Income pooling and demand aggregation in low-income households in Navi Mumbai, India: evidence from willingness to pay, risky choices and anthropometrics

Maternal employment brings with it additional income that may result in benefits to the household such as better nutrition and health for family members, and more autonomy for the mother. However, it could also mean less time that a mother has for housework, childcare and leisure. The benefits and costs of maternal employment depend upon how the mother and other household members utilize their time, money and other resources. Thus, a study of the economic benefits of maternal employment should take issues of intrahousehold resource allocation into account. Traditional analyses based on the common preference model neglect the differences in household member preferences and do not account for issues of intrahousehold resource allocation. Emerging empirical evidence and theoretical advances recognize the differences in household member preferences and recommend that we study the bargaining that takes place among households members. While the literature largely has relied on revealed preference data, an integrated approach that combines revealed and stated preference information can help us understand the complexity of intrahousehold resource allocation to the fullest. In this dissertation, I examine issues of intrahousehold resource allocation in the slums of Navi Mumbai, India, through a novel multidimensional approach. The dissertation consists of three modules, each of which examines issues of intrahousehold resource allocation in its own way. In the first module, I examine the differences in husband and wife preferences and evaluate the utility of a short private discussion between husbands and wives in aggregating preferences. In this study, husbands and wives were interviewed separately first and jointly thereafter in a stated preference framework to obtain their household willingness to pay for a malaria vaccine. This protocol is the first of its kind in a developing or an industrialized nation. The second component examines the differences in anthropometric measurements (z-score for height-for-age and stunting) of children of different genders. These differences may be the result of differences in the investment in children’s health over a period of time. The third component examines intrahousehold resource allocation through differences in income pooling behavior when individuals are faced with a risky choice. Both husbands and wives were offered a lottery choice with real monetary payoffs, designed so that the preferred choice by an income pooler was different from that of a non-income pooler. This is the first study of its type in a developing nation. This research also represents the first time that stated preference data, revealed preference data and choice experiment data were analyzed simultaneously. Husbands’ and wives’ stated demand for vaccines differed significantly at lower prices, where respondents had the freedom of budget space. The short private discussion enabled a majority of husbands and wives to reduce differences in their stated demand, with many couples choosing to purchase a vaccine either for all members of the household or for no one. Respondents tended to be especially accommodative of their spouse’s wishes at lower prices. Wives who had some source of income were less likely to change their opinion in a joint interview indicating that they probably had higher autonomy in decision-making. However, analyses of z-score for height of children revealed that daughters of these women were shorter than those of women who did not work. Furthermore, the eldest daughter was likely to be shorter than her other female siblings, but the eldest son was not shorter than his male siblings. Overall, the analysis demonstrates how intrahousehold allocation asserts itself in multiple ways—maternal employment improved the autonomy of women but did not counterbalance the detrimental effects of the mother’s absence from her home on the well being of her daughters, particularly the eldest daughter, who was likely helping her mother with housework and childcare responsibilities from a young age. In the choice experiment (lottery data), I found that a specific rule of intrahousehold resource allocation did not apply universally to all households. Overall, the research rejects the common preference model of intrahousehold resource allocation in slums of India. The stated demand as estimated by a traditional survey that interviewed both husbands and wives randomly from a household is likely to underestimate demand at lower prices and hence the associated welfare benefits

An economic reappraisal of the Melamchi water supply project – Kathmandu, Nepal

This paper examines whether the benefits of the Melamchi water supply project in Nepal are likely to exceed its costs, assuming that high-quality municipal water services can be delivered to households and firms in the urbanized part of the Kathmandu Valley. Monte Carlo simulations are used to explore the sensitivity of the net present value and economic internal rate of return calculations to a wide range of assumptions and input parameters.We find that extreme assumptions are not required to generate large differences in economic feasibility; quite plausible differences in the values of some key parameters can lead to large differences in the economic attractiveness of the project. The results reveal that the three most important influences on net present value and economic internal rate of return are: (i) the discount rate and discounting procedure; (ii) the magnitude of monthly benefits for households connected to the new water system; and (iii) the annual growth rate in monthly benefits of connected households after the project comes on line. Our contribution lies in illustrating, with an actual case study in a developing country, the degree to which cost-benefit calculations of large infrastructure projects are influenced by key economic modeling assumptions and input parameters.info:eu-repo/semantics/publishedVersio

