Capital formation in Latin America: one and a half century of macroeconomic dynamics

Includes bibliography

An assessment of fiscal and regulatory barriers to deployment of energy efficiency and renewable energy technologies in Guyana

Includes bibliography.

Capital flows to Latin America: recent developments

The external environment has deteriorated sharply as a result of the spiraling financial turmoil, and has led to a weakening in commodity prices and fears of a worldwide recession. Latin America and the Caribbean's fastest expansion in 40 years may be threatened as the global credit crunch makes financing scarce and squeezes demand for the region's commodities. This time around the region is better positioned to weather the crisis than in the past, given improvements in macroeconomic and financial policies as well as a reduced net dependency on external capital inflows. However, Latin American markets are feeling the effects of the crisis through a slowdown in capital inflows, large declines in stock price indexes, significant currency adjustments and an increase in debt spreads. Volatility has soared, with the closely watched Chicago Board Options Exchange Volatility Index moving to an all-time high of 70.33 on October 17, indicating that fear (rather than greed) has been ruling the markets.After reaching record lows in May 2007, emerging markets bond spreads are now above pre-Asian crisis levels. The JPMorgan EMBI+ Latin American composite widened by 146 basis points in the third quarter, with spreads reaching 448 basis points at the end of September. Spreads have widened sharply in recent weeks as foreign investors cut back regional exposure for the safety of U.S. Treasuries. The ongoing lack of liquidity and subsequent liquidation of assets is leading to a collapse in asset prices and a sharp widening in spreads. Daily spreads in October have risen to levels not seen since December 2002, making it much more difficult for governments that need financing to get it. Risk premiums for Latin corporates and sovereigns have risen substantially, but have remained well below U.S. junk (high-yield) bonds. Latin corporates are facing a steep rise in foreign exchange borrowing costs (although less than firms in other emerging markets), which raises concerns that refinancing risks will climb.So far, emerging markets vulnerabilities have been more focused on corporates, as sovereigns have improved public debt dynamics and countries' financing needs are under control. Market performance has been driven by the rapid deterioration of emerging markets bank and corporate market, as well as ongoing losses in emerging markets equities. From January to September 2008, the Morgan Stanley Capital International (MSCI) Latin American Index lost almost 28%, while the Emerging Markets Index lost 37% and the G-7 Index lost 24%. While in 2007 the Latin America component gained 47%, almost nine times as much as the MSCI-G7 index for developed markets, since mid-September 2008 stocks in Latin America have been doing worse than stocks in developed countries, as concerns about access to credit and the adverse impact of sharp falls in commodity prices and in local currencies contribute to increased risk aversion and to outflows of capital. Many governments in the region have used revenue from the commodity boom to pay down debt and build reserves. Now, facing a global financial crisis and the threat of recession in developed countries, the biggest question for Latin America is how long and deep this cyclical downturn will be, and how much it is going to reduce commodity prices. Prices for commodities such as soy, gold, copper and oil, which helped fund the region's boom, have fallen 28% since their July 2 high, according to the RJ/CRB Commodity Price Index. According to Morgan Stanley (in a September 29 report), should prices return to their 10-year average, Latin America's balanced budgets would quickly revert to a deficit of 4.1% of GDP. As risk aversion increases, investors are rapidly pulling out massive amounts of money, creating problems for local markets and banks. There is an ongoing shortage of dollars (as investors liquidate assets in Latin American markets), and as currencies depreciate, inflation concerns increase despite the global slowdown. In Brazil and Mexico, central banks deployed billions of dollars of reserves to stem steep currency declines, as companies in these countries, believing their local currencies would continue to strengthen against the U.S. dollar, took debts in dollars. Some companies also made bets using currency derivatives that have led to losses in the billions of dollars. Dramatic currency swings have caused heavy losses for many companies, from Mexico's cement giant Cemex SAB to the Brazilian conglomerate Grupo Votorantim. Mexico's third-largest retailer, Controladora Comercial Mexicana, declared bankruptcy recently after reporting huge losses related to exchange rate bets. As concerns about corporate exposure to dollar-denominated derivatives increases, yields on bonds issued by many of Brazil's and Mexico's leading companies have started to rise, sharply raising the cost of issuing new debt. Latin American external debt issuance came to a halt in the third quarter of 2008, totaling only US$ 690 million. The cost of obtaining loans for capital expenditures, M&A and debt refinancing is also rising substantially for Latin American corporates amid contagion from the U.S. financial crisis. According to bankers, a protracted trend of shortening tenors and widening spreads has intensified in the past few weeks, indicating that bank lending is quickly following the way of bonds and equity. Finally, money transfers from Latin American migrants are expected to decline for the first time this decade, as a result of economic downturns in the U.S. and Spain, inflation and a weaker dollar. The Mexican Central Bank announced that money transfers from Mexicans living in the U.S. dropped a record 12.2% in August. In 2008, migrants from the region will send some 1.7% less in remittances year-on-year when adjusted for inflation, according to the IADB, compounding the adverse effects of the deepening financial turmoil.

