Household costs of 'malaria' morbidity: a study in Matale district, Sri Lanka

Short-run economic consequences of 'malaria' on households were examined in a household survey in Matale, a malaria-endemic district of Sri Lanka. On average a household incurred a total cost of Rs 318 (US$ 7) per patient who fully recovered from 'malaria'. 24% of this was direct cost, 44% indirect cost for the patient and 32% indirect cost for the household. Direct costs were greater for those seeking treatment in the private sector. Notably a large proportion of direct costs was spent on complementary goods such as vitamins and foods considered to be nutritional. Indirect cost was measured and valued on the basis of output/ income losses incurred at the household level rather than using a general indicator such as average wage rate. Loss of output and wages accounted for the highest proportion of the indirect cost of the patients as well as the households. Relative to children, more young adults and middle-aged people had 'malaria' which also caused greater economic loss in these age groups. Women tended to care for patients rather than substitute their labour to cover productive work lost due to illness. We compare the methods used by other researchers for valuing indirect cost, demonstrating the significant impact that methods of measurement and valuation can have on the estimation of indirect cost, and justify the recommendation for methodological research in this area.

Spatiotemporal distribution of zonulae adherens and associated actin bundles in both epithelium and fiber cells during chicken lens development

Zonulae adherens and associated actin bundles (ZA/AB) are believed to play a major role in epithelial folding and invagination during morphogenesis of neural tube and other vesicular structures. The lens morphogenesis is associated with the formation of the lens vesicle in which ZA/AB would be needed during the formation process. However, the existence of ZA/AB in the lens has never been established. In this study we report for the first time the existence of ZA/AB in both lens epithelium and fiber cells during embryonic development of chicken lens from E4 to E20. Light microscopy revealed contacts between the lens epithelium and primary fiber cells, and between the lens epithelium and secondary fiber cells at E4 and E11, respectively. Thin-section electron microscopy consistently revealed ZA/AB near both the apical ends of lens epithelial cells and primary fiber cells at E4. This arrangement manifests as a parallel pair of belt-like ZA/AB along the epithelium-fiber interface. In semi-tangential sections, a continuous belt-like ZA/AB was also evidenced in individual epithelial cells and fiber cells. Furthermore, the same ZA/AB arrangement was observed near both the apical ends of epithelial cells and secondary fiber cells at E11. Besides ZA/AB, macular-type fasciae adherens were distributed regularly between epithelial cells, between primary fibers, between secondary fibers, and between epithelium and both primary and secondary fibers. Immunofluorescence strongly and preferentially labeled N-cadherin at both the apical ends of lens epithelium and primary or secondary fibers at the corresponding ages, suggesting a direct association with the zonulae adherens. Also punctate N-cadherin labeling was commonly seen along various regions of primary and secondary fiber cells at different ages, and to a larger extent in the mature fibers of older lenses. This study suggests that: (1) ZA/AB located at the apices of lens epithelial cells may play a crucial role in the early stages of lens morphogenesis (e.g. lens vesicle formation); (2) ZA/AB of primary and secondary fiber cells originate from the epithelial cells during their elongation and differentiation; (3) owing to the restricted distribution of ZA/AB, abundant fasciae adherens are needed to maintain the structural stability of the epithelium and fiber cells during development and maturation; and (4) N-cadherin is the principle adhesion protein for both the zonulae adherens and fasciae adherens in the lens.

Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment

Predisposing factors contributing to the development of first carpometacarpal (CMC) osteoarthritis include an inherent laxity or incongruency of this joint, a shallow trapezium saddle, and heavy stresses placed on the joint with pinching and grasping. Splinting is a common mode of conservative treatment for CMC osteoarthritis. This study assessed the objective and subjective responses of patients with CMC osteoarthritis who wore short and long opponens splints, as well as radiographic changes associated with wearing of the splints. The study evaluated 26 hands. Each patient was assigned at random to wear the long or the short splint first. Patients wore the splints for one week. They then documented function in their splints (on 22 activities of daily living) and rated splint satisfaction and pain levels on visual analog scales. One week after application of the first splint, the second splint was applied and worn for one week, and all measures were repeated. On the final visit, tip pinches were evaluated and x-rays were taken to assess subluxation. One-way repeated-measure analysis and paired comparison were used to analyze the pinch, pain, radiographic, and splint-rating measures. Descriptive statistics were used to assess activity-of-daily-living function and splint preference. Both splints appear to reduce subluxation at the first CMC joint in patients with grades 1 and 2 osteoarthritis. The majority of the patients picked the short splint when asked at the end of the study which splint they preferred. The splints do not appear to increase pinch strength or affect pain levels associated with the performance of pinch strength measurements. This study supports anecdotal evidence that patients with CMC osteoarthritis get pain relief with splinting.

