Is cycle network expansion cost-effective? A health economic evaluation of cycling in Oslo

Background: Expansion of designated cycling networks increase cycling for transport that, in turn, increase physical activity, contributing to improvement in public health. This paper aims to determine whether cycle-network construction in a large city is cost-effective when compared to the status-quo. We developed a cycle-network investment model (CIM) for Oslo and explored its impact on overall health and wellbeing resulting from the increased physical activity. Methods: First, we applied a regression technique on cycling data from 123 major European cities to model the effect of additional cycle-networks on the share of cyclists. Second, we used a Markov model to capture health benefits from increased cycling for people starting to ride cycle at the age of 30 over the next 25 years. All health gains were measured in quality-adjusted life years (QALYs). Costs were estimated in US dollars. Other data to populate the model were derived from a comprehensive literature search of epidemiological and economic evaluation studies. Uncertainty was assessed using deterministic and probabilistic sensitivity analyses. Results: Our regression analysis reveals that a 100 km new cycle network construction in Oslo city would increase cycling share by 3%. Under the base-case assumptions, where the benefits of the cycle-network investment relating to increased physical activity are sustained over 25 years, the predicted average increases in costs and QALYs per person are USD416 and 0.019, respectively. Thus, the incremental costs are USD22,350 per QALY gained. This is considered highly cost-effective in a Norwegian setting. Conclusions: The results support the use of CIM as part of a public health program to improve physical activity and consequently avert morbidity and mortality. CIM is affordable and has a long-term effect on physical activity that in turn has a positive impact on health improvement.publishedVersio

Financial risk of road traffic trauma care in public and private hospitals in Addis Ababa, Ethiopia: A cross-sectional observational study

Background Road traffic injuries are among the most important causes of morbidity and mortality and cause substantial economic loss to households in Ethiopia. This study estimates the financial risks of seeking trauma care due to road traffic injuries in Addis Ababa, Ethiopia. Methods This is a cross-sectional survey on out-of-pocket (OOP) expenditures related to trauma care in three public and one private hospital in Addis Ababa from December 2018 to February 2019. Direct medical and non-medical costs (2018 USD) were collected from 452 trauma cases. Catastrophic health expenditures were defined as OOP health expenditures of 10% or more of total household expenditures. Additionally, we investigated the impoverishment effect of OOP expenditures using the international poverty line of $1.90 per day per person (adjusted for purchasing power parity). Results Trauma care seeking after road traffic injuries generate catastrophic health expenditures for 67$256 for outpatient visits and $690 for inpatient visits per road traffic injury. Patients paid more for trauma care in private hospitals, and OOP expenditures were six times higher in private than in public hospitals. Transport to facilities and caregiver costs were the two major cost drivers, amounting to$96 and $68 per patient, respectively. Conclusion Seeking trauma care after a road traffic injury poses a substantial financial threat to Ethiopian households due to lack of strong financial risk protection mechanisms. Ethiopia's government should enact multisectoral interventions for increasing the prevention of road traffic injuries and implement universal public finance of trauma care.publishedVersio

The burden of household out-of-pocket health expenditures in Ethiopia: estimates from a nationally representative survey (2015–16)

In Ethiopia, little is known about the extent of out-of-pocket health expenditures and the associated financial hardships at national and regional levels. We estimated the incidence of both catastrophic and impoverishing health expenditures using data from the 2015/16 Ethiopian household consumption and expenditure and welfare monitoring surveys. We computed incidence of catastrophic health expenditures (CHE) at 10% and 25% thresholds of total household consumption and 40% threshold of household capacity to pay, and impoverishing health expenditures (IHE) using Ethiopia's national poverty line (ETB 7184 per adult per year). Around 2.1% (SE: 0.2, P < 0.001) of households would face CHE with a 10% threshold of total consumption, and 0.9% (SE: 0.1, P < 0.001) of households would encounter IHE, annually in Ethiopia. CHE rates were high in the regions of Afar (5.8%, SE: 1.0, P < 0.001) and Benshangul-Gumuz (4.0%, SE: 0.8, P < 0.001). Oromia (n = 902 000), Amhara (n = 275 000) and Southern Nations Nationalities and Peoples (SNNP) (n = 268 000) regions would have the largest numbers of affected households, due to large population size. The IHE rates would also show similar patterns: high rates in Afar (5.0%, SE: 0.96, P < 0.001), Oromia (1.1%, SE: 0.22, P < 0.001) and Benshangul-Gumuz (0.9%, SE: 0.4, P = 0.02); a large number of households would be impoverished in Oromia (n = 356 000) and Amhara (n = 202 000) regions. In summary, a large number of households is facing financial hardship in Ethiopia, particularly in Afar, Benshangul-Gumuz, Oromia, Amhara and SNNP regions and this number would likely increase with greater health services utilization. We recommend regional-level analyses on services coverage to be conducted as some of the estimated low CHE/IHE regional values might be due to low services coverage. Periodic analyses on the financial hardship status of households could also be monitored to infer progress towards universal health coverage.publishedVersio

