Health system cost for providing antiretroviral therapy, family planning, and pregnancy-related services to women living with HIV in public health settings, Mumbai, India.

Background: Integration of HIV care into family planning (FP) services would help in reducing unintended pregnancies among women living with HIV. Objectives: This study focuses on determining the health system cost for providing the linked HIV-FP services per beneficiary for the year 2019-2020. Materials and Methods: Using mixed micro-costing approach costs were collected from two tertiary hospitals in Maharashtra, India. The economic costs collected from gynaecology department and anti-retroviral treatment center were combined and added with package, program, and intervention costs to obtain health-system costs. We conducted probabilistic sensitivity analysis. Results: The unit cost and annual per-capita cost for providing HIV care (without considering cost of drugs and investigations) per beneficiary were INR 1033.8 (USD 13.6) and INR 9304.2 (USD 122.7), respectively. The unit cost was least for the outpatient services INR 197.5 (USD 2.6), followed by inpatient services INR 2735.92 (USD 36.21) and operation theater INR 4410 (USD 58.2). Cost was highest for dual-permanent (INR 13866.8 [USD 182.9]) followed by dual-reversible user (INR 2104.8 [USD 24.8]). It was the least for a person who only used condoms at INR 1674.1 (USD 22.1). In pregnancy-related services, cost for ante-natal services was least (INR 2043.6 [USD 27.96]), followed by vaginal delivery (INR 7120.5 [USD 93.93]), abortion (INR 11530.5 [USD 152.097]), and C-section (INR 18703.8 [USD 246.7]). Conclusion: We found no staggeringly additional costs for providing FP and pregnancy-related services to HIV-affected population, in comparison to general population. The findings could improve programs and insurance with a focus on this vulnerable population.

Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program.

BACKGROUND: Understanding the resilience of healthcare is critically important. A resilient healthcare system might be expected to consistently deliver high quality care, withstand disruptive events and continually adapt, learn and improve. However, there are many different theories, models and definitions of resilience and most are contested and debated in the literature. Clear and unambiguous conceptual definitions are important for both theoretical and practical considerations of any phenomenon, and resilience is no exception. A large international research programme on Resilience in Healthcare (RiH) is seeking to address these issues in a 5-year study across Norway, England, the Netherlands, Australia, Japan, and Switzerland (2018-2023). The aims of this debate paper are: 1) to identify and select core operational concepts of resilience from the literature in order to consider their contributions, implications, and boundaries for researching resilience in healthcare; and 2) to propose a working definition of healthcare resilience that underpins the international RiH research programme. MAIN TEXT: To fulfil these aims, first an overview of three core perspectives or metaphors that underpin theories of resilience are introduced from ecology, engineering and psychology. Second, we present a brief overview of key definitions and approaches to resilience applicable in healthcare. We position our research program with collaborative learning and user involvement as vital prerequisite pillars in our conceptualisation and operationalisation of resilience for maintaining quality of healthcare services. Third, our analysis addresses four core questions that studies of resilience in healthcare need to consider when defining and operationalising resilience. These are: resilience 'for what', 'to what', 'of what', and 'through what'? Finally, we present our operational definition of resilience. CONCLUSION: The RiH research program is exploring resilience as a multi-level phenomenon and considers adaptive capacity to change as a foundation for high quality care. We, therefore, define healthcare resilience as: the capacity to adapt to challenges and changes at different system levels, to maintain high quality care. This working definition of resilience is intended to be comprehensible and applicable regardless of the level of analysis or type of system component under investigation.

Cost-effectiveness analysis of umeclidinium bromide/vilanterol 62.5/25 mcg versus tiotropium/olodaterol 5/5 mcg in symptomatic patients with chronic obstructive pulmonary disease: a Spanish National Healthcare System perspective.

