Community perceptions on demand-side incentives to promote institutional delivery in Oyam district, Uganda: a qualitative study.

OBJECTIVE: To examine the perceptions of community members and other stakeholders on the use of baby kits and transport vouchers to improve the utilisation of childbirth services. DESIGN: A qualitative study. SETTING: Oyam district, Uganda. PARTICIPANTS: We conducted 10 focus group discussions with 59 women and 55 men, and 18 key informant interviews with local leaders, village health team members, health facility staff and district health management team members. We analysed the data using qualitative content analysis. RESULTS: Five broad themes emerged: (1) context, (2) community support for the interventions, (3) health-seeking behaviours postintervention, (4) undesirable effects of the interventions and (5) implementation issues and lessons learnt. Context regarded perceived long distances to health facilities and high transport costs. Regarding community support for the interventions, the schemes were perceived to be acceptable and helpful particularly to the most vulnerable. Transport vouchers were preferred over baby kits, although both interventions were perceived to be necessary. Health-seeking behaviours entailed perceived increased utilisation of maternal health services and 'bypassing', promotion of collaboration between traditional birth attendants and formal health workers, stimulation of men's involvement in maternal health, and increased community awareness of maternal health. Undesirable effects of the interventions included increased workload for health workers, sustainability concerns and perceived encouragement to reproduce and dependency. Implementation issues included information gaps leading to confusion, mistrust and discontent, transport voucher scheme design; implementation; and payment problems, poor attitude of some health workers and poor quality of care, insecurity, and a shortage of baby kits. Community involvement was key to solving the challenges. CONCLUSIONS: The study provides further insights into the implementation of incentive schemes to improve maternal health services utilisation. The findings are relevant for planning and implementing similar schemes in low-income countries.

Air Pollution and Estimated Health Costs Related to Road Transportations of Goods in Italy: A First Healthcare Burden Assessment.

Background: The Italian Society of Environmental Medicine has performed a preliminary assessment of the health impact attributable to road freight traffic in Italy. Methods: We estimated fine particulate matter (PM10, PM2.5) and nitrogen oxides (NOx) generated by road transportation of goods in Italy considering the number of trucks, the emission factors and the average annual distance covered in the year 2016. Simulations on data concerning Years of Life Lost (YLL) attributable to PM2.5 (593,700) and nitrogen oxides NO2 (200,700) provided by the European Environmental Agency (EEA) were used as a proxy of healthcare burden. We set three different healthcare burden scenarios, varying from 1/5 to 1/10 of the proportion of the overall particulate matter attributable to road freight traffic in Italy (about 7% on a total of 2262 tons/year). Results: Road freight traffic in Italy produced about 189 tons of PM10, 147 tons of PM2.5 and 4125 tons of NOx in year 2016, resulting in annual healthcare costs varying from 400 million up to 1.2 billion EUR per year. Conclusion: Road freight traffic has a relevant impact on air pollution and healthcare costs, especially if considered over a 10-year period. Any solution able to significantly reduce the road transportation of goods could decrease avoidable mortality due to air pollution and related costs.

Oil Price Uncertainty, Transport Fuel Demand and Public Health.

Based on the panel data of 306 cities in China from 2002 to 2012, this paper investigates China's road transport fuel (i.e., gasoline and diesel) demand system by using the Almost Ideal Demand System (AIDS) and the Quadratic AIDS (QUAIDS) models. The results indicate that own-priceelasticitiesfordifferentvehiclecategoriesrangefrom-1.215to-0.459(byAIDS)andfrom -1.399 to-0.369 (by QUAIDS). Then, this study estimates the air pollution emissions (CO, NOx and PM2.5) and public health damages from the road transport sector under different oil price shocks. Compared to the base year 2012, results show that a fuel price rise of 30% can avoid 1,147,270 tonnes of pollution emissions; besides, premature deaths and economic losses decrease by 16,149 cases and 13,817.953 million RMB yuan respectively; while based on the non-linear health effect model, the premature deaths and total economic losses decrease by 15,534 and 13,291.4 million RMB yuan respectively. Our study combines the fuel demand and health evaluation models and is the first attempt to address how oil price changes influence public health through the fuel demand system in China. Given its serious air pollution emission and substantial health damages, this paper provides important insights for policy makers in terms of persistent increasing in fuel consumption and the associated health and economic losses.

