Cost-effectiveness analysis of humanitarian relief interventions: visceral leishmaniasis treatment in the Sudan

Spending by aid agencies on emergencies has quadrupled over the last decade, to over US$ 6 billion. To date, cost-effectiveness has seldom been considered in the prioritization and evaluation of emergency interventions. The sheer volume of resources spent on humanitarian aid and the chronicity of many humanitarian interventions call for more attention to be paid to the issue of 'value for money'. In this paper we present data from a major humanitarian crisis, an epidemic of visceral leishmaniasis (VL) in war-torn Sudan. The special circumstances provided us, in retrospect, with unusually accurate data on excess mortality, costs of the intervention and its effects, thus allowing us to express cost-effectiveness as the cost per Disability Adjusted Life Year (DALY) averted. The cost-effectiveness ratio, of US$ 18.40 per DALY (uncertainty range between US$ 13.53 and US$ 27.63), places the treatment of VL in Sudan among health interventions considered 'very flood value for money' (interventions of less than US$ 25 per DALY). We discuss the usefulness of this analysis to the internal management of the VL programme, the procurement of funds for the programme, and more generally, to priority setting in humanitarian relief interventions. We feel that in evaluations of emergency interventions attempts could be made more often to perform cost-effectiveness analyses, including the use of DALYs, provided that the outcomes of these analyses are seen in the broad context of the emergency situation and its consequences on the affected population. This paper provides a first contribution to what is hoped to become an international database of cost-effectiveness studies of health outcome such as the DALY.

The role of economic evaluation in mental health care

Objective: A consequence of the integration of psychiatry into acute and public health medicine is that psychiatrists are being asked to evaluate their services. There is pressure on mental health-care systems because it is recognized that funds should be directed where they can provide the best health outcomes, and also because there are resource constraints which limit our capacity to meet all demands for health care. This pressure can be responded to by evaluation which demonstrates the effectiveness and efficiency of psychiatric treatment. This paper seeks to remind psychiatrists of the fundamental principles of economic evaluation in the hope that these will enable psychiatrists to understand the methods used in evaluation and to work comfortably with evaluators. Method: The paper reviews the basic principles behind economic evaluation, illustrating these with reference to case studies. It describes: (i) the cost of the burden of illness and treatment, and how these costs are measured; (ii) the measurement of treatment outcomes, both as changes in health status and as resources saved; and (iii) the various types of economic evaluation, including cost-minimization, cost-effectiveness, cost-utility and cost-benefit analysis. Results: The advice in the paper provides psychiatrists with the necessary background to work closely with evaluators. A checklist of the critical questions to be addressed is provided as a guide for those undertaking economic evaluations. Conclusions: If psychiatrists are willing to learn the basic principles of economic evaluation and to apply these, they can respond to the challenges of evaluation.

The Australian Universities Teaching Committee project in 'Learning Outcomes and Curriculum Development in Psychology'

The Australian Universities Teaching Committee (AUTC) funds projects intended to improve the quality of teaching and learning in specific disciplinary areas. The project brief for 'Learning Outcomes and Curriculum Development in Psychology' for 2004/2005 was to 'produce an evaluative overview of courses ... with a focus on the specification and assessment of learning outcomes and ... identify strategic directions for universities to enhance teaching and learning'. This project was awarded to a consortium from The University of Queensland, University of Tasmania, and Southern Cross University. The starting point for this project is an analysis of the scientist-practitioner model and its role in curriculum design, a review of current challenges at a conceptual level, and consideration of the implications of recent changes to universities relating to such things as intemationalisation of programs and technological advances. The project will seek to bring together stakeholders from around the country in order to survey the widest possible range of perspectives on the project brief requirements. It is hoped also to establish mechanisms for fiiture scholarly discussion of these issues, including the establishment of an Australian Society for the Teaching of Psychology and an annual conference.

Achieving the millennium development goals for health - Time to reassess strategies for improving health in developing countries

Making best use of resources is vital in developing countries that are struggling to improve public health with limited funds. The WHO-CHOICE project has developed standardised methods to,evaluate the efficiency of a broad range of interventions. Ibis series starts by assessing die problems with strategies for meeting the millennium development goals. Subsequent articles describe the methods, apply them to maternal and neonatal health, child health, HIV and AIDS, tuberculosis, and malaria, and consider the implications for an overall health strategy. All appear on bmj.com this week.

An Economic Analysis of the Legal Concept of Trustees' Power of Investment

Authorised trustee status is a legal concept which has economic implications; one of the major implications is that it assists in the direction of investment funds into particular securities and areas of the economy. The concept of authorised trustee status, while attempting to achieve specific outcomes for the beneficiaries of trusts cannot be relied upon to secure these results. Economic analysis of the role of the trustee maintains that this role is one of portfolio manager; a role which is complex but which is explicable in terms of definable procedures and practices. The role of trustee as portfolio manager is one which requires greater financial knowledge than can be assumed is possessed by all trustees. The trustee as portfolio manager is required to maintain a review of decisions make under powers to invest trust assets. A solution to the problem of authorised trustee status is proposed. The solution takes two parts: the first is the adoption of the prudent person approach but with the codification of duties of the trustee and the explicit listing of the factors that a trustee should consider in using the investment powers. The second part of the proposed solution is to link the investment powers of trustees to the best practice features of securities advisers who are now licensed by a regulatory body, the Australian Securities and Investment Commission.