The response of providers to capitation payment: a case-study from Thailand

Those designing payment systems for health care in low and middle income countries are increasingly looking to capitation payment, in order to avoid the cost inflation experienced with fee-for-service payment. However, there is virtually no documentation of the experience of introducing capitation payment, or of its effects. This paper draws on several research studies to explore responses by health care providers at both the market and facility level to the introduction of capitation payment, in the context of a new compulsory insurance scheme for workers in Thailand. The paper ends by identifying lessons for both Thailand itself and for other countries.

3'-minor groove binder-DNA probes increase sequence specificity at PCR extension temperatures

DNA probes with conjugated minor groove binder (MGB) groups form extremely stable duplexes with single-stranded DNA targets, allowing shorter probes to be used for hybridization based assays. In this paper, sequence specificity of 3'-MGB probes was explored. In comparison with unmodified DNA, MGB probes had higher melting temperature (T(m)) and increased specificity, especially when a mismatch was in the MGB region of the duplex. To exploit these properties, fluorogenic MGB probes were prepared and investigated in the 5'-nuclease PCR assay (real-time PCR assay, TaqMan assay). A 12mer MGB probe had the same T(m)(65 degrees C) as a no-MGB 27mer probe. The fluorogenic MGB probes were more specific for single base mismatches and fluorescence quenching was more efficient, giving increased sensitivity. A/T rich duplexes were stabilized more than G/C rich duplexes, thereby leveling probe T(m)and simplifying design. In summary, MGB probes were more sequence specific than standard DNA probes, especially for single base mismatches at elevated hybridization temperatures.

What can we learn from international comparisons of health systems and health system reform?

Most commonly, lessons derived from comparisons of international health sector reform can only be generalized in a limited way to similar countries. However, there is little guidance as to what constitutes "similarity" in this respect. We propose that a framework for assessing similarity could be derived from the performance of individual policies in different contexts, and from the cause and effect processes related to the policies. We demonstrate this process by considering research evidence in the "public-private mix", and propose variables for an initial framework that we believe determine private involvement in the public health sector. The most influential model of public leadership places the private role in a contracting framework. Research in countries that have adopted this model suggests an additional list of variables to add to the framework. The variables can be grouped under the headings "demand factors", "supply factors", and "strength of the public sector". These illustrate the nature of a framework that could emerge, and which would help countries aiming to learn from international experience.

Evaluating payment mechanisms: how can we measure unnecessary care?

There has been substantial concern that linking hospital or physician remuneration to the amount of care provided will encourage excessive provision of health care. Studies that seek to explore this relationship require methods to measure unnecessary care. This paper presents and discusses a method used to assess the magnitude of unnecessary care in the context of an evaluation of the impact of paying bonuses to physicians employed in public hospitals in Shandong Province, China.

Parents' judgements about young children's problems: why mothers and fathers might disagree yet still predict later outcomes

Correlates of parents' ratings of behavioural problems were explored in a sample of 93 British families, in which mothers and fathers rated their children at the time of the fourth birthday on the Achenbach Child Behavior Checklist. As in other samples, there was moderate convergence in mothers' and fathers' total problem scores, but also signs that they were reporting different sorts of problems linked to different influences. The father's rating was primarily associated with the child's cognitive ability. The mother's rating was primarily affected by her own mental state and view of her marriage. The father's but not the mother's rating provided unique information that predicted teachers' reports of the children's problems 7 years later. In general, parents' ratings of preschool children's problems reflect particular informants' perspectives on family life.