BACKGROUND: A head-to-head study demonstrated the superiority of once-daily umeclidinium bromide/vilanterol (UMEC/VI) 62.5/25 mcg on trough forced expiratory volume in 1 s (FEV1) versus once-daily tiotropium/olodaterol (TIO/OLO) 5/5 mcg in symptomatic patients with chronic obstructive pulmonary disease (COPD). This analysis evaluated the cost effectiveness of UMEC/VI versus TIO/OLO from a Spanish National Healthcare System perspective, using data from this study and Spanish literature. METHODS: This analysis was conducted from the perspective of the Spanish National Healthcare System with a 3-year horizon as base case. A disease progression model using a linked risk equation approach was used to estimate disease progression and associated healthcare costs, and quality-adjusted life years (QALYs). The Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study was used to develop the statistical risk equations for clinical endpoints, and costs were calculated using a health state approach (by dyspnea severity). Utilities for QALY calculation were estimated using patient baseline characteristics within a regression fit to Spanish observational data. Treatment effect, expressed as change from baseline in FEV1 was obtained from the head-to-head study and used in the model (UMEC/VI minus TIO/OLO difference: + 52 mL [95% confidence interval: 28, 77]). Baseline patient characteristics were sourced from Spanish literature or the head-to-head study if unavailable. A scenario analysis using only the intent-to-treat (ITT) population from the head-to-head study, and sensitivity analyses (including probabilistic sensitivity analyses), were conducted. Direct healthcare costs (2017 Euro) were obtained from Spanish sources and costs and benefits were discounted at 3% per annum. RESULTS: UMEC/VI was associated with small improvements in QALYs (+ 0.029) over a 3-year time horizon, compared with TIO/OLO, alongside cost savings of €393/patient. The ITT scenario analysis and sensitivity analyses had similar results. All probabilistic simulations resulted in UMEC/VI being less costly and more effective than TIO/OLO. CONCLUSION: UMEC/VI dominated TIO/OLO (more effective and less expensive). These results may aid payers and decision-makers in Spain when making judgements on which long-acting muscarinic antagonist/long-acting ß2-agonist (LAMA/LABA) treatments can be considered cost effective in Spain.

Unpacking complexity in public health interventions with the Actor-Network Theory.

This article proposes a sociologically informed theoretical and methodological framework to address the complexity of public health interventions (PHI). It first proposes three arguments in favour of using the Actor-Network Theory (ANT) for the framework. ANT: (1) deals with systems made of human and non-human entities and proposes a relational view of action; (2) provides an understanding of the intervention-context interactions and (3) is a tool for opening the intervention's black box. Three principles derived from ANT addressing theoretical problems with conceptualisation of PHI as complex systems are proposed: (1) to focus on the process of connecting the network entities instead of their stabilised form; (2) both human and non-human entities composing networks have performative capacities and (3) network and intervention shape one another. Three methodological guidelines are further derived: (1) the researcher's task consists in documenting the events that transform the network and intervention; (2) events must be ordered chronologically to represent the intervention's evolution and (3) a broad range of data is needed to capture complex interventions' evolution. Using ANT as a guide, this paper helps reconcile technicist and social views of PHI and provides a mean to integrate process and effect studies of interventions.

Obstacles to using the safe surgery checklist: Perspectives of first-line personnel.

Objectives: The safe surgery checklist, presented by the World Health Organization in 2008, is an aid to performing surgical interventions safely. Research indicates that the use of checklists in clinical activities leads to a reduced number of adverse events. However, research suggests that the use of checklists differs between different institutions and even between units in the same organisation. The intention of this study is to identify factors regarded by the health personnel in 'the sharp end' as obstacles to using the checklist. Methods: The study has a qualitative, case-based design. It is performed by the Hazard Identification method, which is a method for revealing safety hazards based on workers' experiences. Results: Obstacles were identified related to the content of the list, areas of use, distribution of responsibilities connected with the use of the list, and finally the organisation and management of safety efforts related to clinical activities. The use of checklists must be part of a system's perspective, and deviations from checklists must be discussed in the organisation. The informants also claimed that checklists should be implemented for interventions located outside the operating theatres and for emergency treatments. Conclusions: Even though the majority of employees believe that checklists are necessary, many surrounding factors are perceived as obstacles to their use. Not least, site-specific factors may be revealed by use of the Hazard Identification method.

Dielectrophoresis from the System's Point of View: A Tale of Inhomogeneous Object Polarization, Mirror Charges, High Repelling and Snap-to-Surface Forces and Complex Trajectories Featuring Bifurcation Points and Watersheds.

