Global justice and the opportunity costs of conservation

Opportunity costs can represent a significant portion of the costs associated with conservation projects and frequently outstrip other kinds of cost. They are typically understood to refer to the benefits someone would have obtained if conservation projects had not required them to give up current activities, such as farming or hunting or if the land had been available for uses other than conservation. This familiar way of identifying opportunity costs is flawed, however, because it threatens to condone, or take advantage of, the injustices that many people face that affect their opportunities. I integrated ideas from the political theory of global justice to examine how the analysis of opportunity costs illustrates the importance of considering conservation and issues of global justice together, rather than thinking about them in isolation. I distinguish four baselines for defining opportunity costs. A status quo baseline defines opportunity costs by asking what people would have earned had a conservation project not happened. A willingness to accept baseline defines them by asking people what it would take to make them indifferent to whether a conservation project takes place or not. An antipoverty baseline suggests that opportunity costs have been met when people affected by a project are not left in poverty. An egalitarian baseline suggests opportunity costs have been met when people are not left in relative disadvantage, with worse than average opportunities. I argue that the egalitarian baseline is the most acceptable from the point of view of justice. Such a baseline would suggest that, in practice, many of the world's poor are being unjustly treated, or even exploited, as a result of conservation activities.

In search of boredom: beyond a functional account

Boredom has been characterized as a crisis of meaning, a failure of attention, and a call to action. Yet as a self-regulatory signal writ-large, we are still left with the question of what makes any given boredom episode meaningless, disengaging, or a prompt to act. We propose that boredom is an affective signal that we have deviated from an optimal ('Goldilocks') zone of cognitive engagement. Such deviations may be due to a perceived lack of meaning, arise as a consequence of struggles we are experiencing in attending to a task, or be interpreted as a blunt call to find something different to engage with. Thus, the key to understanding boredom lies in its role in keeping us cognitively engaged.

Opportunity costs of attending surgical clinic appointments and experiences with telemedicine for follow-up care

Objectives

Telemedicine has been rapidly implemented in orthopedics during the coronavirus (COVID-19) pandemic. The purpose of this study was to quantify opportunity costs for patients attending typical in-person appointments and understand their perceptions of telemedicine for follow-up care.

Methods

A cross-sectional study was performed by surveying patients who had elective orthopedic surgery and attended at least one in-person and one phone call appointment. The survey assessed opportunity costs associated with in-person appointments, experience with telemedicine, and preferred type of future appointment.

Results

Of the 49 eligible patients, 41 (83.7%) completed the survey. The median travel distance to the clinic was 108 km, and the time spent in the clinic was 60 min. Participants responded "yes" to various forms of opportunity costs associated with attending in-person appointments, including missed work (46.3%), lost income (34.1%), recreational activities (26.8%), home or yard care (14.6%), socializing with friends or family (12.2%), school (2.4%), and childcare (2.4%). In addition, elements of the telemedicine appointment were rated from 1 (least favorable) to 10 (most favorable), and averages were calculated for ease of use (9.2), convenience (8.4), confidence in the doctor's diagnostic ability (8.2), likelihood of using the service again (6.4), and overall satisfaction (8.2). Preferred future appointment types included having the first visit in-person and subsequent visits via telephone (61.0%), in-person only (36.6%), and unsure (2.4%).

Conclusion

This study identifies various opportunity costs associated with in-person orthopedic appointments and a favorable view toward telemedicine for follow-up care.

Fatigue, boredom and objectively measured smartphone use at work

Nowadays, many people take short breaks with their smartphone at work. The decision whether to continue working or to take a smartphone break is a so-called labour versus leisure decision. Motivational models predict that people are more likely to switch from labour (work) to leisure (smartphone) the more fatigue or boredom they experience. In turn, fatigue and boredom are expected to decrease after the smartphone was used. However, it is not yet clear how smartphone use at work relates to fatigue and boredom. In this study, we tested these relationships in both directions. Participants (n = 83, all PhD candidates) reported their current level of fatigue and boredom every hour at work while an application continuously logged their smartphone use. Results indicate that participants were more likely to interact with their smartphone the more fatigued or bored they were, but that they did not use it for longer when more fatigued or bored. Surprisingly, participants reported increased fatigue and boredom after having used the smartphone (more). While future research is necessary, our results (i) provide real-life evidence for the notion that fatigue and boredom are temporally associated with task disengagement, and (ii) suggest that taking a short break with the smartphone may have phenomenological costs.

The opportunity costs of birth in Australia: Hospital resource savings for a post-COVID-19 era

BACKGROUND

COVID-19 caused significant disruptions to health systems globally; however, restricting the family presence during birth saw an increase in women considering community birth options. This study aimed to quantify the hospital resource savings that could occur if all low-risk women in Australia gave birth at home or in birth centers.

METHODS

A whole-of-population linked administrative data set containing all women (n = 44 498) who gave birth in Queensland, Australia, between 01/07/2012 and 30/06/2015 was reweighted to represent all Australian women giving birth in 2017. A static microsimulation model of woman and infant health service resource use was created based on 2017 data. The model was comprised of a base model, representing "current" care, and a counterfactual model, representing hypothetical scenarios where all low-risk Australian women gave birth at home or in birth centers.

