Old conflicts, new rivals? Airline competition in the European market

Christoph Franz of Lufthansa recently identified Ryanair, easyJet, Air Berlin and Emirates as the company’s main competitors – gone are the days when it could benchmark itself against BA or Air France-KLM! This paper probes behind the headlines to assess the extent to which different airlines are in competition, using evidence from the UK and mainland European markets. The issue of route versus network competition is addressed. Many regulators have put an emphasis on the former whereas the latter, although less obvious, can be more relevant. For example, BA and American will cease to compete between London and Dallas Fort Worth if their alliance obtains anti-trust immunity but 80% of the passengers on this route are connecting at one or both ends and hence arguably belong to different markets (e.g. London-San Francisco, Zurich-Dallas, Edinburgh-New Orleans) which may be highly contested. The remaining 20% of local traffic is actually insufficient to support a single point to point service in its own right. Estimates are made of the seat capacity major airlines are offering to the local market as distinct from feeding other routes. On a sector such as Manchester–Amsterdam, 60% of KLM’s passengers are transferring at Schiphol as against only 1% of bmibaby’s. Thus although KLM operates 5 flights and 630 seats per day against bmibaby’s 2 flights and 298 seats, in the point to point market bmibaby offers more seats than KLM. The growth of the Low Cost Carriers (LCCs) means that competition increasingly needs to be viewed on city pair markets (e.g. London-Rome) rather than airport pair markets (e.g. Heathrow-Fiumicino). As the stronger LCCs drive out weaker rivals and mainline carriers retrench to their major hubs, some markets now have fewer direct options than existed prior to the low cost boom. Timings and frequencies are considered, in particular the extent to which services are a true alternative especially for business travellers. LCCs typically offer lower frequencies and more unsociable timings (e.g. late evening arrivals at remote airports) as they are more focused on providing the cheapest service rather than the most convenient schedule. Interesting findings on ‘monopoly’ services are presented (including alliances) - certain airlines have many more of these than others. Lufthansa has a significant number of sectors to itself whereas at the other extreme British Airways has direct competition on almost every route in its network. Ryanair and flybe have a higher proportion of monopoly routes than easyJet or Air Berlin. In the domestic US market it has become apparent since deregulation that better financial returns can come from dominating a large number of smaller markets rather than being heavily exposed in the major markets - which are hotly fought over. Regional niches that appear too thin for Ryanair to serve (with its all 189 seat 737-800 fleet) are identified. Fare comparisons in contrasting markets provide some insights to marketing and pricing strategies. Data sources used include OAG (schedules and capacity), AEA (traditional European airlines traffic by region), the UK CAA (airport, airline and route traffic plus survey information of passenger types) and ICAO (international route traffic and capacity by carrier). It is concluded that airlines often have different competitors depending on the context but in surprisingly many cases there are actually few or no direct substitutes. The competitive process set in train by deregulation of European air services in the 1990s is leading back to one of natural monopolies and oblique alternatives. It is the names of the main participants that have changed however!

Workload Schedulers - Genesis, Algorithms and Comparisons

In this article we provide brief descriptions of three classes of schedulers: Operating Systems Process Schedulers, Cluster Systems, Jobs Schedulers and Big Data Schedulers. We describe their evolution from early adoptions to modern implementations, considering both the use and features of algorithms. In summary, we discuss differences between all presented classes of schedulers and discuss their chronological development. In conclusion, we highlight similarities in the focus of scheduling strategies design, applicable to both local and distributed systems.

A lightweight indoor localization model based on motley-keenan and COST

This paper presents a novel approach to WLAN propagation models for use in indoor localization. The major goal of this work is to eliminate the need for in situ data collection to generate the Fingerprinting map, instead, it is generated by using analytical propagation models such as: COST Multi-Wall, COST 231 average wall and Motley- Keenan. As Location Estimation Algorithms kNN (K-Nearest Neighbour) and WkNN (Weighted K-Nearest Neighbour) were used to determine the accuracy of the proposed technique. This work is based on analytical and measurement tools to determine which path loss propagation models are better for location estimation applications, based on Receive Signal Strength Indicator (RSSI).This study presents different proposals for choosing the most appropriate values for the models parameters, like obstacles attenuation and coefficients. Some adjustments to these models, particularly to Motley-Keenan, considering the thickness of walls, are proposed. The best found solution is based on the adjusted Motley-Keenan and COST models that allows to obtain the propagation loss estimation for several environments.Results obtained from two testing scenarios showed the reliability of the adjustments, providing smaller errors in the measured values values in comparison with the predicted values.