Avoiding problems in clinical practice after the pill scare

The publications of 1995 and 1996 on the risk of venous thrombosis associated with the use of the combined oral contraceptive pill (COC) suggested that the risks were lower than previous estimates. The debate, which ensued, ensured that the safety of the COC with regard to arterial and venous disease was reassessed. This review details the importance of contraception for public health. It reassesses critically current prescribing practice in the light of the new publications on Factor V Leiden, arterial and venous disease. Methods of communicating information about the COC are assessed, and the difficulties of transmitting complex scientific data to health care professionals and the general public are debated. The importance of attempting to quantify the benefits and risks of the COC and explaining them in the context of other life events is emphasized.

Patient satisfaction in Bangkok: the impact of hospital ownership and patient payment status

INTRODUCTION

Patient satisfaction with care received is an important dimension of evaluation that is examined only rarely in developing countries. Evidence about how satisfaction differs according to type of provider or patient payment status is extremely limited.

OBJECTIVE

To (i) compare patient perceptions of quality of inpatient and outpatient care in hospitals of different ownership and (ii) explore how patient payment status affected patient perception of quality.

METHODS

Inpatient and outpatient satisfaction surveys were implemented in nine purposively selected hospitals: three public, three private for-profit and three private non-profit.

RESULTS

Clear and significant differences emerged in patient satisfaction between groups of hospitals with different ownership. Non-profit hospitals were most highly rated for both inpatient and outpatient care. For inpatient care public hospitals had higher levels of satisfaction amongst clientele than private for-profit hospitals. For example 76% of inpatients at public hospitals said they would recommend the facility to others compared with 59% of inpatients at private for-profit hospitals. This pattern was reversed for outpatient care, where public hospitals received lower ratings than private for-profit ones. Patients under the Social Security Scheme, who are paid for on a capitation basis, consistently gave lower ratings to certain aspects of outpatient care than other patients. For inpatient care, patterns by payment status were inconsistent and insignificant.

CONCLUSIONS

The survey confirms, to some extent, the stereotypes about quality of care in hospitals of different ownership. The results on payment status are intriguing but warrant further research.

Why the poor pay more: household curative expenditures in rural Sierra Leone

This paper draws on data from Sierra Leone, and secondary data from elsewhere, to show that the rural poor can be disproportionately disadvantaged by user charges for health care, paying a higher percentage of their incomes for health care than wealthier households. Cost sharing systems at primary care level should include exemptions for the poor, but rarely succeed in consistently protecting them. The regressivity of health expenditures also results from lack of protection from the higher costs of less-frequently used, expensive providers. In Sierra Leone, the burden of curative treatment costs for all groups came mainly from private and NGO providers. Proximity to facilities appeared a more important factor in their use than average price levels. Even if a perfect exemption system existed at government primary care facilities, it would not have had much overall effect because of their relatively small contribution to household health expenditures. The financial burden on households could be relieved by making basic health facilities more accessible and at hospital level using additional resources generated through improved efficiency and cross-subsidization to provide exemptions. Also, pricing policy should take into account local economic conditions. Insurance/prepayment schemes covering the cost of hospitalization would come closer to an ideal solution, but have been implemented in very few of the poorer countries.

Profit, payment and pharmaceutical practices: perspectives from hospitals in Bangkok

Means by which to improve the quality of care offered in the private sector have received increasing interest. This paper considers the influences upon hospital physician prescribing practices. It presents data on drug management practices and prescribing patterns in a sample of private for-profit, private non-profit and public hospitals in Bangkok. Clear differences emerge in prescription patterns between the different groups of hospitals: public hospitals exhibit greater use of essential drugs and generic prescribing than either group of private hospital, and prescriptions at private for-profit hospitals tended to have more essential drugs and drugs prescribed by generic name than non-profit hospitals. Prescribing patterns in public hospitals are probably largely explained by national government policy on pharmaceutical procurement. In contrast, prescribing patterns in private for-profit hospitals appear heavily influenced by pressure upon management to contain costs, in circumstances where high drug costs cannot be passed on to purchasers. Hence hospital management have developed policies encouraging the use of generic drugs and essential drugs. These same financial pressures also explain some less desirable forms of behaviour in private for-profit hospitals such as prescribing courses of antibiotic treatment of extremely short duration. Possible measures which government may take to encourage appropriate prescribing within private hospitals are discussed.