RESULTS

If all low-risk women gave birth at home in 2017, cesarean rates would have reduced from 13.4% to 2.7%. Similarly, there would have been 860 fewer inpatient bed days and 10.1 fewer hours of women's intensive care unit time per 1000 births. If all women gave birth in birth centers, cesarean rates would have reduced to 6.7%. In addition, over 760 inpatient bed days would have been saved along with 5.6 hours of women's intensive care unit time per 1000 births.

CONCLUSIONS

Significant health resource savings could occur by shifting low-risk births from hospitals to home birth and birth center services. Greater examination of Australian women's preferences for home birth and birth center birth models of care is needed.

Incorporating Portfolio Uncertainty in Decision Rules for Healthcare Resource Allocation

Cost-effectiveness analysis is widely adopted as a means to inform policy and decision makers in setting priorities for healthcare resource allocation. In resource-constrained settings, decision makers are confronted with healthcare resource reallocation decisions, e.g., moving funds from one or more existing healthcare programs to fund new healthcare programs. The decision-making plane (DMP) has been developed as a means to graphically present the results of reallocating available healthcare resources when healthcare program costs and effects are uncertain. Mapping a value function over the DMP allows the analyst to value all possible combinations of net costs and net effects that may result from reallocating available healthcare resources under conditions of uncertainty. In this paper, we extend this approach to include a change in portfolio risk, stemming from a change in the portfolios of funded healthcare programs, as an additional source of uncertainty, and demonstrate how this can be incorporated into the value function over net costs and net effects for a risk-averse decision maker. The methodology presented in this paper is of particular interest to decision makers who are risk averse, as it will help to better incorporate their preferences in the process of deciding how to best allocate scarce healthcare resources.

Are capuchin monkeys (Sapajus spp.) sensitive to lost opportunities? The role of opportunity costs in intertemporal choice

Principles of economics predict that the costs associated with obtaining rewards can influence choice. When individuals face choices between a smaller, immediate option and a larger, later option, they often experience opportunity costs associated with waiting for delayed rewards because they must forego the opportunity to make other choices. We evaluated how reducing opportunity costs affects delay tolerance in capuchin monkeys. After choosing the larger option, in the High cost condition, subjects had to wait for the delay to expire, whereas in the Low cost different and Low cost same conditions, they could perform a new choice during the delay. To control for the effect of intake rate on choices, the Low cost same condition had the same intake rate ratio as the High cost condition. We found that capuchins attended both to intake rates and to opportunity costs. They chose the larger option more often in the Low cost different and Low cost same conditions than in the High cost condition, and more often in the Low cost different condition than in the Low cost same condition. Understanding how non-human primates represent and use costs in making decisions not only helps to develop theoretical frameworks to explain their choices but also addresses similarities with and differences from human decision-making. These outcomes provide insights into the origins of human economic behaviour. This article is part of the theme issue 'Existence and prevalence of economic behaviours among non-human primates'.

A Comparison of Patient-Reported Outcomes Related to Telephone Follow-Up Visits and Conventional Office Visits in Medical Specialty Practices

Background/Introduction: Scheduled telephone follow-up visits (TFVs) are one strategy for improving access to specialty care practices, primarily because TFVs can be completed in less time with lower overhead costs than conventional office-based follow-up visits (OFVs). Beginning January 2015, scheduled TFVs were introduced in three specialty care practices at University of California San Francisco (UCSF) as a substitute for scheduled OFVs. As there is limited data on the relative advantage to patients from such a program, we conducted a survey to evaluate patient-reported outcomes associated with both TFVs and OFVs. Materials and Methods: All patients who completed a follow-up visit in Endocrinology, Hepatology, or Multiple Sclerosis clinics between March and May 2016 were surveyed. Primary outcomes included out-of-pocket costs associated with follow-up visits, visit duration, and satisfaction. Responses were analyzed using univariate and bivariate statistics, and both t-tests and chi-square tests were employed to determine significance. Results: A total of 2,741 patients were surveyed, of which 16% (n = 432) responded. Median self-reported costs associated with OFVs, including travel was $50 (interquartile range [IQR]: 20,100), and median visit duration was 240 (IQR: 150; 420) minutes. Of all TFV respondents, only one reported a cost of $15, and 99% of TFV respondents reported being satisfied with their TFV experience. Discussion/Conclusion: At UCSF, TFVs offer an efficient alternative to office-based visits in a manner that is both acceptable and affordable to patients. This study fills an important gap in understanding the patient's perception of telephone follow-up care, and represents a critical first step in mobilizing health plans to pay for TFVs.

Recovery from accumulated strain: the role of daily mood and opportunity costs during a vacation

OBJECTIVE

Recovery from strains accumulated over longer periods of time is essential for health and well-being. Most people take vacations to ensure that they achieve a state of recovery that will allow them to prevent a state of enduring exhaustion. Extending a recent motivational model of recovery, we examined recovery processes during a vacation.

