THE ECONOMICS OF NON-COMMUNICABLE DISEASES IN RURAL BANGLADESH

Background: In Matlab, Bangladesh, a rural sub-district with ongoing demographic surveillance, an epidemiological transition is well under way with an emerging burden of disease attributed to non-communicable diseases (NCD). In this setting there is a need to understand NCDs in terms of socioeconomic determinants and economic impacts to individuals and households, which helps inform the decision to develop NCD-related public policies. This work addresses these issues by characterizing the education gradient in mortality over a period of 24 years and by evaluating the household-level economic impacts after an adult NCD death and subsequent coping strategies. Methods: Paper #1 uses data from the routine Matlab surveillance system for the populations in 1982, 1996 and 2005, looking prospectively at both NCDs and infectious disease mortality over a five year follow-up period. Cox proportional hazard models are used for multivariate analysis to assess the education gradient in mortality for each broad cause of death category and to what extent components of wealth, occupation and marital status contribute to this gradient. In papers #2 and #3, all of the adult NCD deaths in 2010 in Matlab were identified and directly matched to a comparison group of households with no deaths. A regression standardization approach is used in Paper #2 to obtain a marginal estimate of the relative risk of a household being poor after an NCD death in terms of an asset-based wealth index, self-rated economic condition and land ownership. Paper #3 examines the coping strategies that households use after an NCD death. Logistic regression is then used to look at household and individual-level characteristics related to coping and an econometric difference-in-difference (DiD) approach is used to examine changes in household composition. Results: Paper #1 finds a larger education gradient for females for both NCD and infectious disease mortality when the data is pooled for all three time periods. For both males and females, a larger gradient is also found for infectious diseases. Marital status of an individual explains more of the education gradient in mortality than occupational status or household wealth. Paper #2 shows that there is a 14-19% increased risk of a household being poor two years after an adult NCD death, depending on which measure of economic status is used. Individual characteristics of a male death, prime age death or death of a married household member leads to a higher risk of a household being poor. In Paper #3, the results for coping enriches this picture further. The most common coping strategy among households after the death was the reduction of spending on basic household items. A prime age death is positively associated with the most number of coping strategies, four, and there is evidence that poorer households have more limited coping options. The DiD results for household composition show that households moderately replace human capital in terms of recruiting new adults to the household and that households are more likely to recruit adult females after a prime age death. Conclusion: The rising NCD burden in low income countries means that more understanding of the economic impacts of these diseases is needed. Using census data in the demographic surveillance system in rural Matlab, Bangladesh, this dissertation explores the individuals and household economic impacts associated with NCD deaths. An NCD death has the potential to impose severe economic consequences for households, impacting household wealth and propagating a poverty trap where poor household are not able to make gains in terms of economic mobility. Health shocks from NCDs lead to coping strategies that may have long term negative consequences for households. This appears to be especially true when the death is to a prime, working-age household member. Policy Recommendation: This work emphasizes the need for more intense prevention efforts for NCDs in rural Bangladesh. In Matlab, where this study is based, there have been intensive efforts to reduce maternal and childhood mortality that has been documented as a global success story. This work shows that there are important distributional and efficiency concerns related to NCD health that should motivate more public intervention. In terms of equity, there are higher rates of mortality among the least educated and health gains can be made with continuing progress in rural education and access to social psychological resources. As well, there may be longer term costs to household members, in terms of a poverty trap, when there is an NCD death. Better access to financial protection resources and preventive care is needed. This is especially true for households that are at risk of having a premature adult death. The review of the economic impacts from NCDs that are provided from this work provide an argument for developing more NCD-related policies in rural Bangladesh

Effects of a sugar-sweetened beverage tax on prices and affordability of soft drinks in Chile : A time series analysis