Rebound mortality and the cost-effectiveness of malaria control: potential impact of increased mortality in late childhood following the introduction of insecticide treated nets

The efficacy and relative cost-effectiveness of insecticide-treated nets (ITNs) for the control of malaria in children under 5 years of age have recently been demonstrated by several large-scale trials. However, it has been suggested that long-term use of ITNs in areas of high transmission could lead to mortality rebound in later childhood, which would reduce the cost-effectiveness of the intervention, and at the extreme could lead to negative overall effects. A model is presented in which the cost and disability adjusted life years (DALYs) per child aged 1-119 months were estimated for a sub-Saharan African population with and without an ITN intervention. The rebound rate, defined as the percentage increase in age-specific all-cause mortality and malaria specific-morbidity, was varied to estimate the threshold at which the intervention was no longer cost-effective. Rebound was considered over two possible age ranges: 5-9 years and 3-6 years. With mortality and morbidity reductions due to ITNs in children aged 1-59 months and rebound in the 5-9 years age class, one could be reasonably certain that the cost per DALY averted is below $150 up to a rebound rate of 39%. Up to an 84% rebound rate it is highly likely that the intervention will be DALY-averting, that is the DALYs averted by the intervetion outweigh DALYs incurred through rebound effects. These thresholds are sensitive to the age range over which reductions and rebound in morbidity and mortality occur. With reductions confined to children aged 1-35 months and rebound in the 3-6 years age class, the cost per DALY is highly likely to fall below $150 only up to a 2.5% rebound rate, and with a rate in excess of 11% one can no longer be reasonably certain that the intervention is DALY-averting. These rates apply to the whole population. If there is no rebound amongst children who did not comply with the intervention, the actual increases in morbidity and mortality required to reach these thresholds amongst compliers would be much higher. The age range over which rebound occurs is a critical determinant of the thresholds at which one can no longer be reasonably certain that ITNs remain cost-effective in the long term. Based on empirical estimates of age-specific malaria mortality in sub-Saharan Africa, it appears unlikely that this threshold rate would be reached if rebound occurs over the 5-9 years age range. By contrast, if rebound occurs over the ages of 3-6 years, the increase in mortality rates required to reach this threshold falls within the observed range of malaria-specific mortality rates for this age group. It is essential that long-term surveillance is included as part of ITN interventions, with particular attention to the age range over which rebound may occur.

Researching the public/private mix in health care in a Thai urban area: methodological approaches

The private health sector has been growing rapidly in many low and middle income countries, yet not enough is known about its sources of finance or characteristics of its users. Moreover, health care reform measures are leading to alterations in the mix of public and private finance and provision, increasing further the need for information. This paper presents and evaluates some research methods which can be used to collect information relevant to considering policies on the public/private mix. They comprise a household survey, a health diary and interview survey, a bed census, and a health resource survey. Each method is described as it was used in a study in a large urban setting in Thailand, and strengths and weaknesses of the methods are identified. The use of data to estimate the shares of public and private finance and provision, and particularly private sources of finance of public hospitals and public sources of finance for private hospitals, is demonstrated. Policy issues highlighted by the data are identified.

Operational research on the economics of insecticide-treated mosquito nets: lessons of experience

Over the last 10 years or so, awareness has grown of the importance of including an economic component in studies evaluating the potential of new interventions against the main tropical diseases such as malaria. There has been a tendency to regard this as a simple addition to carry out, not requiring specialised knowledge or skills, or substantial time and resources. One consequence has been the rather slow development of knowledge on economic aspects, with a literature that is both small and of uneven quality. This review draws on the experience of supporting the addition of an economic component to the large African trials of the impact of insecticide-treated mosquito nets, as well as on a broader knowledge of the literature on the economics of malaria, to discuss what type of economic information can be useful and what questions it can be used to answer, how the information can be obtained, what pitfalls are likely to be encountered in interpretation, and what needs to be done to improve the quantity and quality of studies.