DESIGN

In the current daily diary study, 147 university students reported their daily recovery, mood, opportunity costs, and subjective time perception over 21 consecutive days (2342 observations) during the summer break.

RESULTS

Multilevel analyses showed that students reported higher recovery on days when they were in a better mood and perceived lower opportunity costs than usual. These results held after controlling for the passage of time and well-established covariates of recovery (i.e., psychological detachment, relaxation, mastery, and control).

CONCLUSION

Supporting the motivational model of recovery, positive mood, the absence of opportunity costs and, to a lesser degree, the perception of time passing quickly contribute to daily recovery during a vacation. Thus, recovery is not simply the result of elapsed time but also depends on the kinds of experiences people have on a given vacation day.

Evaluating approaches for scaling-up community-based marine-protected areas into socially equitable and ecologically representative networks

Marine-protected areas (MPAs) are vital to marine conservation, but their coverage and distribution is insufficient to address declines in global biodiversity and fisheries. In response, many countries have committed through the Aichi Target 11 of the Convention on Biological Diversity to conserve 10% of the marine environment through ecologically representative and equitably managed MPAs by 2020. The rush to fulfill this commitment has raised concerns on how increasing MPA coverage will affect other elements of Target 11, including representation and equity. We examined a Philippines case study to assess and compare 3 MPA planning approaches for biodiversity representation and equitable distribution of costs to small-scale fishers. In the opportunistic approach, MPAs were identified and supported by coastal communities. The donor-assisted approach used local knowledge to select MPAs through a national-scale and donor-assisted conservation project. The systematic conservation planning approach identified MPA locations with the spatial prioritization software Marxan with Zones to achieve biodiversity objectives with minimal costs to fishers. We collected spatial data on biodiversity and fisheries features and performed a gap analysis to evaluate MPAs derived from different approaches. We assessed representation based on the proportion of biodiversity features conserved in MPAs and distribution equity by the distribution of opportunity costs (fishing areas lost in MPAs) among fisher stakeholder groups. The opportunistic approach did not ineffectively represent biodiversity and resulted in inequitable costs to fishers. The donor-assisted approach affected fishers disproportionately but provided near-optimal regional representation. Only the systematic approach achieved all representation targets with minimal and equitable costs to fishers. Our results demonstrate the utility of systematic conservation planning to address key elements of Target 11 and highlight opportunities (e.g., integration of local and scientific knowledge can address representation and equity concerns) and pitfalls (e.g., insufficient stakeholder considerations can exacerbate social inequalities) for planning MPAs in similar contexts.

Healthcare costs and productivity losses associated with county-based home-care service for sick children in Sweden

AIMS

The aim of this study was to estimate the healthcare costs and productivity losses associated with county-based home-care services (HCS) for sick children.

METHODS

In this observational follow-up study, a combination of hospital care and HCS was compared to estimated alternative care solely at the hospital. Data on one year of healthcare utilisation for 32 children, supplied by the hospital and HCS, were collected from administrative systems. Corresponding healthcare unit prices were collected from healthcare pricelists. The human-capital approach was applied to estimate productivity losses and the value of productivity losses for 25 parents. Family characteristics, including parental work absenteeism and income, were collected by a questionnaire distributed to parents at five time points during a year. Descriptive and comparative statistics were used for analysis and carried out with ethical approval.

RESULTS

Healthcare costs for children receiving a combination of hospital care and HCS varied among children with estimated average healthcare cost savings of SEK 50 101 per child compared to the alternative of care provided only in the hospital. The reduced costs were related to children receiving nonpalliative HCS care tasks. Average annual productivity losses due to parental work absenteeism were estimated at 348 hours with an associated monetary value estimated at SEK 137 524 per parent.

CONCLUSION

County-based HCS, provided as complement to and substitute for hospital care for ill children, does not increase healthcare cost and should be a prioritized area when organising paediatric health care. Productivity losses vary greatly among parents and are pronounced also when children receive HCS with signs of gender-related differences.

Reflecting the Health Opportunity Costs of Funding Decisions Within Value Frameworks: Initial Estimates and the Need for Further Research

PURPOSE

Evaluating whether a new health technology provides good value for money requires an assessment of its opportunity cost. If the opportunity cost of the new health technology exceeds the benefits, however measured, a net loss is produced. Value frameworks using economic evaluation methods have been developed to guide the assessment of the value of new technologies within health care in response to rising spending. However, few explicitly consider health opportunity costs and fewer still base health opportunity costs on empirical estimates. This may partly be due to the dearth of estimates available, with only a handful of countries having estimates based on within-country data. To fill this gap, this study provides estimates of cost per disability-adjusted life year (DALY) averted for 33 high-income countries and the remaining Organization for Economic Cooperation and Development (OECD) and BRIICS countries (Brazil, Russia, India, Indonesia, China and South Africa).

