Economic evaluation of health care : cautions for the developing country context

Health economics has expanded enormously as a sub-discipline in the last four decades, drawing primarily on the theoretical foundations of welfare economics. The toolkit for the economic evaluation of health care now extends from the humble cost-minimisation exercise, through cost effectiveness measures, to the more complex cost utility or cost benefit models. These methodologies have differing strengths and drawbacks. This paper evaluates those attributes on both the practical and theoretical dimensions. On the practical dimension: The developing country context differs from the wealthier country context in a number of ways. This paper considers the differences in resource constraints and the differences in health priorities and asks to what extent the methodology is able to accommodate these variations. On the theoretical dimension: Few health care evaluations are conducted in a Pareto Optimal world. This paper considers the extent to which the welfare economic foundations of a methodology are successfully imported into its construction, and then how that foundation translates into its practical application

Paying to waste lives: the affordability of reducing mother-to-child transmission

It is estimated that each HIV-positive child in South Africa costs the government more in terms of health and welfare expenses than it does to reduce mother-to-child transmission (MTCT) of HIV through the use of antiretroviral regimens (where the mother continues to breast-feed). Programmes to reduce MTCT of HIV/AIDS are, thus, clearly affordable. Using Nevirapine (according to the HIVNET 012 Protocol) saves fewer lives, but is more cost-effective than using Zidovudine (CDC 2 weeks regime)

Understanding the demand for health services in Cape Town, South Africa : implications for health equity and effective TB care delivery

This dissertation uses qualitative and quantitative case study data to appraise the application of economic demand models in pluralistic low income settings. Primary data from Cape Town, South Africa, are used to interrogate three elements of the neoclassical paradigm: the budget constraint, utility function and underlying preference-sets, and hyper-rationality and the assumption of full information. The neoclassical budget constraint may be affected by changes in price or income. This dissertation explains how perceptions of quality, community context and fear of social sanction may affect the perceived price of service access. Community context and support networks also affect an individual's available financial resources although conventional demand models do not capture the income effect of payments made directly to providers by non-household members. According to ordinal utility theory, consumers must be able to rank various bundles of commodities according to the satisfaction they yield. This dissertation considers how perceived quality, fear of community sanction, illness type, awareness of different providers and the mismatch of supply with perceived need can affect the composition and ranking of those bundles. Finally, New Institutional Economics (NIB) utilises satisficing and less than full information instead of strict optimisation. This dissertation attempts to formalise the NIB contributions by describing common strategies for satisficing and considering how the household and community context of care seeking may effect service use. A number of empirical and methodological techniques are used to estimate demand functions and move theory into practice. Longitudinal health diaries are used to collect data on health service use, expenditure and self-rated health. The data are analysed using panel data methods. The findings illustrate that, without a better understanding of demand-side barriers to effective diagnosis and treatment, curtailing the spread and impact of communicable diseases in pluralistic, low income settings will be difficult if not impossible.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Can voluntary pooled procurement reduce the price of antiretroviral drugs? a case study of Efavirenz.

PURPOSE: : A number of strategies have aimed to assist countries in procuring antiretroviral therapy (ARV) at lower prices. In 2009, as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) commenced a voluntary pooled procurement scheme, however, the impact of the scheme on ARV prices remains uncertain. This study aims to estimate the effect of VPP on drug prices using Efavirenz as a case study. METHODS: This analysis uses WHO Global price report mechanism (GPRM) data from 2004 to 2013. Due to the highly skewed distribution of drug Prices, a generalized linear model (GLM) was used to conduct a difference-in-difference estimation of drug price changes over time. RESULTS: These analyses found that voluntary pooled procurement reduced both the ex-works price of generic Efavirenz and the incoterms price by 16.2 and 19.1%, respectively ( P <  0.001) in both cases). The year dummies were also statistically significant from 2006 to 2013 ( P <  0.001), indicating a strong decreasing trend in the price of Efavirenz over that period. CONCLUSION: Voluntary pooled procurement significantly reduced the price of 600 mg generic Efavirenz between 2009 and 2013. Voluntary pooled procurement therefore offers a potentially effective strategy for the reduction in HIV drug prices and the improvement of technical efficiency in HIV programming. Further work is required to establish if these findings hold also for other drugs

Cost and cost effectiveness of long-lasting insecticide-treated bed nets - a model-based analysis

Background: The World Health Organization recommends that national malaria programmes universally distribute long-lasting insecticide-treated bed nets (LLINs). LLINs provide effective insecticide protection for at least three years while conventional nets must be retreated every 6-12 months. LLINs may also promise longer physical durability (lifespan), but at a higher unit price. No prospective data currently available is sufficient to calculate the comparative cost effectiveness of different net types. We thus constructed a model to explore the cost effectiveness of LLINs, asking how a longer lifespan affects the relative cost effectiveness of nets, and if, when and why LLINs might be preferred to conventional insecticide-treated nets. An innovation of our model is that we also considered the replenishment need i.e. loss of nets over time.Methods: We modelled the choice of net over a 10-year period to facilitate the comparison of nets with different lifespan (and/or price) and replenishment need over time. Our base case represents a large-scale programme which achieves high coverage and usage throughout the population by distributing either LLINs or conventional nets through existing health services, and retreats a large proportion of conventional nets regularly at low cost. We identified the determinants of bed net programme cost effectiveness and parameter values for usage rate, delivery and retreatment cost from the literature. One-way sensitivity analysis was conducted to explicitly compare the differential effect of changing parameters such as price, lifespan, usage and replenishment need.Results: If conventional and long-lasting bed nets have the same physical lifespan (3 years), LLINs are more cost effective unless they are priced at more than USD 1.5 above the price of conventional nets. Because a longer lifespan brings delivery cost savings, each one year increase in lifespan can be accompanied by a USD 1 or more increase in price without the cheaper net (of the same type) becoming more cost effective. Distributing replenishment nets each year in addition to the replacement of all nets every 3-4 years increases the number of under-5 deaths averted by 5-14% at a cost of USD 17-25 per additional person protected per annum or USD 1080-1610 per additional under-5 death averted.Conclusions: Our results support the World Health Organization recommendation to distribute only LLINs, while giving guidance on the price thresholds above which this recommendation will no longer hold. Programme planners should be willing to pay a premium for nets which have a longer physical lifespan, and if planners are willing to pay USD 1600 per under-5 death averted, investing in replenishment is cost effective. © 2012 Pulkki-Brännström et al; licensee BioMed Central Ltd

