Economic evaluation of prevention of mother – to – child – transmission of HIV/AIDS interventions in developing countries : a systematic review

Les gouvernements mondiaux et les organismes internationaux ont placé une haute priorité dans la prévention de la transmission mère-enfant du VIH. Cependant, bien qu'il y ait eu des progrès énormes rapportés dans des nations industrialisées, la situation dans les pays en voie de développement est encore déplorable; on y constate un grand écart entre l’engagement international pour réduire cette voie de transmission et l'accès aux interventions. Ceci peut être attribué à la situation économique déplorable dans plusieurs pays en voie de développement. Des interventions prioritaires en santé doivent donc être soigneusement sélectionnées afin de maximiser l'utilisation efficace des ressources limitées. L’évaluation économique est un outil efficace qui peut aider des décideurs à identifier quelles stratégies choisir. L'objectif de cette revue systématique est de recenser toutes les études d'évaluation économique existantes qui ont été effectuées dans les pays en voie de développement sur la prévention de la transmission mère-enfant du VIH. Notre revue a retenu 16 articles qui ont répondu aux critères d'inclusion. Nous avons conçu un formulaire pour l’extraction de données, puis nous avons soumis les articles à un contrôle rigoureux de qualité. Nos résultats ont exposé un certain nombre de défauts dans la qualité des études choisies. Nous avons également noté une forte hétérogénéité dans les estimations des paramètres de coût et d'efficacité de base, dans la méthodologie appliquée, ainsi que dans les écarts utilisés dans les analyses de sensibilité. Quelques interventions comportant la thérapie à la zidovudine ou à la nevirapine à court terme se sont avérées rentables, et ont enregistré des valeurs acceptables de coût-utilité. Les résultats des évaluations économiques analysées dans cette revue ont varié sur la base des facteurs suivants : la prévalence du VIH, la classification du pays selon le revenu, les infrastructures disponible, les coûts du personnel, et finalement les coûts des interventions, particulièrement les prix des médicaments.

Le rôle de l’évaluation économique dans la pratique des médecins de famille = The role of economic evaluation in the practice of family physicians

L’évaluation économique en santé consiste en l’analyse comparative d’alternatives de services en regard à la fois de leurs coûts et de leurs conséquences. Elle est un outil d’aide à la décision. La grande majorité des décisions concernant l’allocation des ressources sont prises en clinique; particulièrement au niveau des soins primaires. Puisque chaque décision est associée à un coût d’opportunité, la non-prise en compte des considérations économiques dans les pratiques des médecins de famille peut avoir un impact important sur l’efficience du système de santé. Il existe peu de connaissances quant à l’influence des évaluations économiques sur la pratique clinique. L’objet de la thèse est de comprendre le rôle de l’évaluation économique dans la pratique des médecins de famille. Ses contributions font l’objet de quatre articles originaux (philosophique, théorique, méthodologique et empirique). L’article philosophique suggère l’importance des questions de complexité et de réflexivité en évaluation économique. La complexité est la perspective philosophique, (approche générale épistémologique) qui sous-tend la thèse. Cette vision du monde met l’attention sur l’explication et la compréhension et sur les relations et les interactions (causalité interactive). Cet accent sur le contexte et le processus de production des données souligne l’importance de la réflexivité dans le processus de recherche. L’article théorique développe une conception nouvelle et différente du problème de recherche. L’originalité de la thèse réside également dans son approche qui s’appuie sur la perspective de la théorie sociologique de Pierre Bourdieu; une approche théorique cohérente avec la complexité. Opposé aux modèles individualistes de l’action rationnelle, Bourdieu préconise une approche sociologique qui s’inscrit dans la recherche d’une compréhension plus complète et plus complexe des phénomènes sociaux en mettant en lumière les influences souvent implicites qui viennent chaque jour exercer des pressions sur les individus et leurs pratiques. L’article méthodologique présente le protocole d’une étude qualitative de cas multiples avec niveaux d’analyse imbriqués : les médecins de famille (niveau micro-individuel) et le champ de la médecine familiale (niveau macro-structurel). Huit études de cas furent réalisées avec le médecin de famille comme unité principale d’analyse. Pour le niveau micro, la collecte des informations fut réalisée à l’aide d’entrevues de type histoire de vie, de documents et d’observation. Pour le niveau macro, la collecte des informations fut réalisée à l’aide de documents, et d’entrevues de type semi-structuré auprès de huit informateurs clés, de neuf organisations médicales. L’induction analytique fut utilisée. L’article empirique présente l’ensemble des résultats empiriques de la thèse. Les résultats montrent une intégration croissante de concepts en économie dans le discours officiel des organisations de médecine familiale. Cependant, au niveau de la pratique, l'économisation de ce discours ne semble pas être une représentation fidèle de la réalité puisque la très grande majorité des participants n'incarnent pas ce discours. Les contributions incluent une compréhension approfondie des processus sociaux qui influencent les schèmes de perception, de pensée, d’appréciation et d’action des médecins de famille quant au rôle de l’évaluation économique dans la pratique clinique et la volonté des médecins de famille à contribuer à une allocation efficiente, équitable et légitime des ressources.