Microscopic objects change the apparent permittivity and conductivity of aqueous systems and thus their overall polarizability. In inhomogeneous fields, dielectrophoresis (DEP) increases the overall polarizability of the system by moving more highly polarizable objects or media to locations with a higher field. The DEP force is usually calculated from the object's point of view using the interaction of the object's induced dipole or multipole moments with the inducing field. Recently, we were able to derive the DEP force from the work required to charge suspension volumes with a single object moving in an inhomogeneous field. The capacitance of the volumes was described using Maxwell−Wagner's mixing equation. Here, we generalize this system's-point-of-view approach describing the overall polarizability of the whole DEP system as a function of the position of the object with a numerical "conductance field". As an example, we consider high- and low conductive 200 µm 2D spheres in a square 1 × 1 mm chamber with plain-versus-pointed electrode configuration. For given starting points, the trajectories of the sphere and the corresponding DEP forces were calculated from the conductance gradients. The model describes watersheds; saddle points; attractive and repulsive forces in front of the pointed electrode, increased by factors >600 compared to forces in the chamber volume where the classical dipole approach remains applicable; and DEP motions with and against the field gradient under "positive DEP" conditions. We believe that our approach can explain experimental findings such as the accumulation of viruses and proteins, where the dipole approach cannot account for sufficiently high holding forces to defeat Brownian motion.

The Health Economics of Metastatic Hormone-Sensitive and Non-Metastatic Castration-Resistant Prostate Cancer-A Systematic Literature Review with Application to the Canadian Context.

Background: Health economic evaluations are needed to assess the impact on the healthcare system of emerging treatment patterns for advanced prostate cancer. The objective of this study is to review the scientific literature identifying cost-effectiveness and cost analyses that are assessing treatments for metastatic hormone-sensitive prostate cancer (mHSPC) and nonmetastatic castration-resistant prostate cancer (nmCRPC). Methods: On 29 June 2021, we searched the scientific (MEDLINE, Embase, and EBSCO) and grey literature for health economic studies targeting mHSPC and nmCRPC. We used the CHEC-extended checklist and the Welte checklist for risk-of-bias assessment and transferability analysis, respectively. Results: We retained 20 cost-effectiveness and 4 cost analyses in the mHSPC setting, and 14 cost-effectiveness and 6 cost analyses in the nmCRPC setting. Docetaxel in combination with androgen deprivation therapy (ADT) was the most cost-effective treatment in the mHSPC setting. Apalutamide, darolutamide, and enzalutamide presented similar results vs. ADT alone and were identified as cost-effective treatments for nmCRPC. An increase in costs as patients transitioned from nmCRPC to mCRPC was noted. Conclusions: We concluded that there is an important unmet need for health economic evaluations in the mHSPC and nmCRPC setting incorporating real-world data to support healthcare decision making.

Safer Systems: People Training or System Tuning?

Safety is usually seen as a problem when it is absent rather than when it is present, where accidents, incidents, and the like represent a lack of safety rather than the presence of safety. To explain this lack of safety, one or more causes must be found. In the management of industrial safety, the human factor has traditionally been seen as a weak element; human error is often offered as the first, and sometimes the only cause of lack of safety and human factors have since the early days offered three principal solutions, namely training, design, and automation. Of these, training has considerable face value as an effective means to improve human performance. The drawback of safety training, however, is that it focuses on a single system component, the human, instead of on the system as a whole. Safety training further takes for granted that humans are a liability and focuses on overcoming the weakness of this specific component through simplistic models of what determines human performance. But humans may also be seen as an asset which changes the focus to strengthening how a complex socio-technical system functions. A socio-technical system comprises multiple functions that must be finely tuned in order to ensure expected and acceptable performance. Since systems cannot be made safer without developing effective ways of managing the conditions in which people work, system tuning offers an alternative solution to an old problem.

Bibliographic mapping of post-consumer plastic waste based on hierarchical circular principles across the system perspective.

