Health and Development Discussion Papers
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This repository contains a collection of the Health and Development Discussion Papers, an informal working paper series that began publishing in 2002 by the Boston University Center for Global Health and Development. It is intended to help the Center and individual authors to disseminate work that is being prepared for journal publication or that is not appropriate for journal publication but might still have value to readers.
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Item The cost and cost-effectiveness of alternative strategies to expand treatment to HIV-positive South Africans: scale economies and outreach costs(Boston University Center for Global Health and Development, 2015-04) Bershteyn, Anna; Klein, Daniel; Meyer-Rath, Gesine; Over, MeadThe South African government is currently discussing various alternative approaches to the further expansion of antiretroviral treatment (ART) in public-sector facilities. We used the EMOD-HIV model, a HIV transmission model which projects South African HIV incidence and prevalence and ARV treatment by age-group for alternative combinations of treatment eligibility criteria and testing, to generate 12 epidemiological scenarios. Using data from our own bottom-up cost analyses in South Africa, we separate outpatient cost into nonscale- dependent costs (drugs and laboratory tests) and scale-dependent cost (staff, space, equipment and overheads) and model the cost of production according to the expected future number and size of clinics. On the demand side, we include the cost of creating and sustaining the projected incremental demand for testing and treatment. Previous research with EMOD-HIV has shown that more vigorous recruitment of patients with CD4 counts less than 350 is an advantageous policy over a five-year horizon. Over 20 years, however, the model assumption that a person on treatment is 92% less infectious improves the cost-effectiveness of higher eligibility thresholds, averting HIV infections for between $1,700 and $2,800, while more vigorous expansion under the current guidelines would cost more than $7,500 per incremental HIV infection averted. Based on analysis of the sensitivity of the results to 1,728 alternative parameter combinations at each of four discount rates, we conclude that better knowledge of the behavioral elasticities could reduce the uncertainty of cost estimates by a factor of 4 to 10.Item A method of assessing the quality of pharmaceutical market and industry reports as a source to study access to medicines(Boston University Center for Global Health and Development, 2016-11) Knox, Ryan P.; Wirtz, B.S.; Wirtz, Veronika J.Market and industry reports can be useful in studying access to medicines from a pharmaceutical market perspective. However, many market and industry reports lack some or much of the information required to conduct analyses to study access to medicines and are often not transparent in their data sources and research methodologies. The instrument developed in this study, titled the Pharmaceutical Market and Industry Report Assessment Tool (PIRAT), assesses the quality of pharmaceutical market and industry reports, specifically focusing on the needs of public health researchers, and includes criteria describing the content and quality of the market reports. The assessment tool generates an unweighted score indicating the relative strengths and weaknesses of reports.Item Retention on antiretroviral therapy in low- and middle-income countries: systematic review of papers and abstracts since 2008(Boston University Center for Global Health and Development, 2013-12) Fox, Matthew; Rosen, SydneyItem Defining retention and attrition in pre-antiretroviral HIV care: proposals based on experience in Africa(Boston University Center for Global Health and Development, 2012-03) Fox, Matthew; Larson, Bruce; Rosen, SydneyFewer than 33% of those testing HIV-positive in sub-Saharan Africa are continuously retained in pre-antiretroviral therapy (ART) HIV care until ART initiation. Existing evidence is difficult to synthesize, however, due to unclear and inconsistent definitions of terms. We developed practical, standardized definitions for reporting retention for the three stages of pre-ART care: Stage 1, testing HIV-positive to initial ART eligibility assessment; Stage 2, initial assessment to ART eligibility; and Stage 3, ART eligibility to ART initiation. For each stage, negative outcomes include death, loss, or not being retained. Stage 1 retention is defined as the proportion of patients who complete initial ART eligibility assessment within 3 months of HIV testing, with reporting of cohort outcomes at 3 and 12 months after HIV testing. Patients who end Stage 1 eligible for ART move directly to Stage 3. Stage 2 retention is defined as the proportion of patients who either complete all possible ART eligibility re-assessments within 6 months of the site’s standard visit schedule or had an assessment within 1 year of the time reported to and were not ART eligible at the last assessment. Retention should be reported at 12-month intervals. Stage 3 retention is defined as the proportion of patients eligible for ART who initiate ART (i.e.ARVs dispensed) within 3 months of determining ART eligibility, with reporting at 3 months after eligibility and 3 monthly intervals thereafter. If pre-ART retention is to improve, consistent terminology is needed for collecting data, measuring and reporting outcomes, and comparing results across programs and countries. The definitions we propose offer a strategy for improving the consistency and comparability of future reports.Item Confronting corruption in the health sector