Magister Economicae - MEcon / The provision of health care in South Africa is undergoing major restructuring. The aim is to achieve substantial, visible and sustainable improvements to the efficiency and accessibility of primary healthcare (PHC) services for all South Africans. One of the country's most critical problems is the weak and fragmented public sector PHC system. The most critical problems contributing to this are the maldistribution of resources (financial, physical and human) between hospitals and the primary care system, and between rural and urban areas. The health sector, therefore, faces the challenge of a complete restructuring and transformation of the national health care delivery system and related institutions. Choices need to be made about which services to cut, which to streamline and where savings can be made. Ways need to be found to use ALL of South Africa's resources optimally. This process of restructuring would be facilitated by the availability of accurate information on resource utilisation in the health sector. This study estimates the difference in the cost of primary diabetes treatment at dayhospitals and a provincial hospital in the Western Cape in 1992/93. Health economics is in its infancy in South Africa and serious data limitations exist. This study is therefore a pioneering effort in many ways. An appropriate methodological framework in which to conduct the costing had to be developed. The South African health sector, health spending arid the cost of primary diabetes treatment at day-hospitals and the provincial hospital are reviewed. Theoretical perspectives of the health care market and the methodologies of cost analysis are discussed. The cost analysis method of study is chosen, and arguments are advanced for its suitability in the South African context. A simple method of calculating the direct costs to obtain the average cost is proposed for the purpose of the study. Direct costs consist of staff costs and other related costs, such as medical supplies, non-medical supplies, building operations, equipment etc. These costs are then used to calculate the average costs per diabetic patient at the day-hospitals and the provincial hospital. The average cost per diabetic patient at day-hospitals amounted to R18.76, while at the provincial hospital the cost was R59.60.

Background: Tuberculosis (TB) is a major global health threat that results not only in health consequences but also economic consequences. Since 2015 the World Health Organization (WHO) has developed a strategy with the aim of ending the global burden of TB by reducing TB-related deaths, reducing TB incidence, and eliminating the burden of TB-related catastrophic costs for patients and their families. In order to reach these targets, we need to implement effective TB diagnostic and care strategies that are feasible for both patients as well as the health care system. -- Methods: This study consists of two manuscripts which assess the economic burden of TB - one from the patient perspective and the other from the health system perspective. The first manuscript is a systematic review aimed to determine the costs incurred by patients and their households while receiving TB care with direct (medical and non-medical) as well as indirect costs being examined for the pre-diagnostic, post-diagnostic and total phase of care. It analyzed studies with varying patient populations from low-, middle-, and high-income settings to help estimate key factors that drive patient costs. Furthermore, it assessed the proportion of patients that incurred catastrophic costs and the coping strategies that they resorted to in order to offset the costs of TB care. The second manuscript is a modelling study which aimed to develop, parameterize and analyze a decision analytic model to determine the cost, health outcomes as measured by disability-adjusted life years (DALYs) averted and the cost-effectiveness of second-generation lateral flow lipoarabinomannan assay (SG LF-LAM) diagnostic algorithms in people living with HIV (PLHIV) per DALY averted. This model examined four different strategies - 1) the standard of care (SOC) Gene Xpert MTB/RIF only, 2) Gene Xpert MTB/RIF plus LF-LAM for all patients, 3) Gene Xpert MTB/RIF plus LF-LAM for patients with a negative Xpert result, and 4) Gene Xpert MTB/RIF plus LF-LAM for patients who are symptom negative. -- Results: A systematic review showed that total patient costs related to TB care ranged from a mean of $2.80 to $19,153.80 (2019 USD) with costs largely dependent on geographic location as well as patient population, Direct medical and indirect cost components were the largest source of costs for patients and their families while receiving TB care. Direct medical costs included the cost of medication, consultations, diagnostics, follow-up testing, and hospitalization while indirect costs mainly consisted of loss of income. The costs of TB care were considered catastrophic for the majority of patients resulting in them using coping strategies to offset the burden of costs. In the second manuscript, the cost-effectiveness analysis Xpert only was found to be dominated by Xpert + FujiLAM conditional on a negative Xpert with an ICER of 1,000 USD/per DALY averted compared to the standard of care (SOC) Xpert only. Sensitivity analysis found that variations in the key model parameters had an impact on the cost and effectiveness calculations obtained through the model. -- Conclusions: The burden of TB-related costs impact both patients and the health care system at all stages of TB care. Novel diagnostic strategies like the inclusion of FujiLAM for TB diagnosis in PLHIV are cost-effective tools that can aid in case detection and reduce severe outcomes of TB. In order to reduce the TB burden and achieve the "End TB" strategy goals, studies need to work to understand the key components involved in these costs as well as work to develop and implement effective, feasible interventions for TB diagnostics and care.