An assessment of the economic impact of climate change on the water sector in the Turks and Caicos Islands

The best description of water resources for Grand Turk was offered by Pérez Monteagudo (2000) who suggested that rain water was insufficient to ensure a regular water supply although water catchment was being practised and water catchment possibilities had been analysed. Limestone islands, mostly flat and low lying, have few possibilities for large scale surface storage, and groundwater lenses exist in very delicate equilibrium with saline seawater, and are highly likely to collapse due to sea level rise, improper extraction, drought, tidal waves or other extreme event. A study on the impact of climate change on water resources in the Turks and Caicos Islands is a challenging task, due to the fact that the territory of the Islands covers different environmental resources and conditions, and accurate data are lacking. The present report is based on collected data wherever possible, including grey data from several sources such as the Intergovernmental Panel on Climate Change (IPCC) and Cuban meteorological service data sets. Other data were also used, including the author’s own estimates and modelling results. Although challenging, this was perhaps the best approach towards analysing the situation. Furthermore, IPCC A2 and B2 scenarios were used in the present study in an effort to reduce uncertainty. The main conclusion from the scenario approach is that the trend observed in precipitation during the period 1961 - 1990 is decreasing. Similar behaviour was observed in the Caribbean region. This trend is associated with meteorological causes, particularly with the influence of the North Atlantic Anticyclone. The annual decrease in precipitation is estimated to be between 30-40% with uncertain impacts on marine resources. After an assessment of fresh water resources in Turks and Caicos Islands, the next step was to estimate residential water demand based on a high fertility rate scenario for the Islands (one selected from four scenarios and compared to countries having similar characteristics). The selected scenario presents higher projections on consumption growth, enabling better preparation for growing water demand. Water demand by tourists (stopover and excursionists, mainly cruise passengers) was also obtained, based on international daily consumption estimates. Tourism demand forecasts for Turks and Caicos Islands encompass the forty years between 2011 and 2050 and were obtained by means of an Artificial Neural Networks approach. for the A2 and B2 scenarios, resulting in the relation BAU>B2>A2 in terms of tourist arrivals and water demand levels from tourism. Adaptation options and policies were analysed. Resolving the issue of the best technology to be used for Turks and Caicos Islands is not directly related to climate change. Total estimated water storage capacity is about 1, 270, 800 m3/ year with 80% capacity load for three plants. However, almost 11 desalination plants have been detected on Turks and Caicos Islands. Without more data, it is not possible to estimate long term investment to match possible water demand and more complex adaptation options. One climate change adaptation option would be the construction of elevated (30 metres or higher) storm resistant water reservoirs. The unit cost of the storage capacity is the sum of capital costs and operational and maintenance costs. Electricity costs to pump water are optional as water should, and could, be stored for several months. The costs arising for water storage are in the range of US$ 0.22 cents/m3 without electricity costs. Pérez Monteagudo (2000) estimated water prices at around US$ 2.64/m3 in stand points, US$ 7.92 /m3 for government offices, and US$ 13.2 /m3for cistern truck vehicles. These data need to be updated. As Turks and Caicos Islands continues to depend on tourism and Reverse Osmosis (RO) for obtaining fresh water, an unavoidable condition to maintaining and increasing gross domestic product(GDP) and population welfare, dependence on fossil fuels and vulnerability to increasingly volatile prices will constitute an important restriction. In this sense, mitigation supposes a synergy with adaptation. Energy demand and emissions of carbon dioxide (CO2) were also estimated using an emissions factor of 2. 6 tCO2/ tonne of oil equivalent (toe). Assuming a population of 33,000 inhabitants, primary energy demand was estimated for Turks and Caicos Islands at 110,000 toe with electricity demand of around 110 GWh. The business as usual (BAU), as well as the mitigation scenarios were estimated. The BAU scenario suggests that energy use should be supported by imported fossil fuels with important improvements in energy efficiency. The mitigation scenario explores the use of photovoltaic and concentrating solar power, and wind energy. As this is a preliminary study, the local potential and locations need to be identified to provide more relevant estimates. Macroeconomic assumptions are the same for both scenarios. By 2050, Turks and Caicos Islands could demand 60 m toe less than for the BAU scenario.