US EPA's IRIS pilot program: establishing IRIS as a centralized, peer-reviewed data base with agency consensus. Integrated Risk Information System

The US EPA's Integrated Risk Information System (IRIS) contains Agency consensus scientific positions and quantitative values on cancer and noncancer health effects that may result from lifetime oral or inhalation exposure to specific chemical substances in the environment. Combined with specific exposure assessment information, the summary health information in IRIS may be used as a source in evaluating potential public health risks from environmental contaminants. IRIS is available to the public via EPA's Internet server at http://www.epa.gov/iris. Originally developed for internal EPA use, IRIS usage has broadened since being made publicly available in 1988 to include the private and public sectors nationally and internationally. Up to 1995, IRIS summaries were generated from within various EPA Offices and Regions and reviewed by Agency Workgroups, one for cancer and one for noncancer endpoints, before entry onto IRIS. In response to the increasing usage and recognition of IRIS and suggestions for improvement, an IRIS Pilot program was initiated in 1995. The purpose of the Pilot was 3-fold: To improve efficiency in getting information on to IRIS; to improve documentation for the positions reported in IRIS summaries, including applying new methodologies and guidance; and to improve opportunity for public input including external peer review. A new infrastructure was put in place, consisting of a cross-Agency team of 'Chemical Managers', a Pilot Program Manager, and a set of Agency 'Consensus Reviewers'. Cancer and noncancer assessments were prepared in an integrated fashion for Pilot chemical substances, documented in 'Toxicological Reviews' and derivative IRIS summaries. Public input was emphasized via an initial data call and rigorous external peer review. A final step was Agency-wide consensus review by senior staff scientists representing EPA's Offices and Regions. EPA's experience with the Pilot is forming the basis for designing operational aspects of the long-term IRIS program.

To contract or not to contract? Issues for low and middle income countries

Many low and middle income countries have inherited publicly funded and provided health services, often operating at relatively low levels of technical efficiency. Changing ideas about the management of the public sector, in particular stemming from new public management theory, are spreading to these countries, whether directly or via the recommendations of multilateral and bilateral aid agencies. Pronouncements of agencies such as the World Bank imply that competitive contracting with the private sector is likely to improve the efficiency of services provision. However, very little evidence is available on whether this is likely to be the case, and in what circumstances delivery of services through contracts with the private sector is likely to be preferable to direct provision by the public sector. This paper draws on evidence from five country case-studies of contractual arrangements, in Bombay, Papua New Guinea, South Africa, Thailand and Zimbabwe, done through collaborative research between the LSHTM Health Economics and Financing Programme and local researchers in each country. A common evaluative framework was applied in each country to selected, existing contractual arrangements. Services provided under contract and evaluated included catering, cleaning, security, diagnostic services and whole hospitals. Information is presented on the design of contracts, the process of agreeing contracts including the extent of competition, and the monitoring of contract performance. A variety of evidence, including information on the relative cost and quality of contracted out versus directly provided services in the case of South Africa, Thailand, and Bombay, is used to explore whether or not contracting out to the private sector represented a preferable means of service provision. This analysis, together with information on the capacity of the agency letting the contract, and on the wider environment including the level of development of the private sector, is used to identify which aspects of the contracting process and the context in which it takes place are important in influencing whether or not contracting with the private sector is a desirable means of service provision.

The cost of treating paediatric malaria admissions and the potential impact of insecticide-treated mosquito nets on hospital expenditure

OBJECTIVE

To calculate the costs at Kilifi District Hospital (KDH) and Malindi Sub-district Hospital (MSH) of treating paediatric malaria admissions including three common presentations of severe paediatric malaria, i.e. cerebral malaria, severe malaria anaemia and malaria-associated seizures; and to estimate the implications for hospital expenditure of a reduction in paediatric malaria admissions.

METHODS

Patient data were obtained from hospital records. All costs were allocated to departments that provided direct patient care by a four-stage step-down procedure. Laboratory and drug costs of treating paediatric malaria admissions were separately identified.

RESULT

Unit recurrent costs per admission in KDH ranged from US $57 for 'other' paediatric malaria to US $105 for cerebral malaria, and in MSH from US $33 to US $44 for the same categories. The annual recurrent cost of treating all paediatric malaria admissions to KDH prior to the trial was estimated at US $78 900. Adjusting for preintervention differences in malaria admission rates and age between intervention and control areas, the ITBN trial found a 41% reduction in paediatric malaria admissions. The reduction in admissions resulted in an estimated saving of US $6240 in the cost of treating paediatric malaria admissions from the intervention area.

CONCLUSION

There would be a substantial reduction in costs of treating paediatric malaria admissions if the intervention were introduced in the whole catchment area of the hospital. Actual savings would depend on the proportion of potential savings that can in practice be realised, and on the effectiveness of the intervention when routinely implemented.