Licensing in an international triopoly

We study the effects of entry of two foreign firms on domestic welfare in the presence of licensing, when the incumbent is technologically superior to the entrants. We consider two different situations: (i) the cost-reducing innovation is licensed to both entrants; (ii) the cost- reducing innovation is licensed to just one of the entrants. We analyse three kind of license: (lump- sum) fixed-fee; (per-unit) royalty; and two-part tariff, that is a combination of a fixed-fee and a royalty. We prove that a two part tariff is never an optimal licensing scheme for the incumbent. Moreover, (i) when the technology is licensed to the two entrants, the optimal contract consists of a licensing with only output royalty; and (ii) when the technology is licensed to just one of the entrants, the optimal contract consists of a licensing with only a fixed-fee.

Separating sequential equilibrium in a Bayesian international duopoly

We consider two Cournot firms, one located in the home country and the other in the foreign country, producing substitute goods for consumption in a third country. We suppose that neither the home government nor the foreign firm know the costs of the home firm, while the foreign firm cost is common knowledge. We determine the separating sequential equilibrium outputs.

Cost-Effectiveness of Non-Vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation in Portugal

INTRODUCTION AND OBJECTIVES:Recently, three novel non-vitamin K antagonist oral anticoagulants received approval for reimbursement in Portugal for patients with non-valvular atrial fibrillation (AF). It is therefore important to evaluate the relative cost-effectiveness of these new oral anticoagulants in Portuguese AF patients. METHODS: A Markov model was used to analyze disease progression over a lifetime horizon. Relative efficacy data for stroke (ischemic and hemorrhagic), bleeding (intracranial, other major bleeding and clinically relevant non-major bleeding), myocardial infarction and treatment discontinuation were obtained by pairwise indirect comparisons between apixaban, dabigatran and rivaroxaban using warfarin as a common comparator. Data on resource use were obtained from the database of diagnosis-related groups and an expert panel. Model outputs included life years gained, quality-adjusted life years (QALYs), direct healthcare costs and incremental cost-effectiveness ratios (ICERs). RESULTS:Apixaban provided the most life years gained and QALYs. The ICERs of apixaban compared to warfarin and dabigatran were €5529/QALY and €9163/QALY, respectively. Apixaban was dominant over rivaroxaban (greater health gains and lower costs). The results were robust over a wide range of inputs in sensitivity analyses. Apixaban had a 70% probability of being cost-effective (at a threshold of €20 000/QALY) compared to all the other therapeutic options. CONCLUSIONS:Apixaban is a cost-effective alternative to warfarin and dabigatran and is dominant over rivaroxaban in AF patients from the perspective of the Portuguese national healthcare system. These conclusions are based on indirect comparisons, but despite this limitation, the information is useful for healthcare decision-makers.

Which screening strategy using BMD measurements would be most cost effective for hip fracture prevention in elderly women? A decision analysis based on a Markov model.

INTRODUCTION: Hip fractures are responsible for excessive mortality, decreasing the 5-year survival rate by about 20%. From an economic perspective, they represent a major source of expense, with direct costs in hospitalization, rehabilitation, and institutionalization. The incidence rate sharply increases after the age of 70, but it can be reduced in women aged 70-80 years by therapeutic interventions. Recent analyses suggest that the most efficient strategy is to implement such interventions in women at the age of 70 years. As several guidelines recommend bone mineral density (BMD) screening of postmenopausal women with clinical risk factors, our objective was to assess the cost-effectiveness of two screening strategies applied to elderly women aged 70 years and older. METHODS: A cost-effectiveness analysis was performed using decision-tree analysis and a Markov model. Two alternative strategies, one measuring BMD of all women, and one measuring BMD only of those having at least one risk factor, were compared with the reference strategy "no screening". Cost-effectiveness ratios were measured as cost per year gained without hip fracture. Most probabilities were based on data observed in EPIDOS, SEMOF and OFELY cohorts. RESULTS: In this model, which is mostly based on observed data, the strategy "screen all" was more cost effective than "screen women at risk." For one woman screened at the age of 70 and followed for 10 years, the incremental (additional) cost-effectiveness ratio of these two strategies compared with the reference was 4,235 euros and 8,290 euros, respectively. CONCLUSION: The results of this model, under the assumptions described in the paper, suggest that in women aged 70-80 years, screening all women with dual-energy X-ray absorptiometry (DXA) would be more effective than no screening or screening only women with at least one risk factor. Cost-effectiveness studies based on decision-analysis trees maybe useful tools for helping decision makers, and further models based on different assumptions should be performed to improve the level of evidence on cost-effectiveness ratios of the usual screening strategies for osteoporosis.

