Indecopi has within its functions the defense of free competition and the protection of intellectual property. This institutional design has the advantage of being able to see more clearly what are the points of convergence between the two subject-matter, harmonize them and achieve the goals they have in common. Within this convergence, there are sensitive issues as the granting of compulsory licenses. In this work, we highlight that compulsory licenses are exceptional measures and, to consider its granting, the State must have a procedure that provides confidence and predictability to citizens and clear definitions of what is meant by public interest, emergency and national security. Finally, it is proposed that the granting of compulsory licenses should be justified by a cost benefit analysis showing that is the best choice. / El Instituto Nacional de Defensa de la Competencia y de la Protección de la Propiedad Intelectual (IndecopI) tiene entre sus funciones tanto la defensa de la libre competencia como la protección de la propiedad intelectual. Este diseño institucional tiene la ventaja de permitir apreciar con mayor claridad cuáles son los puntos de convergencia entre ambas materias, armonizarlos y conseguir los objetivos que tienen en común. Dentro de esta convergencia, existen temas sensibles, como el otorgamiento de licencias obligatorias, por lo que en el presente trabajo se destaca su carácter de medida excepcional y se plantea que, para considerar su otorgamiento, el Estado debe contar con un procedimiento que brinde confianza y predictibilidad a la ciudadanía y con definiciones claras sobre qué debemos entender por interés público, emergencia y seguridad nacional. Finalmente, se propone que su otorgamiento tenga justificación en un análisis costo beneficio que arroje como resultado que, en efecto, era la opción más adecuada.

Made available in DSpace on 2014-10-09T12:51:02Z (GMT). No. of bitstreams: 0 / Made available in DSpace on 2014-10-09T14:07:59Z (GMT). No. of bitstreams: 1 11134.pdf: 13236915 bytes, checksum: bc82464227602708ec25d5d0daf70863 (MD5) / Tese (Doutoramento) / IPEN/T / Instituto de Pesquisas Energeticas e Nucleares - IPEN/CNEN-SP

Made available in DSpace on 2014-07-29T15:07:38Z (GMT). No. of bitstreams: 1 Dissertacao Marcus L G Rezende.pdf: 1012119 bytes, checksum: 7a1b79b8bc4ccbbdcb5a9578a1fc487f (MD5) Previous issue date: 2010-11-30 / Producing more in less physical space and in less time, increasing the profitability and reducing sanitary and economical risks are some of the challenges of the Brazilian livestock that the intensive breeding aims to supplant. A considerable increase in the number of confining unities as well as in feedlot cattle is already observed, thus, the attention to the control of pathological alterations deriving from the production intensification that can compromise the profitability and the economical viability of such activities should also increase. Considering the context presented herein, this essay aimed to analyze the economical/sanitary viability of the usage of florfenicol (40 mg/kg) in the metaphylaxis of bovine respiratory diseases (BRD) in feedlot cattle in the state of Goiás, where two groups totalizing 125 animals were concurrently monitored during 100 days. The first group, having 32 animals, was maintained under the standard sanitary protocol of the confining groups and it was called control (G1). The second group, having 93 animals, was submitted to metaphylaxis with florfenicol (40 mg/kg) at the beginning of the confinement and it was called metaphylaxis (G2). In the both groups, the sanitary and the productive standards were evaluated and a financial analysis was performed in order to economically validate the method. The animals were examined, weighted and materials for analyses were collected at the beginning and at the end of the confinement, when the occurrence of respiratory problems in the animals was evaluated. The animals submitted to metaphylaxis with florfenicol had a daily weight gain (DWG) superior to the one of the animals pertaining to the control group, and the indexes of BRD demonstrated through the analysis of the method viability (MV) were superior to 2.7%, which justifies the investment in the prevention of BRD. / Produzir mais em menor espaço físico e em menor tempo, incrementando a lucratividade e reduzindo os riscos sanitários e econômicos são alguns dos desafios da pecuária brasileira que a criação intensiva procura suplantar. Já se observa considerável aumento no número de unidades confinadoras, bem como de animais confinados; e do mesmo modo, cresce a atenção ao controle das alterações patológicas decorrentes da intensificação da produção e que possam comprometer a lucratividade e a viabilidade econômica da atividade. Considerando este cenário, o presente trabalho pretendeu analisar a viabilidade econômico/sanitária da utilização do florfenicol (40mg/Kg) na metafilaxia da doença respiratória bovina (DRB) em bovinos confinados no estado de Goiás, onde foram acompanhados concomitantemente durante o período de 100 dias dois grupos com 125 animais. O primeiro grupo foi mantido sob o protocolo sanitário padrão do grupo confinador e com 32 animais foi designado controle (G1). O segundo grupo, com 93 animais foi submetido à metafilaxia com florfenicol (40mg/Kg) a entrada do confinamento e designado metafilaxia (G2). Em ambos os grupos foram avaliados padrões sanitários e produtivos, também foram realizadas análises financeiras para a validação econômica do método. Os animais foram examinados, pesados e colhidos materiais para análise na entrada e saída do confinamento, período em que se avaliou a ocorrência de problemas respiratórios nos animais. Foi observado que os animais submetidos à metafilaxia com florfenicol tiveram um ganho de peso diário (GPD) superior aos animais do grupo controle, e os índices de DRB demonstrados por meio da análise de viabilidade do método (VM) foram superiores a 2,7%, justificando o investimento na prevenção da DRB.