The economic burden of dementia in China, 1990-2030: implications for health policy.

OBJECTIVE: To quantify and predict the economic burden of dementia in China for the periods 1990-2010 and 2020-2030, respectively, and discuss the potential implications for national public health policy. METHODS: Using a societal, prevalence-based, gross cost-of-illness approach and data from multiple sources, we estimated or predicted total annual economic costs of dementia in China. We included direct medical costs in outpatient and inpatient settings, direct non-medical costs - e.g. the costs of transportation - and indirect costs due to loss of productivity. We excluded comorbidity-related costs. FINDINGS: The estimated total annual costs of dementia in China increased from 0.9 billion United States dollars (US$) in 1990 to US$ 47.2 billion in 2010 and were predicted to reach US$ 69.0 billion in 2020 and US$ 114.2 billion in 2030. The costs of informal care accounted for 94.4%, 92.9% and 81.3% of the total estimated costs in 1990, 2000 and 2010, respectively. In China, population ageing and the increasing prevalence of dementia were the main drivers for the increasing predicted costs of dementia between 2010 and 2020, and population ageing was the major factor contributing to the growth of dementia costs between 2020 and 2030. CONCLUSION: In China, demographic and epidemiological transitions have driven the growth observed in the economic costs of dementia since the 1990s. If the future costs of dementia are to be reduced, China needs a nationwide dementia action plan to develop an integrated health and social care system and to promote primary and secondary prevention.

The Impact of an Increase in User Costs on the Demand for Emergency Services: The Case of Portuguese Hospitals.

Evidence on the impact of user costs on healthcare demand in 'universal' public National Health Services (NHS) is scarce. The changes in copayments and in the regulation of the provision of free patient transportation, introduced in early 2012 in Portugal, provide a natural experiment to evaluate that impact. However, those changes in user costs were accompanied with changes in the criteria that determine which patients are exempt from copayments, implying that simple comparisons of user rates would be biased. In this paper, we develop a new methodology to evaluate the impact of increases in direct and indirect user costs on the demand for emergency services (ES) in the presence of compositional changes in co-payment exempt and non-exempt populations. Our results show that the increase in copayments did not have an effect in moderating ES demand by paying users, but we find significant effects of the change in transport regulation. Thus, our results support the conclusion that indirect costs may be more important than direct costs in determining healthcare demand in NHS-countries where copayments are small and wide exemption schemes are in place, especially for older patients. Copyright © 2015 John Wiley & Sons, Ltd.

Mobilizing communities to improve maternal health: results of an intervention in rural Zambia.

OBJECTIVE: To determine whether a complex community intervention in rural Zambia improved understanding of maternal health and increased use of maternal health-care services. METHODS: The intervention took place in six rural districts selected by the Zambian Ministry of Health. It involved community discussions on safe pregnancy and delivery led by trained volunteers and the provision of emergency transport. Volunteers worked through existing government-established Safe Motherhood Action Groups. Maternal health indicators at baseline were obtained from women in intervention (n = 1775) and control districts (n = 1630). The intervention's effect on these indicators was assessed using a quasi-experimental difference-in-difference approach that involved propensity score matching and adjustment for confounders such as education, wealth, parity, age and distance to a health-care facility. FINDINGS: The difference-in-difference comparison showed the intervention to be associated with significant increases in maternal health indicators: 14-16% in the number of women who knew when to seek antenatal care; 10-15% in the number who knew three obstetric danger signs; 12-19% in those who used emergency transport; 22-24% in deliveries involving a skilled birth attendant; and 16-21% in deliveries in a health-care facility. The volunteer drop-out rate was low. The estimated incremental cost per additional delivery involving a skilled birth attendant was around 54 United States dollars, comparable to that of other demand-side interventions in developing countries. CONCLUSION: The community intervention was associated with significant improvements in women's knowledge of antenatal care and obstetric danger signs, use of emergency transport and deliveries involving skilled birth attendants.

First-line trastuzumab plus taxane-based chemotherapy for metastatic breast cancer: cost-minimization analysis.