Health gains and financial risk protection afforded by public financing of selected malaria interventions in Ethiopia: an extended cost-effectiveness analysis

Background Malaria is a public health burden and a major cause for morbidity and mortality in Ethiopia. Malaria also places a substantial financial burden on families and Ethiopia’s national economy. Economic evaluations, with evidence on equity and financial risk protection (FRP), are therefore essential to support decision-making for policymakers to identify best buys amongst possible malaria interventions. The aim of this study is to estimate the expected health and FRP benefits of universal public financing of key malaria interventions in Ethiopia. Methods Using extended cost-effectiveness analysis (ECEA), the potential health and FRP benefits were estimated, and their distributions across socio-economic groups, of publicly financing a 10% coverage increase in artemisinin-based combination therapy (ACT), long-lasting insecticide-treated bed nets (LLIN), indoor residual spraying (IRS), and malaria vaccine (hypothetical). Results ACT, LLIN, IRS, and vaccine would avert 358, 188, 107 and 38 deaths, respectively, each year at a net government cost of USD 5.7, 16.5, 32.6, and 5.1 million, respectively. The annual cost of implementing IRS would be two times higher than that of the LLIN interventions, and would be the main driver of the total costs. The averted deaths would be mainly concentrated in the poorest two income quintiles. The four interventions would eliminate about USD 4,627,800 of private health expenditures, and the poorest income quintiles would see the greatest FRP benefits. ACT and LLINs would have the largest impact on malaria-related deaths averted and FRP benefits. Conclusions ACT, LLIN, IRS, and vaccine interventions would bring large health and financial benefits to the poorest households in Ethiopia.publishedVersio

Health system modelling research : towards a whole-health-system perspective for identifying good value for money investments in health system strengthening

Global health research has typically focused on single diseases, and most economic evaluation research to date has analysed technical health interventions to identify 'best buys'. New approaches in the conduct of economic evaluations are needed to help policymakers in choosing what may be good value (ie, greater health, distribution of health, or financial risk protection) for money (ie, per budget expenditure) investments for health system strengthening (HSS) that tend to be programmatic. We posit that these economic evaluations of HSS interventions will require developing new analytic models of health systems which recognise the dynamic connections between the different components of the health system, characterise the type and interlinks of the system's delivery platforms; and acknowledge the multiple constraints both within and outside the health sector which limit the system's capacity to efficiently attain its objectives. We describe priority health system modelling research areas to conduct economic evaluation of HSS interventions and ultimately identify good value for money investments in HSS

Respiratory Mechanics and Gas Exchange: The Effect of Surfactants

The purpose of the lung is to exchange gases, primarily oxygen and carbon dioxide, between the atmosphere and the circulatory system. To enable this exchange, the airways in the lungs terminate in some 300 million alveoli that provide adequate surface area for transport. A common lung defect is the dysfunction of a complex mixture called pulmonary surfactant that is found in a thin layer of fluid coating the alveoli. This is a leading cause of respiratory distress syndrome (RDS), a well-known condition that affects premature infants and adults, and results in mortality rates ranging from 10% to 60% depending on patient age. The main goal of this work is to further the understanding of pulmonary surfactants to improve treatments and consequently decrease the high morbidity that accompanies RDS. To do so, we develop a mathematical model to study the action of pulmonary surfactant and its determinative contributions to breathing. The model is used to explore the influence of surfactants on alveolar mechanics, gas exchange and microscale work of breathing. Using the model, we can also examine the role that individual surfactant components such as phospholipids, proteins and cholesterol play during breathing. This provides insight into the design of exogenous pulmonary surfactants for clinical applications to treat RDS

