Health systems analysis of eye care services in Zambia: evaluating progress towards VISION 2020 goals.

BACKGROUND: VISION 2020 is a global initiative launched in 1999 to eliminate avoidable blindness by 2020. The objective of this study was to undertake a situation analysis of the Zambian eye health system and assess VISION 2020 process indicators on human resources, equipment and infrastructure. METHODS: All eye health care providers were surveyed to determine location, financing sources, human resources and equipment. Key informants were interviewed regarding levels of service provision, management and leadership in the sector. Policy papers were reviewed. A health system dynamics framework was used to analyse findings. RESULTS: During 2011, 74 facilities provided eye care in Zambia; 39% were public, 37% private for-profit and 24% owned by Non-Governmental Organizations. Private facilities were solely located in major cities. A total of 191 people worked in eye care; 18 of these were ophthalmologists and eight cataract surgeons, equivalent to 0.34 and 0.15 per 250,000 population, respectively. VISION 2020 targets for inpatient beds and surgical theatres were met in six out of nine provinces, but human resources and spectacles manufacturing workshops were below target in every province. Inequalities in service provision between urban and rural areas were substantial. CONCLUSION: Shortage and maldistribution of human resources, lack of routine monitoring and inadequate financing mechanisms are the root causes of underperformance in the Zambian eye health system, which hinder the ability to achieve the VISION 2020 goals. We recommend that all VISION 2020 process indicators are evaluated simultaneously as these are not individually useful for monitoring progress

Access to Routine Immunization: A Comparative Analysis of Supply-Side Disparities between Northern and Southern Nigeria.

BACKGROUND: The available data on routine immunization in Nigeria show a disparity in coverage between Northern and Southern Nigeria, with the former performing worse. The effect of socio-cultural differences on health-seeking behaviour has been identified in the literature as the main cause of the disparity. Our study analyses the role of supply-side determinants, particularly access to services, in causing these disparities. METHODS: Using routine government data, we compared supply-side determinants of access in two Northern states with two Southern states. The states were identified using criteria-based purposive selection such that the comparisons were made between a low-coverage state in the South and a low-coverage state in the North as well as between a high-coverage state in the South and a high-coverage state in the North. RESULTS: Human resources and commodities at routine immunization service delivery points were generally insufficient for service delivery in both geographical regions. While disparities were evident between individual states irrespective of regional location, compared to the South, residents in Northern Nigeria were more likely to have vaccination service delivery points located within a 5 km radius of their settlements. CONCLUSION: Our findings suggest that regional supply-side disparities are not apparent, reinforcing the earlier reported socio-cultural explanations for disparities in routine immunization service uptake between Northern and Southern Nigeria. Nonetheless, improving routine immunisation coverage services require that there are available human resources and that health facilities are equitably distributed

Turismo enológico en Argentina

Con motivo de la gran cantidad de cambios que en los últimos años se han producido en las actividades vinculadas con el turismo, ha tenido lugar la creación de nuevos productos turísticos, sobre todo los relacionados con las raíces locales y regionales. En este contexto, el turismo enológico es la actividad turística que se relaciona principalmente con el conocimiento in situ del proceso de la elaboración del vino, donde el turista visita las instalaciones de las bodegas y los viñedos, además de poder degustar cada uno de los vinos que se le han presentado con anterioridad; actividad que se complementa con las visitas a museos y casas típicas de la región, y el conocimiento de la historia, entre otras actividades.Fil: Bozzani, María Luciana. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina

Incorporating feasibility in priority setting: a case study of tuberculosis control in South Africa

