming quarters, constitute substantial risks to the macroeconomic forecast presented in this report. Despite the unexpected strength of the recovery, the technical staff continues to project ample excess capacity that is expected to remain on the forecast horizon, alongside core inflation that will likely remain below the target. Domestic demand remains below 2019 levels amid unusually significant uncertainty over the size of excess capacity in the economy. High national unemployment (14.6% for February 2021) reflects a loose labor market, while observed total and core inflation continue to be below 2%. Inflationary pressures from the exchange rate are expected to continue to be low, with relatively little pass-through on inflation. This would be compatible with a negative output gap. Excess productive capacity and the expectation of core inflation below the 3% target on the forecast horizon provide a basis for an expansive monetary policy posture. The technical staff’s assessment of certain shocks and their expected effects on the economy, as well as the presence of several sources of uncertainty and related assumptions about their potential macroeconomic impacts, remain a feature of this report. The coronavirus pandemic, in particular, continues to affect the public health environment, and the reopening of Colombia’s economy remains incomplete. The technical staff’s assessment is that the COVID-19 shock has affected both aggregate demand and supply, but that the impact on demand has been deeper and more persistent. Given this persistence, the central forecast accounts for a gradual tightening of the output gap in the absence of new waves of contagion, and as vaccination campaigns progress. The central forecast continues to include an expected increase of total and core inflation rates in the second quarter of 2021, alongside the lapse of the temporary price relief measures put in place in 2020. Additional COVID-19 outbreaks (of uncertain duration and intensity) represent a significant risk factor that could affect these projections. Additionally, the forecast continues to include an upward trend in sovereign risk premiums, reflected by higher levels of public debt that in the wake of the pandemic are likely to persist on the forecast horizon, even in the context of a fiscal adjustment. At the same time, the projection accounts for the shortterm effects on private domestic demand from a fiscal adjustment along the lines of the one currently being proposed by the national government. This would be compatible with a gradual recovery of private domestic demand in 2022. The size and characteristics of the fiscal adjustment that is ultimately implemented, as well as the corresponding market response, represent another source of forecast uncertainty. Newly available information offers evidence of the potential for significant changes to the macroeconomic scenario, though without altering the general diagnosis described above. The most recent data on inflation, growth, fiscal policy, and international financial conditions suggests a more dynamic economy than previously expected. However, a third wave of the pandemic has delayed the re-opening of Colombia’s economy and brought with it a deceleration in economic activity. Detailed descriptions of these considerations and subsequent changes to the macroeconomic forecast are presented below. The expected annual decline in GDP (-0.3%) in the first quarter of 2021 appears to have been less pronounced than projected in January (-4.8%). Partial closures in January to address a second wave of COVID-19 appear to have had a less significant negative impact on the economy than previously estimated. This is reflected in figures related to mobility, energy demand, industry and retail sales, foreign trade, commercial transactions from selected banks, and the national statistics agency’s (DANE) economic tracking indicator (ISE). Output is now expected to have declined annually in the first quarter by 0.3%. Private consumption likely continued to recover, registering levels somewhat above those from the previous year, while public consumption likely increased significantly. While a recovery in investment in both housing and in other buildings and structures is expected, overall investment levels in this case likely continued to be low, and gross fixed capital formation is expected to continue to show significant annual declines. Imports likely recovered to again outpace exports, though both are expected to register significant annual declines. Economic activity that outpaced projections, an increase in oil prices and other export products, and an expected increase in public spending this year account for the upward revision to the 2021 growth forecast (from 4.6% with a range between 2% and 6% in January, to 6.0% with a range between 3% and 7% in April). As a result, the output gap is expected to be smaller and to tighten more rapidly than projected in the previous report, though it is still expected to remain in negative territory on the forecast horizon. Wide forecast intervals reflect the fact that the future evolution of the COVID-19 pandemic remains a significant source of uncertainty on these projections. The delay in the recovery of economic activity as a result of the resurgence of COVID-19 in the first quarter appears to have been less significant than projected in the January report. The central forecast scenario expects this improved performance to continue in 2021 alongside increased consumer and business confidence. Low real interest rates and an active credit supply would also support this dynamic, and the overall conditions would be expected