in Vietnam: patterns and prospects(Boston University Center for Global Health and Development, 2011-10) Brinkerhoff, Derick; Feeley, Frank; Salomon, Matthieu; Vian, Taryn; Vien, Nguyen Thi KieuCorruption in Vietnam is a national concern which could derail health sector goals for equity, access, and quality. Yet, there is little research on vulnerabilities to corruption or associated factors at the sectoral level. This article examines current patterns of corruption in Vietnam’s health sector, identifies key corruption vulnerabilities, and reviews strategies for addressing corruption in the future. The article builds on the findings and discussion at the sixth Anti-Corruption Dialogue between the Vietnamese Government and the international donor community. Development partners, government agencies, Vietnamese and international non-governmental organizations, media representatives and other stakeholders explored what is known about important problems such as informal payments, procurement corruption, and health insurance fraud. The participants proposed corruption-reduction interventions in the areas of administrative oversight, transparency initiatives and civil society participation, and health reforms to change incentives. The analysis assesses the prospects for success of these interventions given the Vietnamese institutional context, and draws conclusions relevant to addressing health sector corruption in other countries.Item Comparison of key unit costs and outcomes for mobile and fixed site screening/testing programs in Namibia(Boston University Center for Global Health and Development, 2010-11) Bindels, Els; De Beer, Ingrid; Feeley, Frank; Rinke de Wit, TobiasItem The impact on employer operating costs of low cost health insurance including an HIV/treatment benefit: results of a study of five employers in Namibia(Boston University Center for Global Health and Development, 2010-03) Beukes, Crystal; De Beer, Ingrid; Feeley, FrankOBJECTIVE: The impact of low-cost health insurance on the costs incurred by Namibian employers was measured. BACKGROUND: Namibia has a relatively recent HIV epidemic and adult HIV prevalence estimated at 15.3%. AIDS-related mortality would be rising in the absence of antiretroviral treatment. (ART). Medical schemes in Namibia now offer low-cost policies that include good coverage for treatment of AIDS, including ART. In 2006-2007, a number of large Namibian employers agreed to purchase such policies for their uninsured workers. METHODOLOGY: We compared data on worker attrition and related costs for the period before and after purchase of the low cost health insurance policy. RESULTS: Worker attrition (death and medical retirement) reported by the companies declined from a range of 1.5% to 2.0% of the work force in 2005 and 2006 to 0.7% to 1.1% in 2008. When data was pooled, attrition fell from a peak of 1.7% of the combined work force in 2005 to 0.9% in 2008. Attrition-related costs at the companies were lower in 2008 than in the peak attrition years. The downward trend in attrition appears to have begun before the date when the firms purchased the new policies. The 2008 value of the savings measured was less than the annual cost of the premiums for the new policies. DISCUSSION: Antiretroviral treatment appears to reduce workforce attrition and related costs for Namibian employers. However, we cannot say if this is a result of new low-cost insurance policies or the rapid expansion of ART in the public sector.Item Non-clinical outcomes of antiretroviral therapy for HIV/AIDS in developing countries: a systematic literature review(Boston University Center for Global Health and Development, 2008-10) Beard, Jennifer; Feeley, Frank; Rosen, SydneyThe impacts of antiretroviral therapy on quality of life, mental health, labor productivity, and economic wellbeing for people living with HIV/AIDS in developing countries are only beginning to be measured. We conducted a systematic literature review to analyze the effect of antiretroviral therapy (ART) on these non-clinical indicators in developing countries and assess the state of research on these topics. Both qualitative and quantitative studies were included, as were peer-reviewed articles, gray literature, and conference abstracts and presentations. Findings are reported from 12 full-length articles, 7 abstracts, and 1 presentation (representing 16 studies). Compared to HIV-positive patients not yet on treatment, patients on ART reported significant improvements in physical, emotional and mental health and daily function. Work performance improved and absenteeism decreased, with the most dramatic changes occurring in the first three months of treatment and then leveling off. Little research has been done on the impact of ART on household wellbeing, with modest changes in child and family wellbeing within households where adults are receiving ART reported so far. Studies from developing countries have not yet assessed non-clinical outcomes of therapy beyond the first year; therefore, longitudinal outcomes are still unknown. As ART roll out extends throughout high HIV prevalence, low-resource countries and is sustained over years and decades, both positive and adverse non-clinical outcomes need to be empirically measured and qualitatively explored in order to support patient adherence and maximize treatment benefits.Item The impact of AIDS on government service delivery: the case of the Zambia Wildlife Authority(Boston University Center for Global Health and Development, 2006-06) Feeley, Rich; Fox, Matthew; Hamazakaza, Petan; Rosen, SydneyBACKGROUND: The loss of working-aged adults to HIV/AIDS has been shown to increase the costs of labor to the private sector in Africa. There is little corresponding