Development, Validity, and Reliability of the Women's Capabilities Index.

We report the results of a series of validity and reliability tests performed during the development of the Women's Capabilities Index (WCI) in Malawi. The WCI is a multidimensional measure based on Sen's capability framework for assessing women's quality of life. Construct validity was assessed by investigating the expected relationships of the dimensions with key socioeconomic characteristics. The majority of hypothesized associations were found to be statistically significant in the expected direction. This provides evidence that the index is measuring quality of life as intended in the conceptual model. Further evidence in support of the index's validity was given by the high degree of correlation between the WCI and another scale measuring comparable (but not identical) domains of quality of life. The results from the internal consistency and the test-retest repeatability also offered encouraging evidence on the reliability of the instrument. This is the first study to rigorously and comprehensively test for validity and reliability a capabilities index for a low-income setting. The results of the validity and reliability tests provide supportive evidence that a locally developed measure of capabilities can be used as a robust tool for the assessment of women's quality of life

The ART of rationing - the need for a new approach to rationing health interventions

A key element in dealing with HIV/AIDS in South Africa depends on the resolution of the antiretroviral therapy (ART) paradox: while a universal First-World-style ART programme is unaffordable, a rationed treatment programme that includes ART is not only affordable but also vital for basic human rights reasons, to enhance prevention efforts and to keep the fabric of society together. Our recent paper on ART demonstrated how such a rationed programme would be both affordable and highly cost-effective. Traditional rationing mechanisms are unable to provide sufficient guidance as to how to go about this novel form of rationing. An alternative rationing mechanism is therefore proposed which seeks to balance ART in terms of three primary dimensions: total resource allocation to treatment, design of the treatment intervention, and setting targets on numbers to treat. Two secondary dimensions, related to total HIV and social spending, deserve equal attention. The current global context that precipitates and exacerbates the parallel contouring of disease burden and poverty should be constantly challenged

Exploring the costs of a limited public sector antiretroviral treatment programme in South Africa

Background: The role of antiretroviral treatment for adults in the pubic sector in South Africa is debated with little consideration of programme choices that could impact on the cost-effectiveness of the intervention. This study seeks to explore the impact of these programme choices at an individual level, as well as explore the total cost of a rationed national public sector antiretroviral treatment programme. Methods: Eight Scenarios were modelled of limited national treatment programmes over the next 5 years, reflecting different programme design choices. The individual costeffectiveness of these scenarios were compared. The total costs of the most cost-effective scenario were calculated, and the potential for savings in other areas of health care utilisation was explored. Results: The direct programme costs per life-year saved varied between scenarios from R5 923 to R11 829. All the costs of the most cost-effective scenario could potentially be offset depending on assumptions of health care access and utilisation. The total programme costs for the most costeffective scenario in 2007 with 107 000 people on treatment are around R409 million. Conclusion: Specific policy choices could almost double the number of people who could benefit from an investment in a limited national antiretroviral treatment programme. Such a programme is affordable within current resource constraints. The consideration of antiretroviral treatment calls for a unique public health approach to the rationing of health services in the public sector

Validating an Agency-based Tool for Measuring Women's Empowerment in a Complex Public Health Trial in Rural Nepal.

Despite the rising popularity of indicators of women's empowerment in global development programmes, little work has been done on the validity of existing measures of such a complex concept. We present a mixed methods validation of the use of the Relative Autonomy Index for measuring Amartya Sen's notion of agency freedom in rural Nepal. Analysis of think-aloud interviews (n = 7) indicated adequate respondent understanding of questionnaire items, but multiple problems of interpretation including difficulties with the four-point Likert scale, questionnaire item ambiguity and difficulties with translation. Exploratory Factor Analysis of a calibration sample (n = 511) suggested two positively correlated factors (r = 0.64) loading on internally and externally motivated behaviour. Both factors increased with decreasing education and decision-making power on large expenditures and food preparation. Confirmatory Factor Analysis on a validation sample (n = 509) revealed good fit (Root Mean Square Error of Approximation 0.05-0.08, Comparative Fit Index 0.91-0.99). In conclusion, we caution against uncritical use of agency-based quantification of women's empowerment. While qualitative and quantitative analysis revealed overall satisfactory construct and content validity, the positive correlation between external and internal motivations suggests the existence of adaptive preferences. High scores on internally motivated behaviour may reflect internalized oppression rather than agency freedom