Epidemiological and economic burden of Clostridium difficile in the United States: Estimates from a modeling approach

Appendix A: Population and Setting. Appendix B: Demographic, epidemiologic and economic model parameters. Appendix C: Supplementary Methods and Results. (DOCX 132 kb

Cost-Effectiveness of Newborn Circumcision in Reducing Lifetime HIV Risk among U.S. Males

BACKGROUND: HIV incidence was substantially lower among circumcised versus uncircumcised heterosexual African men in three clinical trials. Based on those findings, we modeled the potential effect of newborn male circumcision on a U.S. male's lifetime risk of HIV, including associated costs and quality-adjusted life-years saved. METHODOLOGY/PRINCIPAL FINDINGS: Given published estimates of U.S. males' lifetime HIV risk, we calculated the fraction of lifetime risk attributable to heterosexual behavior from 2005-2006 HIV surveillance data. We assumed 60% efficacy of circumcision in reducing heterosexually-acquired HIV over a lifetime, and varied efficacy in sensitivity analyses. We calculated differences in lifetime HIV risk, expected HIV treatment costs and quality-adjusted life years (QALYs) among circumcised versus uncircumcised males. The main outcome measure was cost per HIV-related QALY saved. Circumcision reduced the lifetime HIV risk among all males by 15.7% in the base case analysis, ranging from 7.9% for white males to 20.9% for black males. Newborn circumcision was a cost-saving HIV prevention intervention for all, black and Hispanic males. The net cost of newborn circumcision per QALY saved was $87,792 for white males. Results were most sensitive to the discount rate, and circumcision efficacy and cost. CONCLUSIONS/SIGNIFICANCE: Newborn circumcision resulted in lower expected HIV-related treatment costs and a slight increase in QALYs. It reduced the 1.87% lifetime risk of HIV among all males by about 16%. The effect varied substantially by race and ethnicity. Racial and ethnic groups who could benefit the most from circumcision may have least access to it due to insurance coverage and state Medicaid policies, and these financial barriers should be addressed. More data on the long-term protective effect of circumcision on heterosexual males as well as on its efficacy in preventing HIV among MSM would be useful

Cost-Effectiveness of HIV Screening in STD Clinics, Emergency Departments, and Inpatient Units: A Model-Based Analysis

Identifying and treating persons with human immunodeficiency virus (HIV) infection early in their disease stage is considered an effective means of reducing the impact of the disease. We compared the cost-effectiveness of HIV screening in three settings, sexually transmitted disease (STD) clinics serving men who have sex with men, hospital emergency departments (EDs), settings where patients are likely to be diagnosed early, and inpatient diagnosis based on clinical manifestations.We developed the Progression and Transmission of HIV/AIDS model, a health state transition model that tracks index patients and their infected partners from HIV infection to death. We used program characteristics for each setting to compare the incremental cost per quality-adjusted life year gained from early versus late diagnosis and treatment. We ran the model for 10,000 index patients for each setting, examining alternative scenarios, excluding and including transmission to partners, and assuming HAART was initiated at a CD4 count of either 350 or 500 cells/µL. Screening in STD clinics and EDs was cost-effective compared with diagnosing inpatients, even when including only the benefits to the index patients. Screening patients in STD clinics, who have less-advanced disease, was cost-effective compared with ED screening when treatment with HAART was initiated at a CD4 count of 500 cells/µL. When the benefits of reduced transmission to partners from early diagnosis were included, screening in settings with less-advanced disease stages was cost-saving compared with screening later in the course of infection. The study was limited by a small number of observations on CD4 count at diagnosis and by including transmission only to first generation partners of the index patients.HIV prevention efforts can be advanced by screening in settings where patients present with less-advanced stages of HIV infection and by initiating treatment with HAART earlier in the course of infection

Cost-Effectiveness of Pooled Nucleic Acid Amplification Testing for Acute HIV Infection after Third-Generation HIV Antibody Screening and Rapid Testing in the United States: A Comparison of Three Public Health Settings