Introdução: As avaliações econômicas em saúde (AES) têm participado como ferramenta de apoio ao processo de decisão no setor de Saúde. No Brasil, seu uso passou a ser amplamente difundido na última década, já sendo obrigatória sua apresentação em processos de incorporações de novas tecnologias no sistema único de saúde. Embora muitas avaliações econômicas de saúde tenham sido conduzidas, nenhum estudo revisou sistematicamente a produção e qualidade das avaliações brasileiras. Objetivo: Revisar sistematicamente e avaliar a qualidade do relato dos estudos publicados de avaliação econômica de tecnologias em saúde desenvolvidos no Brasil. Métodos: Foi conduzida uma revisão sistemática incluindo AES completas e parciais desenvolvidas no Brasil, e publicadas entre 1980 e 2013. Foram utilizadas as bases de dados eletrônicas (Medline, Embase, Lilacs, Scielo, NHS EED, HTA database, Bireme e BVS ECO); os índices de citação (Scopus, Web of science) e Sisrebrats. Resultados: Foram incluídos 535 artigos, dos quais 36,8% foram considerados AES completas, sendo 39,1% análises de custo-efetividade. Quase metade (46,4%) dos estudos não relatou o tipo de análise conduzida, desses 91,9% eram AES parciais. Entre as que informaram, houve concordância entre o relato e o conduzido em 71,4% dos estudos. As modalidades das tecnologias, mais frequentemente, avaliadas foram procedimentos (34,8%) e medicamentos (28,8%) cujo objetivo principal era o de tratamento (72,1%). As três categorias de doenças cujas tecnologias foram, mais frequentemente, avaliadas foram: doenças infecciosas (17,4%), doenças do aparelho circulatório (12,9%) e neoplasia (10,3%). Entre as tecnologias avaliadas pelos estudos incluídos, apenas 64 haviam sido objeto de análise por comissões nacionais de incorporação (CITEC e CONITEC). A maioria dos artigos foi conduzida por autores da academia (65,1%), que se concentram, principalmente, na região Sudeste (73,6%) e Sul (12,5%). O principal veículo de publicação foram as revistas nacionais (72,5%), com escopo médico (55,5%). Apenas 43,5% dos estudos relataram a fonte de financiamento e 36,1% relataram presença de conflito de interesse. Setenta e nove por cento das AES completas obtiveram resultados favoráveis para as tecnologias avaliadas. Com relação à qualidade do relato, apenas 6,6% dos estudos relataram todos os itens avaliados no checklist, mas 47,7% foram considerados em conformidade (relato minimamente satisfatório). Alguns itens como 1) métodos utilizados para mensuração dos dados de custos, 2) taxa de desconto, 3) fontes de financiamento, e 4) conflitos de interesse foram relatados em apenas metade dos estudos. A qualidade do relato apresentou associação estatística significativa (p < 0,001) com o período de publicação (estudos mais recentes apresentaram maior qualidade) e com a presença de conflito de interesse (estudos com conflito de interesse apresentaram maior qualidade). As fontes de dados clínicos, de uso de recursos e de custos foram considerados com melhor nível de evidência quando comparadas às fontes de utilidade. Nos últimos anos, houve um aumento da produção de análises de custo-utilidade, porém a maioria dos estudos utilizou utilidades de outros países validadas por painéis de especialistas brasileiros. Conclusão: Um grande número de AES foi publicado no Brasil entre 1980 e 2013. A qualidade do relato foi considerada satisfatória, principalmente na AES publicadas mais recentemente. Para que as AES possam aumentar sua contribuição nos processos de decisão nacionais, são necessários esforços para melhora da qualidade dos relatos, transparência e padronização da metodologia utilizada e o aperfeiçoamento do sistema de revisão pelos pares nas revistas nacionais não específicas em economia da saúde / Introduction: Health Economic Evaluation (HEE) have participated as a supportive tool to decision-making in health sector. In Brazil, their use has been widespread in the last decade having become mandatory as part of the processes for new technologies in the Brazilian Unified National Health System. Although many Health Economic Evaluation have been conducted, there are no studies that have systematically reviewed the production and quality of Brazilian