The current dominating production and consumption model is based on the linear economy (LE) model, within which raw materials are extracted-processed-consumed-discarded. A circular economy (CE) constitutes a regenerative systemic approach to economic development which views waste as a valuable resource to be reprocessed back into the economy. In order to understand the circular strategy for a systemic change from an LE to a CE as a means of resolving the issue of plastic waste, this research aims to map current circular strategy trends across the system perspective contained in the literature relating to plastic CE literature. The novelty of the research lies in the mapping and review of the distribution of comprehensive circular strategies within the 9R framework across the entire system perspective (e.g. micro-meso-macro) down to its sub-levels in the literature on a plastic CE. The bibliographic mapping and systematic literature review iindicateed that the majority of the research focused on recycle (R8), followed by refuse (R0), reuse (R3), and reduce (R2). Certain circular strategies are more appropriate to handling certain plastic materials, despite CE's favoring of prevention and recycling over incineration. Recover (R9) is often used to process mixed and contaminated plastic. Recycling (R8) is the most popular circular strategy and the most applicable to plastic material with three recycle trends, namely; mechanical recycling, chemical recycling and DRAM (Distributed-Recycling-and-Additive-Manufacturing). Prolonging the product life through refurbishing (R5) is not applicable to plastic due to its material limitations. Reduce (R2) popularity as circular strategy reflects the preference to reduce consumption, either by launching campaigns to prevent waste or increasing production efficiency. Research on Rethink (R1) has largely focused on rethinking product design, consumer and organization behavior and perceptions of CE. Refuse (R0) strategy is an adoption of bio-based plastics which have a similar function to fossil-based plastics.

Leadership and post-traumatic stress disorder: are soldiers' perceptions of organizational justice during deployment protective?

Background: Soldiers' perception of leadership during military deployment has gained research attention as a potentially modifiable factor to buffer against the development of postdeployment post-traumatic stress disorder (PTSD). Within nonmilitary research, the organizational justice (OJ) framework, i.e. distributive justice, procedural justice (PJ) and interactional justice (IJ), has been found to relate to mental health outcomes. Aspects of OJ may, therefore, be protective against PTSD. Objectives: We examined the prospective relationship between aspects of OJ, namely the perceptions of PJ and IJ by subordinate soldiers without leadership obligations in relationship to immediate superiors and PTSD. Method: Participants were soldiers (n = 245) deployed to Helmand Province in Afghanistan in 2009. Logistic regression procedures were used. The primary analysis measured PTSD cases using the Structured Clinical Interview for DSM-IV-TR Axis-I Disorder (SCID) 2½ years after homecoming. PJ/IJ was measured during deployment with a 6-item composite measure ranging from 0 to 12. Supplementary primary analyses were performed with PJ/IJ measured before and immediately after deployment. A secondary PJ/IJ analysis also tested against four postdeployment measures with the Post-Traumatic Stress Disorder Checklist Civilian (PCL-C) dichotomized at screening symptom levels. Results: Higher levels of perceived PJ/IJ for soldiers without leadership obligations during deployment had a prospective relation (OR = 0.86, 95% CI = 0.75-0.98) with PTSD on the SCID 2½ years after homecoming after adjustment for factors including predeployment PTSD symptoms, trauma and combat exposure, and state affectivity. Similar results were found by measuring PJ/IJ before (OR = 0.83, 95% CI = 0.71-0.95) but not immediately after homecoming (OR = 0.97, 95% CI = 0.85-1.11). A relationship with PTSD symptoms at the screening level at the four measurements of PCL-C was found, but only when predeployment PTSD symptoms were not controlled for. Conclusions: These results suggest that PJ/IJ exercised by superiors in relation to military deployments may protect subordinate soldiers against the development of postdeployment PTSD.

