BACKGROUND & OBJECTIVES Decision-analytic modelling can inform healthcare resource allocation and reimbursement decision-making, with modelling approaches adapted from a variety of disciplines. The objective of this thesis was to investigate the evidence surrounding when each approach should be used when conducting health economic evaluations. METHODS Project 1: A systematic review identified selection criteria, referred to as factors, through an evaluation of existing decision frameworks that aimed to differentiate between models. Project 2: Employing the factors identified from Project 1, a systematic review explored the extent to which empirical cross-validation studies agree on the importance of each on its impact to model selection. Project 3: A decision tree evaluating the cost-effectiveness of two vaccination strategies in children was reconstructed as system dynamics and agent-based models and compared. Scenario analyses assessed the situations whereby the model’s results would be sensitive to or be better handled by a particular approach. RESULTS Project 1: Among the eight frameworks identified; each involved a different set of structural or practical factors. Disagreements emerged between frameworks in the classification of the structural features specific to each modelling approach. Project 2: Nine exercises have been conducted, mostly focused on the criteria of interactivity (i.e., static vs. dynamic) and population resolution (i.e., aggregate vs. individual). Aggregate- and individual-level models were found to produce similar results with a practical trade-off between validity and feasibility. In the presence of large indirect effects, dynamic and static models often produced disparate results. Project 3: When calibrated, all three approaches reached consistent findings. Adaptation away from base-case assumptions led to different quantitative results on which vaccination strategy would be most optimal. CONCLUSION Despite disagreement among the frameworks on how to recommend modelling approaches, consistent conclusions were observed in empirical cross-validation studies. More empirical evidence is therefore needed to improve one’s understanding of the impact of the remaining factors on model selection. / Dissertation / Doctor of Philosophy (PhD)

Thesis (Ph.D.) - University of St Andrews, May 2007. / Restricted until 25th November 2008.

This dissertation examined whether or not microcredit, the provision of small loans to people usually excluded from mainstream financial institutions, demonstrably improved health for typical borrowers in Indonesia. The underlying idea behind microcredit is that loans will increase borrowers’ income and lead to positive changes in their lives, including their health. However, microcredit may actually be harmful to borrowers’ health because of stress associated with repayment obligations, extra working hours needed to start a business and tensions caused by shifting power dynamics in the household. Moreover, for some borrowers, a loan may facilitate increased spending on so-called temptation goods that are damaging to health, such as tobacco and processed foods. Previous research has not adequately explored these competing positive and negative pathways linking microcredit and health. The project consisted of three parts: a systematic review and two empirical papers. The systematic review synthesized the scientific literature related to individual microcredit loans, health-related temptation spending, psychological stress and self-reported health outcomes in adults. The empirical papers estimated the causal effect of microcredit on household expenditures on tobacco and processed foods, and individual psychological distress and self-rated health. Both empirical papers used data from the Indonesia Family Life Survey, a longitudinal study that followed more than 7,000 households over 21 years. After adjusting for confounding, people living in borrowing households had levels of psychological distress and self-rated health that were similar to people living in non-borrowing households. These predominantly null findings were relatively robust across multiple models. Microcredit households did spend substantially more money on tobacco than non-borrowers. This difference was driven by households with male borrowers. Still, tobacco spending ultimately did not affect health outcomes. Based on empirical evidence from this dissertation along with findings from other studies, policymakers and practitioners should recalibrate their high expectations of microcredit as a socially transformative intervention. At the same time, fears about the unintended health consequences of microcredit may have been exaggerated. Reliance on longitudinal data generated insights into microcredit and health that could not be established from randomized controlled trials.