evaluations. Objective: To systematically review and evaluate the quality of reporting of published studies of health economic evaluation developed in Brazil. Methods: Was conducted a systematic review including full and partial HEE developed in Brazil and published between 1980 and 2013. Electronic databases (Medline, Embase, Lilacs, Scielo, NHS EED, HTA database, Bireme and the BVS ECO); citation indexes (Scopus, Web of science) and Sisrebrats were searched. Results: We included 535 articles, of which 36.8% were considered full HEE, being 39.1% cost-effectiveness analysis. Almost half (46.4%) of the studies did not report the type of analysis conducted, of these 91.9% were partial HEE. Among the reported, there was 71.4% agreement between the reported and conducted in the studies. The most frequent evaluated modalities of technologies were procedures (34.8%) and drugs (28.8%), whose main objective was treatment (72.1%). The three most often evaluated categories of diseases were infectious diseases (17.4%), cardiovascular diseases (12.9%) and cancer (10.3%). Among the technologies evaluated by the included studies, only 64 had been the subject of analysis by incorporating national commissions (CITEC or CONITEC). Most articles were developed by Authors from academia (65.1%), who are mainly concentrated in the Southeast (73.6%) and South (12.5%) regions. The main vehicles for publication were national journals (72.5%), with medical scope (55.5%). Only 43.5% of the studies reported the source of funding and 36.1% reported conflict of interest. Seventy-nine percent of the full HEE obtained favourable results for the evaluated technologies. Regarding the quality of reporting, only 6.6% of the studies had all items evaluated in the checklist, but 47.7% was considered to be in accordance with the reporting requirements (minimally satisfactory reporting). Items such as 1) methods used to measure the cost data, 2) discount rate, 3) funding sources, and 4) conflicts of interest were reported in only half of the studies. The quality of reporting was significantly related (p < 0.001) to the publication period (more recent studies presented higher quality) and the presence of conflict of interest (presence of conflict of interest presented higher quality). Compared to the utilities, the clinical effect size, resources, and costs data were mostly estimated based on high-ranked evidence. In recent years, there has been an increase in production of cost-utility analysis, but most studies used utilities from other countries validated by Brazilian expert panels. Conclusion: A large number of HEE was published in Brazil between 1980 and 2013. The quality of reporting was considered satisfactory, particularly in most recently published HEE. To increase their contribution in national decision-making processes, efforts are needed in order to improve the quality of reports, transparency and standardization of the methodology and the improvement of the peer-review system in national non-specific journals of health economics

INTRODUÇÃO: Uma epidemia de coqueluche ocorreu no Brasil, de 2011 a 2014. Isto levou à introdução da vacina tríplice acelular de adultos (dTpa) no calendário público de vacinação da gestante. Existem outras estratégias de vacinação envolvendo a dTpa, que poderiam complementar o controle da doença. Os objetivos deste estudo são descrever a epidemiologia da doença e avaliar custo-efetividade da vacinação de adultos com dTpa. MÉTODOS: 1) Uma revisão de literatura foi realizada nas bases MEDLINE, Excerpta Medica, CRD e Lilacs a partir de 2000. 2) Foi desenvolvido estudo observacional incluindo dados de vacinação e os casos notificados para o sistema de vigilância no Estado de São Paulo (ESP), de 2001 a 2015. 3) Foi realizado estudo descritivo dos pacientes com idade de 20 a <40 anos atendidos em um hospital do ESP entre 2010 e 2014, destacando-se a utilização de serviços de saúde. 