Planteamiento: La percepción del liderazgo de los soldados durante un despliegue militar se ha ganado la atención de la investigación como factor potencialmente modificable para amortiguar el desarrollo del trastorno por estrés postraumático (TEPT) después de un despliegue militar. Dentro de la investigación no militar, se ha encontrado que el marco de justicia organizacional (JO) ­es decir, justicia distributiva, justicia procedimental (JP) y justicia interaccional (JI)­ está relacionado con resultados de salud mental. Algunos aspectos de la JO pueden, por lo tanto, proteger contra el TEPT.Objetivos: Examinamos la relación prospectiva entre los aspectos de la JO, es decir, las percepciones de JP y JI de los soldados subordinados sin obligaciones de liderazgo en relación a sus superiores inmediatos y al TEPT. Método: Los participantes fueron soldados (n = 245) desplegados en la provincia de Helmand en Afganistán en 2009. Se usaron procedimientos de regresión logística. El análisis principal midió los casos de TEPT mediante la Entrevista Clínica Estructurada para los trastorno del Eje I del DSM-IV-TR (SCID, por sus siglas en inglés) dos años y medio después del regreso a casa. Se midieron la JP y la JI durante el despliegue con una medida compuesta de seis elementos que van de 0 a 12. Se realizaron análisis primarios adicionales, midiendo la JP y la JI antes e inmediatamente después del despliegue. Un análisis secundario de la JP y la JI también se comparó con cuatro medidas posteriores al despliegue con la Lista de verificación del trastorno por estrés postraumático civil (PCL-C, por sus siglas en inglés) dicotomizada para los niveles de síntomas en la selección.Resultados: Niveles más altos de percepción de JP / JI en soldados sin obligaciones de liderazgo durante el despliegue tuvieron una relación prospectiva (OR = 0.86, 95% -IC = 0.75­0.98) con el TEPT en el SCID 2½ años después del regreso al hogar por factores que incluían síntomas de TEPT previos al despliegue, exposición al trauma y al combate, y afectividad de estado. Se encontraron resultados similares midiendo la JP y la JI antes (OR = 0,83; IC del 95% = 0,71­0,95) pero no inmediatamente después de la vuelta al hogar (OR = 0,97; IC del 95% = 0,85­1,11). Se encontró una relación con los síntomas de TEPT en el nivel de detección en las cuatro medidas del PCL-C, pero solo cuando no se controlaron los síntomas del TEPT antes del despliegue.Conclusiones: Estos resultados sugieren que la JP y la JI ejercidas por los superiores en relación con los despliegues militares puede proteger a los soldados subordinados de desarrollar un TEPT posterior al despliegue.

The Journey to Become a Health Literate Organization: A Snapshot of Health System Improvement.

A health literate health care organization is one that makes it easy for people to navigate, understand, and use information and services to take care of their health. This chapter explores the journey that a growing number of organizations are taking to become health literate. Health literacy improvement has increasingly been viewed as a systems issue, one that moves beyond siloed efforts by recognizing that action is required on multiple levels. To help operationalize the shift to a systems perspective, members of the U.S. National Academies of Sciences, Engineering, Medicine Roundtable on Health Literacy defined ten attributes of health literate health care organizations. External factors, such as payment reform in the U.S., have buoyed health literacy as an organizational priority. Health care organizations often begin their journey to become health literate by conducting health literacy organizational assessments, focusing on written and spoken communication, and addressing difficulties in navigating facilities and complex systems. As organizations' efforts mature, health literacy quality improvement efforts give way to transformational activities. These include: the highest levels of the organization embracing health literacy, making strategic plans for initiating and spreading health literate practices, establishing a health literacy workforce and supporting structures, raising health literacy awareness and training staff system-wide, expanding patient and family input, establishing policies, leveraging information technology, monitoring policy compliance, addressing population health, and shifting the culture of the organization. The penultimate section of this chapter highlights the experiences of three organizations that have explicitly set a goal to become health literate: Carolinas Healthcare System (CHS), Intermountain Healthcare, and Northwell Health. These organizations are pioneers that approached health literacy in a systematic fashion, each exemplifying different routes an organization can take to become health literate. CHS provides an example of how, even when the most senior leadership drives the organization to become health literate, continued progress requires constant reinvigoration. At Intermountain Healthcare, the push to become a health literate organization was the natural consequence of organizational adoption of a model of shared accountability that necessitated patient engagement for its success. Northwell Health, on the other hand, provides a model of how a persistent champion can elevate health literacy to become a system priority and how system-wide policies and procedures can advance effective communication across language differences, health literacy, and cultures. The profiles of the three systems make clear that the opportunities for health literacy improvement are vast. Success depends on the presence of a perfect storm of conditions conducive to transformational change. This chapter ends with lessons learned from the experiences of health literacy pioneers that may be useful to organizations embarking on the journey. The journey is long, and there are bumps along the road. Nonetheless, discernable progress has been made. While committed to transformation, organizations seeking to be health literate recognize that it is not a destination you can ever reach. A health literate organization is constantly striving, always knowing that further improvement can be made.