<p>Food safety is important to prevent foodborne illnesses that can negatively affect public health and the economy. Preventative measures can be taken by government agencies, food-related workers, and consumers to reduce the occurrence of such illnesses. This paper examines the impact of government policies on food safety from the perspective of consumers, restaurant employees and employers, and food processing workers. The first essay explores how food safety recalls affect consumer behavior. The second essay studies the impact of minimum wage policies on service quality in the restaurant industry. The third essay investigates the effect of minimum wage policies on product food safety in the meat and poultry processing industry. </p>

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<p>This thesis studies the impacts of three government policy interventions in Canada on individuals' behaviour and attempts to bound structural coefficients implied by economics theories using the estimated treatment effects. While the last chapter is on the healthcare market, the first three chapters focus on individuals' charitable behaviour, especially volunteer behaviour. A compulsory volunteer policy in Ontario is investigated from theoretical and empirical perspectives in chapters one and two respectively. In a theoretical overlapping generation model with social capital accumulation, we find that such a policy likely increases total public good provision and the social capital level. However, whether it increases long-run volunteering by those no longer subject to the policy depends crucially on the size of a public good demand elasticity. Chapter two empirically examines the impact of a “compulsory volunteerism” policy for adolescents on subsequent behaviour in Ontario, which mandates 40-hours of community service for high school students as a requirement for graduation. We estimate that: 1) the compulsory volunteer policy increased volunteer participation during high school; 2) those affected by the policy likely volunteered less than they otherwise would have after high school completion; 3) young people in Ontario who were not directly affected by the policy volunteered less after its introduction.</p> <p>The third chapter examines the impact of tax policy changes on individuals' volunteer behaviour and attempts to analyze the relationship between donations of time and money. We develop a model where individuals are heterogeneous in their labour market and volunteer productivities, and in their tastes, which shows that positive cross sectional correlation between donations of money and time may occur because of individual-specific effects even though each individual would regard such donations as substitutes. Exploiting the exogenous variation in the tax price introduced by a series of tax policy changes in Canada, we find that individuals make more time donations as the tax price of charitable donations increases, which casts doubt on earlier findings in cross sectional data that monetary and time donations are complements and suggests that they may be substitutes as most theories would imply.</p> <p>The last chapter exploits changes in Canadian public health insurers' reimbursement schedules regarding chiropractic services to identify the impacts of subsidies for providers and patients. Over the past two decades, fiscal pressures have seen these services partly or completely “delisted” from public health insurance programs. Despite a large sample of individuals, there are challenges for inference in this situation where the source of exogenous variation derives from a small number of jurisdiction-level policy changes. To address them, we employ aggregation, a wild cluster bootstrap that provides asymptotic refinement, and other approaches. The results show appreciable decreases in providers’ incomes and in utilization with the latter concentrated among low and middle income patients. But, chiropractors also augment their labour supply, perhaps increasing administration, marketing/promotion, or time per patient visit.</p> / Doctor of Philosophy (PhD)

<p dir="ltr">This study investigated the association between food sufficiency and self-evaluated health status, along with the major determinants influencing them, such as food accessibility, participation in food assistance programs, gender, trust in health-care provider, transportation accessibility, generations, etc. In this research, we applied a bivariate ordered probit model to two different datasets: the North Central Region: Baseline Survey 2022 (NCR-Stat: Baseline) and the National Health Interview Survey (NHIS) to examine the potential association between the various determinants and food sufficiency and self-evaluated health. As obtained, the results from the NCR-Stat dataset suggest that food accessibility and trust in healthcare providers are positively associated with better self-evaluated health and food sufficiency. Additionally, female respondents tend to report negative health association and significant food insufficiency compared to their male counterparts. The findings from the NHIS dataset indicated a positive association between transportation accessibility to healthcare facilities and better health and food security. Similar to the NCR-Stat results, female respondents from NHIS experienced higher levels of food insecurity. However, younger generations demonstrated positive association with better health, but negative association with food security in NHIS, which is similar to the North Central Region’s (NCR) survey data outcomes. We also found that homeownership, physical activity, higher educational attainment, and higher income levels positively correlate with food sufficiency and better self-reported health for the respondents of both datasets.</p>