4) Foi desenvolvido modelo dinâmico, para comparar a estratégia de vacinação com dTpa aos 20 anos de idade com o programa atual (vacinação com dT). Dados epidemiológicos e de custos foram retirados de sistemas de informação de saúde e da literatura nacional e internacional. Foram considerados como desfecho número de casos e mortes por coqueluche e anos de vida ganho (AVG). Considerouse a perspectiva do sistema de saúde, horizonte temporal de vinte anos e custos em Reais (R$) de 2015. Os resultados foram sumarizados em razão de custo-efetividade incremental (RCEI). Análises de sensibilidade uni e multivariadas foram realizadas. RESULTADOS: 1) Foram revisadas 28 avaliações econômicas de estratégias com dTpa. A vacinação de adolescentes e de adultos foram as mais avaliadas. A correção da subnotificação, uso de modelos dinâmicos, proteção de rebanho e altas coberturas vacinas influenciaram para o bom desempenho das estratégias. 2) Houve aumento de incidência da coqueluche entre 2011 e 2014 e queda da mesma em 2015, em todas as faixas etárias no ESP. Os lactentes foram os principais acometidos, mas a proporção de casos nessa faixa etária apresentou tendência de queda ao longo dos anos. A proporção de casos com idade de 1 a < 4, 5 a = 20 anos aumentou significativamente. Houve queda não significativa na proporção dos casos com idade < 2 meses de idade. 3) Entre 36 casos estudados no hospital, 33,3% passou por consulta prévia, 25,3% por consulta de retorno e 8,33% foram hospitalizados. Hemograma e radiografia de tórax foram os exames mais realizados. Não houve complicações ou óbito. 4) A vacinação de adultos com dTpa, com cobertura vacinal de 40% e efetividade de 75%, incluindo proteção de rebanho para os menores de um ano, evitaria 19.300 casos sintomáticos e 221 óbitos em 10 anos. A RCEI seria R$28.054,38/AVG. Na análise de sensibilidade, os resultados foram mais sensíveis a variações da incidência e à retirada da proteção de rebanho. CONCLUSÃO: O comportamento cíclico da doença é a principal causa da epidemia de coqueluche entre 2011 e 2014 e queda da incidência em 2015. A vacinação de adultos com dTpa não se mostrou custo-efetiva na realidade brasileira de 2015 / INTRODUCTION: A pertussis outbreak occurred in Brazil from 2011 to 2014. This led to the introduction of the maternal vaccination with tetanus-diphtheria-acellular pertussis vaccine (Tdap) in the public immunization schedule. There are other vaccination strategies involving Tdap, which could complement the strategies of disease control. The objectives of this study are to describe the epidemiology of the disease and to evaluate cost-effectiveness of vaccination of adults with Tdap. METHODS: 1) A review was performed in the MEDLINE, Excerpta Medica, CRD and Lilacs databases from 2000. 2) Observational study was performed including vaccination data and the cases reported data from health surveillance datasets in the State of São Paulo from 2001 to 2015. 3) A descriptive study of patients aged 20 to < 40 years attended at a State of São Paulo hospital between 2010 and 2014 was performed, highlighting the use of health services.4) A dynamic model was developed to compare the vaccination strategy with Tdap at the age of 20 years with the current program (dT vaccination). Epidemiological and cost data were collected from health information systems and national and international studies. Number of cases and deaths by pertussis and life years saved (LYS) were considered as outcome. It was considered the health system perspective, a time horizon of 20 years and costs in 2015 Real (R$). The results were summarized by incremental costeffectiveness ration (ICER). Univariate and multivariate sensitivity analyzes were performed. RESULTS: 1) 28 economic evaluations of strategies with Tdap were reviewed. Vaccination of adolescents and adults were the most evaluated strategies. Underreporting correction, use of dynamic models, herd protection and high vaccination coverage influenced positively the performance of strategies. 2) The incidence of pertussis increased between 2011 and 2014, and its fall in 2015, among all age groups. Infants were the main affected, but the proportion of cases in this age group showed a downward trend over the years. The proportion of cases aged 1 to < 4, 5 to = 20 years increased significantly. There was a non-significant decrease in the proportion of cases aged < 2 months of age. 3) Among 36 cases studied in the hospital, 33.3% had a prior medical visit, 25.3% a return visit, and 8.33% were hospitalized. Blood count and chest X-ray were the most performed exams. There were no complications or death. 