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

OBJECTIVE: To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004. DESIGN: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS: We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS: Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSIONS: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Participation rates for organized colorectal cancer screening programmes: an international comparison.

OBJECTIVE: Participation, an indicator of screening programme acceptance and effectiveness, varies widely in clinical trials and population-based colorectal cancer (CRC) screening programmes. We aimed to assess whether CRC screening participation rates can be compared across organized guaiac fecal occult blood test (G-FOBT)/fecal immunochemical test (FIT)-based programmes, and what factors influence these rates. METHODS: Programme representatives from countries participating in the International Cancer Screening Network were surveyed to describe their G-FOBT/FIT-based CRC screening programmes, how screening participation is defined and measured, and to provide participation data for their most recent completed screening round. RESULTS: Information was obtained from 15 programmes in 12 countries. Programmes varied in size, reach, maturity, target age groups, exclusions, type of test kit, method of providing test kits and use, and frequency of reminders. Coverage by invitation ranged from 30-100%, coverage by the screening programme from 7-67.7%, overall uptake/participation rate from 7-67.7%, and first invitation participation from 7-64.3%. Participation rates generally increased with age and were higher among women than men and for subsequent compared with first invitation participation. CONCLUSION: Comparisons among CRC screening programmes should be made cautiously, given differences in organization, target populations, and interpretation of indicators. More meaningful comparisons are possible if rates are calculated across a uniform age range, by gender, and separately for people invited for the first time vs. previously.

The implications of being an international medical graduate (IMG) in Canadian society : a qualitative study of foreign-trained physicians' resettlement, sense of identity and health status

This qualitative research study used grounded theory methodology to explore the settlement experiences and changes in professional identity, self esteem and health status of foreign-trained physicians (FTPs) who resettled in Canada and were not able to practice their profession. Seventeen foreign-trained physicians completed a pre-survey and rated their health status, quality of life, self esteem and stress before and after coming to Canada. They also rated changes in their experiences of violence and trauma, inclusion and belonging, and racism and discrimination. Eight FTPs from the survey sample were interviewed in semi-structured qualitative interviews to explore their experiences with the loss of their professional medical identities and attempts to regain them during resettlement. This study found that without their medical license and identity, this group of FTPs could not fully restore their professional, social, and economic status and this affected their self esteem and health status. The core theme of the loss of professional identity and attempts to regain it while being underemployed were connected with the multifaceted challenges of resettlement which created experiences of lowered selfesteem, and increased stress, anxiety and depression. They identified the re-licensing process (cost, time, energy, few residency positions, and low success rate) as the major barrier to a full and successful settlement and re-establishment of their identities. Grounded research was used to develop General Resettlement Process Model and a Physician Re-licensing Model outlining the tasks and steps for the successfiil general resettlement of all newcomers to Canada with additional process steps to be accomplished by foreign-trained physicians. Maslow's Theory of Needs was expanded to include the re-establishment of professional identity for this group to re-establish levels of safety, security, belonging, self-esteem and self-actualization. Foreign-trained physicians had established prior professional medical identities, self-esteem, recognition, social status, purpose and meaning and bring needed human capital and skills to Canada. However, without identifying and addressing the barriers to their full inclusion in Canadian society, the health of this population may deteriorate and the health system of the host country may miss out on their needed contributions.