Economic evaluation of benzodiazepines versus cognitive behavioural therapy among older adults with chronic insomnia

L’insomnie, commune auprès de la population gériatrique, est typiquement traitée avec des benzodiazépines qui peuvent augmenter le risque des chutes. La thérapie cognitive-comportementale (TCC) est une intervention non-pharmacologique ayant une efficacité équivalente et aucun effet secondaire. Dans la présente thèse, le coût des benzodiazépines (BZD) sera comparé à celui de la TCC dans le traitement de l’insomnie auprès d’une population âgée, avec et sans considération du coût additionnel engendré par les chutes reliées à la prise des BZD. Un modèle d’arbre décisionnel a été conçu et appliqué selon la perspective du système de santé sur une période d’un an. Les probabilités de chutes, de visites à l’urgence, d’hospitalisation avec et sans fracture de la hanche, les données sur les coûts et sur les utilités ont été recueillies à partir d’une revue de la littérature. Des analyses sur le coût des conséquences, sur le coût-utilité et sur les économies potentielles ont été faites. Des analyses de sensibilité probabilistes et déterministes ont permis de prendre en considération les estimations des données. Le traitement par BZD coûte 30% fois moins cher que TCC si les coûts reliés aux chutes ne sont pas considérés (231$ CAN vs 335$ CAN/personne/année). Lorsque le coût relié aux chutes est pris en compte, la TCC s’avère être l’option la moins chère (177$ CAN d’économie absolue/ personne/année, 1,357$ CAN avec les BZD vs 1,180$ pour la TCC). La TCC a dominé l’utilisation des BZD avec une économie moyenne de 25, 743$ CAN par QALY à cause des chutes moins nombreuses observées avec la TCC. Les résultats des analyses d’économies d’argent suggèrent que si la TCC remplaçait le traitement par BZD, l’économie annuelle directe pour le traitement de l’insomnie serait de 441 millions de dollars CAN avec une économie cumulative de 112 billions de dollars canadiens sur une période de cinq ans. D’après le rapport sensibilité, le traitement par BZD coûte en moyenne 1,305$ CAN, écart type 598$ (étendue : 245-2,625)/personne/année alors qu’il en coûte moyenne 1,129$ CAN, écart type 514$ (étendue : 342-2,526)/personne/année avec la TCC. Les options actuelles de remboursement de traitements pharmacologiques au lieu des traitements non-pharmacologiques pour l’insomnie chez les personnes âgées ne permettent pas d’économie de coûts et ne sont pas recommandables éthiquement dans une perspective du système de santé.

The costs of alcohol, illegal drugs, and tobacco in Canada, 2002.