4) Vaccination of adults with Tdap, with 40% vaccine coverage and 75% effectiveness, including herd protection for children less than one year, would prevent 19,300 symptomatic cases and 221 deaths in 10 years. The ICER would be R$ 28,054.38/AVG. In the sensitivity analysis, the results were more sensitive to variations in incidence and withdrawal of herd protection. CONCLUSION: The cyclical pattern of the disease is the main cause of the pertussis epidemic between 2011 and 2014, and decreasing incidence in 2015. Adult vaccination with Tdap was not cost-effective in the 2015 Brazilian scenario

Esta tese representa o aprofundamento do estudo das estimativas de custos, componente integrante e determinante das avaliações econômicas, enquanto parte do projeto de pesquisa Estudos de custo-efetividade da incorporação de novas vacinas à rotina do Programa Nacional de Imunizações: Rotavírus, Varicela, Pneumocócica conjugada, Meningocócica C conjugada e Hepatite A desenvolvido por solicitação do Programa Nacional de Imunização/PNI da Secretaria de Vigilância em Saúde/SVS do Ministério da Saúde, a partir de 2005. A tese teve como objetivo analisar as condições de uso, dificuldades e repercussões de diferentes métodos de estimativas de custos em estudos de custo-efetividade de vacinas de duas tecnologias específicas, vacinas contra rotavírus e varicela, assim como a relação entre as estimativas de custos e os resultados. As estimativas de custos estão condicionadas pelas características gerais da doença sob análise (aguda no caso de rotavírus e com seqüela no caso de varicela), assim como por questões metodológicas gerais (escolha teórico-conceitual, métodos e fontes de dados) e especificidades do caso brasileiro. Para esta tese, houve maior detalhamento das estimativas de custos diretos no cuidado da doença, com a inclusão de custos específicos do sistema de saúde suplementar para as duas doenças, inclusão de participação pública na dispensação de medicamentos no caso de rotavírus e inclusão de custos de medicamentos do sistema público de saúde no caso de varicela. Como resultado, houve aumento do custo total da doença estimado de 16% para rotavírus e 11% para varicela, assim como aumento de economia (custo total da doença evitado) de 18% e 16%, respectivamente, com a introdução de cada vacina. Apesar do maior detalhamento das estimativas de custos ter reduzido a razão de custo-efetividade incremental em 20% para rotavírus e 4% para varicela, o nível de custo-efetividade dos dois programas de vacinação não foi alterado. Os resultados das avaliações econômicas de vacinação contra rotavírus e varicela mostraram-se mais sensíveis às estimativas de custos do programa de vacinação, em especial o preço da vacina, apontando a relevância do custo da tecnologia sob análise para incorporação em comparação aos demais custos / This thesis represents a deeper study of the cost estimates, an integrant and determinative component of economic evaluations, as part of the project Costeffectiveness studies of the incorporation of new vaccines into the routine of the National Immunisation Program: Rotavirus, Varicella, Pneumococcal conjugate, Meningococcal C conjugate and Hepatitis A. The project has been developed on the request of the National Immunisation Program/PNI of the Secretary of Sanitary Surveillance/SVS of the Ministry of Health since 2005. The objective of the thesis was to analyse the conditions of use, difficulties and repercussions of different cost estimates methods in the cost-effectiveness studies of two specific technologies, vaccines against rotavirus and varicella, as well as the relationship between the cost estimates and the results. The cost estimates are conditioned by general characteristics of the disease under analysis (acute in the case of rotavirus and with long-term disability in the case of varicella), general methodological issues (theoretical choice, methods and sources of data) and specificities to the Brazilian case. This thesis brings a more detailed estimation of direct medical costs, with the inclusion of specific costs of the private health care system