Chile is one of several countries that recently implemented a fiscal policy to reduce soft drink (SD) intake and obesity. In 2014 the government increased the existing ad-valorem tax on high-sugar SD by 5% and decreased by 3% the tax on low-sugar SD, based on a 6.25gr/100 ml sugar threshold. This study aims to evaluate the tax modification passed-on to consumers through prices, and to calculate changes in affordability of SDs. We analysed nationally representative consumer price index data of 41 soft drinks within 6 beverage categories between 2009 and 2016. Price change post-tax implementation was estimated for different categories (carbonates, juices, concentrates, waters and energy-sport drinks), using time-series analyses. In addition, changes in affordability were evaluated by estimating the changes in prices relative to wages. The price of carbonates increased by 5.60% (CI 95% 3.18–8.03%) immediately after the tax was implemented. A sustained increase in the prices of concentrates was observed after the implementation. Unexpectedly, a smaller increase was also seen for the price of bottled water – a category that saw no tax change. There were no effects for juices and energy-sports drinks. There was a reduction in affordability for carbonates, concentrates and waters. Overall, the fiscal policy was effective in increasing prices and there are some signs of reduced affordability. Results varied substantially among categories directly affected by the tax policy. While for carbonates the price increase exceeded the tax change (‘over-shifting’), in other categories subject to a tax cut, a price reduction was expected but the opposite occurred. As the effect of the tax on prices differed between categories, the effects of the tax policy on consumption patterns are likely to be mixed. Our findings underline the need to better understand and anticipate price setting behaviour of firms in response to a tax

An overview of the perspectives used in health economic evaluations

The term ‘perspective’ in the context of economic evaluations and costing studies in healthcare refers to the viewpoint that an analyst has adopted to define the types of costs and outcomes to consider in their studies. However, there are currently notable variations in terms of methodological recommendations, definitions, and applications of different perspectives, depending on the objective or intended user of the study. This can make it a complex area for stakeholders when interpreting these studies. Consequently, there is a need for a comprehensive overview regarding the different types of perspectives employed in such analyses, along with the corresponding implications of their use. This is particularly important, in the context of low-and-middle-income countries (LMICs), where practical guidelines may be less well-established and infrastructure for conducting economic evaluations may be more limited. This article addresses this gap by summarising the main types of perspectives commonly found in the literature to a broad audience (namely the patient, payer, health care providers, healthcare sector, health system, and societal perspectives), providing their most established definitions and outlining the corresponding implications of their uses in health economic studies, with examples particularly from LMIC settings. We then discuss important considerations when selecting the perspective and present key arguments to consider when deciding whether the societal perspective should be used. We conclude that there is no one-size-fits-all answer to what perspective should be used and the perspective chosen will be influenced by the context, policymakers'/stakeholders’ viewpoints, resource/data availability, and intended use of the analysis. Moving forward, considering the ongoing issues regarding the variation in terminology and practice in this area, we urge that more standardised definitions of the different perspectives and the boundaries between them are further developed to support future studies and guidelines, as well as to improve the interpretation and comparison of health economic evidence

Effectiveness-implementation of COPD case finding and self-management action plans in low- and middle-income countries : global excellence in COPD outcomes (GECo) study protocol