Economics has become a dominant framework for analysing problems in public health and health care and for proposing policy solutions. A separate subdiscipline of health economics has grown out of the welfare economics tradition to develop specific methods for economic inquiry into health care issues. The encroachment of economics into health care and public health has not occurred without consternation from within the health field. Part of the reason for this concern arises from a mismatch between the worldview of public health and that of mainstream economics. However, this mismatch is largely unexamined, and there has been limited attempt to address the mismatch and to propose alternative approaches to economic questions in public health. This thesis examines the project of public health in some detail, making reference to the consensus documents of the World Health Organization that set out the values base of public health and define its approach and some of its activities. Public health is a collective activity, mostly undertaken outside of markets and is primarily concerned with impacts on populations. It is inherently political and focuses on populations as its unit of analysis. This contrasts to the approach of mainstream economics, which presumes that economic decisions are primarily private decisions and focuses on individuals as its unit of analysis. The differing worldviews constitute an impasse between mainstream economics and this view of public health. The solutions of neo-classical economics are often at odds with the public health approach. An alternative view of economics, from the heterodox Institutional School may provide an alternative approach to economic questions in public health. In contrast to neoclassical economics, it claims to be holistic and not to engage in methodological individualism and to be explicitly concerned with questions of power. The case studies of role of government and ageing as a public health issue provide a lens through which the neoclassical approach can be examined and contrasted to the public health approach. These case studies are based on reports written for Australian governments by neoclassical economists. The two case studies are then inspected from an institutional perspective to examine whether this approach does indeed generate explanations and solutions that are more compatible with a public health approach. Other insights into the reports that can be gained from an institutional perspective are also discussed. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1287041 / Thesis (Ph.D.) -- School of Population Health and Clinical Practice, 2007.

To ensure that the resources of the health care sector are used effectively, new technologies need to be evaluated before implementation to examine if they generate health outcomes at an acceptable cost. This information can be collected by performing health economic evaluations in which the costs and health outcomes of different technologies are compared. To estimate the effect on health care budgets, there is also a need for information about the prevalence of the specific disease. Health outcomes in health economic evaluations are often measured in quality-adjusted life years (QALYs), which are calculated by multiplying the remaining life years after an intervention by a weight representing the health-related quality of life (HRQoL) during those years. This thesis aims to provide deeper knowledge of the health economic aspects of diabetic retinopathy (DR), an eye complication that affects patients with diabetes and may in the worst case lead to blindness. The focus is on three empirical and two methodological health economic research questions. The empirical research areas cover prevalence, costs, and HRQoL related to patients with DR. The methodological research questions explore the performance of different methods for estimation of QALY weights. This is of interest since it has been argued that the most common methods for estimating QALY weights may not capture all relevant vision-related aspects of quality of life. The analyses comprehend the validity of different methods for estimating QALY weights among patients with DR and if the results of one of the specific methods for estimating QALY weights, the time trade-off (TTO) exercise, are affected by patients’ subjective life expectancy (SLE). The empirical results demonstrate that DR is seen in approximately 40% and 30% of patients with type I and type II diabetes respectively, indicating that the prevalence of DR has decreased in both of these patient groups. Healthcare costs vary considerably between different severity levels of the disease, being estimated at €26, €257, €216, and €433 per patient per year for background retinopathy, proliferative diabetic retinopathy (PDR), diabetic macular oedema (DMO), and PDR combined with DMO respectively. Blindness due to DR is associated with an increased use of transportation services, caregiving services, and assistive technologies as well as productivity losses. This suggests that preventing the progression of DR may lower healthcare costs. Patients with vision impairment due to DR have lowered HRQoL in various dimensions, but the diagnosis of DR in itself has only a limited effect on HRQoL. The results on the methodological research questions show that different methods for estimating QALY weights seem to give different results. In comparison to EQ-5D, the Health Utilities Index Mark 3 (HUI-3) is the most sensitive method for detecting differences in QALY weights due to DR, and if decisions are to be made based on values from the general public, it can be recommended for use in cost-utility analyses of interventions directed at DR. Neither of the direct methods, TTO and the visual analogue scale, seems to be sensitive to differences in visual function, and more research is needed concerning the role of vision in people’s responses to the TTO exercises. In TTO exercises with time frames based on actuarial life expectancy, the patients’ SLE has an effect on their willingness to trade off years for full health. Thus, applying time frames deviating from patients’ SLE may result in biased QALY weights. Such bias may appear stronger within patient populations than within the general public. In conclusion, this thesis offers estimates for prevalence, costs, and QALY weights that can be used in economic evaluations of interventions directed at DR and as benchmarks for future DR research in order to follow up consequences of changes in diabetes care. In addition, it demonstrates that the choice of method for estimating QALY weights may have an impact on whether an intervention is considered cost-effective.

