Conselho Nacional de Desenvolvimento Científico e Tecnológico / O objetivo deste trabalho é realizar uma avaliação econômica analisando o tratamento com atorvastatina e sinvastatina em comparação ao tratamento com placebo, no cenário do Sistema Único de Saúde (SUS), para subgrupos de pacientes classificados como alto risco de doença cardiovascular; avaliando se o custo adicional das estatinas em comparação ao tratamento placebo é justificado pelo ganho clínico esperado, em termos de redução de evento cardiovascular e redução de mortalidade. Utilizou-se o risco de eventos cardiovascular e a taxa de mortalidade como parâmetros de desfecho. Os dados epidemiológicos da doença e eficácia dos agentes terapêuticos foram obtidos de revisão e análise crítica da literatura. Um modelo analítico de decisão (Markov) foi desenhado para estimar a razão de custo-efetividade incremental da atorvastatina 10mg/dia e sinvastatina 40mg/dia em comparação ao placebo. A população analisada foi uma coorte hipotética composta por homens e mulheres, com idade média de 50 anos e com alto risco de doença cardiovascular. O modelo considera apenas custos médicos diretos, obtidos dos Sistemas de Informações Ambulatoriais e Hospitalares e Banco de Preços do Ministério da Saúde e de estudos de dados primários. A análise de custo-efetividade foi realizada através de planilha Excel, para o horizonte de tempo de 5 e 30 anos. O resultado revela que a atorvastatina 10mg/dia em comparação ao placebo tem maior custo e é mais efetiva, tanto no horizonte de tempo de 5 como no de 30 anos. A sinvastatina 40mg/dia mostrou ser uma estratégia de menor custo e maior efetividade, em comparação ao placebo, em ambos os horizontes de tempo analisados. O resultado da análise de impacto no orçamento demonstrou que o uso de sinvastatina 40mg/dia, em pacientes de alto risco de evento cardiovascular, representa minimização do custo anual em comparação ao uso de atorvastatina 10mg/dia. Observa-se que o tratamento com sinvastatina proporciona uma economia de, aproximadamente, 1,1 bilhão de reais em comparação ao tratamento com placebo. Em contrapartida, o tratamento dos pacientes com atorvastatina leva a um gasto adicional de cerca de 118,6 bilhões de reais em comparação ao tratamento com placebo. / The objective of this study is to perform an economic evaluation analyzing the treatment with atorvastatin and sinvastatin in comparison to placebo treatment, within the Brazilian Public Healthcare System (SUS) scenario, for patients with high risk of cardiovascular disease; analyzing if the additional cost related to statin treatment is justified by the clinical benefits expected, in terms of cardiovascular event and mortality reduction. Cardiovascular event risk and mortality risk were used as outcomes. Statin efficacy at LDL-c and cardiovascular events levels lowering data was obtained from a critical literature review. A decision analytic model was developed to perform a cost-effectiveness analysis comparing atorvastatin 10mg/day and sinvastatin 40mg/day to placebo treatment in patients with dyslipidemia in Brazil. The target population of this study was a hypothetic cohort of men and women with a mean age of 50 years old and high risk of cardiovascular disease. The model includes only direct costs obtained from Ambulatory and Hospital Information System and Price Database of Brazilian Ministry of Health. The comparative cost-effectiveness analysis itself was done through Excel spreadsheets covering a 5 or 30-years time horizon. The result shows that atorvastatin 10mg/day in comparison to placebo has higher cost with higher effectiveness in the time horizon of 5 and 30 years. The sinvastatin 40mg/day appears to be a strategy with lower cost and higher effectiveness in comparison to placebo, in both times horizon analyzed. The budget impact analysis shows that the use of sinvastatin 40mg/day, in patients with high risk of cardiovascular disease, leads to a cost minimization in comparison to the use of atorvastatin 10mg/day. The treatment with sinvastatin is responsible for an economy of, approximately, BRL1.1 billion in comparison to treatment with placebo. Otherwise, the treatment with atorvastatin leads to an additional cost of, approximately, BRL118.6 billions in comparison to the treatment with placebo.