AIM: To carry out a cost-minimization analysis including a comparison of the costs arising from first-line treatment by trastuzumab plus docetaxel versus trastuzumab plus paclitaxel in patients with metastatic breast cancer. METHODS: All consecutive patients with human epidermal growth receptor 2-postive metastatic breast cancer who were treated at Besançon University Hospital and Saint Vincent private hospital between 2001 and 2010 by first-line therapy containing trastuzumab plus taxane were retrospectively studied. Economic analysis took into account costs related to drugs, hospitalization, and healthcare travel. RESULTS: Progression-free survival difference between the two treatments was not significant (p = 0.65). First-line treatment by trastuzumab plus taxane was estimated at approximately €68,000 (p = 0.74). The drug costs represented around 70-75% of the total cost, mainly related to the use of trastuzumab. CONCLUSION: Our economic analysis shows that although the costs of the two trastuzumab plus taxane regimens are similar, they may contribute to the on-going debate about the availability and use of innovative chemotherapy drugs, in particular in human epidermal growth factor receptor 2-positive metastatic breast cancer with new therapies such as trastuzumab-DM1 and pertuzumab.

Explicit and implicit copayments for phototherapy: examining the cost of commuting.

BACKGROUND: Whereas phototherapy is a safe and cost-effective treatment modality for psoriasis, economic disincentives discourage its use, including both direct and indirect costs to the patient. PURPOSE: To determine when it may be cost-effective for patients to purchase a home light unit versus driving to clinic for outpatient phototherapy sessions. METHODS: Estimates of expenses associated with 3 months of outpatient phototherapy were determined and compared to the price of a home phototherapy unit. Factors examined included the cost of gasoline (based on the national average), fuel efficiency of the vehicle, cost of owning and operating a motor vehicle, lost wages, and copayments. RESULTS: The cost for a standard 6-bulb narrowband UVB home unit is approximately $2600. Direct and indirect expenses imposed on patients increase with distance travelled to the dermatologist. If a patient lives 20 or more miles away from the dermatologist, the expenses associated with travel can total more than the out of pocket expense of purchasing a home phototherapy unit. LIMITATIONS: This small analysis only accounted for the first 3 months of treatment and likely underestimates the total costs that patients would experience over a lifetime of treatment. CONCLUSIONS: It may be beneficial for physicians to educate patients on the cost-burden of in-office versus home phototherapy because patients can use these parameters to determine which option would be more cost-effective for them.

Comparison of clinical and cost-effectiveness of psoralen + ultraviolet A versus psoralen + sunlight in the treatment of chronic plaque psoriasis in a developing economy.

Psoralen + ultraviolet A (PUVA) therapy is an established modality for psoriasis. As India is a tropical country that has good availability of natural sunlight psoralen + sunlight (PUVAsol) may be a more convenient option. To compare the efficacy and cost-effectiveness of PUVA versus PUVAsol in chronic plaque psoriasis. Cases of chronic plaque psoriasis with body surface area ≥10% or Psoriasis Area and Severity Index (PASI) ≥10, excluding erythrodermic or pustular psoriasis, were randomized to receive either PUVA or PUVAsol, with endpoint being the achievement of PASI 90 or completion of 12 weeks treatment, whichever is earlier. Cost analysis was also undertaken. Thirty-six cases (16 in PUVA and 20 in PUVAsol group) completed treatment. In the PUVA group, 15 cases (93.75%) responded to therapy while in the PUVAsol group, 15 (75%) responded (P = 0.29). Mean baseline PASI in the PUVA and PUVAsol groups was 16 and 14.4, respectively, and at endpoint was 1.62 and 3.77. There was a significantly greater reduction in PASI in the PUVA group at 2 and 4 weeks but at 8 and 12 weeks and endpoint, it was comparable. Treatment failure occurred in 6.25% and 25% of cases respectively (P = 0.29). Side effects were higher with PUVA. Total cost of therapy was significantly higher in the PUVA group (P = 0.002). Cost-effectiveness ratio was US$0.72 with PUVA and US$0.37 with PUVAsol. Both PUVA and PUVAsol were equally efficacious, with PUVAsol being twice as cost effective. Hence, PUVAsol may be recommended as treatment for psoriasis in a developing economy such as India.

Integrated health impact assessment of travel behaviour: model exploration and application to a fuel price increase.