Priority setting for infectious disease control has evolved beyond simple descriptions of costs and consequences of single interventions. Applications of economic evaluation alongside disease transmission modelling now include user-friendly models, which account for setting-specific variations in input prices and epidemiological characteristics, as well as optimisation routines. These developments allow the straightforward assessment of the local cost-effectiveness of new health technologies and rankings of multiple intervention options. At the same time, priority setting increasingly recognises that policymakers may be fulfilling multiple objectives alongside efficient resource allocation, such as pursuing equity in health outcomes, access to health care and financial protection, and that they are faced with a range of health system constraints in any given settings. These constraints may encompass physical input shortages on the supply side (e.g. lack of skilled human resources or disruptions in procuring supplies) and lack of uptake on the demand side (e.g. financial or other barriers such as hesitancy or stigma). Failure to take these into account can result in unfeasible health interventions being recommended and, ultimately, in economic evaluation evidence being disregarded. Different methods for incorporating constraints in priority setting have been put forward, both within the traditional cost-effectiveness analysis framework and alongside it. All these methods present strengths and weaknesses in terms of how they deal with different types of constraints and priority setting contexts, as well as in the extent to which decisions are arrived at algorithmically or through a more deliberative process. My PhD thesis was conceived during two years spent on a project advising the South African National Department of Health on tuberculosis (TB) control policy and implementation. In 2015, the South African Deputy President announced plans for a comprehensive TB screening programme to tackle one of the world’s worst TB epidemics driven by HIV. A key question was how to implement such a complex and costly intervention as intensified TB case-finding (ICF) at full scale in an over-stretched health system. The aim of my thesis was therefore to explore and develop the methods for incorporating feasibility concerns, and specifically health systems constraints, in priority setting models both internally and externally to the traditional cost-effectiveness analysis framework, using priority setting around TB prevention and control in South Africa as a case study. The first step was to carry out a systematic review of the literature on the possible ways to restrict disease transmission model outputs to account for health system constraints that affect the achievable coverage and outputs of disease control interventions. I then carried out an incremental micro-costing exercise of the TB control interventions that the South African Department of Health was considering for inclusion in the latest National TB Plan. The costing covered all the resources needed to deliver the intervention at scale, including the costs of the extra resources needed to relax health system constraints, such as hiring additional clinical staff and budgeting for additional diagnostic equipment. These constraints were identified in consultation with experts on the South African TB Think Tank. Intervention costs were then attached to disease transmission model outputs to generate incremental cost-effectiveness ratios under three different scenarios: (1) without considering the constraints to implementation; (2) considering the constrains; and (3) including the costs of ‘relaxing’ the constraints to achieve unconstrained coverage. This exercise showed that the cost-effectiveness ranking of interventions is substantially affected by considering health system constraints. It also provided valuable information for policymakers on the practical feasibility of the proposed interventions. Lastly, the use of group model building, a qualitative system dynamics modelling technique, was explored to elicit information on the health system constraints that apply to a given setting and set of interventions. This approach was found to be superior to the unstructured expert elicitation usually employed to generate unit cost and quantities assumptions in economic evaluation, as it takes into account the dynamic interactions between the intervention and the health system. The approach was also more likely to identify high level health system constraints that are difficult to incorporate in quantitative analyses. Information on these constraints might be best presented to decisionmakers either alongside, but externally to cost-effectiveness analysis results; or in the form of disease transmission model ‘exemplary’ scenarios where intervention effects (but not costs) are restricted

Cost-effectiveness of eye care services in Zambia.

OBJECTIVE: To estimate the cost-effectiveness of cataract surgery and refractive error/presbyopia correction in Zambia. METHODS: Primary data on costs and health related quality of life were collected in a prospective cohort study of 170 cataract and 113 refractive error/presbyopia patients recruited from three health facilities. Six months later, follow-up data were available from 77 and 41 patients who had received cataract surgery and spectacles, respectively. Costs were determined from patient interviews and micro-costing at the three health facilities. Utility values were gathered by administering the EQ-5D quality of life instrument immediately before and six months after cataract surgery or acquiring spectacles. A probabilistic state-transition model was used to generate cost-effectiveness estimates with uncertainty ranges. RESULTS: Utility values significantly improved across the patient sample after cataract surgery and acquiring spectacles. Incremental costs per Quality Adjusted Life Years gained were US$259 for cataract surgery and US$ 375 for refractive error correction. The probabilities of the incremental cost-effectiveness ratios being below the Zambian gross national income per capita were 95% for both cataract surgery and refractive error correction. CONCLUSION: In spite of proven cost-effectiveness, severe health system constraints are likely to hamper scaling up of the interventions

Opportunities and challenges for implementing cost accounting systems in the Kenyan health system.

Low- and middle-income countries need to sustain efficiency and equity in health financing on their way to universal health care coverage. However, systems meant to generate quality economic information are often deficient in such settings. We assessed the feasibility of streamlining cost accounting systems within the Kenyan health sector to illustrate the pragmatic challenges and opportunities. We reviewed policy documents, and conducted field observations and semi-structured interviews with key informants in the health sector. We used an adapted Human, Organization and Technology fit (HOT-fit) framework to analyze the components and standards of a cost accounting system. Among the opportunities for a viable cost accounting system, we identified a supportive broad policy environment, political will, presence of a national data reporting architecture, good implementation experience with electronic medical records systems, and the availability of patient clinical and resource use data. However, several practical issues need to be considered in the design of the system, including the lack of a framework to guide the costing process, the lack of long-term investment, the lack of appropriate incentives for ground-level staff, and a risk of overburdening the current health management information system. To facilitate the implementation of cost accounting into the health sector, the design of any proposed system needs to remain simple and attuned to the local context