No mundo, as hepatites decorrentes de infecções virais têm sido uma das grandes preocupações em saúde pública devido a seu caráter crônico, curso assintomático e pela sua capacidade de determinar a perda da função hepática. Com o uso em larga escala de medicamentos antirretrovirais, a doença hepática relacionada à infecção pelo vírus da hepatite C (VHC) contribuiu para uma mudança radical na história natural da infecção pelo vírus da imunodeficiência humana (HIV). Não se sabe ao certo o peso da coinfecção VHC/HIV no Brasil, mas evidências apontam que independentemente da região geográfica, esses indivíduos apresentam maiores dificuldades em eliminar o VHC após o tratamento farmacológico, quando comparados a monoinfectados. No âmbito do SUS, o tratamento antiviral padrão para portadores do genótipo 1 do VHC e do HIV é a administração de peguinterferon associado à Ribavirina. Quanto ao período de tratamento e aos indivíduos que devem ser incluídos, os dois protocolos terapêuticos mais recentes possuem divergências. A diretriz mais atual preconiza o tratamento de indivíduos respondedores precoces somados a respondedores virológicos lentos, enquanto a diretriz imediatamente anterior exclui na 12 semana indivíduos que não respondem completamente. Com base nessa divergência, esse estudo objetivou avaliar o custo-efetividade do tratamento contra o VHC em indivíduos portadores do genótipo 1, coinfectados com o HIV, virgens de tratamento antiviral, não cirróticos e imunologicamente estabilizados, submetidos às regras de tratamento antiviral estabelecidos pelas duas mais recentes diretrizes terapêuticas direcionadas ao atendimento pelo SUS. Para tal, foi elaborado um modelo matemático de decisão, baseado em cadeias de Markov, que simulou a progressão da doença hepática mediante o tratamento e não tratamento. Foi acompanhada uma coorte hipotética de mil indivíduos homens, maiores de 40 anos. Adotou-se a perspectiva do Sistema Único de Saúde, horizonte temporal de 30 anos e taxa de desconto de 5% para os custos e consequências clínicas. A extensão do tratamento para respondedores lentos proporcionou incremento de 0,28 anos de vida ajustados por qualidade (QALY), de 7% de sobrevida e aumento de 60% no número de indivíduos que eliminaram o VHC. Além dos esperados benefícios em eficácia, a inclusão de respondedores virológicos lentos mostrou-se uma estratégia custo-efetiva ao alcançar um incremental de custo efetividade de R$ 44.171/QALY, valor abaixo do limiar de aceitabilidade proposto pela Organização Mundial da Saúde OMS - (R$ 63.756,00/QALY). A análise de sensibilidade demonstrou que as possíveis incertezas contidas no modelo são incapazes de alterar o resultado final, evidenciando, assim, a robustez da análise. A inclusão de indivíduos coinfectados VHC/HIV respondedores virológicos lentos no protocolo de tratamento apresenta-se, do ponto de vista fármaco-econômico, como uma estratégia com relação de custoefetividade favorável para o Sistema Único de Saúde. Sua adoção é perfeitamente compatível com a perspectiva do sistema, ao retornar melhores resultados em saúdeassociados a custos abaixo de um teto orçamentário aceitável, e com o da sociedade, ao evitar em maior grau, complicações e internações quando comparado à não inclusão. / Worldwide, hepatitis caused by viral infections has been a major concern for public health because of its chronicity, asymptomatic course and its ability to determine the loss of liver function. With the widespread use of antiretroviral drugs, liver disease related to infection with hepatitis C virus (HCV) contributed to a radical change in the natural history of infection with human immunodeficiency virus (HIV). No one knows for sure the weight of coinfection HCV/HIV in Brazil, but evidence suggests that, regardless of geographic region, these individuals have greater difficulty in eliminating HCV compared to monoinfected. In the Brazilian Unified Health System (SUS), the standard antiviral treatment for patients infected with genotype 1 HCV and HIV is the association of pegylated interferon with ribavirin. Regarding the treatment period and which individuals should treat the two most recent protocols have disagreements. The most current protocol calls for treatment of early responders individuals added to slow responders. Since the guideline immediately preceding the 12th week excludes individuals who do not respond completely. Based on this difference, this study aimed to evaluate the costeffectiveness of HCV treatment in individuals with the genotype 1 coinfected with HIV, antiviral-naïve, non-cirrhotic and immunologically stable, undergoing antiviral treatment rules established by two most recent therapeutic guidelines directed to attend by SUS. To this evaluation, was developed a mathematical model of decision, based on Markov chains, simulating the progression of liver disease under treatment and no treatment. It was accompanied by a hypothetical cohort of thousand men individuals, more than 40 years. Was adopted the perspective of the Brazilian Unified Health System, time horizon of 30 years and a discount rate of 5% for the costs and for clinical consequences. The extension of treatment to slow responders provided an increase of 0.28 years of quality-adjusted life (QALY), 7% survival rate and an increase of 60% in the number of individuals who eliminated HCV. Besides the expected benefits in efficacy, the slow viral responders inclusion proved to be a costeffective strategy to achieve an incremental cost-effectiveness of BRL 44,171.00/QALY, value below of acceptability threshold proposed by the World Health Organization (BRL 63,756.00/QALY). Sensitivity analysis demonstrated that the potentials uncertainties in the model are unable to alter the final result, thus demonstrating the robustness of the analysis. The Inclusion of HCV/HIV co-infected individuals slow virologic responders to treatment protocol, is presented from the point of pharmacoeconomic view, as a strategy to cost-effectiveness favorable for the Brazilian Health System. Its adoption is perfectly compatible with the system perspective, returning better health outcomes with costs below an acceptable budget cap, and the society, to avoid a greater extent, complications and hospitalizations when compared to non-inclusion.

