Economic analysis for health projects

The author applies to the health sector an approach to analyzing projects advocated in a recent paper by Devarajan, Squire, and Suthiwart-Narueput. In the health sector, a project evaluation should: 1) Establish a firm justification for public involvement. The author identifies a number of common failures in the markets for both health services and insurance but argues that this should be the starting place for economic analysis, not a reason to ignore economics; 2) Establish the counterfactual: what happens with and without the project. Project outputs should be predicted net of the reaction of consumers and providers in the private sector. This requires knowledge of the market structure (supply, demand, and equilibrium) for health services; 3) Determine the fiscal effect of the project. The issue of appropriate levels for fees should be handled jointly with project evaluation; and 4) Acknowledge the fungibility of project resources and examine the incentives facing public servants. Ministries of health may shift their own resources away from activities that are funded by project to those that are not evaluated at all. Project outputs depend on the incentives for civil servants to provide good service--a consideration rarely taken into account in project evaluations. The author concludes that much of the analysis relevant to projects should be done before project evaluation. If the issues of fungibility and incentives are given due respect, the donors'best form of intervention may not be traditional projects at all but rather general loans with conditions related to general sector strategy and reform. For a standard project, a fair amount of information from supporting sector work is needed before evaluation. If clinical services (or anything depending on people s behavior) are part of the project, information is needed about the supply and demand for substitute services. The market structure of health care is an essential part of the background work.Public Health Promotion,Environmental Economics&Policies,Health Systems Development&Reform,Health Economics&Finance,Health Monitoring&Evaluation,Health Economics&Finance,Health Monitoring&Evaluation,Environmental Economics&Policies,Health Systems Development&Reform,Economic Theory&Research

Prices and protocols in public health care

The author tries to derive price and rationing rules for public health facilities. He highlights the effect on these rules of different assumptions about the objectives of government (health versus welfare), the limits of available policy instruments, and the market environment in which the public system operates. One recurrent finding: policy reform must be assessed in relation to the changes it induces relative to the status quo before reform. This point may seem obvious, but it represents a distinct gap in the literature on resource allocation in health. To assess changes, the behavior of the private sector must be known in the type of care given in a system and on how this care will change in response to the policy. Substituting for a reasonably well-functioning private sector is not as valuable as providing services that the private sector cannot be expected to sustain. Research is needed to characterize market equilibrium for medical care and its response to policy measures. The author could not examine many issues - most important, those related to uncertainty and insurance. But if the research he calls for in this paper is pursued, those issues must figure prominently as major determinants in the demand for care. This need was originally identified by Arrow, and there is still a long way to go. The author's analysis is not done in terms of preventive or curative care, and he argues for assessing interventions on the basis of changes in the stated objectives of a public system. But there could well be a connection with the preventive-curative dichotomy if there were reason to believe that preventive care will systematically lose out to curative care in a market setting. Onthe basis of people's generally acknowledged undervaluation of preventive services, this may well be the case. Other prevention activities also have many public good features, with few private alternatives, and will look good when improvements over stauts quo are examined for all interventions. But all activities must be evaluated in their improvement over market provision. It is not necessary to prejudge the case for certain types of intervention.Economic Theory&Research,Health Monitoring&Evaluation,Health Economics&Finance,Health Systems Development&Reform,Environmental Economics&Policies

Ghost doctors - absenteeism in Bangladeshi health facilities

The authors report on a study in which unannounced visits were made to health clinics in Bangladesh with the intention of discovering what fraction of medical professionals were present at their assigned post. This survey represents the first attempt to quantify the extent of the problem on a nationally representative scale. Nationwide the average number of vacancies over all types of providers in rural health centers is 26 percent. Regionally, vacancy rates (unfilled posts) are generally higher in the poorer parts of the country. Absentee rates at over 40 percent are particularly high for doctors. When separated into level of facility, the absentee rate for doctors at the larger clinics is 40 percent, but at the smaller sub-centers with a single doctor, the rate is 74 percent. Even though the primary purpose of this survey is to document the extent of the problem among medical staff, the authors also explore the determinants of staff absenteeism. Whether the medical provider lives near the health facility, access to a road, and rural electrification are important determinants of the rate and pattern of staff absentee rates.Public Health Promotion,Gender and Health,Health Systems Development&Reform,Health Monitoring&Evaluation,Housing&Human Habitats,Health Systems Development&Reform,Health Monitoring&Evaluation,Housing&Human Habitats,Gender and Health,Agricultural Knowledge&Information Systems