Evaluación de sanidad, rendimiento en biomasa, grano y peso hectolítrico en líneas y cultivares de avena

El objetivo del trabajo fue comparar el comportamiento de líneas de avena pertenecientes al plan de mejoramiento de la Cátedra de Cerealicultura de la FCAyF, con los cultivares comerciales más utilizados. Se sembraron dos ensayos en la Estación Experimental Julio Hirschhorn (grano y doble propósito) en bloques al azar con siete líneas en filiales avanzadas del Criadero y trece variedades comerciales con tres repeticiones. Se evaluó el rendimiento en materia seca, grano, resistencia a enfermedades, peso hectolitrico (PH) y la relación existente entre éste y el peso de mil granos con el porcentaje de granos terciarios. Los datos de severidad, ABCPE, biomasa en el ensayo de pasto y para el peso hectolítrico en el ensayo de grano se analizaron mediante análisis de varianza para ensayos en bloques al azar. Para el rendimiento y sus componentes en el ensayo de grano y de doble propósito se utilizó un diseño de parcela dividida en que se consideró como parcela principal el ensayo de grano y de doble propósito y como subparcela los genotipos. Las medias se compararon mediante el test de LSD (P=0.05). Para el estudio de las relaciones entre las variables peso hectolítrico, peso de mil granos y porcentaje de granos terciarios se empleó un análisis de regresión lineal. Los resultados mostraron que las líneas del Criadero presentaron menores % de severidad, destacándose las líneas 2 y 5. En cuanto a la producción forrajera las líneas mostraron valores similares e incluso superiores a las variedades comerciales, resaltando la mayor producción de materia seca que lograron en el primer corte. En relación al rendimiento en grano en la mayoría de los genotipos fue superior en el ensayo de grano que en el de doble propósito, siendo estas diferencias estadísticamente no significativas. Las líneas del Criadero de la FCAyF tuvieron rendimientos similares a las mejores variedades comerciales, siendo las líneas 2 y 5 las que presentaron los mayores rendimientos en el ensayo de doble propósito y también las de mayor rendimiento en el ensayo de grano, solamente superada por una variedad comercial. Los valores de PH de cada uno de los genotipos evaluados estuvieron por debajo del requerido por la industria, en tanto que el porcentaje de granos terciarios fue superior en las variedades comerciales, en comparación a las líneas del Criadero. Por último se encontró que el PH está asociado en forma altamente significativa con el PMG, en cambio no se encontró una asociación significativa entre el PH y el % de granos terciarios, como tampoco entre PMG y el % de granos terciarios.Facultad de Ciencias Agrarias y Forestale

Evaluación de sanidad, rendimiento en biomasa, grano y peso hectolítrico en líneas y cultivares de avena

El objetivo del trabajo fue comparar el comportamiento de líneas de avena pertenecientes al plan de mejoramiento de la Cátedra de Cerealicultura de la FCAyF, con los cultivares comerciales más utilizados. Se sembraron dos ensayos en la Estación Experimental Julio Hirschhorn (grano y doble propósito) en bloques al azar con siete líneas en filiales avanzadas del Criadero y trece variedades comerciales con tres repeticiones. Se evaluó el rendimiento en materia seca, grano, resistencia a enfermedades, peso hectolitrico (PH) y la relación existente entre éste y el peso de mil granos con el porcentaje de granos terciarios. Los datos de severidad, ABCPE, biomasa en el ensayo de pasto y para el peso hectolítrico en el ensayo de grano se analizaron mediante análisis de varianza para ensayos en bloques al azar. Para el rendimiento y sus componentes en el ensayo de grano y de doble propósito se utilizó un diseño de parcela dividida en que se consideró como parcela principal el ensayo de grano y de doble propósito y como subparcela los genotipos. Las medias se compararon mediante el test de LSD (P=0.05). Para el estudio de las relaciones entre las variables peso hectolítrico, peso de mil granos y porcentaje de granos terciarios se empleó un análisis de regresión lineal. Los resultados mostraron que las líneas del Criadero presentaron menores % de severidad, destacándose las líneas 2 y 5. En cuanto a la producción forrajera las líneas mostraron valores similares e incluso superiores a las variedades comerciales, resaltando la mayor producción de materia seca que lograron en el primer corte. En relación al rendimiento en grano en la mayoría de los genotipos fue superior en el ensayo de grano que en el de doble propósito, siendo estas diferencias estadísticamente no significativas. Las líneas del Criadero de la FCAyF tuvieron rendimientos similares a las mejores variedades comerciales, siendo las líneas 2 y 5 las que presentaron los mayores rendimientos en el ensayo de doble propósito y también las de mayor rendimiento en el ensayo de grano, solamente superada por una variedad comercial. Los valores de PH de cada uno de los genotipos evaluados estuvieron por debajo del requerido por la industria, en tanto que el porcentaje de granos terciarios fue superior en las variedades comerciales, en comparación a las líneas del Criadero. Por último se encontró que el PH está asociado en forma altamente significativa con el PMG, en cambio no se encontró una asociación significativa entre el PH y el % de granos terciarios, como tampoco entre PMG y el % de granos terciarios.Facultad de Ciencias Agrarias y Forestale

