Assessing the Economic Impact of HIV/AIDS on Nigerian Households: A Propensity Score Matching Approach

We assess the impact of HIV/AIDS on individuals’ health care utilization and spending in the Oyo and Plateau states of Nigeria and income foregone from work time lost. Data was from a 2004 survey of nearly 1,500 households, including 482 individuals living with HIV/AIDS. Estimating the effect of HIV is complicated by the fact that our sample of HIV positive individuals is non-random; there are selection effects, both in acquiring HIV, and in being in our sample our HIV positive people, which was based on contacts through non-governmental organizations. To overcome this selection effect, we compare HIV positive people with a control group with similar observed characteristics, using propensity score matching. The matched control group has very different health and economic outcomes than a random sample of the population indicating that our HIV sample would not have had "average" outcomes even if they had not acquired HIV. HIV is associated with significantly increased morbidity, health care utilization, public health facility use, lost work time and increased time devoted to care-giving relative to outcomes in the control group. Direct health care costs and indirect income loss per HIV positive individual were 16,569 Naira, about 32% of annual income per capita in affected households. About 40% of these costs are income losses associated with sickness and care-giving. 15% of the cost of HIV is accounted for by public subsidies on health. The largest single economic cost, representing 45% of the total economic burden of HIV, are out of pocket expenses, mainly for health care.HIV, Nigeria, Economic Impacts, Households, Direct Costs, Propensity Score

Economic security arrangements in the context of population ageing in India

The rapid ageing of India's population, in conjunction with migration out of rural areas and the continued concentration of the working population in the informal sector, has highlighted the need for better economic security arrangements for the elderly. Traditional family ties that have been key to ensuring a modicum of such security are beginning to fray, and increased longevity is making care of the elderly more expensive. As a result, the elderly are at increased risk of being poor or falling into poverty. In parallel with its efforts to address this issue, the Government of India and some of the Indian states have initiated an array of programmes for providing some level of access to health care or health insurance to the great majority of Indians who lack sufficient access. Formal-sector workers have greater social security than those in the informal sector, but they only represent a small share of the workforce. Women are particularly vulnerable to economic insecurity. India's experience offers some lessons for other countries. Although there is space for private initiatives in the social security arena, it is clear that most such efforts will need to be tax-financed. The role that private providers can play is substantial, even when most funding comes from public sources, but such activity will face greater challenges as more individuals seek benefits. India has also shown that implementation can often be carried out well by states using central government funds, with a set of advantages and disadvantages that such decentralization brings. Finally, India's experience with implementation can offer guidance on issues such as targeting, the use of information technology in social security systems, and human resource management.old age risk, old age benefit, medical care, social security administration, demographic aspect, India

Does the AIDS Epidemic Really Threaten Economic Growth?

This study examines the claim that the AIDS epidemic will slow the pace of economic growth. We do this by examining the association, across fifty-one developing and industrial countries for which we were able to assemble data, between changes in the prevalence of AIDS and the rate of growth of GDP per capita. Our analysis uses well-established empirical growth models to control for a variety of factors possibly correlated with AIDS prevalence that migt also influence growth. We also account for possible simultaneity in the relationship between AIDS and economic growth. Our main finding is that the AIDS epidemic has had an insignificant effect on the growth rate of per capita income, with no evidence of reverse causality. We also find evidence that the insignificant effect of AIDS on income per capita is qualitatively similar to an insignificantly effect on wages of the Black Death in England and France during the Middle Ages and an insignificant effect on output per capita of influenza in India during 1918-19

The AIDS Epidemic and Economic Policy Analysis

Economists have a vital role to play in helping public health officials and policymakers understand the AIDS epidemic and design efficient policies to limit its impact. AIDS is first and foremost a public health problem, but it is a problem with deep economic roots and potentially devastating economic consequences. The main purpose of this article is to document this assertion

The Contribution of Population Health and Demographic Change to Economic Growth in China and India

We find that a cross-country model of economic growth successfully tracks the growth takeoffs in China and India. The major drivers of the predicted takeoffs are improved health, increased openness to trade, and a rising labor force-to-population ratio due to fertility decline. We also explore the effect of the reallocation of labor from low-productivity agriculture to the higher productivity industry and service sectors. Including the money value of longevity improvements in a measure of full income reduces the gap between the magnitude of China's takeoff relative to India's due to the relative stagnation in life expectancy in China since 1980.aging, health, retirement