Objective: The aim of this study was to estimate costs attributable to substance use and misuse in Canada in 2002. Method: Based on information about prevalence of exposure and risk relations for more than 80 disease categories, deaths, years of life lost, and hospitalizations attributable to substance use and misuse were estimated. In addition, substance-attributable fractions for criminal justice expenditures were derived. Indirect costs were estimated using a modified human capital approach. Results: Costs of substance use and misuse totaled almost Can. $40 billion in 2002. The total cost per capita for substance use and misuse was about Can. $1,267: Can. $463 for alcohol, Can. $262 for illegal drugs, and Can. $541 for tobacco. Legal substances accounted for the vast majority of these costs (tobacco: almost 43% of total costs; alcohol: 37%). Indirect costs or productivity losses were the largest cost category (61%), followed by health care (22%) and law enforcement costs (14%). More than 40,000 people died in Canada in 2002 because of substance use and misuse: 37,209 deaths were attributable to tobacco, 4,258 were attributable to alcohol, and 1,695 were attributable to illegal drugs. A total of about 3.8 million hospital days were attributable to substance use and misuse, again mainly to tobacco. Conclusions: Substance use and misuse imposes a considerable economic toll on Canadian society and requires more preventive efforts.

Economic evaluation of proposed pure and mixed stands in Central Vietnam highlands

In comparison with mixed forest stands, the cultivation of pure plantations in Vietnam entails serious ecological consequences such as loss of biodiversity and higher rate of soil erosion. The economic evaluation is elaborated between pure plantations and mixed forests where the fast-growing tree species are mixed with slow growing tree species which are planted in stripes separating the segments with fast-growing tree species (Acacia sp.). For the evaluation, the input values were used from local costs of goods, services and labour. The results show that the internal rate of return is the highest in the case of pure plantation in comparison with mixed forests – 86% to 77%(first planting pattern: Acacia sp. + noble hardwood species) and 54% (second planting pattern: Acacia + Dipterocarpus sp. + Sindora sp.). The average profit per hectare and year is almost five times higher in the case of mixed stands. The first planting pattern reaches 2,650 $, the second planting pattern 2,280 $ and the pure acacia plantation only 460 $. From an economic point of view, the cultivation of mixed forests that corresponds to the principles of sustainable forestry generates a good economical profit while maintaining habitat complexity and biodiversity.

Essays on International trade and economic growth

At present, we are witnessing globalization as a truly worldwide phenomenon. Trade agreements among differing countries, a reduction in trade costs, the mobility of production factors, the free flow of information and so on are all proof of the present day era of globalization. Countries are trading with one another more and more every day and the effects of international trade on economies represent a central discussion in all economic spheres. In spite of increasing trade around the world and the promotion of globalization by multilateral organisms such as WTO and IMF, the effects of international trade are not yet clear. Economics literature concerning the effects of international trade on economic growth and welfare remains ambiguous in terms of both theoretical models and empirical research. The present thesis tries to contribute to the theoretical debate surrounding the effects of dynamic international trade, focusing in particular on the implications for economic growth, welfare and changes in the preferences of individuals.

Reductions in insecticide use from adoption of Bt cotton in South Africa: impacts on economic performance and toxic load to the environment

The study reported presents the findings relating to commercial growing of genetically-modified Bt cotton in South Africa by a large sample of smallholder farmers over three seasons (1998/99, 1999/2000, 2000/01) following adoption. The analysis presents constructs and compares groupwise differences for key variables in Bt v. non-Bt technology and uses regressions to further analyse the production and profit impacts of Bt adoption. Analysis of the distribution of benefits between farmers due to the technology is also presented. In parallel with these socio-economic measures, the toxic loads being presented to the environment following the introduction of Bt cotton are monitored in terms of insecticide active ingredient (ai) and the Biocide Index. The latter adjusts ai to allow for differing persistence and toxicity of insecticides. Results show substantial and significant financial benefits to smallholder cotton growers of adopting Bt cotton over three seasons in terms of increased yields, lower insecticide spray costs and higher gross margins. This includes one particularly wet, poor growing season. In addition, those with the smaller holdings appeared to benefit proportionately more from the technology (in terms of higher gross margins) than those with larger holdings. Analysis using the Gini-coefficient suggests that the Bt technology has helped to reduce inequality amongst smallholder cotton growers in Makhathini compared to what may have been the position if they had grown conventional cotton. However, while Bt growers applied lower amounts of insecticide and had lower Biocide Indices (per ha) than growers of non-Bt cotton, some of this advantage was due to a reduction in non-bollworm insecticide. Indeed, the Biocide Index for all farmers in the population actually increased with the introduction of Bt cotton. The results indicate the complexity of such studies on the socio-economic and environmental impacts of GM varieties in the developing world.