Evaluación de sanidad, rendimiento en biomasa, grano y peso hectolítrico en líneas y cultivares de avena

El objetivo del trabajo fue comparar el comportamiento de líneas de avena pertenecientes al plan de mejoramiento de la Cátedra de Cerealicultura de la FCAyF, con los cultivares comerciales más utilizados. Se sembraron dos ensayos en la Estación Experimental Julio Hirschhorn (grano y doble propósito) en bloques al azar con siete líneas en filiales avanzadas del Criadero y trece variedades comerciales con tres repeticiones. Se evaluó el rendimiento en materia seca, grano, resistencia a enfermedades, peso hectolitrico (PH) y la relación existente entre éste y el peso de mil granos con el porcentaje de granos terciarios. Los datos de severidad, ABCPE, biomasa en el ensayo de pasto y para el peso hectolítrico en el ensayo de grano se analizaron mediante análisis de varianza para ensayos en bloques al azar. Para el rendimiento y sus componentes en el ensayo de grano y de doble propósito se utilizó un diseño de parcela dividida en que se consideró como parcela principal el ensayo de grano y de doble propósito y como subparcela los genotipos. Las medias se compararon mediante el test de LSD (P=0.05). Para el estudio de las relaciones entre las variables peso hectolítrico, peso de mil granos y porcentaje de granos terciarios se empleó un análisis de regresión lineal. Los resultados mostraron que las líneas del Criadero presentaron menores % de severidad, destacándose las líneas 2 y 5. En cuanto a la producción forrajera las líneas mostraron valores similares e incluso superiores a las variedades comerciales, resaltando la mayor producción de materia seca que lograron en el primer corte. En relación al rendimiento en grano en la mayoría de los genotipos fue superior en el ensayo de grano que en el de doble propósito, siendo estas diferencias estadísticamente no significativas. Las líneas del Criadero de la FCAyF tuvieron rendimientos similares a las mejores variedades comerciales, siendo las líneas 2 y 5 las que presentaron los mayores rendimientos en el ensayo de doble propósito y también las de mayor rendimiento en el ensayo de grano, solamente superada por una variedad comercial. Los valores de PH de cada uno de los genotipos evaluados estuvieron por debajo del requerido por la industria, en tanto que el porcentaje de granos terciarios fue superior en las variedades comerciales, en comparación a las líneas del Criadero. Por último se encontró que el PH está asociado en forma altamente significativa con el PMG, en cambio no se encontró una asociación significativa entre el PH y el % de granos terciarios, como tampoco entre PMG y el % de granos terciarios.Facultad de Ciencias Agrarias y Forestale

Diagnostic work-up and management of young patients with ulcer-like dyspepsia: A cost-minimisation study

Objective: We initiated a cost-minimisation modelling study to compare the costs of strategies based on initial endoscopy or initial non-invasive tests for the detection of Helicobacter (C13 UBT or serology) from the perspective of the Italian National Health Service. The secondary outcomes were the number of patients undergoing unnecessary Helicobacter pylori (HP) eradication treatment and the number of endoscopic examinations spared.Methods: The study was based on a decision analysis model referring to patients aged less than 45 years with ulcer-like dyspepsia and no alarming symptoms. The probabilities entered in the model were weighted means from published studies, and the costs were derived from the Italian NHS reimbursement schedule. Sensitivity analyses were conducted over a wide range of probability and cost estimates in order to test the robustness of the model.Results: Non-invasive tests (such as the preliminary work-up of patients with ulcer-like dyspepsia aged less than 45 years) were cheaper ..