Background: Health economic evaluations are becoming an increasingly important means of analysing which care alternative resource utilisation is the most cost effective. It is a new topic in the medical device industry that causes much uncertainty and unstructured use of the actors involved. Study questions: Why is it difficult to develop, implement and disseminate this standardized health economic evaluation models in medical technology? Is there a possibility to standardize health economic evaluations within the medical device industry? Purpose: The purpose of this study is to investigate the standardization issues for health economic evaluations within the medical device industry. Method: A qualitative approach was used in the form of interviews with five actors that are active or have a connection to the medical device industry. The data collection consists of journals, reports, Internet searches and literature among other things. Conclusion: It is possible to standardize, but with certain restrictions such as the county council's budget, influence of industry-specific factors, lack of knowledge and the important interaction between actors.

Physical activity among children and adolescents around the world is decreasing and will imply negative effects on their current and future health, which also contributes to higher costs for the society. Interventions promoting physical activity among youths could increase their physical activity and, at the same time, reduce the costs for society. The purpose of this study is to evaluate interventions for increased physical activity targeted towards children and adolescents from a health economic perspective. The results indicate that there exist different types of interventions and that the choice of health economic evaluation method differs widely between studies. In order for policymakers to choose the most effective interventions that allocate the society’s scarce resources in the best way, there is a need for a more streamlined methodological approach for health economic evaluations of the interventions that promote psychical activity among children and adolescents. / Fysisk aktivitet minskar bland barn och ungdomar runt om i världen och kan medföra negativa effekter på deras nuvarande och kommande hälsa, vilket också bidrar till högre kostnader för samhället. En intervention som främjar fysisk aktivitet bland barn och ungdomar, kan öka den fysiska aktiviteten och samtidigt minska samhällets kostnader. Syftet med denna studie är att utvärdera interventioner som främjar fysisk aktivitet riktad mot barn och ungdomar ur ett hälsoekonomiskt perspektiv. Resultaten indikerar att det finns olika typer av interventioner och att valet av hälsoekonomisk utvärdering skiljer sig mellan interventioner. För att beslutsfattare ska kunna välja de mest effektiva interventioner som fördelar samhällets knappa resurser på bästa sätt finns det ett behov av gemensamma tillvägagångssätt i hälsoekonomiska utvärderingar på interventioner som främjar psykisk aktivitet bland barn och ungdomar.

In the first chapter of this dissertation, I ask what role bank presence plays in improving health of households. To explore this question, I use a policy of the Reserve Bank of India from 2005 that incentivizes banks to set up new branches in underbanked districts, defined as having a population-to-branch ratio larger than the national average. In a regression discontinuity design, I compare households in districts just above and just below the national average. Six years after the policy introduction, households in treatment districts are a third less likely to be affected by an illness in a month. They miss fewer days of work or school due to an illness and have lower medical expenses. Ten years after the policy was introduced, I observe persistently lower morbidity rates, higher vaccination rates, and lower risks associated with pregnancies. I provide evidence that two previously understudied aspects of banking contribute to the effect: households gain access to health insurance and health care providers gain access to credit. In equilibrium, I observe an increase in healthcare demand and supply. In the second chapter of this dissertation, co-authored with Naz Koont, we provide first empirical evidence that consumer peer effects matter for banks’ deposit demand. Using a novel measure that depicts for each county how exposed peers are to a specific bank in a given year, we tightly identify the causal effect of peer exposure on deposit demand through a fixed effects identification strategy. We address key empirical challenges such as time-invariant homophily. We find that a one percent increase in a bank’s peer exposure leads to a 0.05 percent increase in deposit market share. This effect has become stronger over time with the rise of the internet and social media, which facilitate cross-county communication. Peer exposure is especially relevant for smaller banks and customers that have access to the internet.