An assessment of the economic impact of climate change on the health sector In Jamaica

Climate change is a naturally occurring phenomenon in which the earth‘s climate goes through cycles of warming and cooling; these changes usually take place incrementally over millennia. Over the past century, there has been an anomalous increase in global temperature, giving rise to accelerated climate change. It is widely accepted that greenhouse gas emissions from human activities such as industries have contributed significantly to the increase in global temperatures. The existence and survival of all living organisms is predicated on the ability of the environment in which they live not only to provide conditions for their basic needs but also conditions suitable for growth and reproduction. Unabated climate change threatens the existence of biophysical and ecological systems on a planetary scale. The present study aims to examine the economic impact of climate change on health in Jamaica over the period 2011-2050. To this end, three disease conditions with known climate sensitivity and importance to Jamaican public health were modelled. These were: dengue fever, leptospirosis and gastroenteritis in children under age 5. Historical prevalence data on these diseases were obtained from the Ministry of Health Jamaica, the Caribbean Epidemiology Centre, the Climate Studies Group Mona, University of the West Indies Mona campus, and the Meteorological Service of Jamaica. Data obtained spanned a twelve-year period of 1995-2007. Monthly data were obtained for dengue and gastroenteritis, while for leptospirosis, the annual number of cases for 1995-2005 was utilized. The two SRES emission scenarios chosen were A2 and B2 using the European Centre Hamburg Model (ECHAM) global climate model to predict climate variables for these scenarios. A business as usual (BAU) scenario was developed using historical disease data for the period 2000-2009 (dengue fever and gastroenteritis) and 1995-2005 (leptospirosis) as the reference decades for the respective diseases. The BAU scenario examined the occurrence of the diseases in the absence of climate change. It assumed that the disease trend would remain unchanged over the projected period and the number of cases of disease for each decade would be the same as the reference decade. The model used in the present study utilized predictive empirical statistical modelling to extrapolate the climate/disease relationship in time, to estimate the number of climate change-related cases under future climate change scenarios. The study used a Poisson regression model that considered seasonality and lag effects to determine the best-fit model in relation to the diseases under consideration. Zhang and others (2008), in their review of climate change and the transmission of vector-borne diseases, found that: ―Besides climatic variables, few of them have included other factors that can affect the transmission of vector-borne disease….‖ (Zhang 2008) Water, sanitation and health expenditure are key determinants of health. In the draft of the second communication to IPCC, Jamaica noted the vulnerability of public health to climate change, including sanitation and access to water (MSJ/UNDP, 2009). Sanitation, which in its broadest context includes the removal of waste (excreta, solid, or other hazardous waste), is a predictor of vector-borne diseases (e.g. dengue fever), diarrhoeal diseases (such as gastroenteritis) and zoonoses (such as leptospirosis). In conceptualizing the model, an attempt was made to include non-climate predictors of these climate-sensitive diseases. The importance of sanitation and water access to the control of dengue, gastroenteritis and leptospirosis were included in the Poisson regression model. The Poisson regression model obtained was then used to predict the number of disease cases into the future (2011-2050) for each emission scenario. After projecting the number of cases, the cost associated with each scenario was calculated using four cost components. 1. Treatment cost morbidity estimate. The treatment cost for the number of cases was calculated using reference values found in the literature for each condition. The figures were derived from studies of the cost of treatment and represent ambulatory and non-fatal hospitalized care for dengue fever and gastroenteritis. Due to the paucity of published literature on the health care cost associated with leptospirosis, only the cost of diagnosis and antibiotic therapy were included in the calculation. 2. Mortality estimates. Mortality estimates are recorded as case fatality rates. Where local data were available, these were utilized. Where these were unavailable, appropriate reference values from the literature were used. 3. Productivity loss. Productivity loss was calculated using a human capital approach, by multiplying the expected number of productive days lost by the caregiver and/or the infected person, by GDP per capita per day (US$ 14) at 2008 GDP using 2008 US$ exchange rates. 4. No-option cost. The no-option cost refers to adaptation strategies for the control of dengue fever which are ongoing and already a part of the core functions of the Vector Control Division of the Ministry of Health, Jamaica. An estimated US$ 2.1 million is utilized each year in conducting activities to prevent the post-hurricane spread of vector borne diseases and diarrhoea. The cost includes public education, fogging, laboratory support, larvicidal activities and surveillance. This no-option cost was converted to per capita estimates, using population estimates for Jamaica up to 2050 obtained from the Statistical Institute of Jamaica (STATIN, 2006) and the assumption of one expected major hurricane per decade. During the decade 2000-2009, Jamaica had an average inflation of 10.4% (CIA Fact book, last updated May 2011). This average decadal inflation rate was applied to the no-option cost, which was inflated by 10% for each successive decade to adjust for changes in inflation over time.

