Cost and cost-effectiveness of HIV/AIDS prevention strategies in developing countries: is there an evidence base?

Many donors and countries are striving to respond to the HIV/AIDS epidemic by implementing prevention programmes. However, the resources available for providing these activities relative to needs are limited. Hence, decision-makers must choose among various types of interventions. Cost information, both measures of cost and cost-effectiveness, serves as a critical input into the processes of setting priorities and allocating resources efficiently. This paper reviews the cost and cost-effectiveness evidence base of HIV/AIDS prevention programmes in low- and middle-income countries (LMICs). None of the studies found have complete cost data for a full range of HIV/AIDS prevention programmes in any one country. However, the range of studies highlight the relative emphasis of different types of HIV/AIDS prevention strategies by region, reflecting the various modes of transmission and hence, to a certain extent, the stage of the epidemic. The costing methods applied and results obtained in this review give rise to questions of reliability, validity and transparency. First, not all of the studies report the methods used to calculate the costs, and/or do not provide all the necessary data inputs such that recalculation of the results is possible. Secondly, methods that are documented vary widely, rendering different studies, even within the same country and programme setting, largely incomparable. Finally, even with consistent and replicable measurement, the results as presented are generally not comparable because of the lack of a common outcome measure. Therefore, the extent to which the available cost and cost-effectiveness evidence base on HIV/AIDS prevention strategies can provide guidance to decision-makers is limited, and there is an urgent need for the generation of this knowledge for planning and decision-making

Efficiency of primary health care in low and middle-income countries : case studies from Bangladesh

Most of the research concerned with the economics of health systems has focussed on allocative efficiency. Specifically, much effort has been devoted to the development and application of techniques of economic evaluation. The consideration of technical efficiency has figured less prominently in the search for 'solutions' to the problems of health systems. Those working on the economic evaluation of health care interventions have adopted the assumption that interventions are being, or will be, produced in a technically efficient manner. The aim of this thesis is to challenge this assumption and illustrate the potential implications of assuming technical efficiency when allocating scarce resources. Two case studies from Bangladesh are presented: vaccination services in Dhaka City and primary health care in rural Bangladesh. The specific objectives of this thesis are to: estimate the cost of these services using standard costing methods; and analyse the same data sets using parametric (stochastic frontier analysis) and non-parametric (data envelopment analysis) techniques in order to identify whether, and to what degree, the services were being delivered efficiently. Applying efficiency measurement techniques illustrated that standard costing methods disguise a high degree of inefficiency. By investigating production practices, costs related to inefficiencies can be identified and addressed. The thesis illustrates that if something is deemed worth doing then it should be carried out in a way which ensures the optimum use of scarce resources. An exclusive focus on switching resources from less cost-effective to more cost-effective activities will not realise the full benefits in terms of improved allocative efficiency if providers on the ground are not producing services at lowest cost. Recommendations are made for policy-makers on how technical efficiency can be improved. Recommendations for future research are also made.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

An economic analysis of midwifery training programmes in South Kalimantan, Indonesia.

In order to improve the knowledge and skills of midwives at health facilities and those based in villages in South Kalimantan, Indonesia, three in-service training programmes were carried out during 1995-98. A scheme used for both facility and village midwives included training at training centres, peer review and continuing education. One restricted to village midwives involved an internship programme in district hospitals. The incremental cost-effectiveness of these programmes was assessed from the standpoint of the health care provider. It was estimated that the first scheme could be expanded to increase the number of competent midwives based in facilities and villages in South Kalimantan by 1% at incremental costs of US$764.6 and US$ 1175.7 respectively, and that replication beyond South Kalimantan could increase the number of competent midwives based in facilities and villages by 1% at incremental costs of US$1225.5 and US$ 1786.4 per midwife respectively. It was also estimated that the number of competent village midwives could be increased by 1% at an incremental cost of US$898.1 per intern if replicated elsewhere, and at a cost of US$ 146.2 per intern for expanding the scheme in South Kalimantan. It was not clear whether the training programmes were more or less cost-effective than other safe motherhood interventions because the nature of the outcome measures hindered comparison

The Effect of Maternal Tetanus Immunization on Children’s Schooling Attainment in Matlab, Bangladesh: Follow-up of a Randomized Trial

We investigate the effects of ante-natal maternal vaccination against tetanus on the schooling attained by children in Bangladesh. Maternal vaccination prevents the child from acquiring tetanus at birth through blood infection and substantially reduces infant mortality and may prevent impairment in children who would otherwise acquire tetanus but survive. We follow up on a 1974 randomized trial of maternal tetanus toxoid, looking at outcomes for children born in the period 1975-1979. We find significant schooling gains from maternal tetanus vaccination for children whose parents had no schooling, showing a large impact on a small number of children.Vaccination, tetanus, schooling, education, Bangladesh