METHODS

Cost per DALY averted for each country was based on estimated elasticities of the health effects of changes in expenditure on health outcomes from applying an existing published econometric model that uses cross-country data to an expanded dataset and other existing elasticities drawn from selected UK within-country studies to country-level data on health expenditure, demographic characteristics, and burden of ill health. To provide a comprehensive picture of the state of research around empirical estimates of health opportunity costs for these countries, results from this study are reported against previously published estimates of cost per quality-adjusted life year (QALY) gained for the same countries.

FINDINGS

All but one of the ranges estimated fall below 3× the gross domestic product (GDP) per capita, the upper end of the widely applied range of 1-3× GDP per capita. The range of estimates based on applying an existing published econometric model that uses cross-country data to an expanded dataset are higher than when cost per DALY averted is calculated from other existing elasticities of the health effects of changes in expenditure drawn from selected UK within-country studies. They also tend to be higher than published estimates of cost per QALY gained.

IMPLICATIONS

This study provides placeholder cost per DALY averted estimates that reflect health opportunity costs for 33 high-income countries and the remaining OECD and BRIICS countries. These estimates can be used to estimate the health opportunity costs of government health care expenditure until country-specific health opportunity cost are estimated using within-country data.

Employee Acceptance of Use: A Precondition for Enhancing Therapy Effectiveness, Patient Safety, and Economic Efficiency

Introduction: From the workplace engineering sciences, it is evident that work efficiency, measured by the criteria efficiency and effectiveness of therapy, economy and patient safety, is determined mainly by staff acceptance of new technology and reengineered workflows. Accordingly, the aim of this study was to ascertain and assess differences in terms of the acceptance of alternative types of prosthesis instrument configurations, oriented around the research question: “Which product features and process effects determine a high level of employee acceptance of use?”

Materials and Methods: This study is designed as a before-and-after comparison, based on the usability engineering approach. In the first study phase, 46 employees participating in the process of providing instruments for a total knee arthroplasty (TKA) procedure were asked to examine the current working situation, using a standard instrumentation set, in terms of instrument handling, work burden, proneness to errors, patient risks, process efficiency, and effectiveness. In the second study phase, 20 weeks after having implemented a size-specific instrumentation set, the same 46 individuals were surveyed on the identical questions. Additionally, in both study phases the time needed to perform the sub-processes related to instrumentation logistics inside the operating room (OR) was measured, in order to identify process efficiency and cost-saving effects.

Results: By using standard sets only 30% perceived a need for improvement. After 20 weeks, only 8% of the employees were satisfied with the previous equipment and 69% regarded the standard set as being relatively error-prone, endangering patient safety. In addition, 85% regarded the effectiveness of the standard process as limited. Finally, 75% considered the effectiveness of the reengineered process to be significantly higher, and 69% drew attention to the reduction of handling disadvantages. Furthermore, the time needed for instrumentation logistics inside the OR estimated at about 13 min less when using size-specific sets. This effect on process efficiency cost savings or the generation of additional revenue by performing additional procedures. Based on these findings, an ergonomic decision-making model has been developed.

Conclusion: Innovative medical products such as size-specific instrumentation sets contribute to lower procedure costs and improved process efficiency in the operating room (OR). However, employee motivation to use a new technology as part of an optimized workflow organization, is crucial to achieving an enhanced level of effectiveness, efficiency and patient safety. Hence, it is advisable to enhance change-management efforts in order to reduce resistance to change and ensure the new technology is successful.

A cost-effectiveness threshold based on the marginal returns of cardiovascular hospital spending

Traditionally, threshold levels of cost-effectiveness have been derived from willingness-to-pay studies, indicating the consumption value of health (v-thresholds). However, it has been argued that v-thresholds need to be supplemented by so-called k-thresholds, which are based on the marginal returns to health care. The objective of this research is to estimate a k-threshold based on the marginal returns to cardiovascular disease (CVD) hospital care in the Netherlands. To estimate a k-threshold for hospital care on CVD, we proceed in two steps: First, we estimate the impact of hospital spending on mortality using a Bayesian regression modelling framework, using data on CVD mortality and CVD hospital spending by age and gender for the period 1994-2010. Second, we use life tables in combination with quality of life data to convert these estimates into a k-threshold expressed in euros per quality-adjusted life year gained. Our base case estimate resulted in an estimate of 41,000 per quality-adjusted life year gained. In our sensitivity analyses, we illustrated how the incorporation of prior evidence into the estimation pushes estimates downwards. We conclude that our base case estimate of the k-threshold may serve as a benchmark value for decision making in the Netherlands as well as for future research regarding k-thresholds.

Sleep variability and nighttime activity among Tsimane forager-horticulturalists

OBJECTIVES

A common presumption in sleep research is that "normal" human sleep should show high night-to-night consistency. Yet, intra-individual sleep variation in small-scale subsistence societies has never been studied to test this idea. In this study, we assessed the degree of nightly variation in sleep patterns among Tsimane forager-horticulturalists in Bolivia, and explored possible drivers of the intra-individual variability.

METHODS

We actigraphically recorded sleep among 120 Tsimane adults (67 female), aged 18-91, for an average of 4.9 nights per person using the Actigraph GT3X and Philips Respironics Actiwatch 2. We assessed intra-individual variation using intra-class correlations and average deviation from each individual's average sleep duration, onset, and offset times ( ɛ¯).