Os processos relacionais na pós-graduação sob a perspectiva da bioecologia do desenvolvimento humano / The proximal processes in postgraduate education under the bioecological human development concepts / Los procesos relacionales en el posgrado bajo la perspectiva de la bioecología del desarrollo humano

O texto apresenta um relato de experiência do tipo estudo de caso descritivo, com foco na análise das interfaces entre os processos relacionais nos Programas de Pós-Graduação (PPGs). Buscou-se estudar o desenvolvimento pessoal e acadêmico de discentes em um Seminário Integrador de uma universidade comunitária do Sul do Brasil pela ótica da teoria ecológico-sistêmica de Urie Bronfenbrenner, com ênfase no conceito de processos proximais. O trabalho, de caráter qualitativo, pretende disseminar a ideia de que uma prática humanizadora pode levar a resultados satisfatórios no que tange à produtividade dos PPGs. Aproximando o leitor de conceitos como díades, tríades e tétrades, apresenta o fator interacional como aliado à superação do dilema produtividade e qualidade, pois insere o elemento resiliência, criando uma nova hipótese, seriam os PPGs mais humanos, também mais produtivos e com mais qualidade? Se a corrida ao Lattes é iminente, que possamos construir juntos a resiliência necessária, passando a tornar o espaço acadêmico mais humano e menos hostil.

This essay presents an experience report of a descriptive case study, focusing on the analysis of the interfaces between the relational processes in the Postgraduate Programs (PPGs). The objective was to study the personal and academic development of students in an Integrative Seminar of a community university in the South of Brazil by the perspective of the Ecological Systems Theory, developed by Urie Bronfenbrenner, with emphasis on the concept of proximal processes. The paper, of a qualitative nature, intends to disseminate the idea that a humanizing practice can lead to satisfactory results regarding the productivity of PPGs. Approximating the reader to concepts such as dyads, triads and tetrads, presents the interactional factor as ally to overcome the dilemma of productivity and quality, because it inserts the element resilience, creating a new hypothesis - would the more human PPGs, more productive and with more quality, either? If the contest to complete the academic curriculum is imminent, we can build together the necessary resilience, making the academic environment more human and less hostile.

El texto presenta un relato de experiencia del tipo estudio de caso descriptivo, con enfoque en el análisis de las interfaces entre los procesos relacionales en los Programas de Posgrado (PPGs). Se ha buscado estudiar el desarrollo personal y académico de discentes en un Seminario Integrador de una universidad comunitaria del Sur de Brasil por la óptica de la teoría ecológico-sistémica de Urie Bronfenbrenner con énfasis en el concepto de procesos proximales. El trabajo, de carácter cualitativo, pretende diseminar la idea de que una práctica humanizadora puede conllevar a resultados satisfactorios en lo que atañe a la productividad de los PPGs. Acercando el lector a conceptos como diadas, triadas y tétradas, presenta el factor interacción como aliado a la superación del dilema productividad y calidad, pues inserta el elemento resiliencia, creando una nueva hipótesis - ¿serían los PPGs más humanos también más productivos y con más calidad? Si la carrera por la productividad científica es inminente, que se pueda construir en conjunto la resiliencia necesaria, volviendo el espacio académico más humano y menos hostil.

Risks, prices, and positions: A social network analysis of illegal drug trafficking in the world-economy.

BACKGROUND: Illegal drug prices are extremely high, compared to similar goods. There is, however, considerable variation in value depending on place, market level and type of drugs. A prominent framework for the study of illegal drugs is the "risks and prices" model (Reuter & Kleiman, 1986). Enforcement is seen as a "tax" added to the regular price. In this paper, it is argued that such economic models are not sufficient to explain price variations at country-level. Drug markets are analysed as global trade networks in which a country's position has an impact on various features, including illegal drug prices. METHODOLOGY: This paper uses social network analysis (SNA) to explain price markups between pairs of countries involved in the trafficking of illegal drugs between 1998 and 2007. It aims to explore a simple question: why do prices increase between two countries? Using relational data from various international organizations, separate trade networks were built for cocaine, heroin and cannabis. Wholesale price markups are predicted with measures of supply, demand, risks of seizures, geographic distance and global positioning within the networks. Reported prices (in $US) and purchasing power parity-adjusted values are analysed. RESULTS: Drug prices increase more sharply when drugs are headed to countries where law enforcement imposes higher costs on traffickers. The position and role of a country in global drug markets are also closely associated with the value of drugs. Price markups are lower if the destination country is a transit to large potential markets. Furthermore, price markups for cocaine and heroin are more pronounced when drugs are exported to countries that are better positioned in the legitimate world-economy, suggesting that relations in legal and illegal markets are directed in opposite directions. CONCLUSION: Consistent with the world-system perspective, evidence is found of coherent world drug markets driven by both local realities and international relations.