The carbon disclosure project, an evolution in international environmental corporate governance : motivations and determinants of market response to voluntary disclosures

This paper examines the factors associated with Canadian firms voluntarily disclosing climate change information through the Carbon Disclosure Project. Five hypotheses are presented to explain the factors influencing management's decision to disclose this information. These hypotheses include a response to shareholder activism, domestic institutional investor shareholder activism, signalling, litigation risk, and low cost publicity. Both binary logistic regressions as well as a cross-sectional analysis of the equity market's response to the environmental disclosures being made were used to test these hypotheses. Support was found for shareholder activism, low cost publicity, and litigation risk. However, the equity market's response was not found to be statistically significant.

Essays in International Trade

Dans ma thèse doctorale, j'étudie trois facteurs importants qui caractérisent le commerce international : les différences technologiques entre les pays, les barrières à l'entrée sous la forme de coûts fixes et la migration internationale. Le premier chapitre analyse si les différences technologiques entre les pays peuvent expliquer la spécialisation dans le commerce international entre les pays. Pour mesurer le niveau de la spécialisation, je calcule les index de concentration pour la valeur des importations et des exportations et décompose la concentration totale dans la marge de produits extensive (nombre de produits commercialisés) et la marge de produits intensive (volume de produits commercialisés). En utilisant des données commerciales détaillées au niveau du produit dans 160 pays, mes résultats montrent que les exportations sont plus concentrées que les importations, que la spécialisation se produit principalement au niveau de la marge intensive du produit, et que les économies plus grandes disposent d'importations et d'exportations plus diversifiées, car elles commercialisent plus de produits. Compte tenu de ces faits, j'évalue la capacité du modèle Eaton-Kortum, le principal modèle de la théorie ricardienne du commerce, pour représenter les preuves empiriques. Les résultats montrent que la spécialisation à travers l'avantage comparatif induit par les différences de technologie peut expliquer les faits qualitatifs et quantitatifs. De plus, j'évalue le rôle des déterminants clés de la spécialisation : le degré de l'avantage comparatif, l'élasticité de la substitution et la géographie. Une implication de ces résultats est qu'il est important d’évaluer jusqu'à quel point la volatilité de production mesurée par la volatilité du PIB est motivée par la spécialisation des exportations et des importations. Étant donné le compromis entre l'ouverture du commerce et la volatilité de production, les bénéfices tirés du commerce peuvent s'avérer plus faibles que ceux estimés précédemment. Par conséquent, les politiques commerciales alternatives telles que l'ouverture graduelle au commerce combinée à la diversification de la production pour réduire la concentration de l'exportation peuvent se révéler être une meilleure stratégie que l'approche du laissez-faire. En utilisant la relation entre la taille du marché et l’entrée de firmes et produits, le deuxième chapitre évalue si les barrières à l'entrée sous la forme de coûts fixes à exporter sont au niveau de la firme ou au niveau du produit. Si les coûts fixes se trouvent au niveau de la firme, la firme multiproduits a un avantage de coût de production par rapport aux autres firmes parce qu’elles peuvent diviser les coûts fixes sur plusieurs produits. Dans ce cas, le commerce international sera caractérisé par peu de firmes qui exportent beaucoup des produits. Si les coûts fixes sont au niveau du produit, l’entrée d’un produit est associée avec l’entrée de plusieurs firmes. La raison est qu’une fois que la première firme entre et paye les coûts fixes du produit, elle crée un effet d’entrainement qui réduit les coûts fixes pour des firmes rivales. Dans ce cas, le commerce international sera caractérisé par plusieurs firmes qui vendent des variétés différentes du même produit. En utilisant des données détaillées provenant de 40 pays exportateurs à travers 180 marchés de destination, mes résultats montrent que les barrières à l'entrée se trouvent principalement au niveau du produit. Un marché plus large favorise l'expansion d'un plus grand nombre d’entreprises au sein d'une catégorie de produit plutôt que de permettre aux entreprises produisant plusieurs produits de croître dans une gamme de produits. En regardant la différence entre le nombre d'exportateurs au sein d'une catégorie de produit dans des destinations données, je trouve que le taux d'entrée de firmes augmente significativement après qu'un produit entre la première fois dans le marché. J'en déduis donc que le premier entrant réduit les coûts fixes pour les firmes suivantes. Mes recherches démontrent également que malgré une plus grande compétition sur le marché du produit, les entreprises disposent de revenus d'exportation supérieurs et sont plus susceptibles de rester sur les marchés internationaux. Ces résultats sont cohérents avec l’hypothèse que l’effet d’entrainement incite l'entrée de firmes rivales et permettent aux entreprises de produire à plus grande échelle. Cette recherche dévoile un nombre de conclusions importantes. D'abord, les politiques commerciales encouragent l'entrée de nouveaux produits, par exemple, en promouvant des produits dans les marchés de destination entraînant ainsi des retombées qui se traduiront par un taux de participation plus élevé de l'entreprise et une croissance de l'exportation. Deuxièmement, les consommateurs du pays importateur peuvent bénéficier de prix plus bas pour le produit en réduisant les barrières techniques du commerce. Troisièmement, lorsque l'on effectue des expérimentations politiques sous la forme de réduction des coûts commerciaux, il est de coutume de considérer uniquement une baisse des coûts marginaux et d'évaluer les répercussions sur le bien-être du consommateur. Cependant, un élément important des accords commerciaux est la réduction des barrières techniques au commerce grâce à la négociation de normes communes pour un produit. Négliger l'existence des barrières à l'entrée et les conséquences des réaffectations de l'industrie affaiblit l'impact des réformes commerciales. Le troisième chapitre prend en compte le rôle de l'information dans la facilitation du commerce international. Les immigrants réduisent les coûts de transaction dans le commerce international en fournissant des informations sur les possibilités d'échange avec leur pays d'origine. En utilisant des données géographiques détaillées sur l'immigration et les importations aux États-Unis entre 1970 et 2005, je quantifie l'incidence qu'ont les nouveaux immigrants sur la demande pour les importations de biens intermédiaires aux États-Unis. Pour établir le lien cause à effet entre le commerce et la migration, j’exploite l'important afflux d'immigrants d'Amérique centrale après l'ouragan Mitch. Les résultats montrent que l'augmentation de dix pour cent d'immigrants a fait croître la demande pour les importations de biens intermédiaires de 1,5 pour cent. Mes résultats sont robustes aux problèmes de la causalité inverse ou la décision d’émigrer est causée par des opportunités de faire du commerce.