Thesis submitted in partial fulfilment of the requirements for the degree Master of Technology in Environmental Management In the Faculty of Applied Sciences Department of Environmental and Occupational Studies At the Cape Peninsula University of Technology / Rivers, lakes and streams are the only way people encounter water sources in urban areas. Human endeavours have consequently deteriorated the environmental quality provided by river systems thus rivers are supporting a fraction of their original biodiversity and abundance. Urban streams are highly valuable and sensitive systems which, can be assessed by means of impacts of urban catchment and pathway influences. Many of the problems associated with environmental quality and management of urban watercourses are as a result of poor public perception. Advances in river assessment and management has come about through the recognition that water resource problems involve biological, physical and chemical components and more recently the addition of social and economic aspects. Social public participation is therefore achieved by studying and acting on people’s values, behaviours and perceptions of environmental quality. The main aim of this research was to identify whether a difference in socio-economic status is an influential factor in people’s perception of environmental quality. The objectives of the research were to determine whether the Elsieskraal River has a perceived low environmental relevance and quality (health and aesthetics), to determine what sensitizes people about issues relating to the natural environment and to identify people’s uses and perceptions of the Elsieskraal River corridor and its importance to the enjoyment as a recreational space. The study used a qualitative approach to obtain the data using the focus group technique. The purposive sample of participants from Pinelands and Thornton were the population that this study sought to investigate. Two focus group discussions; one in each study area was conducted. The results of this study found both similarities and differences in people’s perceptions of the Elsieskraal River between the two different socioeconomic urban communities. The perceived observation that the Elsieskraal River was a canal and not a river set the foundation for the envisaged low environmental quality the river so acquired. The majority overall environmental quality scores for the attributes of aquatic life, vegetation and water quality were found to be lower than they were scientifically found to be. Two clear avenues concerning environmental information sourcing and sensitization to the public was found. Politicians and government officials were unreliable to relay environmental information of a trustworthy nature. Community newspapers were a useful tool to present theevidence of information concerning the status of the natural environment especially at a local level. Three themes namely safety, maintenance and facilities and community attachment emerged on the importance of the Elsieskraal River as a recreational space. It is recommended that further studies should examine the perceptions of other similar rivers in the urban environment, both natural and canalised within Cape Town and the greater South Africa. The findings can assist environmental managers, planners and educators identify the gaps between the scientific environmental conditions and what people’s perceived awareness and knowledge about environmental quality are (factual versus perceived). It is also recommended that emphasis and support from local authorities must be given to non-governmental organisations (NGO’s) and adjacent property owners to aid in mobilising people into “ownership of rivers” within their communities to enhance their value and utilisation.

Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro / Trata-se de uma pesquisa documental, retrospectiva de fonte secundária,que adota uma abordagem quantitativa descritiva-exploratória. A partir da constatação de altos índices de absenteísmo nas unidades hospitalares, despertou-se o interesse em estudar os custos diretos das doenças ocupacionais que levam aos afastamentos e seu impacto econômico para o orçamento de recursos humanos de um hospital universitário do Rio de Janeiro. Neste contexto, definiu-se como objeto de estudo, o impacto econômico do absenteísmo por doença na equipe de enfermagem e, como objetivos: identificar as causas prevalentes de afastamentos no hospital universitário, de acordo com Classificação Internacional de Doenças e Problemas Relacionados a Saúde (CID-10); estimar os custos diretos mínimos das doenças que afastaram o trabalhador de enfermagem; estimar o custo real aproximado do absenteísmo relacionado a 1 (um) dia de trabalho prestado pelos trabalhadores de enfermagem, com projeção de 1 (um) mês e 1(um) ano numa visão operacional do Sistema Único de Saúde (SUS). Foi utilizada uma amostra estratificada de prontuários dos profissionais de saúde da equipe de enfermagem (enfermeiros e técnicos de enfermagem), a partir do seguinte critério de inclusão: profissionais de enfermagem concursados com afastamento no ano de 2010 e com diagnóstico médico determinante do afastamento, definido claramente. Para a coleta das informações foi feita a apreciação dos documentos arquivados no Serviço de Saúde do Trabalhador do hospital estudado e contou com a apreciação de especialistas médicos relativos aos grupos de diagnósticos estudados, orientados por roteiros criados pela pesquisadora. Os dados foram analisados e armazenados no programa Statistical Package for the Social Sciences (SPSS) versão 15 e no editor Microsoft excel 2003. Dentre os resultados obtidos tiveram destaque para as seguintes causas de afastamento, respectivamente, às doenças do sistema osteomuscular, os fatores que influenciam o estado de saúde e o contato com serviços de saúde, os transtornos mentais e comportamentais, as lesões, envenenamento e outras consequencias de causas externas e, as doenças do sistema circulatório, que representam um custo estimado aproximado de R$ 2,6 milhões. Pôde-se constatar que o impacto econômico do absenteísmo decorrentes dos agravos à saúde para o orçamento de recursos humanos do hospital universitário foi de aproximadamente 2,7%. O custo real aproximado do absenteísmo de enfermagem por dia, foi avaliado em R$ 92,50, tendo projeção mensal de R$ 2.775,00 e anual de R$ 33.300,00. Recomenda-se avaliar o absenteísmo dos profissionais regularmente para identificar as causas reais do absenteísmo por doença, a fim de definir metas para os programas de intervenção à saúde dos trabalhadores e promover uma Gestão participativa que favoreça uma análise do processo de trabalho no que concerne o atendimento das necessidades de saúde e operacionais da força de trabalho, determinantes do absenteísmo. / It is a documentary research, retrospective from secondary source , which adopts a quantitative descriptive- exploratory aprouch. From the observation of high rates of absenteeism in hospital the interest in studying the direct costs of occupational diseases that lead cleareances and their economic impact to the human resources budget of a university hospital in Rio de Janeiro. In this context, it was defined as an object of study the economic impact of sickness absenteeism among nursing and the following objectives: to identify the prevalent causes of absenteeism at the university hospital studied, according to the Internacional Classification of Diseases and Related Health Problems (ICD-10), to estimate the minimum directs costs of the diseases conditions that lead absenteeism to the nursing worker, to estimate the real cost of absenteeism related to one day of work provided by the nursing staff, with projection for one month and one year in operational vision of the Unified Health System (SUS). We used a stratified sample of health professionals records representing nursing staff (nurses and nursing technicians) according to the following inclusion criteria: gazetted professional nursing, with absences in 2010 with medical diagnosis, clearly defined. For data go thing, we used the files the university hospital worker health service and had the appraisal of medical experts for the diagnostic groups studied, according to scripts created by the researcher. Data were analyzed and stored in the program Statistical Package for Social Sciences (SPSS) version 15 and Microsoft excel 2003 in the editor. Among the results obstained, emphasis respectively for diseases of the musculoskeletal system, the factors influencing health status and contact with health services; disorders mental and behavioral disorders, injuries, poisoning and other consequences of external causes, and diseases of the circulatory system, representing an estimated approximate total cost of the R$ 2,6 million. Perceives that the economic impact absenteeism due to the health problems in the studied university hospital humam resources budget was approximately 2,7%. The approximate daily real cost of absenteeism in nursing was valued at R$ 92,50, and monthly forecast of R$2.775,00 and R$ 33.300,00 annually . It is recommended to usually evaluate the absenteeism of professionals to identify the real causes of sickness absenteeism in order to set intervention programs for the health workers and promote participatory management that encourages the evaluation of work process with respect to the health needs and operational workforce, determinants of absenteeism.