Needle Sharing and HIV Transmission: A Model with Markets and Purposive Behavior

Without well designed empirical studies, mathematical models are an important way to use data on needle infection for inferences about human infection. We develop a model with explicit behavioral foundations to explore an array of policy interventions related to HIV transmission among IDU. In our model, needle exchanges affect the spread of HIV in three ways: more HIV-negative IDUs use new needles instead of old ones; needles are retired after fewer uses; and the proportion of HIV-positive IDUs among users of both old and new needles rises owing to sorting effects. The first and second effects reduce the long-run incidence of HIV, while the third effect works in the opposite direction. We compare the results of our model with those of Kaplan and O'Keefe (1993) that is the foundation of many later models of HIV transmission among IDU.

The effect of community health worker-led education on women's health and treatment-seeking: A cluster randomised trial and nested process evaluation in Gujarat, India.

BACKGROUND: A community-based health insurance scheme operated by the Self-Employed Women's Association in Gujarat, India reported that the leading reasons for inpatient hospitalisation claims by its members were diarrhoea, fever and hysterectomy - the latter at the average age of 37. This claims pattern raised concern regarding potentially unnecessary hospitalisation amongst low-income women. METHODS: A cluster randomised trial and mixed methods process evaluation were designed to evaluate whether and how a community health worker-led education intervention amongst insured and uninsured adult women could reduce insurance claims, as well as hospitalisation and morbidity, related to diarrhoea, fever and hysterectomy. The 18-month intervention consisted of health workers providing preventive care information to women in a group setting in 14 randomly selected clusters, while health workers continued with regular activities in 14 comparison clusters. Claims data were collected from an administrative database, and four household surveys were conducted amongst a cohort of 1934 randomly selected adult women. RESULTS: 30% of insured women and 18% of uninsured women reported attending sessions. There was no evidence of an intervention effect on the primary outcome, insurance claims (risk ratio (RR) = 1.03; 95% confidence interval (CI) 0.81, 1.30) or secondary outcomes amongst insured and uninsured women, hospitalisation (RR = 1.05; 95% CI 0.58, 1.90) and morbidity (RR = 1.09; 95% CI 0.87, 1.38) related to the three conditions. The process evaluation suggested that participants retained knowledge from the sessions, but barriers to behaviour change were not overcome. CONCLUSIONS: We detected no evidence of an effect of this health worker-led intervention to decrease claims, hospitalisation and morbidity related to diarrhoea, fever and hysterectomy. Strategies that capitalise on health workers' role in the community and knowledge, as well as those that address the social determinants of diarrhoea, fever and the frequency of hysterectomy - such as water and sanitation infrastructure and access to primary gynaecological care - emerged as areas to strengthen future interventions

Incidence and determinants of hysterectomy in a low-income setting in Gujarat, India.

Hysterectomy is a leading reason for use of health insurance amongst low-income women in India, but there are limited population-level data available to inform policy. This paper reports on the findings of a mixed-methods study to estimate incidence and identify predictors of hysterectomy in a low-income setting in Gujarat, India. The estimated incidence of hysterectomy, 20.7/1000 woman- years (95% CI: 14.0, 30.8), was considerably higher than reported from other countries, at a relatively low mean age of 36 years. There was strong evidence that among women of reproductive age, those with lower income and at least two children underwent hysterectomy at higher rates. Nearly two-thirds of women undergoing hysterectomy utilized private hospitals, while the remainder used government or other non-profit facilities. Qualitative research suggested that weak sexual and reproductive health services, a widespread perception that the post-reproductive uterus is dispensable and lack of knowledge of side effects have resulted in the normalization of hysterectomy. Hysterectomy appears to be promoted as a first or second-line treatment for menstrual and gynaecological disorders that are actually amenable to less invasive procedures. Most women sought at least two medical opinions prior to hysterectomy, but both public and private providers lacked equipment, skills and motivation to offer alternatives. Profit and training benefits also appeared to play a role in some providers' behaviour. Although women with insecure employment underwent the procedure knowing the financial and physical implications of undergoing a major surgery, the future health and work security afforded by hysterectomy appeared to them to outweigh risks. Findings suggest that sterilization may be associated with an increased risk of hysterectomy, potentially through biological or attitudinal links. Health policy interventions require improved access to sexual and reproductive health services and health education, along with surveillance and medical audits to promote high-quality choices for women through the life cycle

Cost-effectiveness of a lifestyle intervention in high-risk individuals for diabetes in a low- and middle-income setting:Trial-based analysis of the Kerala Diabetes Prevention Program