Background: Chronic obstructive pulmonary disease (COPD) is the end result of a susceptible individual being exposed to sufficiently deleterious environmental stimuli. More than 90% of COPD-related deaths occur in low- and middle-income countries (LMICs). LMICs face unique challenges in managing COPD; for example, deficient primary care systems present challenges for proper diagnosis and management. Formal diagnosis of COPD requires quality assured spirometry, which is often limited to urban health centres. Similarly, standard treatment options for COPD remain limited where few providers are trained to manage COPD. The Global Excellence in COPD Outcomes (GECo) studies aim to assess the performance of a COPD case-finding questionnaire with and without peak expiratory flow (PEF) to diagnose COPD, and inform the effectiveness and implementation of COPD self-management Action Plans in LMIC settings. The ultimate goal is to develop simple, low-cost models of care that can be implemented in LMICs. This study will be carried out in Nepal, Peru and Uganda, three distinct LMIC settings. Methods/design: We aim to assess the diagnostic accuracy of a simple questionnaire with and without PEF to case-find COPD (GECo1), and examine the effectiveness, cost-effectiveness and implementation of a communityhealth-worker-supported self-management Action Plan strategy for managing exacerbations of COPD (GECo2). To achieve the first aim, we will enrol a randomly selected sample of up to 10,500 adults aged ≥ 40 years across our three sites, with the goal to enrol 240 participants with moderate-to-severe COPD in to GECo2. We will apply two case-finding questionnaires (Lung Function Questionnaire and CAPTURE) with and without PEF and compare performance against spirometry. We will report ROC areas, sensitivity and specificity. Individuals who are identified as having COPD grades B–D will be invited to enrol in an effectiveness-implementation hybrid randomised trial of a multi-faceted COPD self-management Action Plan intervention delivered by CHWs. The intervention group will receive (1) COPD education, (2) facilitated-self management Action Plans for COPD exacerbations and (3) monthly visits by community health workers. The control group will receive COPD education and standard of care treatment provided by local health providers. Beginning at baseline, we will measure quality of life with the EuroQol-5D (EQ5D) and St. George’s Respiratory Questionnaire (SGRQ) every 3 months over a period of 1 year. The primary endpoint is SGRQ at 12 months. Quality-adjusted life years (QALYs) using the Short-Form 36 version 2 will also be calculated. We will additionally assess the acceptability and feasibility of implementing COPD Action Plans in each setting among providers and individuals with COPD. Discussion: This study should provide evidence to inform the use of pragmatic models of COPD diagnosis and management in LMIC settings

Evaluating the 2014 Sugar-Sweetened Beverage Tax in Chile : An Observational Study in Urban Areas

Background In October 2014, Chile implemented a tax modification on SSBs called the Impuesto Adicional a las Bebidas Analcohólicas (IABA). The design of the tax was unique, increasing the tax on soft drinks above 6.25 grams of added sugar per 100 millilitres and decreasing the tax for those below this threshold. Methods and Findings This study evaluates Chile’s sugar sweetened beverage (SSB) tax, which was announced in March 2014 and implemented in October 2014. We used household level grocery purchasing data from 2011 to 2015, for 2,836 households living in cities and representative of the urban population of Chile. We employed a fixed-effects econometric approach and estimated the before-after change in purchasing of SSBs controlling for seasonality, general time trend, temperature, economic fluctuations as well as time invariant household characteristics. Results showed significant changes in purchasing for the statistically preferred model: while there was a barely significant decrease in the volume of all soft drinks, there was a highly significant decrease in the monthly purchased volume of the higher taxed, sugary soft drinks by 21.6%. The direction of this reduction was robust to different empirical modelling approaches, but the statistical significance and the magnitude of the changes varied considerably. The reduction in soft drink purchasing was most evident amongst higher socioeconomic groups and higher pre-tax purchasers of sugary soft drinks. There was no systematic, robust pattern in the estimates by households’ obesity status. After tax implementation, the purchase prices of soft drinks decreased for the items where the tax rate was reduced, but remained unchanged for sugary items, for which the tax was increased. However, the purchase prices increased for sugary soft drinks at the time of the policy announcement. The main limitations include a lack of a randomized design limiting the extent of causal inference possible, and the focus on purchasing data, rather than consumption or health outcomes. Conclusions The results of sub-group analyses suggest that the policy may have been partially effective, though not necessarily in ways that are likely to reduce socioeconomic inequalities in diet-related health. It remains unclear, whether the policy has had a major, overall population level impact. Additionally, since the present study examined purchasing of soft drinks for only one year, a longer-term evaluation, ideally including an assessment of the consumption and health impacts, should be conducted in future research