The Economic Case for Expanding Vaccination Coverage of Children

While childhood vaccination programs, such as WHO’s Expanded Program on Immunization, have had a dramatic impact on child morbidity and mortality worldwide, lack of coverage with several existing vaccines is responsible for large numbers of child deaths each year, mostly in developing countries. According to WHO estimates, increased coverage of three vaccines alone – pneumococcal conjugate vaccine (PCV), rotavirus vaccine (Rota), and Haemophilus influenzae type b (Hib) vaccine – could have prevented one and a half million deaths in children under five years in 2002. In deciding whether to implement interventions to expand vaccination coverage policy makers often consider economic evaluations. Past evaluations, however, have usually ignored both important vaccination benefits and potentially large cost reductions in vaccination delivery. We demonstrate for the example of benefit-cost analysis (BCA) of the Hib vaccination that past studies have mostly taken narrow evaluation perspectives, focusing on health gains, health care cost savings, and reductions in the time costs that parents incur when taking care of sick children, while ignoring other benefits, in particular, outcome-related productivity gains (Hib vaccination can prevent permanent mental and physical disabilities) behavior-related productivity gains (reductions in child mortality due to Hib can trigger changes in fertility which in turn may stimulate economic growth) and community externalities (Hib vaccination can prevent the development of antibiotic resistance and reduce the risk of Hib infections in unvaccinated persons). We further show that the costs of Hib vaccine delivery can be reduced if the monovalent Hib vaccine is replaced by combination vaccines. Such cost reductions have usually been ignored in CBA of Hib. Our analysis thus suggests that past BCAs are likely to have substantially underestimated the value of Hib vaccination, even though most have found it to be cost-beneficial. Unless future BCAs of childhood vaccinations take full account of benefits and costs, policy makers may lack sufficient information to make the right decisions on vaccination interventions.vaccination coverage, children, economics

The social justice issues of smoke im/mobilities

In 2014, the Hazelwood mine fire burned for 45 days. Local communities were impacted by smoke and ash, and there were reports of raised carbon monoxide levels. Local news and social media reported residents experiencing numerous physical symptoms of smoke inhalation, including bleeding noses, coughing, wheezing and chest tightness. Paper masks to filter particulate matter were made available to residents to wear outside. The dust and ash constantly seeped into homes and offices, which required cleaning daily and sometimes multiple times during the day. Smoke was free to move across physical and bodily boundaries while those most vulnerable were hampered by lack of movement: pregnant women, the elderly and children were advised to leave the area. However, this suggestion to ‘simply’ move ignored the context of a community disproportionately impacted through years of economic decline and societal change. This paper explores the unequal mobilities of smoke and people that arose as a result of this event and draws on concepts of mobility justice (Sheller 2018) and emergency mobilities (Adey 2016) to reflect on the political dimensions of uneven mobility in times of crisi

Rethinking the benefits and costs of childhood vaccination: the example of the Haemophilus influenzae type b vaccine

Economic evaluations of health interventions, such as vaccinations, are important tools for informing health policy. Approaching the analysis from the appropriate perspective is critical to ensuring the validity of evaluation results for particular policy decisions. Using the example of benefit-cost analysis (BCA) of Haemophilus influenzae type b (Hib) vaccination, we demonstrate that past economic evaluations have mostly adopted narrow evaluation perspectives, focusing primarily on health gains, health care cost savings, and reductions in the time costs of caring, while ignoring other important benefits including outcome-related productivity gains (prevention of mental and physical disabilities), behavior-related productivity gains (economic growth due to fertility reductions as vaccination improves child survival), and community externalities (prevention of antibiotic resistance and herd immunity). We further show that the potential cost reductions that could be attained through changes in the delivery of the Hib vaccine have also usually been ignored in economic evaluations. Future economic evaluations of childhood vaccinations should take full account of benefits and costs, so that policy makers have sufficient information to make well-informed decisions on vaccination implementation.Economic evaluation, review, Haemophilus influenzae type b vaccine

Vaccine-preventable haemophilus influenza type B disease burden and cost-effectiveness of infant vaccination in Indonesia.

BACKGROUND: Most of Asia, including Indonesia, does not use Haemophilus influenzae type b (Hib) conjugate vaccines. We estimated total vaccine-preventable disease burden and the cost-effectiveness of Hib conjugate vaccine in Indonesia. METHODS: Hib pneumonia and meningitis incidences for children with access to health care were derived from a randomized vaccine probe study on Lombok Island, Indonesia during 1998-2002. Incidences were adjusted for limited access to care. Health system and patient out-of-pocket treatment cost data were collected concurrent with the probe study. For Hib vaccine in monovalent and combined (with DTP-HepB) presentations, we used 2007 UNICEF vaccine prices of US$3.30 and$3.75 per dose. RESULTS: For the 2007 Indonesian birth cohort, Hib vaccine would prevent meningitis in 1 of every 179 children, pneumonia in 1 of every 18 children, and 4.9% of mortality among those younger than 5 years. The total incremental societal costs of introducing Hib vaccine in monovalent and pentavalent presentations were, respectively, US$11.74 and$8.93 per child vaccinated. Annual discounted treatment costs averted amounted to 20% of pentavalent vaccine costs. For the pentavalent vaccine, the incremental costs per discounted death and disability adjusted life-year averted amounted to US$3102 and$74, respectively, versus $4438 and$102 for monovalent vaccine. CONCLUSIONS: Routine infant Hib vaccination would prevent a large burden of pediatric illness and death in Indonesia. Even without external funding support, Hib vaccine will be a highly cost-effective intervention in either a monovalent or pentavalent presentation based on commonly used benchmarks

Liquid Crystal Dimers and Smectic Phases from the Intercalated to the Twist-Bend

Funding: This research received no external funding. Acknowledgments: The authors gratefully acknowledge Professor Nataša Vaupoticˇ for her central role in the interpretation of the resonant soft X-ray scattering (RSoXS) data and the preparation of the original figures. The authors also wish to thank Ewan Cruickshank for many helpful discussions.Peer reviewedPublisher PD

Remarkable smectic phase behaviour in odd-membered liquid crystal dimers : The CT6O.mseries

Funding Information: EG and DP acknowledge the support of the National Science Centre (Poland): (Grant Number 2016/22/A/ST5/00319). RW gratefully acknowledges The Carnegie Trust for the Universities of Scotland for funding the award of a PhD scholarship 2015-2018.Peer reviewedPublisher PD