Transportation policy measures often aim to change travel behaviour towards more efficient transport. While these policy measures do not necessarily target health, these could have an indirect health effect. We evaluate the health impact of a policy resulting in an increase of car fuel prices by 20% on active travel, outdoor air pollution and risk of road traffic injury. An integrated modelling chain is proposed to evaluate the health impact of this policy measure. An activity-based transport model estimated movements of people, providing whereabouts and travelled kilometres. An emission- and dispersion model provided air quality levels (elemental carbon) and a road safety model provided the number of fatal and non-fatal traffic victims. We used kilometres travelled while walking or cycling to estimate the time in active travel. Differences in health effects between the current and fuel price scenario were expressed in Disability Adjusted Life Years (DALY). A 20% fuel price increase leads to an overall gain of 1650 (1010-2330) DALY. Prevented deaths lead to a total of 1450 (890-2040) Years Life Gained (YLG), with better air quality accounting for 530 (180-880) YLG, fewer road traffic injuries for 750 (590-910) YLG and active travel for 170 (120-250) YLG. Concerning morbidity, mostly road safety led to 200 (120-290) fewer Years Lived with Disability (YLD), while air quality improvement only had a minor effect on cardiovascular hospital admissions. Air quality improvement and increased active travel mainly had an impact at older age, while traffic safety mainly affected younger and middle-aged people. This modelling approach illustrates the feasibility of a comprehensive health impact assessment of changes in travel behaviour. Our results suggest that more is needed than a policy rising car fuel prices by 20% to achieve substantial health gains. While the activity-based model gives an answer on what the effect of a proposed policy is, the focus on health may make policy integration more tangible. The model can therefore add to identifying win-win situations for both transport and health.

The co-benefits for health of investing in active transportation.

Amid growing concerns about the impact of rising obesity and physical inactivity levels, climate change, population growth, increasing traffic congestion and declining oil supplies, multiple sectors are now promoting active transportation as an alternative to driving. This paper considers the health benefits and co-benefits of investing in active transportation, enabling comparison of policy options to optimise societal objectives aimed at creating healthy, socially and environmentally sustainable communities. Policies promoting the use of both energy-efficient motor vehicles and increased active transportation would almost double the impact on greenhouse gas emissions and would reduce disease burden by increasing physical activity. More co-benefit and economic analyses research is required to inform 'joined-up' policy solutions.

Evaluating the impact of decision making during construction on transport project outcome.

Decisions made during the project construction phase may bear considerable impacts on the success of transport projects and undermine the ex-ante project evaluation. An innovative and holistic approach has been taken to assess and address this issue by (a) examining the decision process and procedure during project construction, through a field survey, (b) assessing the impact of decisions made during construction on respective transport project and, finally, (c) developing a quality monitoring framework model which links decisions made during the project implementation (construction) phase with the ex-ante and ex-post project evaluations. The framework model is proposed as a guiding and support tool for decision makers.

Decision making in childbirth: the influence of traditional structures in a Ghanaian village.

BACKGROUND: The regional health administration of the Brong-Ahafo Region in Ghana identified that although informed about the advantages of both aspects of care, pregnant women made use of antenatal services but not of the supervised delivery. Quantitative studies have identified economic factors that influence the decisions of pregnant women. AIM: To describe and understand the traditional structures of childbirth in Kwame Danso/Ghana and to explore why the pregnant women do not make use of supervised deliveries in the modern institutions. METHODS: A mini-ethnographic study, using participant observation and ethnographic interviews. FINDINGS: Cultural and social factors have a significant influence on the decisions related to childbirth. One of the most important factors identified was that the responsible persons for decisions related to a delivery were the older female relatives, rather than the mothers themselves. Older females used rational judgements to weigh up the possibilities of risks, interests and advantages related to their cultural, spiritual and social system. Other factors were staff behaviour that was characterized as unfriendly and lacking for respect as to the living conditions and thinking of the pregnant women in the village. CONCLUSIONS: Ethnographic research provided an understanding of traditional structures that have an influence on the decisions and behaviour of the community related to childbirth. Appreciation of these structures enabled health promotion and structured health services to be delivered in a more culturally appropriate way.

Evaluation of broiler litter transportation in northern Alabama, USA.

The profitability of using broiler litter as a source of crop nutrients was calculated using a phosphorus-consistent litter application rule. A ton of litter can cost effectively be transported up to 164 miles from the production facility. A cost-minimizing phosphorus-consistent transportation model developed to meet the nutrient needs of 29 counties in northern Alabama revealed that not all of the litter can be utilized in the region. The total cost increased when transportation of the litter out of the heavily surplus counties was prioritized. Total litter use was minimally affected by changes in chemical fertilizer prices. Shadow prices indicated the robustness of the model.