Using Cost-Effectiveness Analysis to Address Health Equity Concerns

This articles serves as a guide to using cost-effectiveness analysis (CEA) to address health equity concerns. We first introduce the "equity impact plane," a tool for considering trade-offs between improving total health-the objective underpinning conventional CEA-and equity objectives, such as reducing social inequality in health or prioritizing the severely ill. Improving total health may clash with reducing social inequality in health, for example, when effective delivery of services to disadvantaged communities requires additional costs. Who gains and who loses from a cost-increasing health program depends on differences among people in terms of health risks, uptake, quality, adherence, capacity to benefit, and-crucially-who bears the opportunity costs of diverting scarce resources from other uses. We describe two main ways of using CEA to address health equity concerns: 1) equity impact analysis, which quantifies the distribution of costs and effects by equity-relevant variables, such as socioeconomic status, location, ethnicity, sex, and severity of illness; and 2) equity trade-off analysis, which quantifies trade-offs between improving total health and other equity objectives. One way to analyze equity trade-offs is to count the cost of fairer but less cost-effective options in terms of health forgone. Another method is to explore how much concern for equity is required to choose fairer but less cost-effective options using equity weights or parameters. We hope this article will help the health technology assessment community navigate the practical options now available for conducting equity-informative CEA that gives policymakers a better understanding of equity impacts and trade-offs

What next after GDP-based cost-effectiveness thresholds? [version 1; peer review: 2 approved]

Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One widely referenced and used threshold in the last decade has been the 1-3 GDP per capita, which is often attributed to the Commission on Macroeconomics and WHO guidelines on Choosing Interventions that are Cost Effective (WHO-CHOICE). For many reasons, however, this threshold has been widely criticised; which has led experts across the world, including the WHO, to discourage its use. This has left a vacuum for policy-makers and technical staff at a time when countries are wanting to move towards Universal Health Coverage. This article seeks to address this gap by offering five practical options for decision-makers in low- and middle-income countries that can be used instead of the 1-3 GDP rule, to combine existing evidence with fair decision-rules or develop locally relevant CETs. It builds on existing literature as well as an engagement with a group of experts and decision-makers working in low, middle and high income countries

Evaluating the implementation related challenges of Shasthyo Suroksha Karmasuchi (health protection scheme) of the government of Bangladesh: a study protocol

Background Rapidly increasing healthcare costs and the growing burden of noncommunicable diseases have increased the out-of-pocket (OOP) spending (63.3% of total health expenditure) in Bangladesh. This increasing OOP spending for healthcare has catastrophic economic impact on households. To reduce this burden, the Health Economics Unit (HEU) of the Ministry of Health and Family Welfare has developed the Shasthyo Surokhsha Karmasuchi (SSK) health protection scheme for the below-poverty line (BPL) population. The key actors in the scheme are HEU, contracted scheme operator and hospital. Under this scheme, each enrolled household is provided 50,000 BDT (620 USD) coverage per year for healthcare services against a government financed premium of 1000 BDT (12 USD). This initiative faces some challenges e.g., delays in scheme activities, registering the targeted population, low utilization of services, lack of motivation of the providers, and management related difficulties. It is also important to estimate the financial requirement for nationwide scale-up of this project. We aim to identify these implementation-related challenges and provide feedback to the project personnel. Methods This is a concurrent process documentation using mixed-method approaches. It will be conducted in the rural Kalihati Upazila where the SSK is being implemented. To validate the BPL population selection process, we will estimate the positive predictive value. A community survey will be conducted to assess the knowledge of the card holders about SSK services. From the SSK information management system, numbers of different services utilized by the card holders will be retrieved. Key-informant interviews with personnel from three key actors will be conducted to understand the barriers in the implementation of the project as per plan and gather their suggestions. To estimate the project costs, all inputs to be used will be identified, quantified and valued. The nationwide scale-up cost of the project will be estimated by applying economic modeling. Discussion SSK is the first ever government initiated health protection scheme in Bangladesh. The study findings will enable decision makers to gain a better understanding of the key challenges in implementation of such scheme and provide feedback towards the successful implementation of the program