Correspondence
Colombia seems to have a paradoxical health system. Despite increasing its health expenditure from 5·4% of GDP in 2004 to 6·5% in 20111 and extending insurance coverage to almost 91% of the population in 2012, the country has not improved effective access and health-care quality to the same extent. This insurance based health system faces serious problems. On Feb 16, 2015, Law 1751, also known as the Statutory Health Law,2 was passed in Colombia. The law was presented by the Colombian Government as a legal guarantee of the fundamental right to health for all citizens. This new health reform promises to produce diverse positive changes. First, it establishes a link between the right to health and essential public health interventions. Second, it specifically aims to address the social determinants of health. Finally, it states that fiscal or financial sustainability should not become a barrier to access to health care. However, the practical application of this law reveals important antagonisms between the public health approach and the Government’s market driven vision. On the one hand, the Constitutional Court of the country suggested the broad notion of health as a human right, as enshrined in the UN Committee on Economic, Social and Cultural Rights (CESCR),3 while on the other, the potential positive social effects of the reform could be hampered by ministerial decrees and other government regulations. In fact, current government initiatives4 allow for the closure of public hospitals and establishment of copayments for high-cost diseases, reinforcing the lucrative health insurance business. The Colombian health system needs structural reform.5 Such reform must, at the very least, include cessation of the so-called financial intermediation www.thelancet.com Vol 385 May 16, 2015
in the health sector (in which health insurance companies are financial and administrative intermediates between health providers and users), design of comprehensive care models, and increased independence from the private sector. Switching the logic of the health system from profits to health benefits will make the right to health not merely a legal statement, but a real possibility for all Colombian citizens. We declare no competing interests.
*Esteban Londoño, Patricia Molano [email protected] Institute of Tropical Medicine, Antwerp B-2000, Belgium (EL); and Research Group on Public Policies and the Right to Health, University of AntioquiaColombia, Medellín, Colombia (PM) 1
2
3
4
5
Ministry of Health and Social ProtectionColombia. Cifras financieras del sector salud. Boletín bimestral No. 2. Enero-Febrero 2014. http://www.minsalud.gov.co/sites/rid/Lists/ BibliotecaDigital/RIDE/VP/FS/Cifras%20 financieras%20del%20Sector%20Salud%20 -%20Bolet%C3%ADn%20No%202.pdf (accessed Feb 27, 2015). Colombia Gobierno Nacional. Ley estatutaria no. 1751: por medio de la cual se regula el derecho fundamental a la salud y se dictan otras disposiciones. Feb 16, 2015. http://onsb. com.co/images/pdf/Noticias/ Leyestatutaria17512015.pdf (accessed March 6, 2015). UN Committee on Economic, Social and Cultural Rights. General comment no. 14: the right to the highest attainable standard of health. Aug 11, 2000. http://www.nesri.org/ sites/default/files/Right_to_health_ Comment_14.pdf (accessed March 6, 2015). Gobierno de Colombia-Departamento Nacional de Planeacion. Plan nacional de desarrollo 2014-2018. https://colaboracion. dnp.gov.co/CDT/Prensa/ArticuladoVF.pdf (accessed March 12, 2015). Londoño E, Dario-Gómez R, de Vos P. Colombia’s health reform: false debates, real imperatives. Lancet 2010; 375: 803.
Antenatal corticosteroids for preterm births in resource-limited settings
(Feb 14, p 629).1 Absence of beneficial effects could be accounted for by the research setting in which a birthweight of less than the 5th percentile of the population (about 2250 g) was used to define a premature birth. Such a weight corresponds with the median birthweight at about 36 weeks’ gestation, implying that half of the preterm deliveries reported by the authors happened after 36 weeks’ gestation. Of the remaining preterm births most will have been born between 34 and 36 weeks’ gestation, in which no beneficial effect of corticosteroids has been shown, with incomplete courses of steroids in a third of cases. Thus, for most preterm births the use of corticosteroids was inappropriate, as was the case for most of the 84% of infants with a birthweight above the 5th percentile who were given corticosteroids.1 This Article1 clearly shows the risks associated with corticosteroids in women with uncertain gestational ages. It also contains important lessons for high-income countries where corticosteroids are liberally given to elective early caesarean deliveries and diagnoses of true preterm deliveries generally do not include information about cervical length and presence of fibronectin (which help to improve predictions of women at risk of preterm births),2 thereby unnecessarily exposing many infants to these drugs. Corticosteroids are potent drugs and if used in newborns can reduce fetal and placental growth, induce apoptosis in their developing brains,3 and cause cerebral palsy. However, if given appropriately, corticosteroids can reduce perinatal morbidity and mortality, but their inappropriate use is likely to be harmful.