Introdução: A malária humana apresenta sintomas inespecíficos e exige diagnóstico laboratorial e identificação da espécie para o seu manejo. O diagnóstico baseia-se na microscopia, exame barato, que exige profissionais experientes. Nos últimos anos surgiram testes imunocromatográficos de execução rápida e custo mais elevado em comparação à microscopia. Estudos de validação demonstraram sensibilidade e especificidade comparáveis à microscopia, podendo ser alternativa confiável em áreas sem laboratório. Objetivo: Realizar análise de custo-efetividade do uso do OptiMAL® - teste rápido (TR) registrado no Brasil e validado em áreas endêmicas - comparado à microscopia. Métodos: A perspectiva da análise foi a do sistema público de saúde brasileiro SUS, o horizonte analítico de seis meses e o ano de 2006, a referência temporal. Doze municípios do Estado do Pará constituíram a área de estudo. Foi construído modelo de decisão considerando dois desfechos: casos diagnosticados adequadamente e casos conduzidos adequadamente em três cenários: o cenário 1 corresponde a 100% dos exames realizados, o cenário 2 considera somente os exames feitos nas áreas com laboratório e o cenário 3 corresponde a 30% dos exames, realizados em áreas isoladas. Os parâmetros epidemiológicos principais foram prevalência da malária entre indivíduos sintomáticos e acurácia - sensibilidade e especificidade - dos métodos diagnósticos, cujas estimativas foram obtidas a partir do Sistema de Informação de Vigilância Epidemiológica da Malária e literatura científica. Foram estimados custos diretos médicos e não-médicos, considerando diretrizes nacionais e dados municipais. Fontes de dados de custos incluíram o Sistema de Informação de Insumos Estratégicos, a Tabela de Procedimentos do SUS e o Sistema de Informação Hospitalar do SUS. Foram estimadas as razões média e adicional de custo-efetividade (RCEA) e realizada análise de sensibilidade. O software utilizado foi o TreeAge Pro 2005. Resultados: O TR foi dominado pela microscopia nos cenários 1 e 2. Em áreas isoladas a estratégia microscopia apresentou RCEA de R$1.193,00 por caso diagnosticado adequadamente e de R$1.016,67 por caso conduzido adequadamente quando comparada com o OptiMAL®. O TR tornou-se mais custo-efetivo nos dois desfechos dos três cenários com a redução da acurácia da gota espessa, na análise de sensibilidade. Conclusões: o TR foi menos custo-efetivo em todos os cenários, quando a acurácia da microscopia manteve-se elevada. / Introduction: Diagnosis of malaria is based on blood microscopy, a lowcost procedure that requires experienced technicians. Rapid immunochromatography tests (RDT) were developed with the advantage of being easy-to-use tools but with higher costs. RDT validation showed similar accuracy compared to microscopy suggesting that the RDT could be a reliable alternative in areas without lab facilities. Objective: To perform costeffectiveness analysis for the use of OptiMAL® in comparison with the thick blood smear microscopy. Methods: The study was conducted from the perspective of the Brazilian Public Health System, the analytic horizon was of six months, and the time frame was 2006. The analysis was performed through a decision tree with two outcomes: properly diagnosed cases and properly conducted cases. There were defined three scenarios in 12 municipalities of the State of Pará: the scenario 1 considered the whole malaria tests performed in 2006; the scenario 2 considered the malaria tests performed in the endemic areas with access to lab facilities; and the scenario 3 considered the 30% malaria tests performed in areas without lab facilities. The main epidemiological measures were the prevalence of malaria and the accuracy of the diagnostic methods. Epidemiological estimates were obtained from the Brazilian Malaria Surveillance Information System and the scientific literature. Direct medical and non-medical costs were estimated taking into consideration the national guidelines and the data obtained from the municipalities. Cost data sources were the Information System for Strategic Resources from the Health Surveillance Secretariat, the Reimbursement Values Table and the Hospital Information System of the Brazilian Public Health System. The average and the incremental costeffectiveness ratio (ICER) were estimated and it was conducted a sensitivity analysis. Data were analyzed with the TreeAge Pro 2005 software. Results: RDT strategy was dominated by the microscopy strategy in the scenarios 1 and 2. The ICER for the microscopy strategy in the scenario 3 was R$1,193.00 per properly diagnosed case and it was R$1,016.67 per properly conducted case compared with the OptiMAL® strategy. The sensitivity analysis showed that the RDT was cost-effective for both outcomes in all the scenarios when the thick blood smear accuracy was reduced. Conclusions: The RDT is the least cost effective strategy, providing that microscopy accuracy is high.