evidence for the public sector. This study evaluated the impact of AIDS on the capacity of a government agency, the Zambia Wildlife Authority (ZAWA), to patrol Zambia’s national parks. METHODS: Data were collected from ZAWA on workforce characteristics, recent mortality, costs, and the number of days spent on patrol between 2003 and 2005 by a sample of 76 current patrol officers (reference subjects) and 11 patrol officers who died of AIDS or suspected AIDS (index subjects). An estimate was made of the impact of AIDS on service delivery capacity and labor costs and the potential net benefits of providing treatment. RESULTS: Reference subjects spent an average of 197.4 days on patrol per year. After adjusting for age, years of service, and worksite, index subjects spent 62.8 days on patrol in their last year of service (68% decrease, p<0.0001), 96.8 days on patrol in their second to last year of service (51% decrease, p<0.0001), and 123.7 days on patrol in their third to last year of service (37% decrease, p<0.0001). For each employee who died, ZAWA lost an additional 111 person-days for management, funeral attendance, vacancy, and recruitment and training of a replacement, resulting in a total productivity loss per death of 2.0 person-years. Each AIDS-related death also imposed budgetary costs for care, benefits, recruitment, and training equivalent to 3.3 years’ annual compensation. In 2005, AIDS reduced service delivery capacity by 6.2% and increased labor costs by 9.7%. If antiretroviral therapy could be provided for $500/patient/year, net savings to ZAWA would approach $285,000/year. CONCLUSION: AIDS is constraining ZAWA’s ability to protect Zambia’s wildlife and parks. Impacts on this government agency are substantially larger than have been observed in the private sector. Provision of ART would result in net budgetary savings to ZAWA and greatly increase its service delivery capacity.Item The private sector and HIV/AIDS in Africa: taking stock of six years of applied research(Boston University Center for Global Health and Development, 2006-06) Connelly, Patrick; Feeley, Rich; Rosen, Sydney; Simon, JonathonBACKGROUND: Until recently, little was known about the costs of the HIV/AIDS epidemic to businesses in Africa and business responses to the epidemic. This paper synthesizes the results of a set of studies conducted between 1999 and 2006 and draws conclusions about the role of the private sector in Africa’s response to AIDS. METHODS: Detailed human resource, financial, and medical data were collected from 14 large private and parastatal companies in South Africa, Uganda, Kenya, Zambia, and Ethiopia. Surveys of small and medium-sized enterprises (SMEs) were conducted in South Africa, Kenya, and Zambia. Large companies’ responses or potential responses to the epidemic were investigated in South Africa, Uganda, Kenya, Zambia, and Rwanda. RESULTS: Among the large companies, estimated workforce HIV prevalence ranged from 5%- 37%. The average cost per employee lost to AIDS varied from 0.5-5.6 times the average annual compensation of the employee affected. Labor cost increases as a result of AIDS were estimated at anywhere from 0.6%-10.8% but exceeded 3% at only 2 of 14 companies. Treatment of eligible employees with ART at a cost of $360/patient/year was shown to have positive financial returns for most but not all companies. Uptake of employer-provided testing and treatment services varied widely. Among SMEs, HIV prevalence in the workforce was estimated at 10%-26%. SME managers consistently reported low AIDS related employee attrition, little concern about the impacts of AIDS on their companies, and relatively little interest in taking action, and fewer than half had ever discussed AIDS with their senior staff. AIDS was estimated to increase the average operating costs of small tourism companies in Zambia by less than 1%; labor cost increases in other sectors were probably smaller. CONCLUSIONS: Although there was wide variation among the firms studied, clear patterns emerged that will permit some prediction of impacts and responses in the future.Item Household health and cocoa production: a baseline survey of smallholder farming households in Western Region, Ghana(Boston University Center for Global Health and Development, 2005-11) Anim-Somuah, Henry; Asuming-Brempong, Samuel; Larson, Bruce; Rosen, Sydney; Sarpong, DanielItem Treatment of HIV/AIDS at South Africa's largest employers: myth and reality(Boston University Center for Global Health and Development, 2005-06) Connelly, Patrick; Rosen, SydneyBACKGROUND: In the past three years, many large employers in South Africa have announced publicly their intention of making antiretroviral treatment (ART) available to employees. Reports of the scope and success of these programs have been mostly anecdotal. This study surveyed the largest private sector employers in South Africa to determine the proportion of employees with access to ART through employer-sponsored HIV/AIDS treatment programs. METHODS: All 64 private sector and parastatal employers in South Africa with more than 6,000 employees were identified and contacted. Those that agreed to participate were interviewed by telephone using a structured questionnaire. RESULTS: 52 companies agreed to participate. Among these companies, 63% of employees had access to employer-sponsored care and treatment for HIV/AIDS. Access varied widely by sector, however. Approximately 27% of suspected HIV-positive employees were enrolled in HIV/AIDS disease management programs, or 4.4% of the workforce overall. Fewer than 4,000 employees in the entire sample were receiving antiretroviral therapy. In-house (employer) disease management programs and independent disease management programs achieved higher uptake of services than did medical aid schemes. CONCLUSIONS: Publicity by large employers about their treatment programs should be interpreted cautiously. While there is a high level of access to treatment, uptake of services is low and only a small fraction of employees medically eligible for antiretroviral therapy are receiving it.Item Why do Nigerian manufacturing firms take action on AIDS?