Geoeye/Science Photo Library
Are Colombia’s reforms enough for a health-care system in crisis?
We declare no competing interests.
Corticosteroids given to women at risk of preterm birth in low-income and middle-income countries did not reduce but instead increased perinatal mortality, as shown by Fernando Althabe and colleagues
*Gerard H A Visser, Gian Carlo DiRenzo [email protected] University Medical Center, Lundlaan, 3584 EA Utrecht, Netherlands (GHAV); and Department of Obstetrics, University Hospital, Perugia, Italy (GCDR)
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1943
Correspondence
1
2
For more about the Kangaroo Mother Care steps see http:// www.kangaroomothercare.com/
For more about the Helping Babies Breathe resuscitation steps see http://www. helpingbabiesbreathe.org/
1944
3
Althabe F, Belizán JM, McClure EM, et al. A population-based multifaceted strategy to implement antenatal corticosteroid treatment versus standard care for the reduction of neonatal mortality due to preterm birth in low-income and middle-income countries: the ACT cluster-randomised trial. Lancet 2015; 385: 629–39. van Baaren GJ, Vis JY, Wilms FF, et al. Predictive value of cervical length measurement and fibronectin testing in threatened preterm labor. Obstet Gynecol 2014; 123: 1185–92. Thijsseling D, Wijnberger LD, Derks JB, et al. Effects of antenatal glucocorticoid therapy on hippocampal histology of preterm infants. PLoS One 2012; 7: e33369.
Fernando Althabe and colleagues’ study1 in low-income and middleincome countries compared antenatal corticosteroid treatment versus standard care, showing comparable 28-day neonatal mortality outcome in infants in the less than the 5th percentile for birthweight (a proxy for premature babies) between groups, but suspected maternal infection was more common in the intervention group. Principal causes of death in premature infants in resource-limited settings include birth asphyxia, moderate or severe hypothermia (axillary temperature
Colombia seems to have a paradoxical health system. Despite increasing its health expenditure from 5·4% of GDP in 2004 to 6·5% in 20111 and extending insurance coverage to almost 91% of the population in 2012, the country has not improved effective access and health-care quality to the same extent. This insurance based health system faces serious problems. On Feb 16, 2015, Law 1751, also known as the Statutory Health Law,2 was passed in Colombia. The law was presented by the Colombian Government as a legal guarantee of the fundamental right to health for all citizens. This new health reform promises to produce diverse positive changes. First, it establishes a link between the right to health and essential public health interventions. Second, it specifically aims to address the social determinants of health. Finally, it states that fiscal or financial sustainability should not become a barrier to access to health care. However, the practical application of this law reveals important antagonisms between the public health approach and the Government’s market driven vision. On the one hand, the Constitutional Court of the country suggested the broad notion of health as a human right, as enshrined in the UN Committee on Economic, Social and Cultural Rights (CESCR),3 while on the other, the potential positive social effects of the reform could be hampered by ministerial decrees and other government regulations. In fact, current government initiatives4 allow for the closure of public hospitals and establishment of copayments for high-cost diseases, reinforcing the lucrative health insurance business. The Colombian health system needs structural reform.5 Such reform must, at the very least, include cessation of the so-called financial intermediation www.thelancet.com Vol 385 May 16, 2015
in the health sector (in which health insurance companies are financial and administrative intermediates between health providers and users), design of comprehensive care models, and increased independence from the private sector. Switching the logic of the health system from profits to health benefits will make the right to health not merely a legal statement, but a real possibility for all Colombian citizens. We declare no competing interests.