Submitted by Geandra Rodrigues (geandrar@gmail.com) on 2018-10-11T13:25:57Z No. of bitstreams: 1 flavialiciarodriguesmagacho.pdf: 2211542 bytes, checksum: 17ff2c88b41d6fd8f0a559f9d79f8d7e (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2018-10-16T13:58:49Z (GMT) No. of bitstreams: 1 flavialiciarodriguesmagacho.pdf: 2211542 bytes, checksum: 17ff2c88b41d6fd8f0a559f9d79f8d7e (MD5) / Made available in DSpace on 2018-10-16T13:58:49Z (GMT). No. of bitstreams: 1 flavialiciarodriguesmagacho.pdf: 2211542 bytes, checksum: 17ff2c88b41d6fd8f0a559f9d79f8d7e (MD5) Previous issue date: 2018-07-12 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Introdução: a doença renal crônica destaca-se por afetar a vida de milhares de brasileiros e onerar os cofres públicos. Na fase terminal da doença, a sobrevivência do paciente é condicionada à realização de um tipo de terapia renal substitutiva. A literatura tem demonstrado ser o transplante renal a alternativa custo-efetiva dentre as terapias renais substitutivas, pois permite a reintegração do paciente às suas atividades cotidianas, aumentando a expectativa e qualidade de vida. Um fator que tem contribuído para o sucesso dos transplantes renais é o avanço tecnológico dos imunossupressores. Recomenda-se para o tratamento de manutenção dos transplantes renais a administração de esquemas tríplices de medicamentos, compostos por um esteroide mais dois medicamentos de classes farmacológicas distintas (inibidores da calcineurina ou antimetabólitos ou inibidores da rapamicina). Objetivo: avaliar o custo-efetividade da administração de tacrolimo com micofenolato de sódio e Prednisona (Grupo 1= 93 pacientes) comparado com a associação de tacrolimo com everolimo e Prednisona (Grupo 2= 91 pacientes), no tratamento de manutenção pós-transplante renal, em uma Unidade de Prática Integrada do Hospital Santa Casa de Misericórdia de Juiz de Fora, Minas Gerais. Material e métodos: para a análise farmacoeconômica dos esquemas imunossupressores foi utilizado o modelo estático, do tipo Árvore de Decisão. O modelo foi desenvolvido no software Treeage Suite 2011 e acompanhou uma coorte de pós-transplantados renais, estimando os benefícios clínicos em termos de sobrevida e incidência de eventos adversos (rejeição, doença/infecção por citomegalovírus, perda do enxerto e morte), bem como os custos associados aos regimes imunossupressores, na perspectiva do Sistema Único de Saúde. Resultados: a supremacia do everolimo em relação ao micofenolato de sódio se fez presente principalmente nos eventos relacionados à incidência de pacientes que apresentaram infecção ou doença decorrente por citomegalovírus (4,4% com everolimo versus 20,4% com micofenolato de sódio, p = 0,001). Na análise considerando sobrevida como desfecho, o Grupo 2 não pode ser considerado custo-efetivo quando comparado ao uso de Grupo 1, pois a razão de custo-efetividade incremental foi cerca de R$229.876,30, excedendo o limiar de custo-efetividade recomendado pela Organização Mundial da Saúde, três vezes o produto interno bruto brasileiro. Já na análise que diz respeito à incidência de eventos adversos, a razão de custo-efetividade incremental foi cerca de R$52.760,52, portanto, o Grupo 2 foi considerado custo-efetivo em relação ao Grupo 1. Conclusão: o regime imunossupressor contendo ácido micofenólico é ainda considerado o padrão-ouro para o tratamento de manutenção do transplante renal, no entanto, está associado a muitos efeitos adversos para os transplantados. Esse estudo desmistifica tal regime, à medida que o regime imunossupressor contendo everolimo apresentou-se custo-efetivo em relação ao micofenolato na análise feita a partir da incidência de efeitos adversos, bem como na redução significativa de eventos relacionados ao citomegalovírus, o qual é responsável pela maior causa de morbimortalidade em transplantados. / Introduction: chronic kidney disease stands out as affecting the lives of thousands of Brazilians and burdening the public coffers. In the terminal phase of the disease, the survival of the patient is conditioned to a type of substitutive renal therapy. The literature has demonstrated that kidney transplantation is the cost-effective alternative among the substitutive renal therapies, since it allows reintegration of the patient into their daily activities, increasing the expectation and quality of life. One factor that has contributed to the success of kidney transplantation is the technological advancement of immunosuppressants. The administration of three-drug regimens consisting of a steroid plus two drugs of different pharmacological classes (calcineurin inhibitors or antimetabolites or inhibitors of rapamycin) is recommended for the maintenance treatment of kidney transplantation. Aim: to evaluate the cost-effectiveness of administration of tacrolimus with mycophenolate sodium and prednisone (Group 1 = 93 patients) compared to the combination of tacrolimus with everolimus and Prednisone (Group 2 = 91 patients) in post-transplant renal maintenance, in an Integrated Practice Unit of the Santa Casa de Misericórdia Hospital of Juiz de Fora, Minas Gerais. Material and methods: for the pharmacoeconomic analysis of the immunosuppressive regimens, the static model, of the decision tree type, was used. The model was