RESULTS

Only 31% of total variation in sleep duration was due to differences among different individuals, with the remaining 69% due to nightly differences within the same individuals. We found no statistically significant differences in Tsimane sleep duration by day-of-the-week. Nightly variation in sleep duration was driven by highly variable sleep onset, especially for men. Nighttime activities associated with later sleep onset included hunting, fishing, housework, and watching TV.

CONCLUSIONS

In contrast to nightly sleep variation in the United States being driven primarily by "sleeping-in" on weekends, Tsimane sleep variation, while comparable to that observed in the United States, was driven by changing "bedtimes," independent of day-of-the-week. We propose that this variation may reflect adaptive responses to changing opportunity costs to sleep/nighttime activity.

Estimating the Hospital Burden of Norovirus-Associated Gastroenteritis in England and Its Opportunity Costs for Nonadmitted Patients

Background

Norovirus places a substantial burden on healthcare systems, arising from infected patients, disease outbreaks, beds kept unoccupied for infection control, and staff absences due to infection. In settings with high rates of bed occupancy, opportunity costs arise from patients who cannot be admitted due to beds being unavailable. With several treatments and vaccines against norovirus in development, quantifying the expected economic burden is timely.

Methods

The number of inpatients with norovirus-associated gastroenteritis in England was modeled using infectious and noninfectious gastrointestinal Hospital Episode Statistics codes and laboratory reports of gastrointestinal pathogens collected at Public Health England. The excess length of stay from norovirus was estimated with a multistate model and local outbreak data. Unoccupied bed-days and staff absences were estimated from national outbreak surveillance. The burden was valued conventionally using accounting expenditures and wages, which we contrasted to the opportunity costs from forgone patients using a novel methodology.

Results

Between July 2013 and June 2016, 17.7% (95% confidence interval [CI], 15.6%‒21.6%) of primary and 23.8% (95% CI, 20.6%‒29.9%) of secondary gastrointestinal diagnoses were norovirus attributable. Annually, the estimated median 290000 (interquartile range, 282000‒297000) occupied and unoccupied bed-days used for norovirus displaced 57800 patients. Conventional costs for the National Health Service reached £107.6 million; the economic burden approximated to £297.7 million and a loss of 6300 quality-adjusted life-years annually.

Conclusions

In England, norovirus is now the second-largest contributor of the gastrointestinal hospital burden. With the projected impact being greater than previously estimated, improved capture of relevant opportunity costs seems imperative for diseases such as norovirus.

Estimating the opportunity costs of bed-days

Opportunity costs of bed-days are fundamental to understanding the value of healthcare systems. They greatly influence burden of disease estimations and economic evaluations involving stays in healthcare facilities. However, different estimation techniques employ assumptions that differ crucially in whether to consider the value of the second-best alternative use forgone, of any available alternative use, or the value of the actually chosen alternative. Informed by economic theory, this paper provides a taxonomic framework of methodologies for estimating the opportunity costs of resources. This taxonomy is then applied to bed-days by classifying existing approaches accordingly. We highlight differences in valuation between approaches and the perspective adopted, and we use our framework to appraise the assumptions and biases underlying the standard approaches that have been widely adopted mostly unquestioned in the past, such as the conventional use of reference costs and administrative accounting data. Drawing on these findings, we present a novel approach for estimating the opportunity costs of bed-days in terms of health forgone for the second-best patient, but expressed monetarily. This alternative approach effectively re-connects to the concept of choice and explicitly considers net benefits. It is broadly applicable across settings and for other resources besides bed-days.

Evidence for Opportunity Cost Neglect in the Poor

People often neglect opportunity costs: They do not fully take into account forgone alternatives outside of a particular choice set. Several scholars have suggested that poor people should be more likely to spontaneously consider opportunity costs, because budget constraints should lead to an increased focus on trade-offs. We did not find support for this hypothesis in five high-powered experiments (total N = 2325). The experiments used different products (both material and experiential) with both high and low prices (from $8.50 to $249.99) and different methods of reminding participants of opportunity costs. High-income and low-income participants showed an equally strong decrease in willingness to buy when reminded of opportunity costs, implying that both the rich and the poor neglect opportunity costs.

The political economy of the assessment of value of new health technologies

Health technology assessment provides a common framework for evaluating the costs and benefits of new health technologies to inform decisions on the public funding of new pharmaceuticals and other health technologies. In Australia and England, empirical analyses of the opportunity costs of government spending on new health technologies suggest more quality adjusted life years are being forgone than are being gained by a non-trivial proportion of funded health technologies. This essay considers the relevance of available empirical estimates of opportunity costs and explores the relationship between the public funding of health technologies and broader political and economic factors. We conclude that the benefits of a general reduction in the prices paid by governments for new technologies outweigh the costs, but evidence of informed public acceptance of reduced access to new health technologies may be required to shift the current approach to assessing the value of new health technologies.