Respiratory Mechanics and Gas Exchange: The Effect of Surfactants

The purpose of the lung is to exchange gases, primarily oxygen and carbon dioxide, between the atmosphere and the circulatory system. To enable this exchange, the airways in the lungs terminate in some 300 million alveoli that provide adequate surface area for transport. A common lung defect is the dysfunction of a complex mixture called pulmonary surfactant that is found in a thin layer of fluid coating the alveoli. This is a leading cause of respiratory distress syndrome (RDS), a well-known condition that affects premature infants and adults, and results in mortality rates ranging from 10% to 60% depending on patient age. The main goal of this work is to further the understanding of pulmonary surfactants to improve treatments and consequently decrease the high morbidity that accompanies RDS. To do so, we develop a mathematical model to study the action of pulmonary surfactant and its determinative contributions to breathing. The model is used to explore the influence of surfactants on alveolar mechanics, gas exchange and microscale work of breathing. Using the model, we can also examine the role that individual surfactant components such as phospholipids, proteins and cholesterol play during breathing. This provides insight into the design of exogenous pulmonary surfactants for clinical applications to treat RDS

Is cycle network expansion cost-effective? A health economic evaluation of cycling in Oslo

Background: Expansion of designated cycling networks increase cycling for transport that, in turn, increase physical activity, contributing to improvement in public health. This paper aims to determine whether cycle-network construction in a large city is cost-effective when compared to the status-quo. We developed a cycle-network investment model (CIM) for Oslo and explored its impact on overall health and wellbeing resulting from the increased physical activity. Methods: First, we applied a regression technique on cycling data from 123 major European cities to model the effect of additional cycle-networks on the share of cyclists. Second, we used a Markov model to capture health benefits from increased cycling for people starting to ride cycle at the age of 30 over the next 25 years. All health gains were measured in quality-adjusted life years (QALYs). Costs were estimated in US dollars. Other data to populate the model were derived from a comprehensive literature search of epidemiological and economic evaluation studies. Uncertainty was assessed using deterministic and probabilistic sensitivity analyses. Results: Our regression analysis reveals that a 100 km new cycle network construction in Oslo city would increase cycling share by 3%. Under the base-case assumptions, where the benefits of the cycle-network investment relating to increased physical activity are sustained over 25 years, the predicted average increases in costs and QALYs per person are USD416 and 0.019, respectively. Thus, the incremental costs are USD22,350 per QALY gained. This is considered highly cost-effective in a Norwegian setting. Conclusions: The results support the use of CIM as part of a public health program to improve physical activity and consequently avert morbidity and mortality. CIM is affordable and has a long-term effect on physical activity that in turn has a positive impact on health improvement

Examining the density in out-of-pocket spending share in the estimation of catastrophic health expenditures

Universal health coverage (UHC) aims to provide access to health services for all without financial hardship. Moving toward UHC while ensuring financial risk protection (FRP) from out-of-pocket (OOP) health expenditures is a critical objective of the Sustainable Development Goal for Health. In tracking country progress toward UHC, analysts and policymakers usually report on two summary indicators of lack of FRP: the prevalence of catastrophic health expenditures (CHE) and the prevalence of impoverishing health expenditures. In this paper, we build on the CHE indicator: we examine the distribution (density) of health OOP budget share as a way to capture both the magnitude and dispersion in the ratio of households’ OOP health expenditures relative to consumption or income at the population level. We illustrate our approach with country-specific examples using data from the World Health Organization’s World Health Surveys.</p

Financial burden of HIV and TB among patients in Ethiopia: a cross-sectional survey

Objectives HIV and tuberculosis (TB) are major global health threats and can result in household financial hardships. Here, we aim to estimate the household economic burden and the incidence of catastrophic health expenditures (CHE) incurred by HIV and TB care across income quintiles in Ethiopia. Design A cross-sectional survey. Setting 27 health facilities in Afar and Oromia regions for TB, and nationwide household survey for HIV. Participants A total of 1006 and 787 individuals seeking HIV and TB care were enrolled, respectively. Outcome measures The economic burden (ie, direct and indirect cost) of HIV and TB care was estimated. In addition, the CHE incidence and intensity were determined using direct costs exceeding 10% of the household income threshold. Results The mean (SD) age of HIV and TB patient was 40 (10), and 30 (14) years, respectively. The mean (SD) patient cost of HIV was $78 ($170) per year and $115 ($118) per TB episode. Out of the total cost, the direct cost of HIV and TB constituted 69% and 46%, respectively. The mean (SD) indirect cost was $24 ($66) per year for HIV and $63 ($83) per TB episode. The incidence of CHE for HIV was 20%; ranges from 43% in the poorest to 4% in the richest income quintile (p<0.001). Similarly, for TB, the CHE incidence was 40% and ranged between 58% and 20% among the poorest and richest income quintiles, respectively (p<0.001). This figure was higher for drug-resistant TB (62%). Conclusions HIV and TB are causes of substantial economic burden and CHE, inequitably, affecting those in the poorest income quintile. Broadening the health policies to encompass interventions that reduce the high cost of HIV and TB care, particularly for the poor, is urgently needed