*Esteban Londoño, Patricia Molano [email protected] Institute of Tropical Medicine, Antwerp B-2000, Belgium (EL); and Research Group on Public Policies and the Right to Health, University of AntioquiaColombia, Medellín, Colombia (PM) 1
2
3
4
5
Ministry of Health and Social ProtectionColombia. Cifras financieras del sector salud. Boletín bimestral No. 2. Enero-Febrero 2014. http://www.minsalud.gov.co/sites/rid/Lists/ BibliotecaDigital/RIDE/VP/FS/Cifras%20 financieras%20del%20Sector%20Salud%20 -%20Bolet%C3%ADn%20No%202.pdf (accessed Feb 27, 2015). Colombia Gobierno Nacional. Ley estatutaria no. 1751: por medio de la cual se regula el derecho fundamental a la salud y se dictan otras disposiciones. Feb 16, 2015. http://onsb. com.co/images/pdf/Noticias/ Leyestatutaria17512015.pdf (accessed March 6, 2015). UN Committee on Economic, Social and Cultural Rights. General comment no. 14: the right to the highest attainable standard of health. Aug 11, 2000. http://www.nesri.org/ sites/default/files/Right_to_health_ Comment_14.pdf (accessed March 6, 2015). Gobierno de Colombia-Departamento Nacional de Planeacion. Plan nacional de desarrollo 2014-2018. https://colaboracion. dnp.gov.co/CDT/Prensa/ArticuladoVF.pdf (accessed March 12, 2015). Londoño E, Dario-Gómez R, de Vos P. Colombia’s health reform: false debates, real imperatives. Lancet 2010; 375: 803.
Antenatal corticosteroids for preterm births in resource-limited settings
(Feb 14, p 629).1 Absence of beneficial effects could be accounted for by the research setting in which a birthweight of less than the 5th percentile of the population (about 2250 g) was used to define a premature birth. Such a weight corresponds with the median birthweight at about 36 weeks’ gestation, implying that half of the preterm deliveries reported by the authors happened after 36 weeks’ gestation. Of the remaining preterm births most will have been born between 34 and 36 weeks’ gestation, in which no beneficial effect of corticosteroids has been shown, with incomplete courses of steroids in a third of cases. Thus, for most preterm births the use of corticosteroids was inappropriate, as was the case for most of the 84% of infants with a birthweight above the 5th percentile who were given corticosteroids.1 This Article1 clearly shows the risks associated with corticosteroids in women with uncertain gestational ages. It also contains important lessons for high-income countries where corticosteroids are liberally given to elective early caesarean deliveries and diagnoses of true preterm deliveries generally do not include information about cervical length and presence of fibronectin (which help to improve predictions of women at risk of preterm births),2 thereby unnecessarily exposing many infants to these drugs. Corticosteroids are potent drugs and if used in newborns can reduce fetal and placental growth, induce apoptosis in their developing brains,3 and cause cerebral palsy. However, if given appropriately, corticosteroids can reduce perinatal morbidity and mortality, but their inappropriate use is likely to be harmful.
Geoeye/Science Photo Library
Are Colombia’s reforms enough for a health-care system in crisis?
We declare no competing interests.
Corticosteroids given to women at risk of preterm birth in low-income and middle-income countries did not reduce but instead increased perinatal mortality, as shown by Fernando Althabe and colleagues
*Gerard H A Visser, Gian Carlo DiRenzo [email protected] University Medical Center, Lundlaan, 3584 EA Utrecht, Netherlands (GHAV); and Department of Obstetrics, University Hospital, Perugia, Italy (GCDR)
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1943
Correspondence
1
2
For more about the Kangaroo Mother Care steps see http:// www.kangaroomothercare.com/
For more about the Helping Babies Breathe resuscitation steps see http://www. helpingbabiesbreathe.org/
1944
3
Althabe F, Belizán JM, McClure EM, et al. A population-based multifaceted strategy to implement antenatal corticosteroid treatment versus standard care for the reduction of neonatal mortality due to preterm birth in low-income and middle-income countries: the ACT cluster-randomised trial. Lancet 2015; 385: 629–39. van Baaren GJ, Vis JY, Wilms FF, et al. Predictive value of cervical length measurement and fibronectin testing in threatened preterm labor. Obstet Gynecol 2014; 123: 1185–92. Thijsseling D, Wijnberger LD, Derks JB, et al. Effects of antenatal glucocorticoid therapy on hippocampal histology of preterm infants. PLoS One 2012; 7: e33369.
Fernando Althabe and colleagues’ study1 in low-income and middleincome countries compared antenatal corticosteroid treatment versus standard care, showing comparable 28-day neonatal mortality outcome in infants in the less than the 5th percentile for birthweight (a proxy for premature babies) between groups, but suspected maternal infection was more common in the intervention group. Principal causes of death in premature infants in resource-limited settings include birth asphyxia, moderate or severe hypothermia (axillary temperature