Screening for adolescent idiopathic scoliosis: an information statement by the scoliosis research society international task force

Background: Routine screening of scoliosis is a controversial subject and screening efforts vary greatly around the world. METHODS: Consensus was sought among an international group of experts (seven spine surgeons and one clinical epidemiologist) using a modified Delphi approach. The consensus achieved was based on careful analysis of a recent critical review of the literature on scoliosis screening, performed using a conceptual framework of analysis focusing on five main dimensions: technical, clinical, program, cost and treatment effectiveness. FINDINGS: A consensus was obtained in all five dimensions of analysis, resulting in 10 statements and recommendations. In summary, there is scientific evidence to support the value of scoliosis screening with respect to technical efficacy, clinical, program and treatment effectiveness, but there insufficient evidence to make a statement with respect to cost effectiveness. Scoliosis screening should be aimed at identifying suspected cases of scoliosis that will be referred for diagnostic evaluation and confirmed, or ruled out, with a clinically significant scoliosis. The scoliometer is currently the best tool available for scoliosis screening and there is moderate evidence to recommend referral with values between 5 degrees and 7 degrees. There is moderate evidence that scoliosis screening allows for detection and referral of patients at an earlier stage of the clinical course, and there is low evidence suggesting that scoliosis patients detected by screening are less likely to need surgery than those who did not have screening. There is strong evidence to support treatment by bracing. INTERPRETATION: This information statement by an expert panel supports scoliosis screening in 4 of the 5 domains studied, using a framework of analysis which includes all of the World Health Organisation criteria for a valid screening procedure.

Supprimer les paiements directs des soins en Afrique subsaharienne : débat international, défis de mise en oeuvre et revue réaliste du recours aux soins