for the two diseases, inclusion of public participation for dispensing drugs in the case of rotavirus and inclusion of drugs costs in the public health care system in the case of varicella. As a result, there was an estimated disease total cost increase of 16% for rotavirus and 11% for varicella, as well as increase of savings (disease total cost avoided) of 18% and 16%, respectively, with the introduction of each vaccine. Although the more detailed cost estimates have reduced the incremental cost-effectiveness ratio by 20% for rotavirus and 4% for varicella, the cost-effectiveness level of the two vaccination programs was not altered. The results of the economic evaluations of vaccination against rotavirus and varicella were more sensitive to the vaccination program cost estimates, especially the vaccine price, pointing out the relevance of the cost of the technology under analysis for incorporation comparatively to the other costs

Context: Exploratory Testing (ET) and Scripted Testing (ST) are two of the more commonly practiced manual testing approaches in industry. ST is a traditional testing approach in which testing is carried out by executing pre-designed test cases. While in ET, learning, test designing and test execution are carried out simultaneously. In many instances, ET and ST complement each other very well in projects; however, proponents of ET claim that ET is more cost-beneficial in comparison to ST. Moreover, a few studies have indicated that ET is more effective in defect detection. Nevertheless, to the best of our knowledge, no study has been conducted to compare the costs and benefits of these two approaches. Objectives: The aim of this study was to conduct a qualitative Cost-Benefit Analysis (CBA) of ET in comparison with ST. By comparing and analyzing these two testing approaches, this study attempts to aid in decision-making with respect to how resources should be allocated for ET and ST for certain projects. Methods: The factors of costs and benefits of ET and ST were identified by conducting six semi-structured interviews in industry. Based on the analysis of these factors, a CBA model is proposed. The academic and industrial evaluation of the proposed CBA model was performed by conducting five interviews with researchers and practitioners. In addition, a qualitative CBA of a process of ET, Session-Based Testing Management (SBTM), and a process of ST, Test-Case Based Testing (TCBT) is conducted by collecting data through questionnaires and interviews with industry practitioners. A total of 22 questionnaire responses and seven interviews were analyzed. Results: By analyzing the identified cost and benefit factors, a CBA model was developed based on the testing phases stated in the ISO/IEC 29119 standard. A qualitative CBA of the SBTM process in comparison with the TCBT process was conducted by applying the CBA model in a questionnaire. The following findings were gathered from the CBA: • The differences of the SBTM and TCBT processes are identified by an analysis of the activities performed in various organizations, which the respondents belonged to. • The results of the analysis and comparison, of the costs (in terms of effort) and benefits (quality of the testing activities) of these two testing processes, are presented with respect to each testing phase. • The factors that impact the costs and benefits of using SBTM and TCBT, are summarized and discussed in this report. • The scenarios, in which SBTM and TCBT can be more cost-beneficial, are identified based on practitioners’ opinions. Conclusions: According to the survey results, industry practitioners consider SBTM as more cost-beneficial in comparison with TCBT, particularly in the test design, implementation and test execution phases. However, industry practitioners also stressed that ET should not be considered as a replacement for ST. In some contexts, testing objectives are better achieved through a more scripted approach, while, in other contexts, testing objectives will benefit more from the ability to create and improve tests as they are being executed. Whether a testing approach is valuable or cost-beneficial also depends on the context of project and the required benefits.