Genetically modified insect resistance in cotton: some farm level economic impacts in India

The paper explores the impact of insect-resistant Bacillus thuringiensis (Bt) cotton on costs and returns over the first two seasons of its commercial release in three sub-regions of Maharashtra State, India. It is the first such research conducted in India based on farmers' own practices rather than trial plots. Data were collected for a total of 7793 cotton plots in 2002 and 1577 plots in 2003. Results suggest that while the cost of cotton seed was much higher for farmers growing Bt cotton relative to those growing non-Bt cotton, the costs of bollworm spray were much lower. While Bt plots had greater costs (seed plus insecticide) than non-Bt plots, the yields and revenue from Bt plots were much higher than those of non-Bt plots (some 39% and 63% higher in 2002 and 2003, respectively). Overall, the gross margins of Bt plots were some 43% (2002) and 73% (2003) higher than those of non-Bt plots, although there was some variation between the three sub-regions of the state. The results suggest that Bt cotton has provided substantial benefits for farmers in India over the 2 years, but there are questions as to whether these benefits are sustainable. (c) 2004 Elsevier Ltd. All rights reserved.

The impact of contractor selection method on transaction costs: a review

The basic premise of transaction-cost theory is that the decision to outsource, rather than to undertake work in-house, is determined by the relative costs incurred in each of these forms of economic organization. In construction the "make or buy" decision invariably leads to a contract. Reducing the costs of entering into a contractual relationship (transaction costs) raises the value of production and is therefore desirable. Commonly applied methods of contractor selection may not minimise the costs of contracting. Research evidence suggests that although competitive tendering typically results in the lowest bidder winning the contract this may not represent the lowest project cost after completion. Multi-parameter and quantitative models for contractor selection have been developed to identify the best (or least risky) among bidders. A major area in which research is still needed is in investigating the impact of different methods of contractor selection on the costs of entering into a contract and the decision to outsource.

The 'direct costs' of livestock disease: The development of a system of models for the analysis of 30 endemic livestock diseases in Great Britain

The 'direct costs' attributable to 30 different endemic diseases of farm animals in Great Britain are estimated using a standardised method to construct a simple model for each disease that includes consideration of disease prevention and treatment costs. The models so far developed provide a basis for further analyses including cost-benefit analyses for the economic assessment of disease control options. The approach used reflects the inherent livestock disease information constraints, which limit the application of other economic analytical methods. It is a practical and transparent approach that is relatively easily communicated to veterinary scientists and policy makers. The next step is to develop the approach by incorporating wider economic considerations into the analyses in a way that will demonstrate to policy makers and others the importance of an economic perspective to livestock disease issues.

Reductions in insecticide use from adoption of Bt cotton in South Africa: impacts on economic performance and toxic load to the environment

The study reported presents the findings relating to commercial growing of genetically-modified Bt cotton in South Africa by a large sample of smallholder farmers over three seasons (1998/99, 1999/2000, 2000/01) following adoption. The analysis presents constructs and compares groupwise differences for key variables in Bt v. non-Bt technology and uses regressions to further analyse the production and profit impacts of Bt adoption. Analysis of the distribution of benefits between farmers due to the technology is also presented. In parallel with these socio-economic measures, the toxic loads being presented to the environment following the introduction of Bt cotton are monitored in terms of insecticide active ingredient (ai) and the Biocide Index. The latter adjusts ai to allow for differing persistence and toxicity of insecticides. Results show substantial and significant financial benefits to smallholder cotton growers of adopting Bt cotton over three seasons in terms of increased yields, lower insecticide spray costs and higher gross margins. This includes one particularly wet, poor growing season. In addition, those with the smaller holdings appeared to benefit proportionately more from the technology (in terms of higher gross margins) than those with larger holdings. Analysis using the Gini-coefficient suggests that the Bt technology has helped to reduce inequality amongst smallholder cotton growers in Makhathini compared to what may have been the position if they had grown conventional cotton. However, while Bt growers applied lower amounts of insecticide and had lower Biocide Indices (per ha) than growers of non-Bt cotton, some of this advantage was due to a reduction in non-bollworm insecticide. Indeed, the Biocide Index for all farmers in the population actually increased with the introduction of Bt cotton. The results indicate the complexity of such studies on the socio-economic and environmental impacts of GM varieties in the developing world.