Payer ses soins est une réalité coûteuse pour les usagers des services de santé en Afrique subsaharienne. Plusieurs pays suppriment donc certains types de paiements directs des soins au point de service, en instaurant des politiques d’exemption des paiements (PEP). Cette thèse explore trois enjeux majeurs soulevés par ces réformes. Le premier article analyse le positionnement des acteurs de la santé mondiale dans le débat sur les paiements directs des soins dans les pays à faible et moyen revenu. Cette étude documentaire montre que la majorité des acteurs s’exprime en défaveur des paiements directs en invoquant notamment leurs effets néfastes sur l’équité d’accès aux soins. Le second article met en lumière les effets perturbateurs des PEP sur les systèmes de santé des pays à faible et moyen revenu. Cette synthèse exploratoire indique que leur mise en œuvre perturbe les systèmes de santé de plusieurs manières : augmentation immédiate de l’utilisation des services gratuits, indisponibilité des médicaments, financement imprévisible et insuffisant, multiplicité des organes impliqués dans la mise en œuvre, et déficiences dans la planification et la communication. Le troisième article examine la manière dont les PEP influencent le recours aux soins des usagers. La revue réaliste a permis de développer une théorie qui explique ce processus, et de la mettre à l’épreuve d’études empiriques. Selon cette théorie, les PEP sont une ressource contribuant à renforcer le pouvoir d’agir des usagers. Ce pouvoir d’agir est également influencé par des facteurs structurels, locaux et individuels qui agissent sur la « capabilité » des usagers de se saisir de cette ressource, et de choisir de recourir aux services de santé gratuits. Trois mécanismes jouent un rôle essentiel dans ce choix : la confiance, l’acceptabilité, et la reconnaissance du risque. Cette thèse contribue au développement des connaissances empiriques sur une réforme majeure des systèmes de santé en Afrique subsaharienne. Elle apporte également des enseignements méthodologiques à la revue réaliste, et participe à la construction du champ de la recherche sur les politiques et systèmes de santé dans les pays à faible et moyen revenu.

Droit du transport intermodal international de marchandises : une perspective « supply chain management ».

La thèse propose d’introduire une perspective globale dans le traitement juridique du transport intermodal international qui prendrait racine dans la stratégie logistique des entreprises. La conception juridique se heurte, en effet, aux évolutions opérationnelles et organisationnelles des transports et aboutit à une incertitude juridique. Les transporteurs ont dû s’adapter aux exigences d’optimisation des flux des chargeurs dont les modes de production et de distribution reposent sur le supply chain management (SCM). Ce concept est le fruit de la mondialisation et des technologies de l’information. La concurrence induite par la mondialisation et le pilotage optimal des flux ont impulsé de nouvelles stratégies de la part des entreprises qui tentent d’avoir un avantage concurrentiel sur le marché. Ces stratégies reposent sur l’intégration interfonctionnelle et interoganisationnelle. Dans cette chaîne logistique globale (ou SCM) l’intermodal est crucial. Il lie et coordonne les réseaux de production et de distribution spatialement désagrégés des entreprises et, répond aux exigences de maîtrise de l’espace et du temps, à moindre coût. Ainsi, le transporteur doit d’une part, intégrer les opérations de transport en optimisant les déplacements et, d’autre part, s’intégrer à la chaîne logistique du client en proposant des services de valeur ajoutée pour renforcer la compétitivité de la chaîne de valeur. Il en découle une unité technique et économique de la chaîne intermodale qui est pourtant, juridiquement fragmentée. Les Conventions internationales en vigueur ont été élaborées pour chaque mode de transport en faisant fi de l’interaction entre les modes et entre les opérateurs. L’intermodal est considéré comme une juxtaposition des modes et des régimes juridiques. Ce dépeçage juridique contraste avec la gestion de la chaîne intermodale dont les composantes individuelles s’effacent au profit de l’objectif global à atteindre. L’on expose d’abord l’ampleur de l’incertitude juridique due aux difficultés de circonscrire le champ d’opérations couvert par les Conventions en vigueur. Une attention est portée aux divergences d’interprétations qui débouchent sur la « désunification » du droit du transport. On s’intéresse ensuite aux interactions entre le transport et la chaîne logistique des chargeurs. Pour cela, on retrace l’évolution des modes de production et de distribution de ces derniers. C’est effectivement de la stratégie logistique que découle la conception de la chaîne intermodale. Partant de ce système, on identifie les caractéristiques fondamentales de l’intermodal. La thèse aboutit à dissiper les confusions liées à la qualification de l’intermodal et qui sont à la base des divergences d’interprétations et de l’incertitude juridique. De plus, elle met en exergue l’unité économique du contrat de transport intermodal qui devrait guider la fixation d’un régime de responsabilité dédié à ce système intégré de transport. Enfin, elle initie une approche ignorée des débats juridiques.