Human induced climate change poses a series of ethical challenges to the current political economy, although it has often be regarded by economists as only an ethical issue for those concerned about future generations. The central debate in economics has then concerned the rate at which future costs and benefits should be discounted. Indeed the full range of ethical aspects of climate change are rarely even discussed. Despite recent high profile and lengthy academic papers on the topic the ethical remains at best superficial within climate change economics. Recognising the necessary role of ethical judgment poses a problem for economists who conduct exercises in cost-benefit analysis and deductive climate modelling under the presumption of an objectivity that excludes values. Priority is frequently given to orthodox economic methodology, but that this entails a consequentialist utilitarian philosophy is forgotten while the terms of the debate and understanding is simultaneously restricted. We set out to raise the relevance of a broader range of ethical issues including: intergenerational ethics as the basis for the discount rate, interregional distribution of harm, equity and justice issues concerning the allocation of carbon budgets, incommensurability in the context of compensation, and the relationship of climate ethics to economic growth. We argue that the pervasiveness of strong uncertainty in climate science, incommensurability of values and nonutilitarian ethics are inherent features of the climate policy debate. That mainstream economics is ill-equipped to address these issues relegates it to the category of misplaced concreteness and its policy prescriptions are then highly misleading misrepresentations of what constitutes ethical action. (authors' abstract) / Series: SRE - Discussion Papers

Objetivos. Determinar la relación costo-efectividad de la vacunación contra el (virus del papiloma humano) VPH y el tamiz de lesiones cervicales, frente a un programa de tamiz solo. Materiales y métodos. Se realizó una evaluación costo-efectividad y se empleó un modelo de Markov, con un horizonte temporal de 70 años y tres alternativas de prevención para el (cáncer del cuello uterino) CCU (tamiz solo, tamiz + vacuna bivalente, y tamiz + vacuna cuadrivalente), en una cohorte hipotética de niñas de diez años, desde la perspectiva del Ministerio de Salud. Resultados. La vacunación contra el VPH y tamiz es más costo-efectiva que el tamiz solo a partir de una voluntad de pago de S/ 2000 (USD 1 290,32). En el análisis determinístico, la vacuna bivalente es marginalmente más costo-efectiva que la vacuna cuadrivalente (S/ 48 [USD 30,97] frente a S/ 166 [USD 107,10] por AVAC, respectivamente). Sin embargo, en el análisis probabilístico ambas intervenciones generan nubes de puntos superpuestos, con una tendencia de la vacuna cuadrivalente a ser más costo-efectiva. Es decir, ambas son costo-efectivas y, por ende, intercambiables. El modelo fue especialmente sensible a variaciones de la cobertura y en la prevalencia de infección persistente por genotipos oncológicos no incluidos en la vacuna. Conclusiones. A partir de una disponibilidad de pago de S/ 2000 [USD 1 290,32] el tamiz y la vacunación son más costo-efectivos que el tamiz solo. La diferencia de costo-efectividad entre ambas vacunas carece de robustez probabilística y ambas vacunas pueden considerarse intercambiables desde la perspectiva costo-efectividad. / Objectives. To determine the cost-effectiveness of human papillomavirus (HPV) vaccination and cervical lesion screening versus screening alone for the prevention of uterine cervical cancer (UCC). Materials and methods. This cost-effectiveness evaluation from the perspective of the Ministry of Health employed a Markov model with a 70-year time horizon and three alternatives for UCC prevention (screening alone, screening + bivalent vaccine, and screening + quadrivalent vaccine) in a hypothetical cohort of 10-year-old girls. Results. Our model, which was particularly sensitive to variations in coverage and in the prevalence of persistent infection by oncologic genotypes not included in the vaccine, revealed that HPV vaccination and screening is more cost-effective than screening alone, assuming a payment availability from S/ 2 000 (US dollars (USD) 1 290.32) per subject. In the deterministic analysis, the bivalent vaccine was marginally more cost-effective than the quadrivalent vaccine (S/ 48 [USD 30.97] vs. S/ 166 [USD 107.10] per quality-adjusted life-year, respectively). However, in the probabilistic analysis, both interventions generated clouds of overlapping points and were thus cost-effective and interchangeable, although the quadrivalent vaccine tended to be more cost-effective. Conclusions. Assuming a payment availability from S/ 2000 [USD 1,290.32], screening and vaccination were more cost-effective than screening alone. The difference in cost-effectiveness between the two vaccines lacked probabilistic robustness, and therefore the vaccines can be considered interchangeable from a cost-effectiveness perspective.