to spur a recovery in consumption and investment. Increased growth in public spending and public works based on the national government’s spending plan (Plan Financiero del Gobierno) are other factors to consider. Additionally, an expected recovery in global demand and higher projected prices for oil and coffee would further contribute to improved external revenues and would favor investment, in particular in the oil sector. Given the above, the technical staff’s 2021 growth forecast has been revised upward from 4.6% in January (range from 2% to 6%) to 6.0% in April (range from 3% to 7%). These projections account for the potential for the third wave of COVID-19 to have a larger and more persistent effect on the economy than the previous wave, while also supposing that there will not be any additional significant waves of the pandemic and that mobility restrictions will be relaxed as a result. Economic growth in 2022 is expected to be 3%, with a range between 1% and 5%. This figure would be lower than projected in the January report (3.6% with a range between 2% and 6%), due to a higher base of comparison given the upward revision to expected GDP in 2021. This forecast also takes into account the likely effects on private demand of a fiscal adjustment of the size currently being proposed by the national government, and which would come into effect in 2022. Excess in productive capacity is now expected to be lower than estimated in January but continues to be significant and affected by high levels of uncertainty, as reflected in the wide forecast intervals. The possibility of new waves of the virus (of uncertain intensity and duration) represents a significant downward risk to projected GDP growth, and is signaled by the lower limits of the ranges provided in this report. Inflation (1.51%) and inflation excluding food and regulated items (0.94%) declined in March compared to December, continuing below the 3% target. The decline in inflation in this period was below projections, explained in large part by unanticipated increases in the costs of certain foods (3.92%) and regulated items (1.52%). An increase in international food and shipping prices, increased foreign demand for beef, and specific upward pressures on perishable food supplies appear to explain a lower-than-expected deceleration in the consumer price index (CPI) for foods. An unexpected increase in regulated items prices came amid unanticipated increases in international fuel prices, on some utilities rates, and for regulated education prices. The decline in annual inflation excluding food and regulated items between December and March was in line with projections from January, though this included downward pressure from a significant reduction in telecommunications rates due to the imminent entry of a new operator. When controlling for the effects of this relative price change, inflation excluding food and regulated items exceeds levels forecast in the previous report. Within this indicator of core inflation, the CPI for goods (1.05%) accelerated due to a reversion of the effects of the VAT-free day in November, which was largely accounted for in February, and possibly by the transmission of a recent depreciation of the peso on domestic prices for certain items (electric and household appliances). For their part, services prices decelerated and showed the lowest rate of annual growth (0.89%) among the large consumer baskets in the CPI. Within the services basket, the annual change in rental prices continued to decline, while those services that continue to experience the most significant restrictions on returning to normal operations (tourism, cinemas, nightlife, etc.) continued to register significant price declines. As previously mentioned, telephone rates also fell significantly due to increased competition in the market. Total inflation is expected to continue to be affected by ample excesses in productive capacity for the remainder of 2021 and 2022, though less so than projected in January. As a result, convergence to the inflation target is now expected to be somewhat faster than estimated in the previous report, assuming the absence of significant additional outbreaks of COVID-19. The technical staff’s year-end inflation projections for 2021 and 2022 have increased, suggesting figures around 3% due largely to variation in food and regulated items prices. The projection for inflation excluding food and regulated items also increased, but remains below 3%. Price relief measures on indirect taxes implemented in 2020 are expected to lapse in the second quarter of 2021, generating a one-off effect on prices and temporarily affecting inflation excluding food and regulated items. However, indexation to low levels of past inflation, weak demand, and ample excess productive capacity are expected to keep core inflation below the target, near 2.3% at the end of 2021 (previously 2.1%). The reversion in 2021 of the effects of some price relief measures on utility rates from 2020 should lead to an increase in the CPI for regulated items in the second half of this year. Annual price changes are now expected to be higher than estimated in the January report due to an increased expected path for fuel prices and unanticipated increases in regulated education prices. The projection for the CPI for foods has increased compared to the previous report, taking into account certain factors that were not anticipated in January (a less favorable agricultural cycle, increased pressure from international prices, and transport costs). Given the above, year-end annual inflation for 2021 and 2022 is now expected to be 3% and 2.8%, respectively, which