Expanding Kenya's protected areas under the Convention on Biological Diversity to maximize coverage of plant diversity

Biodiversity is highly valuable and critically threatened by anthropogenic degradation of the natural environment. In response, governments have pledged enhanced protected-area coverage, which requires scarce biological data to identify conservation priorities. To assist this effort, we mapped conservation priorities in Kenya based on maximizing alpha (species richness) and beta diversity (species turnover) of plant communities while minimizing economic costs. We used plant-cover percentages from vegetation surveys of over 2000 plots to build separate models for each type of diversity. Opportunity and management costs were based on literature data and interviews with conservation organizations. Species richness was predicted to be highest in a belt from Lake Turkana through Mount Kenya and in a belt parallel to the coast, and species turnover was predicted to be highest in western Kenya and along the coast. Our results suggest the expanding reserve network should focus on the coast and northeastern provinces of Kenya, where new biological surveys would also fill biological data gaps. Meeting the Convention on Biological Diversity target of 17% terrestrial coverage by 2020 would increase representation of Kenya's plant communities by 75%. However, this would require about 50 times more funds than Kenya has received thus far from the Global Environment Facility.

The Precautionary Principle and the Tolerability of Blood Transfusion Risks

Tolerance for blood transfusion risks is very low, as evidenced by the implementation of expensive blood tests and the rejection of gay men as blood donors. Is this low risk tolerance supported by the precautionary principle, as defenders of such policies claim? We discuss three constraints on applying (any version of) the precautionary principle and show that respecting these implies tolerating certain risks. Consistency means that the precautionary principle cannot prescribe precautions that it must simultaneously forbid taking, considering the harms they might cause. Avoiding counterproductivity requires rejecting precautions that cause more harm than they prevent. Proportionality forbids taking precautions that are more harmful than adequate alternatives. When applying these constraints, we argue, attention should not be restricted to harms that are human caused or that affect human health or the environment. Tolerating transfusion risks can be justified if available precautions have serious side effects, such as high social or economic costs.

Developing a Value Framework: The Need to Reflect the Opportunity Costs of Funding Decisions

A growing number of health care systems internationally use formal economic evaluation methods to support health care funding decisions. Recently, a range of organizations have been advocating forms of analysis that have been termed "value frameworks." There has also been a push for analytical methods to reflect a fuller range of benefits of interventions through multicriteria decision analysis. A key principle that is invariably neglected in current and proposed frameworks is the need to reflect evidence on the opportunity costs that health systems face when making funding decisions. The mechanisms by which opportunity costs are realized vary depending on the system's financial arrangements, but they always mean that a decision to fund a specific intervention for a particular patient group has the potential to impose costs on others in terms of forgone benefits. These opportunity costs are rarely explicitly reflected in analysis to support decisions, but recent developments to quantify benefits forgone make more appropriate analyses feasible. Opportunity costs also need to be reflected in decisions if a broader range of attributes of benefit is considered, and opportunity costs are a key consideration in determining the appropriate level of total expenditure in a system. The principles by which opportunity costs can be reflected in analysis are illustrated in this article by using the example of the proposed methods for value-based pricing in the United Kingdom.

A microcosting study of immunogenicity and tumour necrosis factor alpha inhibitor drug level tests for therapeutic drug monitoring in clinical practice

OBJECTIVES

To identify and quantify resource required and associated costs for implementing TNF-α inhibitor (TNFi) drug level and anti-drug antibody (ADAb) tests in UK rheumatology practice.

METHODS

A microcosting study, assuming the UK National Health Service perspective, identified the direct medical costs associated with providing TNFi drug level and ADAb testing in clinical practice. Resource use and costs per patient were identified via four stages: identification of a patient pathway with resource implications; estimation of the resources required; identification of the cost per unit of resource (2015 prices); and calculation of the total costs per patient. Univariate and multiway sensitivity analyses were performed using the variation in resource use and unit costs.

RESULTS

Total costs for TNFi drug level and concurrent ADAb testing, assessed using ELISAs on trough serum levels, were £152.52/patient (range: £147.68-159.24) if 40 patient samples were tested simultaneously. For the base-case analysis, the pre-testing phase incurred the highest costs, which included booking an additional appointment to acquire trough blood samples. The additional appointment was the key driver of costs per patient (67% of the total cost), and labour accounted for 10% and consumables 23% of the total costs. Performing ELISAs once per patient (rather than in duplicate) reduced the total costs to £133.78/patient.

CONCLUSION

This microcosting study is the first assessing the cost of TNFi drug level and ADAb testing. The results could be used in subsequent cost-effectiveness analyses of TNFi pharmacological tests to target treatments and inform future policy recommendations.