(Boston University Center for Global Health and Development, 2003-01) MacLeod, William; Rosen, Sydney; Simon, Jonathon; Thea, Donald; Vincent, JeffreyOBJECTIVE: To identify differences between manufacturing firms in Nigeria that have undertaken HIV/AIDS prevention activities and those that have not as a step toward improving the targeting of HIV policies and interventions. METHODS: A survey of a representative sample of registered manufacturing firms in Nigeria, stratified by location, workforce size, and industrial sector. The survey was administered to managers of 232 firms representing most major industrial areas and sectors in March-April 2001. RESULTS: 45.3 percent of the firms’ managers received information about HIV/AIDS from a source outside the firm in 2000; 7.7 percent knew of an employee who was HIV-positive at the time of the survey; and 13.6 percent knew of an employee who had left the firm and/or died in service due to AIDS. Only 31.7 percent of firms took any action to prevent HIV among employees in 2000, and 23.9 percent had discussed the epidemic as a potential business concern. The best correlates of having taken action on HIV were knowledge of an HIV-positive employee or having lost an employee to AIDS (odds ratio [OR] 6.36, 95% confidence interval [CI]: 2.30, 17.57) and receiving information about the disease from an outside source (OR 7.83, 95% CI: 3.46, 17.69). CONCLUSIONS: Despite a nationwide HIV seroprevalence of 5.8 percent, as of 2001 most Nigerian manufacturing firm managers did not regard HIV/AIDS as a serious problem and had neither taken any action on it nor discussed it as a business issue. Providing managers with accurate, relevant information about the epidemic and practical prevention interventions might strengthen the business response to AIDS in countries like Nigeria.Item The retail market for bednets in Kenya: how well is it working?(Boston University Center for Global Health and Development, 2002-11) Larson, Bruce; Rosen, SydneyBACKGROUND: Achieving the goals set by Roll Back Malaria and the Government of Kenya for use of insecticide treated bednets (ITNs) will require that the private retail market for nets and insecticide treatments grow substantially. This paper applies some basic concepts of market structure and pricing to a set of recently-collected retail price data from Kenya in order to answer the question, “How well are Kenyan retail markets for ITNs working?” METHODS: Data on the availability and prices of ITNs at a wide range of retail outlets throughout Kenya were collected in January 2002, and vendors and manufacturers were interviewed regarding market structure. FINDINGS: Untreated nets are manufactured in Kenya by a number of companies and are widely available in large and medium-sized towns. Availability in smaller villages is limited. There is relatively little geographic price variation, and nets can be found at competitive prices in towns and cities. Marketing margins on prices appear to be within normal ranges. No finished nets are imported. Few pre-treated nets or net+treatment combinations are available, with the exception of the subsidized Supanet/Power Tab combination marketed by a donor-funded social marketing project. CONCLUSIONS: Retail markets for untreated nets in Kenya are well established and appear to be competitive. Markets for treated nets and insecticide treatment kits are not well established. The role of subsidized ITN marketing projects should be monitored to ensure that these projects support, rather than hinder, the development of retail markets.Item Shifting the burden of HIV/AIDS(Boston University Center for Global Health and Development, 2002-05) Rosen, Sydney; Simon, JonathonAs the economic burden of HIV/AIDS increases in sub-Saharan Africa, the allocation of the burden among levels and sectors of societies is changing. The private sector has greater scope than government, households, or NGOs to avoid the economic burden of AIDS, and a systematic shifting of the burden away from the private sector is underway. Common practices that shift the AIDS burden from businesses to households and government include pre-employment screening, reduced employee benefits, restructured employment contracts, outsourcing of less skilled jobs, selective retrenchments, and changes in production technologies. In South Africa, more than two thirds of large employers have reduced health care benefits or required larger contributions by employees. Most firms have replaced defined benefit retirement funds, which expose the firm to large annual costs but provide long-term support for families, with defined contribution funds, which eliminate firm risk but provide little to families of younger workers who die of AIDS. Contracting out of previously permanent jobs also shields firms from costs while leaving households and government to care for affected workers and their families. Many of these changes are responses to globalization and would have occurred in the absence of AIDS, but they are devastating for employees with HIV/AIDS. This paper argues that the shifting of the economic burden of AIDS is a predictable response by business to which a thoughtful public policy response is needed. Countries should make explicit decisions about each sector’s responsibilities if a socially desirable allocation is to be achieved.