Cette thèse aborde la question de la fiabilité du temps de transport. L’étude de la fiabilité du temps de transport trouve ses sources dans le fait que, dans biens des situations, le temps de transport n’est pas certain, mais aléatoire. De nombreux évènements peuvent en effet modifier le temps de transport prévu par les opérateurs ou espéré par les usagers. Par ailleurs, lors de l’évaluation socioéconomique de projets d’investissement en infrastructure de transport, il peut exister un arbitrage entre gain de temps et gain de fiabilité. Or, comme la fiabilité est encore à l’heure actuelle, difficilement intégrable dans ce type d’évaluation, ces projets d’investissement voient leur rentabilité collective sous-estimée conduisant à leurs reports. Il émerge ainsi trois problématiques majeures relatives à l’étude de la fiabilité du temps de transport : sa mesure, sa valorisation monétaire (i.e. la disposition à payer des individus pour améliorer la fiabilité du temps de transport) et enfin, sa prise en compte dans les analyses coûts-avantages. Un premier chapitre permet d’adapter les mesures usuelles de la fiabilité du temps de transport appliquées dans le cadre du transport routier, aux modes de transport collectif (fer et aérien plus particulièrement). Nous proposons également une nouvelle mesure de la fiabilité, le Delay-at-Risk (DaR) inspiré de la littérature financière. Le DaR est une transposition de la mesure de la Value-at-Risk (V aR) à l’économie des transports. Cette mesure est plus utile du point de vue des usagers pour la planification des trajets avec correspondance que les autres mesures. Le deuxième chapitre a pour principal objectif de déterminer la disposition à payer des individus pour améliorer la fiabilité du temps de transport. Nous proposons un cadre théorique inspiré de la théorie de la décision en univers risqué à partir duquel nous définissons la préférence des individus à l’égard de la fiabilité (i.e. reliabilityproneness) ainsi que la prudence. Nous développons des nouvelles mesures de la fiabilité du temps de transport, exprimées comme des primes de risque : la reliability-premium et la V OR. La reliability-premium détermine le temps de transport maximum supplémentaire qu’un individu est prêt à accepter pour supprimer l’intégralité du risque sur le temps de transport. La V OR, quant à elle, se définit comme la disposition maximale à payer d’un individu pour supprimer l’intégralité du risque sur le temps de transport. Par ailleurs, nous établissons également les conséquences sur la valeur du temps (V TTS) et de la fiabilité (V OR), de la prise en considération de l’attitude à l’égard du risque sur le temps de transport des usagers (aversion et prudence). Le dernier chapitre de cette thèse a pour objet d’intégrer la fiabilité dans les évaluations socioéconomiques de projet d’investissement et plus particulièrement dans la détermination du surplus des usagers. Nous mettons en exergue un effet de diffusion des gains de fiabilité par rapport aux gains de temps. Ainsi, nous proposons des recommandations quant à l’arbitrage entre les projets générateurs de gain de temps et de gain de fiabilité en fonction des valeurs monétaires du temps (V TTS) et de la fiabilité (V OR). / This thesis deals with the issue of travel time reliability. The study of travel time reliability emerges from the fact that in many situations, travel time is random. Many events can change the travel time forecasted by operators or expected by users. Moreover, a tradeoff may exist between time and reliability benefits when evaluating socio economic appraisal of transport infrastructure. However, since reliability is still difficult to integrate in this type of evaluation, investment projects’ collective profitability is underestimated and often postponed. Thus, three main issues of travel time reliability analysis emerge: measurement, monetary valuation and implication for cost benefit analysis. This thesis is organized in three chapters. The first chapter adapts the measure of travel time reliability typically used in the road transport context to the collective modes (rail and air, in particular). We also develop a new reliability measure: the Delay-at-Risk (DaR). DaR is an implementation of the Value-at-Risk (V aR) measure into the transport economic framework. The DaR seem to be relevant and understandable information for the users, especially to plan their travel and avoid missing their connections. The main objective of the second chapter is to define the users’ willingness to pay to improve travel time reliability. We present a theoretical framework based on decision theory under risk. We introduce the concept of reliability-proneness (i.e. travel time risk aversion) and prudence. We develop new measures of travel time reliability expressed as risk premium: the reliability-premium and V OR. The reliability-premium is the maximum amount of additional travel time that an individual is willing to accept to escape all the risk of travel time. The V OR is defined as the maximum monetary amount that an individual is willing to pay to escape all the risk of travel time. Furthermore, we also establish the link with attitudes towards risks of travel time (aversion and prudence) and the impact of the value of travel time (V TTS) and the value of reliability (V OR). The final chapter of this thesis integrates reliability in investments project’s socioeconomic appraisal. More particularly, it allows to determine users’ surplus valuation. We highlight a diffusion effect of reliability benefits with regard to travel time benefits. Thus, we propose recommendations regarding the tradeoff between projects that generate time benefits compared with reliability benefits, according to the monetary values of travel time (V TTS) and reliability (V OR).