The economic control of infectious diseases

Despite interesting work on infectious diseases by such economists as Peter Francis, Michael Kremer, and Tomas Philipson, the literature does not set out the general structure of externalities involved in the prevention, and care of such diseases. The authors identify two kinds of externality. First, infectious people can infect other people, who in turn can infect others, and so on, in what the authors call the pure infection externality. In controlling their own infection, people do not take into account the social consequence of their infection. Second, in the pure prevention externality, one individual's preventive actions (such as killing mosquitoes) may directly affect the probability of others becoming infected, whether or not the preventive action succeeds for the individual undertaking it. The authors provide a general framework for discussing these externalities, and the role of government interventions to offset them. They move the discussion away from its focus on HIV (a fatal infection for which there are few interventions), and on vaccinations (which involve plausibly discrete decisions), to more general ideas of prevention, and cure applicable to many diseases for which interventions exhibit a continuum of intensities, subject to diminishing marginal returns. Infections, and actions to prevent, or cure them entail costs. Individuals balance those parts of different costs that they can actually control. In balancing costs to society, government policy should take individual behavior into account. Doing so requires a strategy combining preventive, and curative interventions, to offset both the pure infection externality, and the pure prevention externality. The relative importance of the strategy's components depends on: 1) The biology of the disease - including whether an infection is transmitted from person to person, or by vectors. 2) The possible outcomes of infection: death, recovery with susceptibility, or recovery with immunity. 3) The relative costs of the interventions. 4) Whether interventions are targeted at the population as a whole, the uninfected, the infected, or contacts between the uninfected, and the infected. 5) The behavior of individuals that leads to the two types of externalities.Disease Control&Prevention,Economic Theory&Research,Environmental Economics&Policies,Decentralization,Poverty Impact Evaluation,Economic Theory&Research,Environmental Economics&Policies,Poverty Impact Evaluation,Health Monitoring&Evaluation,Agricultural Knowledge&Information Systems

The design of incentives for health care providers in developing countries : contracts, competition, and cost control

The authors examine the design and limitations of incentives for health care providers to serve in rural areas in developing countries. Governments face two problems: it is costly to compensate well-trained urban physicians enough to relocate to rural areas, and it is difficult to ensure quality care when monitoring performance is costly or impossible. The goal of providing universal primary health care has been hard to meet, in part because of the difficulty of staffing rural medical posts with conscientious caregivers. The problem is providing physicians with incentives at a reasonable cost. Governments are often unable to purchase medical services of adequate quality even from civil servants. Using simple microeconomic models of contracts and competition, the authors examine questions about: a) The design of rural service requirements and options for newly trained physicians. b) The impact of local competition on the desirable level of training for new doctors. c) The incentive power that can be reasonably expected from explicit contracts. One problem a government faces is choosing how much training to give physicians it wants to send to rural areas. Training is costly, and a physician relocated to the countryside is outside the government's direct control. Should rural doctors face a ceiling on the prices they charge patients?Can it be enforced? The authors discuss factors to consider in determining how to pay rural medical workers but conclude that we might have to set realistic bounds on our expectations about delivering certain kinds of services. If we can identify reasons why the best that can be expected is not a particularly good, it might lead us to explore entirely different policy systems. Maybe it is too hard to run certain decentralized systems. Maybe we should focus on less ambitious but more readily achievable goals, such as providing basic infrastructure.

Strategies for pricing publicly provided health services

The authors examine how governments finance and allocate public spending, with an eye to developing strategies for pricing publicly provided health services. They also examine the implications of current policy and the possibility for rationalizing competing government priorities. Because governments face budget constraints and cannot fully subsidize all programs and activities, the authors argue the following: a) Public spending on health can (1) improve health outcomes, (2) promote nonhealth aspects of well-being (for example, reducing individuals'risk of economic losses from random health crises), and (3) finance redistribution to the poor. Optimal subsidy and fee policy will depend on how much relative weight government places on those competing objectives. Subsidies need to be reallocated toward the poor and toward public health sector can financed by increasing public subsidies. b) Prices for curative services (user fee) have two distinct roles. They can raise revenue, freeing public resources to be reallocated to public health activities and for limited cofinancing to improve the quality of curative care. More important, they can improve efficiency in the use of public facilities and the health care system as a whole. But those gains must be weighed against evidence that increased fees can compromise public health's three main goals. The literature has focused largely on how raising revenue affects the poor, but the more important effect is likely to be the guidance of resources. User fees are important in cofinancing health care but shouldn't be the primary means of finance. c) Revenue generated from user fees is sometimes used to improve the quality of, and access to, curative medical care. There is some evidence that people are willing to pay some of the cost of improving health care (especially for drugs), but the wealthy are willing to pay a lot more than the poor. If governments charge the average"willingness to pay,"the wealthy will use the services more, the poor, less. d) Prepayment social insurance plans hold promise, but there is evidence that they may introduce inefficient inflation of medical care costs that lower- and middle- income countries cannot afford.Public Sector Economics&Finance,Health Systems Development&Reform,Environmental Economics&Policies,Payment Systems&Infrastructure,Health Economics&Finance,Environmental Economics&Policies,Public Sector Economics&Finance,Health Systems Development&Reform,Health Economics&Finance,Urban Economics