developed in the Treeage Suite 2011 software and followed a cohort of renal transplant recipients, estimating the clinical benefits in terms of survival and incidence of adverse events (rejection, cytomegalovirus disease / infection, graft loss and death), as well as the costs associated with immunosuppressive regimens, from the Unified Health System perspective. Results: the efficacy of everolimo in relation to mycophenolate sodium was mainly present in the events related to the incidence of patients who presented infection or disease due to cymegalovirus (4.4% with everolimo versus 20.4% with mycophenolate sodium, p = 0.001). In the analysis considering survival as an outcome, Group 2 can not be considered cost-effective when compared to Group 1 use, as the incremental Cost-Effectiveness Ratio was around R$229,876.30, exceeding the cost thresholdeffectiveness recommended by the World Health Organization, three times the Brazilian GDP. In the analysis related to the incidence of adverse events, the ICR was around R$52,760.52, therefore, Group 2 was considered cost-effective in relation to Group 1. Conclusion: the immunosuppressive regimen containing mycophenolic acid is still considered the gold standard for the maintenance treatment of kidney transplantation, however, is associated with many adverse effects for transplant recipients. This study demystifies this regimen, as the immunosuppressive regimen containing everolimo was cost-effective in relation to mycophenolate in the analysis made from the incidence of adverse effects, as well as in the significant reduction of events related to citamegalovirus, which is responsible the greatest cause of morbidity and mortality in transplant patients.

O Sistema Único de Saúde (SUS), modelo universalista que existe atualmente no Brasil, encontra-se em posição de destaque dentre as políticas sociais vigentes. Num contexto de aumento de recursos e crescimento da demanda, o SUS constantemente sofre alterações que visam aumentar a qualidade, o acesso e a efetividade do serviço prestado; dessa forma, são necessários instrumentos para acompanhar seu desempenho. Não obstante, este trabalho versa em seu marco teórico sobre a trajetória do Sistema Único de Saúde e as avaliações de políticas públicas em saúde, visto que a incorporação de novas ferramentas é incontestavelmente importante para a produtividade do recurso destinado à saúde pública no Brasil - cada vez mais, a utilização de novas tecnologias e processos contribuirá para a adequada tomada de decisão dos gestores, melhores políticas públicas de saúde e um sistema verdadeiramente universal e funcional. Uma das novas ferramentas utilizadas pelo SUS é o IDSUS, que se propõe a medir o desempenho de cada município e região em relação ao acesso e à efetividade do sistema. O índice é composto por 24 indicadores, em que 14 medem o acesso à saúde e 10 se referem à efetividade do sistema. Oportunamente, para este trabalho utilizou-se como universo amostral o Grupo Homogêneo 2, divisão estabelecida pelo IDSUS para classificar os municípios de acordo com características similares de estrutura e condições de saúde. O grupo formado por 94 municípios do país foi analisado por meio de dados provenientes das bases do IDSUS e Siops, para o ano de 2011, e dados complementares do IBGE e PNUD. Após a estruturação dessas informações, procedeu-se à análise estatística descritiva e à análise de clusters, com o intuito de reagrupar os municípios semelhantes de acordo com as variáveis estabelecidas: nota do IDSUS, população e receita total em saúde per capita. Diante disso, o objetivo deste trabalho foi propor um modelo de análise de custo-efetividade para comparar as notas alcançadas no IDSUS do Grupo Homogêneo 2, diante da nova configuração de agrupamento, com as respectivas receitas totais per capita destinadas à saúde pública, além de serem detalhadas as análises por bloco de financiamento, no total de cinco, de acordo com especificações do Ministério da Saúde. A análise de custo-efetividade foi escolhida pelo fato de, dentre as ferramentas de análise econômica, permitir mensurar tanto benefícios monetários quanto benefícios sociais. Mesmo com a divisão dos municípios por grupos homogêneos e após a utilização de variáveis como população e receita para reagrupá-los, os resultados evidenciaram que existem municípios que apresentam características heterogêneas. Outro achado encontra-se na utilização e no cruzamento de duas bases distintas (IDSUS e Siops), o que proporcionou a visualização sobre o impacto dos recursos em saúde no desempenho dos municípios; isso parece complementar a avaliação de desempenho já realizada. Além disso, a análise de custo-efetividade culminou na verificação de que não só o montante de recurso financeiro impacta no melhor desempenho, como também outras variáveis, a exemplo de população e formas de alocação do recurso nos blocos de financiamento. Espera-se que este trabalho sirva como uma ferramenta de consolidação de informações e tomadas de decisão para os gestores, posto que são observados não só os dados clínicos, mas também a efetividade na alocação dos recursos no sistema de saúde. Vislumbra-se a possibilidade de contribuição para a melhoria de instrumentos de avaliação já utilizados pelo SUS. / The Public