Angela Hutchinson and colleagues conducted a cost-effectiveness analysis of pooled nucleic acid amplification testing following HIV testing and show that it is not cost-effective at recommended antibody testing intervals for high-risk persons except in very high-incidence settings

Tests of Intrahousehold Resource Allocation Using a CV Framework: A Comparison of Husbands' and Wives' Separate and Joint WTP in the Slums of Navi-Mumbai, India

Summary Husbands and wives from 422 households in the slums of Navi-Mumbai, India, were interviewed separately first and jointly thereafter in a contingent valuation framework to assess their individual and joint household willingness to pay (WTP) for malaria vaccines. Husbands' and wives' demand differed significantly when they were interviewed separately but not when they were interviewed jointly. The author rejects the common preference model and unified (bargaining) model of intrahousehold resource allocation. Researchers should consider the complexity of intrahousehold decision making when they conduct stated preference surveys, even in patriarchal societies.intrahousehold resource allocation Malaria vaccine willingness to pay (WTP) behavioral aggregation contingent valuation India Asia

Public health impact and cost-effectiveness of catch-up 9-valent HPV vaccination of individuals through age 45 years in the United States

The Advisory Committee on Immunization Practices (ACIP) recommended catch-up 9-valent Human Papillomavirus (HPV) vaccination through age 26 years, and shared clinical decision-making for adults aged 27–45 years, compared with catch-up through age 26 years and 21 years for females and males, respectively (status quo; pre-June-2019 recommendations). This study assessed the public health impact and cost-effectiveness of expanded catch-up vaccination through age 45 years (expanded catch-up) compared with status quo. We used an HPV dynamic transmission infection and disease model to assess disease outcomes and incremental cost-effectiveness ratio (ICER) of expanded catch-up compared with status quo. Costs (2018 USD), calculated from a healthcare sector perspective, and quality-adjusted life years (QALY) were discounted at 3% annually. Historical vaccination coverage was estimated using NIS-TEEN survey data (NHANES data for sensitivity analysis). Alternative scenario analyses included restricting upper age of expanded catch-up through 26 years (June-2019 ACIP recommendation), 29 years, and further 5-year increments. Our results show expanded catch-up vaccination would prevent additional 37,856 cancers, 314,468 cervical intraepithelial neoplasia-2/3s, 1,743,461 genital warts, and 10,698 deaths compared with status quo over 100 years at cost of $141,000/QALY. With NHANES coverage, the ICER was$96,000/QALY. The June-2019 ACIP recommendation also provided public health benefits with an ICER of $117,000/QALY, compared with status quo. The ICER for expanded vaccination through age 34 years was$107,000/QALY. Expanding catch-up vaccination program through age 45 years-old in the US is expected to provide public health benefits, and cost-effectiveness improves with expanding catch-up through age 34

Economic Value of Lost Productivity Attributable to Human Papillomavirus Cancer Mortality in the United States

Objectives: To estimate years of potential life lost (YPLL) and present value of future lost productivity (PVFLP) associated with premature mortality due to HPV-attributable cancers, specifically those targeted by nonavalent HPV (9vHPV) vaccination, in the United States (US) before vaccine use.Methods: YPLL was estimated from the reported number of deaths in 2017 due to HPV-related cancers, the proportion attributable to 9vHPV-targeted types, and age- and sex-specific US life expectancy. PVFLP was estimated as the product of YPLL by age- and sex-specific probability of labor force participation, annual wage, value of non-market labor, and fringe benefits markup factor.Results: An estimated 7,085 HPV-attributable cancer deaths occurred in 2017 accounting for 154,954 YPLL, with 6,482 deaths (91%) and 141,019 YPLL (91%) attributable to 9vHPV-targeted types. The estimated PVFLP was $3.8 billion for cancer deaths attributable to 9vHPV-targeted types (84% from women). The highest productivity burden was associated with cervical cancer in women and anal and oropharyngeal cancers in men.Conclusions: HPV-attributable cancer deaths are associated with a substantial economic burden in the US, much of which could be vaccine preventable