Rolling Adhesion of Yeast Engineered to Express Cell Adhesion Molecules

Selectins are cell adhesion molecules that mediate capture of leukocytes on vascular endothelium as an essential component of the inflammatory response. Here we describe a method for yeast surface display of selectins, together with a functional assay that measures rolling adhesion of selectin-expressing yeast on a ligand-coated surface. E-selectin-expressing yeast roll specifically on surfaces bearing sialyl-Lewisx ligands. Observation of yeast rolling dynamics at various stages of their life cycle indicates that the kinematics of yeast motion depends on the ratio of the bud radius to the parent radius (B/P). Large-budded yeast walk across the surface, alternately pivoting about bud and parent. Small-budded yeast wobble across the surface, with bud pivoting about parent. Tracking the bud location of budding yeast allows measurement of the angular velocity of the yeast particle. Comparison of translational and angular velocities of budding yeast demonstrates that selectin-expressing cells are rolling rather than slipping across ligand-coated surfaces

Adapton: Composable, Demand-Driven Incremental Computation

Many researchers have proposed programming languages that support incremental computation (IC), which allows programs to be efficiently re-executed after a small change to the input. However, existing implementations of such languages have two important drawbacks. First, recomputation is oblivious to specific demands on the program output; that is, if a program input changes, all dependencies will be recomputed, even if an observer no longer requires certain outputs. Second, programs are made incremental as a unit, with little or no support for reusing results outside of their original context, e.g., when reordered. To address these problems, we present lambdaCDDIC, a core calculus that applies a demand-driven semantics to incremental computation, tracking changes in a hierarchical fashion in a novel demanded computation graph. lambdaCDDIC also formalizes an explicit separation between inner, incremental computations and outer observers. This combination ensures lambdaCDDIC programs only recompute computations as demanded by observers, and allows inner computations to be composed more freely. We describe an algorithm for implementing lambdaCDDIC efficiently, and we present AdaptOn, a library for writing lambdaCDDIC-style programs in OCaml. We evaluated AdaptOn on a range of benchmarks, and found that it provides reliable speedups, and in many cases dramatically outperforms prior state-of-the-art IC approaches

Bringing Molecular Biology to Bear on Adhesion Prevention: Postsurgical Adhesion Reduction Using Intraperitoneal Inoculation of Hyaluronic Acid–Inducing Adenoviral Vector in a Murine Model

Objective: Seprafilm (Genzyme, Cambridge, MA) an absorbable adhesion barrier incorporating hyaluronic acid (HA), a high molecular mass glycosaminoglycan and important component of the extracellular matrix, has been shown to prevent adhesions in both experimental models and human subjects. Yet, the application of HA as a sheet at the time of surgery has several important logistic limitations. Recently, our laboratory has identified and cloned the genes encoding murine hyaluronic acid synthase 2 (mHAS2) and 3 (mHAS3) and engineered adenoviruses incorporating these genes, which, on intraperitoneal injection, significantly increases HA in peritoneal fluid. We hypothesized that intraperitoneal gene therapy with mHAS2 or mHAS3 via an adenoviral vector prior to a standardized cecal abrasion surgery would lead to a reduction in postoperative adhesion severity. Methods: Mice were assigned to one of four groups: (1) intraperitoneal inoculation with adenovirus encoding mHAS2; (2) mHAS3; (3) a control reporter adenovirus (RV) encoding GFP; or (4) intraoperative placement of a commercially available and murine-validated hyaluronic acid adhesion barrier (Seprafilm, SF). An a priori sample size calculation was performed. Mice in groups 1, 2, and 3 underwent injection of 2 x 107 viral particles in 1 ml of fluid on day -1. Sham injection was performed on group 4 SF mice. On day 0, laparotomy was performed in random sequence by surgeon blinded to the experimental group. On day 7, adhesion scores (0-3) were assigned independently by two blinded investigators. Results: Mean adhesion scores (n = 247) were 0.68 (mHAS2), 0.91 (mHAS3), 1.28 (RV), and 0.47 (SF). Pairwise comparisons using Wilcoxon rank-sum test revealed significant reduction in severity of adhesions between mHAS2, mHAS3, and SF compared to RV (p = 0.0004, 0.039, and 0.0001, respectively). Significance persisted despite correction for multiple comparisons (p = 0.0002, Kruskal-Wallis). There was a direct relationship between intraperitoneal HA concentration and adhesion reduction. Only one death (RV) was secondary to adhesive disease; differential risk of death between groups was statistically significant (p = 0.008) (highest in mHAS2 group). Conclusions: In a dose-response relationship, an intraperitoneal gene therapy approach to adhesion prevention in a murine model was successful, with adenoviruses most productive of HA resulting in the most significant reduction in adhesion scores compared to empty virus (RV). Although SF best reduced postoperative adhesions, the adenoviral gene delivery approach may prove to be more effective in clinical use when peritoneal injury is less localized or at laparoscopy where the application of SF is not possible. Further studies to elucidate the reason for the differential death rates (time bias may have played a role) and to validate results are in progress