A urdidura espacial do capital e do trabalho no cerrado do sudoeste goiano

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Cost and energy density of diet in Brazil, 2008-2009

This study aimed to evaluate the relationship between the cost and energy density of diet consumed in Brazilian households. Data from the Brazilian Household Budget Survey (POF 200812009) were used to identify the main foods and their prices. Similar items were grouped, resulting in a basket of 67 products. Linear programming was applied for the composition of isoenergetic baskets, minimizing the deviation from the average household diet. Restrictions were imposed on the inclusion of items and the energy contribution of the various food groups. A reduction in average cost of diet was applied at intervals of R$0.15 to the lowest possible cost. We identified an inverse association between energy density and cost of diet (p < 0.05), and at the lowest possible cost we obtained the maximum value of energy density Restrictions on the diet's cost resulted in the selection of diets with higher energy density, indicating that cost of diet may lead to the adoption of inadequate diets in Brazil.

Cost-effectiveness of conventional and modified supervised toothbrushing in preventing caries in permanent molars among 5-year-old children

The cost-effectiveness of a modified supervised toothbrushing program was compared to a conventional program. A total of 284 five-year-old children presenting at least one permanent molar with emerged/sound occlusal surface participated. In the control group, oral health education and dental plaque dying followed by toothbrushing with fluoride dentifrice was carried outfour times per year. With the test group, children also underwent professional cross-brushing on surfaces of first permanent molar rendered by a dental assistant five times per year. Enamel/dentin caries were recorded on buccal, occlusal and lingual surfaces of permanent molars for a period of 18 months. The incidence density (ID) ratio was estimated using Poisson's regression model. The ID was 50% lower among boys in the test group (p = 0.016). The cost of the modified program was US$ 1.79 per capita. The marginal cost-effectiveness ratio among boys was US$ 6.30 per avoided carie. The modified supervised toothbrushing program was shown to be cost-effective in the case of boys.