Prioritizing Intentions on the Margins: Effects of Marginally Higher Prioritization Strategies on Physical Activity Participation

Previous research documented that "extremely high prioritization" strategies that involved allocation of all resources for time or energy on pursuing goals related to leisure-time physical activity and none of available resources on competing behavioral goals were optimal in terms of yielding highest levels of participation in physical activities. This study examined whether a "marginally higher prioritization" strategy that involved an intention to invest large but slightly more resources on physical activity than competing behaviors was optimal. In addition, we examined whether linear and quadratic models supported different conclusions about optimal prioritizations strategies. Response surface analyses of a quadratic model revealed that marginally higher prioritization was the most effective strategy. In addition, a linear regression model led us to incorrectly reject a "simultaneous goal pursuit" strategy in favor of an extremely high prioritization strategy. Findings suggest that prioritization strategies that "garner" low opportunity costs are the most optimal.

Valuing the work of unpaid community health workers and exploring the incentives to volunteering in rural Africa

Community health worker (CHW) programmes are currently being scaled-up in sub-Saharan Africa to improve access to healthcare. CHWs are often volunteers; from an economic perspective, this raises considerations whether reliance on an unpaid workforce is sustainable and how to appropriately cost and value the work of CHWs. Both these questions can be informed by an understanding of CHWs' workload, their opportunity costs of time and the perceived benefits of being a CHW. However, to date few studies have fully explored the methodological challenges in valuing CHW time. We examined the costs and benefits of volunteering in a sample of 45 CHWs providing integrated community case management of common childhood illnesses in rural Uganda in February 2012 using different methods. We assessed the value of CHW time using the minimum public sector salary rate and a CHW-elicited replacement wage, as well as the opportunity cost of time based on CHW-estimated annual income and alternative work opportunities, respectively. Reported monthly CHW workload, a median of 19.3 h (range 2.5-57), was valued at USD 6.9 (range 0.9-20.4) per month from the perspective of the healthcare system (applicable replacement wage) and at a median of USD 4.1 (range 0.4-169) from the perspective of the CHWs (individual opportunity cost of time). In a discrete choice experiment on preferred work characteristics, remuneration and community appreciation dominated. We find that volunteering CHWs value the opportunity to make a social contribution, but the decision to volunteer is also influenced by anticipated future rewards. Care must be taken by those costing and designing CHW programmes to acknowledge the opportunity cost of CHWs at the margin and over the long term. Failure to properly consider these issues may lead to cost estimations below the amount necessary to scale up and sustain programmes.

Opportunity Cost Neglect Attenuates the Effect of Choices on Preferences

The idea that choices alter preferences has been widely studied in psychology, yet prior research has focused primarily on choices for which all alternatives were salient at the time of choice. Opportunity costs capture the value of the best forgone alternative and should be considered as part of any decision process, yet people often neglect them. How does the salience of opportunity costs at the time of choice influence subsequent evaluations of chosen and forgone options? In three experiments, we found that there was a larger postchoice spread between evaluations of focal options and opportunity costs when opportunity costs were explicit at the time of choice than when they remained implicit.

Cost analysis of hospitalized Clostridium difficile-associated diarrhea (CDAD)

Aim:Clostridium difficile-associated diarrhea (CDAD) causes heavy financial burden on healthcare systems worldwide. As with all hospital-acquired infections, prolonged hospital stays are the main cost driver. Previous cost studies only include hospital billing data and compare the length of stay in contrast to non-infected patients. To date, a survey of actual cost has not yet been conducted.

Method: A retrospective analysis of data for patients with nosocomial CDAD was carried out over a 1-year period at the University Hospital of Greifswald. Based on identification of CDAD related treatment processes, cost of hygienic measures, antibiotics and laboratory as well as revenue losses due to bed blockage and increased length of stay were calculated.

Results: 19 patients were included in the analysis. On average, a CDAD patient causes additional costs of € 5,262.96. Revenue losses due to extended length of stay take the highest proportion with € 2,555.59 per case, followed by loss in revenue due to bed blockage during isolation with € 2,413.08 per case. Overall, these opportunity costs accounted for 94.41% of total costs. In contrast, costs for hygienic measures (€ 253.98), pharmaceuticals (€ 22.88) and laboratory (€ 17.44) are quite low.

Conclusion: CDAD results in significant additional costs for the hospital. This survey of actual costs confirms previous study results.

Efficient and equitable design of marine protected areas in Fiji through inclusion of stakeholder-specific objectives in conservation planning

The efficacy of protected areas varies, partly because socioeconomic factors are not sufficiently considered in planning and management. Although integrating socioeconomic factors into systematic conservation planning is increasingly advocated, research is needed to progress from recognition of these factors to incorporating them effectively in spatial prioritization of protected areas. We evaluated 2 key aspects of incorporating socioeconomic factors into spatial prioritization: treatment of socioeconomic factors as costs or objectives and treatment of stakeholders as a single group or multiple groups. Using as a case study the design of a system of no-take marine protected areas (MPAs) in Kubulau, Fiji, we assessed how these aspects affected the configuration of no-take MPAs in terms of trade-offs between biodiversity objectives, fisheries objectives, and equity in catch losses among fisher stakeholder groups. The achievement of fisheries objectives and equity tended to trade-off concavely with increasing biodiversity objectives, indicating that it is possible to achieve low to mid-range biodiversity objectives with relatively small losses to fisheries and equity. Importantly, the extent of trade-offs depended on the method used to incorporate socioeconomic data and was least severe when objectives were set for each fisher stakeholder group explicitly. We found that using different methods to incorporate socioeconomic factors that require similar data and expertise can result in plans with very different impacts on local stakeholders.