Health System (SUS), universalist model that currently exists in Brazil, is in a prominent position compared to the existing social politics. In a context of increased resources and demand, SUS is constantly changed toward to increase quality, access and effectiveness of the services; this way, tools are needed to monitor its performance. Nevertheless, the theoretical framework of this dissertation focus on SUS trajectory and the reviews of public health politics, as the incorporation of new tools is undeniably important to the funds productivity for public health in Brazil - the use of new technologies and processes will increasingly contribute to adequate decision making of managers, better public health politics and a truly universal and functional system. One of the new tools used by SUS is IDSUS, which purposes to measure the performance of each municipality and region in relation to access and effectiveness of the system. The index consists of 24 indicators: 14 measure access to health and 10 refer to the effectiveness of the system. The Homogeneous Group 2 was used as a sampling universe, division established by IDSUS to classify municipalities according to similar characteristics of structure and health conditions. The group formed by 94 municipalities in the country was analyzed using data from IDSUS and SIOPS bases, for the year 2011, and additional data from IBGE and PNUD. After structuring this information, it was carried to a descriptive statistical analysis and a cluster analysis in order to regroup similar municipalities in accordance with the established variables: IDSUS performance, population and total revenue in health per capita. Therefore, the aim of this study was to propose a model of cost-effectiveness to compare IDSUS performance achieved in Homogeneous Group 2, according to the new group setting, with its per capita total revenues for public health, besides the details of analyzes for finance package, totaling five, according to specifications of Ministry of Health. The cost-effectiveness was chosen because, among the economic analysis tools, it allows to measure both monetary and social benefits. Even with the division of municipalities by homogeneous groups and after the usage of variables such as population and income to regroup them, the results have shown there are municipalities with heterogeneous characteristics. Another finding is in use and intersection of two distinct bases (IDSUS and SIOPS), which provided visualizing the impact of health care resources in the performance of municipalities; it seems to complement the performance evaluation that was already made. Moreover, the cost-effectiveness culminated in the verification that not only the amount of financial resource impacts in better performance, but also other variables (population and ways of resource allocation in finance packages, for example). It is hoped that this work will serve as a tool to consolidate information and decision-making for managers, as not only the clinical data are observed, but also effectiveness in the resources allocation in the health system. It is seen the possibility of contributing to improve the assessment tools already used by SUS.

M.Ing. / A company can execute a number of different projects. Some of these projects will increase production volumes, plant efficiency or plant productivity. Others may only be projects that are executed in order to conform to legislation requirements. As such projects can broadly be placed in the following categories: • Compliance • Emergency • Operational • Strategic and • Sustainability A project needs to go through a number of steps before it is decided to finally execute the project. The first step is to place the project in the correct category. The second step is to screen the project on a high level to ensure that it meets all of the required criteria. The third phase would be to prioritise the projects. The final step would then be to decide which projects to execute. This type of staged approach determines which projects to complete and ensures that resources are not wasted unnecessarily on projects that should not be executed and that do not meet the minimum criteria.

Abstract The purpose of this study was to compare the effectiveness, costs and benefits of screening for diabetic retinopathy with retinal photography and with ophthalmoscopic examination in health care centres by primary care physicians, and also to study the quality of life and mortality of visually impaired diabetics. There are about 150 000 diabetics in Finland. There were 881 visually impaired persons due to diabetic retinopathy in the Finnish Register of Visually Impaired Patients in 1994 (1122 in 1997). Laser photocoagulation has proved to be an effective treatment in diabetic retinopathy preventing visual loss. The screening methods are ophthalmoscopic examination and retinal photography. The incidence of retinopathy was calculated from the photogaphy screening in the Oulu Health Care Centre in 1987 (N = 1015), in 1991–92 (N = 1844) and in 1993–94 (N = 1484). The ophthalmoscopy screening was studied from patients' records (N = 242) in the Raahe Health Care Centre. Out of 120 visually impaired persons with diabetic retinopathy in the province of Pohjois-Pohjanmaa, 50 were