Cost-effectiveness of introducing the 10-valent pneumococcal conjugate vaccine into the universal immunisation of infants in Brazil

Background Cost-effectiveness studies have been increasingly part of decision processes for incorporating new vaccines into the Brazilian National Immunisation Program. This study aimed to evaluate the cost-effectiveness of 10-valent pneumococcal conjugate vaccine (PCV10) in the universal childhood immunisation programme in Brazil. Methods A decision-tree analytical model based on the ProVac Initiative pneumococcus model was used, following 25 successive cohorts from birth until 5 years of age. Two strategies were compared: (1) status quo and (2) universal childhood immunisation programme with PCV10. Epidemiological and cost estimates for pneumococcal disease were based on National Health Information Systems and literature. A 'top-down' costing approach was employed. Costs are reported in 2004 Brazilian reals. Costs and benefits were discounted at 3%. Results 25 years after implementing the PCV10 immunisation programme, 10 226 deaths, 360 657 disability-adjusted life years (DALYs), 433 808 hospitalisations and 5 117 109 outpatient visits would be avoided. The cost of the immunisation programme would be R$10 674 478 765, and the expected savings on direct medical costs and family costs would be R$1 036 958 639 and R$209 919 404, respectively. This resulted in an incremental cost-effectiveness ratio of R$778 145/death avoided and R$22 066/DALY avoided from the society perspective. Conclusion The PCV10 universal infant immunisation programme is a cost-effective intervention (1-3 GDP per capita/DALY avoided). Owing to the uncertain burden of disease data, as well as unclear long-term vaccine effects, surveillance systems to monitor the long-term effects of this programme will be essential.

Asset management of wastewater networks

Asset Management (AM) is a set of procedures operable at the strategic-tacticaloperational level, for the management of the physical asset’s performance, associated risks and costs within its whole life-cycle. AM combines the engineering, managerial and informatics points of view. In addition to internal drivers, AM is driven by the demands of customers (social pull) and regulators (environmental mandates and economic considerations). AM can follow either a top-down or a bottom-up approach. Considering rehabilitation planning at the bottom-up level, the main issue would be to rehabilitate the right pipe at the right time with the right technique. Finding the right pipe may be possible and practicable, but determining the timeliness of the rehabilitation and the choice of the techniques adopted to rehabilitate is a bit abstruse. It is a truism that rehabilitating an asset too early is unwise, just as doing it late may have entailed extra expenses en route, in addition to the cost of the exercise of rehabilitation per se. One is confronted with a typical ‘Hamlet-isque dilemma’ – ‘to repair or not to repair’; or put in another way, ‘to replace or not to replace’. The decision in this case is governed by three factors, not necessarily interrelated – quality of customer service, costs and budget in the life cycle of the asset in question. The goal of replacement planning is to find the juncture in the asset’s life cycle where the cost of replacement is balanced by the rising maintenance costs and the declining level of service. System maintenance aims at improving performance and maintaining the asset in good working condition for as long as possible. Effective planning is used to target maintenance activities to meet these goals and minimize costly exigencies. The main objective of this dissertation is to develop a process-model for asset replacement planning. The aim of the model is to determine the optimal pipe replacement year by comparing, temporally, the annual operating and maintenance costs of the existing asset and the annuity of the investment in a new equivalent pipe, at the best market price. It is proposed that risk cost provide an appropriate framework to decide the balance between investment for replacing or operational expenditures for maintaining an asset. The model describes a practical approach to estimate when an asset should be replaced. A comprehensive list of criteria to be considered is outlined, the main criteria being a visà- vis between maintenance and replacement expenditures. The costs to maintain the assets should be described by a cost function related to the asset type, the risks to the safety of people and property owing to declining condition of asset, and the predicted frequency of failures. The cost functions reflect the condition of the existing asset at the time the decision to maintain or replace is taken: age, level of deterioration, risk of failure. The process model is applied in the wastewater network of Oslo, the capital city of Norway, and uses available real-world information to forecast life-cycle costs of maintenance and rehabilitation strategies and support infrastructure management decisions. The case study provides an insight into the various definitions of ‘asset lifetime’ – service life, economic life and physical life. The results recommend that one common value for lifetime should not be applied to the all the pipelines in the stock for investment planning in the long-term period; rather it would be wiser to define different values for different cohorts of pipelines to reduce the uncertainties associated with generalisations for simplification. It is envisaged that more criteria the municipality is able to include, to estimate maintenance costs for the existing assets, the more precise will the estimation of the expected service life be. The ability to include social costs enables to compute the asset life, not only based on its physical characterisation, but also on the sensitivity of network areas to social impact of failures. The type of economic analysis is very sensitive to model parameters that are difficult to determine accurately. The main value of this approach is the effort to demonstrate that it is possible to include, in decision-making, factors as the cost of the risk associated with a decline in level of performance, the level of this deterioration and the asset’s depreciation rate, without looking at age as the sole criterion for making decisions regarding replacements.