The Old Age Pension (OAP) program for elderly South Africans puts a significant cash transfer in the hands of many poor households. This dissertation investigates its impact on labor force participation and consumption of selected household items. In the first half of the dissertation, we take advantage of a policy reform that lowered men's OAP eligibility age from 65 to 60 for men to match that of women for estimation identification. Using the General Household Survey data, we first demonstrate that both men and women respond to the eligibility age by dropping from labor force participation at the eligibility age, as expected. Using a difference-in-difference-in-difference estimator, we estimate that at the median predicted wage, age eligibility reduces men's probability of labor force participation by approximately 6.14 percentage points. Previous studies show that not only is the OAP take-up rate high among the age-eligible, but its value is sufficiently high to generally make it a significant component of total household income for the majority of pensioners and their households. Other studies add that it is a dominant source of income in older households, such that it is often the sole source of income in these households, especially those in rural areas. In the second half of the dissertation, therefore, we examine the impact of age-eligibility status on a number of selected household outcomes, such as food security, sanitation, source of drinking water, and ownership of consumer durable goods. We also examine the extent to which gender influences its impact on household outcomes. We find positive effects on a select number of outcomes; however, we note this is more associated with females' age-eligibility status, but not that of males.

Background: Diabetes is a common and costly disease that is expected to continue even to grow in prevalence and health expenditures over the coming decades. Type 2 diabetes is the most common diabetes type and is characterized by insulin resistance and relative insulin deficiency. Type 2 diabetes develops over a long period and is often undetected over years. During this time, people almost always first develop any of the pre-diabetic states, i.e. impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or a combination of both (IFG&amp;IGT). This thesis focuses on type 2 diabetes only. In the following, the term diabetes is used to refer to type 2 diabetes only. Diabetes is associated with a sedentary lifestyle and obesity. While those are not the only factors contributing to the development and maintenance of diabetes, several studies have shown that prevention of diabetes among individuals at high risk through lifestyle change is possible, effective and cost-effective, especially targeting diet and exercise to reduce weight. No previous study had, however, estimated the cost-effectiveness of diabetes prevention strategies from a population-based perspective including healthy individuals and also considered IFG and IGT as two distinct pre-diabetic states. Objective: The overall objective of this thesis was to establish, describe and evaluate a model that can assess the cost-effectiveness of lifestyle intervention programs to prevent diabetes. Methods: First, a Markov Model was established using data from the literature. The cost of a German diabetes prevention program was estimated. Second, risk equations for change to worsened glucose states were estimated using factor analysis and logistic regression based on consecutive data from the Västerbotten Intervention Program (VIP). The risk equations described transition probabilities in the final model and were based on several risk factors such as age, sex, physical activity and smoking status. Third, information on the Short-Form 36 questionnaire from the VIP population was transformed into Short-Form 6D. Health utility weights (HUW) by glucose group and four risk factors were estimated using beta regression. Fourth, an updated Markov model was established using an updated model structure compared to the one in Paper I, program costs of Paper I, risk equations of Paper II, health utility weights of Paper III and updated cost and mortality estimates. Results: The first model in Paper I showed that lifestyle intervention programs have the potential to be cost-effective with a high degree of uncertainty. The risk equations in Paper II indicated that the impact of each risk factor depended on the starting and ending pre-diabetes state, where high levels of triglyceride, hypertension, and high body mass index were the strongest risk factors to transit to a worsened glucose state. The overall mean HUW in Paper III was 0.764 with healthy individuals having the highest HUW, those with diabetes the lowest and those in pre-diabetic states ranging in between. The intervention described in Paper IV was cost-effective for all sex and age scenarios ranging from 3,833 EUR/QALY gained (women, 30 years) to 9,215 EUR/QALY gained (men, 70 years). The probability that the intervention is cost-effective was high (85.0-91.1%). Conclusion: We established a model that can estimate the cost-effectiveness of different scenarios of initiatives to prevent diabetes. The prevention or the delay of the onset of diabetes is feasible and cost-effective. A small investment in a healthy lifestyle with the change in physical activity and diet together with weight loss can have a decent, cost-effective result. The full range of possibilities this model offers has not been evaluated so far. We have, however, shown that implementing a lifestyle intervention program like the Västerbotten Intervention Programme would be cost-effective.