Conservation businesses and conservation planning in a biological diversity hotspot

The allocation of land to biological diversity conservation competes with other land uses and the needs of society for development, food, and extraction of natural resources. Trade-offs between biological diversity conservation and alternative land uses are unavoidable, given the realities of limited conservation resources and the competing demands of society. We developed a conservation-planning assessment for the South African province of KwaZulu-Natal, which forms the central component of the Maputaland-Pondoland-Albany biological diversity hotspot. Our objective was to enhance biological diversity protection while promoting sustainable development and providing spatial guidance in the resolution of potential policy conflicts over priority areas for conservation at risk of transformation. The conservation-planning assessment combined spatial-distribution models for 646 conservation features, spatial economic-return models for 28 alternative land uses, and spatial maps for 4 threats. Nature-based tourism businesses were competitive with other land uses and could provide revenues of >US$60 million/year to local stakeholders and simultaneously help meeting conservation goals for almost half the conservation features in the planning region. Accounting for opportunity costs substantially decreased conflicts between biological diversity, agricultural use, commercial forestry, and mining. Accounting for economic benefits arising from conservation and reducing potential policy conflicts with alternative plans for development can provide opportunities for successful strategies that combine conservation and sustainable development and facilitate conservation action.

Daily variation in natural disaster casualties: information flows, safety, and opportunity costs in tornado versus hurricane strikes

Casualties from natural disasters may depend on the day of the week they strike. With data from the Spatial Hazard Events and Losses Database for the United States (SHELDUS), daily variation in hurricane and tornado casualties from 5,043 tornado and 2,455 hurricane time/place events is analyzed. Hurricane forecasts provide at-risk populations with considerable lead time. Such lead time allows strategic behavior in choosing protective measures under hurricane threat; opportunity costs in terms of lost income are higher during weekdays than during weekends. On the other hand, the lead time provided by tornadoes is near zero; hence tornados generate no opportunity costs. Tornado casualties are related to risk information flows, which are higher during workdays than during leisure periods, and are related to sheltering-in-place opportunities, which are better in permanent buildings like businesses and schools. Consistent with theoretical expectations, random effects negative binomial regression results indicate that tornado events occurring on the workdays of Monday through Thursday are significantly less lethal than tornados that occur on weekends. In direct contrast, and also consistent with theory, the expected count of hurricane casualties increases significantly with weekday occurrences. The policy implications of observed daily variation in tornado and hurricane events are considered.

A bottom-up approach to estimating cost elements of REDD+ pilot projects in Tanzania

BACKGROUND

Several previous global REDD+ cost studies have been conducted, demonstrating that payments for maintaining forest carbon stocks have significant potential to be a cost-effective mechanism for climate change mitigation. These studies have mostly followed highly aggregated top-down approaches without estimating the full range of REDD+ costs elements, thus underestimating the actual costs of REDD+. Based on three REDD+ pilot projects in Tanzania, representing an area of 327,825 ha, this study explicitly adopts a bottom-up approach to data assessment. By estimating opportunity, implementation, transaction and institutional costs of REDD+ we develop a practical and replicable methodological framework to consistently assess REDD+ cost elements.

RESULTS

Based on historical land use change patterns, current region-specific economic conditions and carbon stocks, project-specific opportunity costs ranged between US$ -7.8 and 28.8 tCOxxxx for deforestation and forest degradation drivers such as agriculture, fuel wood production, unsustainable timber extraction and pasture expansion. The mean opportunity costs for the three projects ranged between US$ 10.1 - 12.5 tCO2. Implementation costs comprised between 89% and 95% of total project costs (excluding opportunity costs) ranging between US$ 4.5 - 12.2 tCO2 for a period of 30 years. Transaction costs for measurement, reporting, verification (MRV), and other carbon market related compliance costs comprised a minor share, between US$ 0.21 - 1.46 tCO2. Similarly, the institutional costs comprised around 1% of total REDD+ costs in a range of US$ 0.06 - 0.11 tCO2.

CONCLUSIONS

The use of bottom-up approaches to estimate REDD+ economics by considering regional variations in economic conditions and carbon stocks has been shown to be an appropriate approach to provide policy and decision-makers robust economic information on REDD+. The assessment of opportunity costs is a crucial first step to provide information on the economic baseline situation of deforestation and forest degradation agents and on the economic incentives required to halt unsustainable land use. Since performance based REDD+ carbon payments decrease over time (as deforestation rates drop and for each saved ha of forest payments occur once), investments in REDD+ implementation have a crucial role in triggering sustainable land use systems by investing in the underlying assets and the generation of sustainable revenue streams to compensate for opportunity costs of land use change. With a potential increase in the land value due to effective REDD+ investments, expenditures in an enabling institutional environment for REDD+ policies are crucial to avoid higher deforestation pressure on natural forests.