Life cycle assessment in construction field: A life cycle cost analysis of reinforcement concrete bridge

The present work is included in the context of the assessment of sustainability in the construction field and is aimed at estimating and analyzing life cycle cost of the existing reinforced concrete bridge “Viadotto delle Capre” during its entire life. This was accomplished by a comprehensive data collection and results evaluation. In detail, the economic analysis of the project is performed. The work has investigated possible design alternatives for maintenance/rehabilitation and end-of-life operations, when structural, functional, economic and also environmental requirements have to be fulfilled. In detail, the economic impact of different design options for the given reinforced concrete bridge have been assessed, whereupon the most economically, structurally and environmentally efficient scenario was chosen. The Integrated Life-Cycle Analysis procedure and Environmental Impact Assessment were also discussed in this work. The scope of this thesis is to illustrate that Life Cycle Cost analysis as part of Life Cycle Assessment approach could be effectively used to drive the design and management strategy of new and existing structures. The final objective of this contribution is to show how an economic analysis can influence decision-making in the definition of the most sustainable design alternatives. The designers can monitor the economic impact of different design strategies in order to identify the most appropriate option.

Cost-Effectiveness of Alternative Retrofit Options to Support Decision Making

How to evaluate the cost-effectiveness of repair/retrofit intervention vs. demolition/replacement and what level of shaking intensity can the chosen repairing/retrofit technique sustain are open questions affecting either the pre-earthquake prevention, the post-earthquake emergency and the reconstruction phases. The (mis)conception that the cost of retrofit interventions would increase linearly with the achieved seismic performance (%NBS) often discourages stakeholders to consider repair/retrofit options in a post-earthquake damage situation. Similarly, in a pre-earthquake phase, the minimum (by-law) level of %NBS might be targeted, leading in some cases to no-action. Furthermore, the performance measure enforcing owners to take action, the %NBS, is generally evaluated deterministically. Not directly reflecting epistemic and aleatory uncertainties, the assessment can result in misleading confidence on the expected performance. The present study aims at contributing to the delicate decision-making process of repair/retrofit vs. demolition/replacement, by developing a framework to assist stakeholders with the evaluation of the effects in terms of long-term losses and benefits of an increment in their initial investment (targeted retrofit level) and highlighting the uncertainties hidden behind a deterministic approach. For a pre-1970 case study building, different retrofit solutions are considered, targeting different levels of %NBS, and the actual probability of reaching Collapse when considering a suite of ground-motions is evaluated, providing a correlation between %NBS and Risk. Both a simplified and a probabilistic loss modelling are then undertaken to study the relationship between %NBS and expected direct and indirect losses.

Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness

The obesity epidemic is spreading to low-income and middle-income countries as a result of new dietary habits and sedentary ways of life, fuelling chronic diseases and premature mortality. In this report we present an assessment of public health strategies designed to tackle behavioural risk factors for chronic diseases that are closely linked with obesity, including aspects of diet and physical inactivity, in Brazil, China, India, Mexico, Russia, and South Africa. England was included for comparative purposes. Several population-based prevention policies can be expected to generate substantial health gains while entirely or largely paying for themselves through future reductions of health-care expenditures. These strategies include health information and communication strategies that improve population awareness about the benefits of healthy eating and physical activity; fiscal measures that increase the price of unhealthy food content or reduce the cost of healthy foods rich in fibre; and regulatory measures that improve nutritional information or restrict the marketing of unhealthy foods to children. A package of measures for the prevention of chronic diseases would deliver substantial health gains, with a very favourable cost-effectiveness profile.

A review of the cost effectiveness of bisphosphonates in the treatment of post-menopausal osteoporosis in Switzerland

The economic burden associated with osteoporosis is considerable. As such, cost-effectiveness analyses are important contributors to the diagnostic and therapeutic decision-making process. The aim of this study was to review the cost effectiveness of treating post-menopausal osteoporosis with bisphosphonates and identify the key factors that influence the cost effectiveness of such treatment in the Swiss setting. A systematic search of databases (MEDLINE, EMBASE and the Cochrane Library) was conducted to identify published literature on the cost effectiveness of bisphosphonates in post-menopausal osteoporosis in the Swiss setting. Outcomes were compared with similar studies in Western European countries. Three cost-effectiveness studies of bisphosphonates in this patient population were identified; all were from a healthcare payer perspective. Outcomes showed that, relative to no treatment, treatment with oral bisphosphonates was predicted to be cost saving for most women aged ≥70 years with osteoporosis or at least one risk factor for fracture, and cost effective for women aged ≥75 years without prior fracture when used as a component of a population-based screen-and-treat programme. Results were most sensitive to changes in fracture risk, cost of fractures, cost of treatment, nursing home admissions and adherence with treatment. Swiss results were generally comparable to those in other European settings. Assuming similar clinical efficacy, lowering treatment cost (through the use of price-reduced brand-name or generic drugs) and/or improving adherence should both contribute to further improving the cost effectiveness of bisphosphonates in women with post-menopausal osteoporosis. Published evidence indicates that bisphosphonates are estimated to be similarly cost effective or cost saving in most treatment scenarios of post-menopausal osteoporosis in Switzerland and in neighbouring European countries.

Pilot study on the comprehensive economic costs of major trauma: Consequential costs are well in excess of medical costs

BACKGROUND: Trauma care is expensive. However, reliable data on the exact lifelong costs incurred by a major trauma patient are lacking. Discussion usually focuses on direct medical costs--underestimating consequential costs resulting from absence from work and permanent disability. METHODS: Direct medical costs and consequential costs of 63 major trauma survivors (ISS >13) at a Swiss trauma center from 1995 to 1996 were assessed 5 years posttrauma. The following cost evaluation methods were used: correction cost method (direct cost of restoring an original state), human capital method (indirect cost of lost productivity), contingent valuation method (human cost as the lost quality of life), and macroeconomic estimates. RESULTS: Mean ISS (Injury Severity Score) was 26.8 +/- 9.5 (mean +/- SD). In all, 22 patients (35%) were disabled, causing discounted average lifelong total costs of USD 1,293,800, compared with 41 patients (65%) who recovered without any disabilities with incurred costs of USD 147,200 (average of both groups USD 547,800). Two thirds of these costs were attributable to a loss of production whereas only one third was a result of the cost of correction. Primary hospital treatment (USD 27,800 +/- 37,800) was only a minor fraction of the total cost--less than the estimated cost of police and the judiciary. Loss of quality of life led to considerable intangible human costs similar to real costs. CONCLUSIONS: Trauma costs are commonly underestimated. Direct medical costs make up only a small part of the total costs. Consequential costs, such as lost productivity, are well in excess of the usual medical costs. Mere cost averages give a false estimate of the costs incurred by patients with/without disabilities.