An economic decision support tool for simulating paratuberculosis control strategies in a UK suckler beef herd

A dynamic, deterministic, economic simulation model was developed to estimate the costs and benefits of controlling Mycobacterium avium subsp. paratuberculosis (Johne's disease) in a suckler beef herd. The model is intended as a demonstration tool for veterinarians to use with farmers. The model design process involved user consultation and participation and the model is freely accessible on a dedicated website. The 'user-friendly' model interface allows the input of key assumptions and farm specific parameters enabling model simulations to be tailored to individual farm circumstances. The model simulates the effect of Johne's disease and various measures for its control in terms of herd prevalence and the shedding states of animals within the herd, the financial costs of the disease and of any control measures and the likely benefits of control of Johne's disease for the beef suckler herd over a 10-year period. The model thus helps to make more transparent the 'hidden costs' of Johne's in a herd and the likely benefits to be gained from controlling the disease. The control strategies considered within the model are 'no control', 'testing and culling of diagnosed animals', 'improving management measures' or a dual strategy of 'testing and culling in association with improving management measures'. An example 'run' of the model shows that the strategy 'improving management measures', which reduces infection routes during the early stages, results in a marked fall in herd prevalence and total costs. Testing and culling does little to reduce prevalence and does not reduce total costs over the 10-year period.

Economic assessment of bovine tuberculosis and alternative policies

Break-even analyses of the costs and benefits of six alternative bovine tuberculosis (bTB) control strategies were undertaken. The results show that some strategies, such as zoning, would require relatively small reductions in bTB incidence as a result to be cost effective, whilst for others, such as proactive badger removal, the costs would require a substantial and relatively rapid reduction in bTB incidence to be worthwhile.

Genetically modified insect resistance in cotton: some farm level economic impacts in India

The paper explores the impact of insect-resistant Bacillus thuringiensis (Bt) cotton on costs and returns over the first two seasons of its commercial release in three sub-regions of Maharashtra State, India. It is the first such research conducted in India based on farmers' own practices rather than trial plots. Data were collected for a total of 7793 cotton plots in 2002 and 1577 plots in 2003. Results suggest that while the cost of cotton seed was much higher for farmers growing Bt cotton relative to those growing non-Bt cotton, the costs of bollworm spray were much lower. While Bt plots had greater costs (seed plus insecticide) than non-Bt plots, the yields and revenue from Bt plots were much higher than those of non-Bt plots (some 39% and 63% higher in 2002 and 2003, respectively). Overall, the gross margins of Bt plots were some 43% (2002) and 73% (2003) higher than those of non-Bt plots, although there was some variation between the three sub-regions of the state. The results suggest that Bt cotton has provided substantial benefits for farmers in India over the 2 years, but there are questions as to whether these benefits are sustainable. (c) 2004 Elsevier Ltd. All rights reserved.

Potential economic impacts of terminator technologies: policy implications for developing countries

The terminator gene can render seeds sterile, so forcing farmers to purchase fresh seed every year. It is a technological solution to the problem of market failure that could increase the appropriability of R&D investment more effectively than intellectual property rights legislation or patents. This paper shows that appropriability should be more than tripled and that this leads to greater private R&D investment, which may be expected to double or triple. This would bring open-pollinating varieties into line with F1 hybrids, for which seed cannot be saved. In turn, the increased investment should raise yield increases to levels similar to those for hybrid crops. Thus, there are benefits to set against the possible ecological and environmental costs and the clear distributional and social consequences. The paper discusses the way the seed market is developing, the possible impacts, especially from a developing country viewpoint, and considers the policy changes that are needed.