BACKGROUND: Data on the cost-effectiveness of lifestyle-based diabetes prevention programs are mostly from high-income countries, which cannot be extrapolated to low- and middle-income countries. We performed a trial-based cost-effectiveness analysis of a lifestyle intervention targeted at preventing diabetes in India. METHODS: The Kerala Diabetes Prevention Program was a cluster-randomized controlled trial of 1007 individuals conducted in 60 polling areas (electoral divisions) in Kerala state. Participants (30-60 years) were those with a high diabetes risk score and without diabetes on an oral glucose tolerance test. The intervention group received a 12-month peer-support lifestyle intervention involving 15 group sessions delivered in community settings by trained lay peer leaders. There were also linked community activities to sustain behavior change. The control group received a booklet on lifestyle change. Costs were estimated from the health system and societal perspectives, with 2018 as the reference year. Effectiveness was measured in terms of the number of diabetes cases prevented and quality-adjusted life years (QALYs). Three times India's gross domestic product per capita (US$6108) was used as the cost-effectiveness threshold. The analyses were conducted with a 2-year time horizon. Costs and effects were discounted at 3$2.0 (intervention group: US$303.6; control group: US$301.6), incremental societal cost of US$6.2 (intervention group: US$367.8; control group: US$361.5), absolute risk reduction of 2.1$95.2, and the cost per QALY gained was US$50.0. From a societal perspective, the corresponding figures were US$295.1 and US$155.0. For the number of diabetes cases prevented, the probability for the intervention to be cost-effective was 84.0% and 83.1% from the health system and societal perspectives, respectively. The corresponding figures for QALY gained were 99.1% and 97.8%. The results were robust to discounting and sensitivity analyses. CONCLUSIONS: A community-based peer-support lifestyle intervention was cost-effective in individuals at high risk of developing diabetes in India over 2 years. TRIAL REGISTRATION: The trial was registered with Australia and New Zealand Clinical Trials Registry ( ACTRN12611000262909 ). Registered 10 March 2011

The long-term effects of Kerala Diabetes Prevention Program on diabetes incidence and cardiometabolic risk:a study protocol

Introduction: India currently has more than 74.2 million people with Type 2 Diabetes Mellitus (T2DM). This is predicted to increase to 124.9 million by 2045. In combination with controlling blood glucose levels among those with T2DM, preventing the onset of diabetes among those at high risk of developing it is essential. Although many diabetes prevention interventions have been implemented in resource-limited settings in recent years, there is limited evidence about their long-term effectiveness, cost-effectiveness, and sustainability. Moreover, evidence on the impact of a diabetes prevention program on cardiovascular risk over time is limited. Objectives: The overall aim of this study is to evaluate the long-term cardiometabolic effects of the Kerala Diabetes Prevention Program (K-DPP). Specific aims are 1) to measure the long-term effectiveness of K-DPP on diabetes incidence and cardiometabolic risk after nine years from participant recruitment; 2) to assess retinal microvasculature, microalbuminuria, and ECG abnormalities and their association with cardiometabolic risk factors over nine years of the intervention; 3) to evaluate the long-term cost-effectiveness and return on investment of the K-DPP; and 4) to assess the sustainability of community engagement, peer-support, and other related community activities after nine years. Methods: The nine-year follow-up study aims to reach all 1007 study participants (500 intervention and 507 control) from 60 randomized polling areas recruited to the original trial. Data are being collected in two phases. In phase 1 (Survey), we are admintsering a structured questionnaire, undertake physical measurements, and collect blood and urine samples for biochemical analysis. In phase II, we are inviting participants to undergo retinal imaging, body composition measurements, and ECG. All data collection is being conducted by trained Nurses. The primary outcome is the incidence of T2DM. Secondary outcomes include behavioral, psychosocial, clinical, biochemical, and retinal vasculature measures. Data analysis strategies include a comparison of outcome indicators with baseline, and follow-up measurements conducted at 12 and 24 months. Analysis of the long-term cost-effectiveness of the intervention is planned. Discussion: Findings from this follow-up study will contribute to improved policy and practice regarding the long-term effects of lifestyle interventions for diabetes prevention in India and other resource-limited settings. Trial registration: Australia and New Zealand Clinical Trials Registry–(updated from the original trial)ACTRN12611000262909; India: CTRI/2021/10/037191.publishedVersionPeer reviewe