would be above projections from January (2.3% and 2,7%). For its part, expected inflation based on analyst surveys suggests year-end inflation in 2021 and 2022 of 2.8% and 3.1%, respectively. There remains significant uncertainty surrounding the inflation forecasts included in this report due to several factors: 1) the evolution of the pandemic; 2) the difficulty in evaluating the size and persistence of excess productive capacity; 3) the timing and manner in which price relief measures will lapse; and 4) the future behavior of food prices. Projected 2021 growth in foreign demand (4.4% to 5.2%) and the supposed average oil price (USD 53 to USD 61 per Brent benchmark barrel) were both revised upward. An increase in long-term international interest rates has been reflected in a depreciation of the peso and could result in relatively tighter external financial conditions for emerging market economies, including Colombia. Average growth among Colombia’s trade partners was greater than expected in the fourth quarter of 2020. This, together with a sizable fiscal stimulus approved in the United States and the onset of a massive global vaccination campaign, largely explains the projected increase in foreign demand growth in 2021. The resilience of the goods market in the face of global crisis and an expected normalization in international trade are additional factors. These considerations and the expected continuation of a gradual reduction of mobility restrictions abroad suggest that Colombia’s trade partners could grow on average by 5.2% in 2021 and around 3.4% in 2022. The improved prospects for global economic growth have led to an increase in current and expected oil prices. Production interruptions due to a heavy winter, reduced inventories, and increased supply restrictions instituted by producing countries have also contributed to the increase. Meanwhile, market forecasts and recent Federal Reserve pronouncements suggest that the benchmark interest rate in the U.S. will remain stable for the next two years. Nevertheless, a significant increase in public spending in the country has fostered expectations for greater growth and inflation, as well as increased uncertainty over the moment in which a normalization of monetary policy might begin. This has been reflected in an increase in long-term interest rates. In this context, emerging market economies in the region, including Colombia, have registered increases in sovereign risk premiums and long-term domestic interest rates, and a depreciation of local currencies against the dollar. Recent outbreaks of COVID-19 in several of these economies; limits on vaccine supply and the slow pace of immunization campaigns in some countries; a significant increase in public debt; and tensions between the United States and China, among other factors, all add to a high level of uncertainty surrounding interest rate spreads, external financing conditions, and the future performance of risk premiums. The impact that this environment could have on the exchange rate and on domestic financing conditions represent risks to the macroeconomic and monetary policy forecasts. Domestic financial conditions continue to favor recovery in economic activity. The transmission of reductions to the policy interest rate on credit rates has been significant. The banking portfolio continues to recover amid circumstances that have affected both the supply and demand for loans, and in which some credit risks have materialized. Preferential and ordinary commercial interest rates have fallen to a similar degree as the benchmark interest rate. As is generally the case, this transmission has come at a slower pace for consumer credit rates, and has been further delayed in the case of mortgage rates. Commercial credit levels stabilized above pre-pandemic levels in March, following an increase resulting from significant liquidity requirements for businesses in the second quarter of 2020. The consumer credit portfolio continued to recover and has now surpassed February 2020 levels, though overall growth in the portfolio remains low. At the same time, portfolio projections and default indicators have increased, and credit establishment earnings have come down. Despite this, credit disbursements continue to recover and solvency indicators remain well above regulatory minimums. 1.2 Monetary policy decision In its meetings in March and April the BDBR left the benchmark interest rate unchanged at 1.75%.

As noted in this monograph, marriage forms a central element of social life for Egyptians. Marriage in Egypt is nearly universal, and parents invest heavily to establish their children in married life. Once married, couples are faced with social pressures to begin childbearing immediately, a reflection of the high value placed on parenthood and children. But not all marriages begin with the same prospects for stability and satisfaction. This study draws attention to the problems faced by women who marry at very early ages in parts of rural Egypt. Despite a legal minimum age of 16, significant numbers of young girls marry below that age, and many experience social, emotional, and health-related difficulties. This study tells why these young women married early and how that decision affected their later life. The study points to areas where the aspirations of these girls have been clearly thwarted—to go to school, delay marriage, and postpone childbearing until they feel physically and psychologically ready. A related picture emerges of the social and economic forces that propel rural girls into marriage at very young ages. Each of these problems suggest areas for policy attention.