interviewed by the health care secretary. The study included cost-benefit analysis for the costs of screening and treatment of diabetic retinopathy compared with the costs of visual impairment. Furthermore the quality of life of patients with visual impairment due to diabetic retinopathy was studied using the Nottingham Health Profile questionaire (NHP) and compared with diabetic patients without visual impairment. The mortality rate of visually impaired patients was compared to that of diabetic retinopathy patients who had been treated with laser photocoagulation. The incidence of all diabetic retinopathy was 9.4 per cent per year and 2.8 per cent per year for moderate to severe retinopathy, and in patients with no insulin in their treatment the incidence of all retinopathy was 3.0 and 1.2 per cent per year respectively. The screening costs per diabetic person screened were 148 Finnish marks (FIM) in the photographic method and 68 FIM in the ophthalmoscopic method. It was calculated that 156 visual impairment cases could be prevented per year in Finland with the photographic method. The screening and treating costs in finding one preventable case of visual impairment were 185 000 FIM. The costs of visual impairment were 594 000 FIM per patient. So retinal photography screening and treatment of diabetic retinopathy could lead to savings of 63.9 million FIM per yearly screening in Finland. The quality of life of visually impaired persons was worse than that of other diabetics in two dimensions of the NHP, Energy and Mobility. In the second part of the NHP, the quality of life of visually impaired persons was worse than that of other diabetics in all questions except working. The mortality rate of visually impaired persons, 14.5 per cent per year was twice as high as that of diabetic patients treated with laser photocoagulation. The incidence of diabetic retinopathy in Finland was about the same as in other industrialized countries. Retinal photography seemed to be a cost-effective screening method for preventing visual impairment and the cost benefit ratio of screening and treating diabetic retinopathy was 3.2. The quality of life of visually impaired patients was worse and mortality risk higher than that of other diabetics. / Tiivistelmä Tarkoituksena oli tutkia perusterveydenhuollossa silmänpohjakuvauksella tai oftalmoskopialla tehdyn diabeettisen retinopatian seulonnan vaikuttavuutta, kustannuksia ja hyötyjä näkövammaisuuden ehkäisyssä sekä diabeettisen retinopatian ilmaantuvuutta, ja sen vuoksi näkövammaisten elämänlaatua ja kuolleisuutta. Suomessa on noin 150 000 diabeetikkoa. Diabeettisen retinopatian aiheuttama näkövamma oli Näkövammarekisterin mukaan vuoden 1994 alussa 881:lla suomalaisella (vuoden 1997 lopussa 1122:lla suomalaisella). Diabeettisen retinopatian aiheuttamaa näkövammaisuutta voidaan ehkäistä ajoissa toteutetulla silmänpohjan laser-fotokoagulaatiohoidolla. Uusien tautitapausten löytämiseksi käytetään oftalmoskopiaa ja silmänpohjakuvausta. Diabeettisen retinopatian ilmaantuvuus laskettiin Oulussa vuosina 1987 (N = 1015), 1991–92 (N = 1844) ja 1993–95 (N = 1484) toteutettujen silmänpohjakuvausten perusteella. Diabeettisen retinopatian oftalmoskooppista toteamista tutkittiin Raahen seudun terveyskeskuksen diabetesvastaanoton potilaiden sairauskertomuksista (N = 242). Seulontamenetelmien tehokkuutta arvioitiin kustannusvaikuttavuusanalyysillä ja diabeettisen retinopatian seulonnan ja hoidon hyötyä näkövammaisuuden ehkäisyssä kustannus-hyötyanalyysillä. Pohjois-Pohjanmaalta diabeettisen retinopatian johdosta näkövammarekisteriin ilmoitetuista (N = 120) haastateltiin tavoitetut 50 henkilöä. Haastatelluilla näkövammaisille sekä Oulussa vuosina 1991–92 silmänpohjakuvaukseen osallistuneille tehtiin elämänlaatukysely NHP-mittarilla. Elämänlaatua ja kuolleisuutta tutkittiin tapaus-verrokki asetelmalla. Tutkimuksen mukaan Diabeettisen retinopatian koko ilmaantuvuus oli 9,4 % vuodessa ja diabeetikoilla, joiden hoidossa ei käytetty insuliinia, ilmaantuvuus oli 3,0 % vuodessa. Vaikean tausta- ja proliferatiivisen retinopatian ilmaantuvuus oli vastaavasti 2,8 % ja 1,2 % vuodessa. Silmänpohjakuvaukseen perustuvan seulonnan ja laserhoidon kustannukset olivat 192 mk seulottua kohti. Silmänpohjakuvausseulonnalla olisi tämän tutkimuksen mukaan mahdollista estää Suomessa vuosittain 156 näkövammaa kustannusten ollessa noin 185 000 mk estettyä näkövammaa kohti. Yhden näkövamman kustannukset olivat yhteensä 594 000 mk. Silmänpohjakuvaukseen perustuvalla seulonnalla olisi mahdollista säästää noin 63,9 milj. mk vuodessa edellyttäen, että tulokset ovat yleistettävissä koko maahan. Diabeettisen retinopatian johdosta näkövammaisten elämänlaatu oli selvästi muita diabeetikkoja huonompi NHP-mittarin ulottuvuuksilla tarmokkuus ja liikkuminen sekä useilla keskeisillä elämänalueilla. Näkövammaisten diabeetikkojen kuolemanriski oli yli kaksinkertainen laserhoidettuhin näkönsä säilyttäneiisiin diabeettista retinopatiaa sairastaviin verrattuna. Tutkimuksen mukaan diabeettisen retinopatian ilmaantuvuus oli Suomessa samalla tasolla kuin muissa teollistuneissa maissa. Silmänpohjakuvaussseulonta osoittautui taloudellisesti kannattavaksinäkövammojen ehkäisyssä. Näkövammaisuus heikensi diabeetikkojen elämänlaatua ja lisäsi kuolemanriskiä.