RB redactó el primer borrador del artículo y realizó la revisión final. EM redactó la versión presentada al comité editorial, elaboró las figuras del artículo, levantó las observaciones del comité editorial y redactó la versión final del artículo. AG realizó contribuciones al texto inicial, desarrolló la primera versión del resumen y revisó la versión final. GM realizó contribuciones al texto inicial, levantó las observaciones del comité editorial, realizó contribuciones al texto final y revisó la versión final. / Los estudios de síntesis (EDS): revisiones sistemáticas y metanálisis, son base para llevar a cabo las evaluaciones económicas en salud (EES). Los EDS, al permitir obtener parámetros para las probabilidades de estimación y de efectividad a partir de la combinación de resultados de estudios primarios y, al incluir en su metodología procesos de selección, evaluación, sistematización y síntesis, son considerados como el primer nivel de jerarquía en la evidencia científica. No obstante, pueden estar sometidos a sesgos y fallas metodológicas que afectan su validez. El presente artículo expone, inicialmente, la importancia de la aleatorización en la jerarquización de los diseños de investigación; luego se revisa los principales factores que afectan la validez de los EDS, incidiendo en el sesgo de publicación, la heterogeneidad y la inclusión de estudios primarios con objetivos principales distintos al del EDS; asimismo, se presenta a los estudios individuales como una alternativa válida para el desarrollo de una EES. Se concluye que uno de los aspectos claves en una EES es la selección adecuada de los tipos de estudio, sean estos primarios o secundarios. / Synthesis studies (SS): systematic review and meta-analysis are the basis for developing Health Economic Evaluations (HEE). SS allow us to obtain parameters for estimating probabilities and effectiveness from the combination of the results of primary studies, and, as they include in their methodology the selection, evaluation, systematization and synthesis processes, they are considered the first level of hierarchy in scientific evidence. Nevertheless, they can be prone to bias and methodological failures that can affect the validity of their results. This article initially presents the relevance of the randomization in the hierarchic classification of research designs, then it reviews the main factors affecting the validity of the SS, emphasising the publication bias, the heterogeneity and the inclusion of primary studies with main objective differing from the one of the SS. Moreover, it presents individual studies like a valid alternative for the development of a SS. The conclusion is that one of the key aspects in a SS is the correct evaluation of the study types and the objective evaluation of their quality, being these primary or secondary.

Clinical laboratory test results are integral to patient management. Important aspects of laboratory tests’ contributions are the use of the test information and the role they have in facilitating efficient and effective use of healthcare resources. Methods of measuring those contributions were examined using quantitative HCV RNA test results (HCV VL) in therapeutic management decisions as a model. Test precision is important in those decisions; therefore, the clinical use was evaluated by studying the impact that knowledge of inherent assay imprecision had on clinicians’ decisions. A survey describing a simulated patient at a decision point for HCV triple-combination therapy management was sent to 1491 hepatology clinicians. Participants saw HCV RNA results at five different levels and were asked to choose to: continue therapy, discontinue therapy, or repeat the test. Test results were presented both with and without the 95% confidence intervals (CIs). Three of the VLs had CIs that overlapped the therapeutic decision level. Participants saw both sets of results in random order. Demographics and practice preferences were also surveyed. One-hundred-thirty-eight responses were received. Adherence to clinical guidelines was demonstrated in self-reported behaviors and in most decisions. However, participants chose to repeat the test up to 37% of the time. The impact of the knowledge of assay imprecision did not have a statistically significant effect on clinicians’ decisions. To determine economic value, an analytic decision-tree model was developed. Transition probabilities, costs, and Quality of Life values were derived from published literature. Survey respondents’ decisions were used as model inputs. Across all HCV VL levels, the calculated test value was approximately $2600, with up to $17,000 in treatment-related cost savings per patient at higher HCV VLs. The test value prevailed regardless of the presence or absence of CIs, and despite repeat testing. The calculated value in cost savings/patient was up to 100 times the investment for HCV VL testing. Laboratory tests are investments in efficient uses of healthcare resources. Proper interpretation and use of their information is integral to that value. This type of analysis can inform institutional decisions and higher level policy discussions.