Visitor profiles and environmental attributes, especially of birds, attracting visitors to Lamington National Park: Tourist attitudes and economic issues

Uses a sample of 622 day and overnight visitors to the O’ Reilly’s/Green Mountains site of Lamington National Park, Queensland, Australia, to identify their socio-economic and other pertinent characteristics and the main reasons and attributes that attract them to the site. Particular attention is given to birds and their attributes as attractions. The primary economic injection accruing locally as a result of visits is examined and the difference that the presence of birds makes to local expenditure by visitors is explored. The extent of support for and objection to the introduction of a fee for entering Lamington National Park is estimated. The many suggestions received from visitors for environmental improvements at this site are discussed. It is suggested that unless a way can be found to regulate the number of visitors to this site and obtain extra funds to finance improvements at this site, the magnitude of many of these problems will grow. This will necessitate a fresh look at the desirability or otherwise for charging entry fees to Lamington National Park.

Influences on knowledge of wildlife species on patterns of willingness to pay for their conservation

Examines the influence of respondents’ knowledge of wildlife species on their willingness to pay for conservation of the individual species. It does so by using data generated by surveys of 204 individuals who participated in a structured experiment in which their knowledge of a selected set of wildlife species was increased. The species selected were Australian ones, mostly but not entirely, tropical ones. The species were divided into three taxa for the experiment; reptiles, mammals and birds. Each set of species in the taxa included some species expected to be poorly known initially and some anticipated to be well known. Respondents rated their knowledge of each species on a Likert scale, and changes in their average allocation of funds for the conservation of each species were examined as their knowledge increased. Some general relationships are observed.

Knowledge about a species' conservation status and funding for its preservation: Analysis

Using a species’ population to measure its conservation status, this note explores how an increase in knowledge about this status would change the public’s willingness to donate funds for its conservation. This is done on the basis that the relationship between the level of donations and a species’ conservation status satisfies stated general mathematical properties. This level of donation increases, on average, with greater knowledge of a species’ conservation status if it is endangered, but falls if it is secure. Game theory and other theory is used to show how exaggerating the degree of endangerment of a species can be counterproductive for conservation.

Veterinary employment patterns

Rolls and electronic records of The Veterinary Surgeons Board of Queensland between 1940 and 2000 were analysed to identify changes in the numbers and employment patterns of veterinarians. The number of veterinarians increased at a much more rapid rate than the population and on a state-wide level reached a plateau a decade ago at 340 per million. A plateau has not been reached in the capital city of Brisbane. The percentage of veterinarians employed with government funds has decreased, and the percentage of private practitioners increased to more than 80%. In 2000, single veterinarian practices represented 50% of all practices and 24% of practitioners. Women represented less than 10% of Queensland veterinarians until 1980, but 33% in 2000, and they are in higher concentration in Brisbane than elsewhere in the state.

Relationship of high energy expenditure and variation in dietary intake with reporting accuracy on 7 day food records and diet histories in a group of healthy adult volunteers

Objectives: To assess the accuracy of reporting from both a diet history and food record and identify some of the characteristics of more accurate reporters in a group of healthy adult volunteers for an energy balance study. Design: Prospective measurements in free-living people. Setting: Wollongong, Australia. Subjects: Fifteen healthy volunteers (seven male, eight female; aged 22 -59 y; body mass index (BMI) 19 - 33 kg/m(2)) from the local community in the city of Wollongong, Australia. Interventions: Measurement of energy intake via diet history interview and 7 day food records, total energy expenditure by the doubly labelled water technique over 14 days, physical activity by questionnaire, and body fat by dual-energy X-ray absorptiometry. Results: Increased misreporting of energy intake was associated with increased energy expenditure (r = 0.90, P < 0.0001, diet history; r(s)=0.79, P=0.0005, food records) but was not associated with age, sex, BMI or body fat. Range in number of recorded dinner foods correlated positively with energy expenditure (r(s)=0.63, P=0.01) and degree of misreporting (r(s)=0.71, P=0.003, diet history; r(s)=0.63, P=0.01, food records). Variation in energy intake at dinner and over the whole day identified by the food records correlated positively with energy expenditure (r=0.58, P = 0.02) and misreporting on the diet history (r=0.62, P=0.01). Conclusions: Subjects who are highly active or who have variable dietary and exercise behaviour may be less accurate in reporting dietary intake. Our findings indicate that it may be necessary to screen for these characteristics in studies where accuracy of reporting at an individual level is critical. Sponsorship: The study was supported in part by Australian Research Council funds made available through the University of Wollongong.

Performance measurement in child protection

The increasing use of performance measurement by government means that child protection services are under pressure to demonstrate effectiveness in protecting children from harm and efficiency in the use of public funds to help children and families. From a policy perspective, the way performance measurement is conceptualised and implemented can have major consequences for service delivery. This paper examines key issues raised in the literature about performance measurement, the context for its introduction in child protection, how the concepts of effectiveness and efficiency are dealt with, how client outcomes are defined, and assumptions about 'good performance'. An overview of performance measurement in child protection in Australia is provided. The paper argues that a critical approach to performance measurement in child protection can contribute to improved service delivery to clients.