1.1 Background to, and motivation for, the study: The Working for Water programme (WfW) is a public works programme designed to clear South Africa of water-consuming invasive alien tree and plants, and to replace them with low water consuming indigenous species. This would prevent a loss of more than 4000 million cubic metres water per annum from the hydrological cycle (DWAF, 1998). The economic viability of the programme has been established in the Western Cape and Kwazulu-Natal (van Wilgen, Little, Chapman, Görgens, Willems and Marais, 1997; Gilham and Haynes, 2001), but questioned in the Eastern and Southern Cape (Hosking, du Preez, Campbell, Wooldridge and du Plessis, 2002). Hosking et al. (2002) investigated the economic case for the programme by performing a Cost Benefit Analysis (CBA), based on increased water yield and livestock potential, on six selected sites in the Eastern and Southern Cape, viz. Albany, Kat River, Pot River, Tsitsikamma, Kouga and Port Elizabeth Driftsands.

Context. Cloud computing is getting more and more interest with every year. It is an approach that allows Internet based applications to work in distributed and virtualized cloud environment. It is characterized by on-demand resources and payper-use pricing. Software-as-a-Service (SaaS) is a software distribution paradigm in cloud computing and represents the highest, software layer in the cloud stack. Since most cloud services providers charge for the resource use it is important to create resource efficient applications. One of the way to achieve that is multi-tenant architecture of SaaS applications. It allows the application for efficient self-managing of the resources Objectives. In this study I investigate the influence of tenant-based resource allocation model on cost-effectiveness of SaaS systems. I try to find out weather that model can decrease the system's actual costs in commercial public cloud environment. Methods. I am implementing two authorial SaaS systems: first tenant-unaware and then using tenant-based resource allocation model. Then they are deployed into Amazon public cloud environment. Tests focused on measuring over- and underutilization are conducted in order to compare cost-effectiveness of the solutions. Public cloud provider's billing service is used as a final cost measure. Results. The tenant-based resource allocation model proved to decrease my system's running costs. It also reduced the system's resources underutilization. Similar research was done, but the model was tested in private cloud. In this work the systems were deployed into commercial public cloud. Conclusions. The tenant-based resource allocation model is one of the method to tackle under-optimal resource utilization. When compared to traditional resource scaling it can reduce the costs of running SaaS systems in cloud environments. The more tenant-oriented the SaaS systems are the more benefits that model can provide.

This thesis consists of three chapters. The first chapter explores the effects of prenatal nutritional deficiency on depression in adulthood. It is well established that maternal behaviour during pregnancy has a lasting effect on the child for years to come. Studies show that in utero nutritional shocks can have prolonged effects on health and labour market outcomes later in life of the offspring. In this paper I investigate whether such nutritional deficiencies during gestation can have an extended impact on mental health in adulthood. Using the fourth wave of Indonesian Family Life Survey (IFLS), I find that Muslim individuals who were potentially exposed to Ramadan in the first and third trimester have significantly higher scores on the depression scale than those who were not exposed. This effect is particularly significant among Muslim males who were exposed in the first trimester and Muslim females who were exposed in the third trimester. Similar effects of exposure are also found on the probability of being depressed in the Muslim population. The absence of such impact of exposure in the non-Muslim population suggests that nutritional deficiencies during the gestation period can have lasting effects on mental health and may increase the possibility of developing depression later in life. Next, the literature on socioeconomic health inequality uses individuals' socioeconomic rank (p) to develop the concentration index. In the second chapter of the thesis, I construct an alternative framework by directly using individuals' income level (y) to rank them and develop stochastic dominance conditions to investigate whether this method leads to the same conclusion as using the socioeconomic ranks (p). Using World Health Survey data for five South Asian countries, I conclude that using the socioeconomic ranks (p) and income levels (y) to rank individuals lead to different results in dominance tests adjusted for different equivalence scales. Lastly, to address the arbitrariness problem of the health concentration index's value caused by assuming the existence of a ratio-scaled variable, Makdissi and Yazbeck (2014) adopted a counting approach to measure health inequality. In the third chapter of the thesis, I apply this counting approach in a two-fold way. Firstly, I estimate the values of population health status and health inequality in United States using the National Health Interview Survey (2010) data. Then, assuming increased government expenditure on health awareness, I simulate the effects such policy interventions and see what improvements in the public health can be achieved. Also, I propose the count-approach incremental cost effectiveness ratio (C-ICER) which is a simple measure to assess the cost effectiveness of public health awareness campaigns.