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This thesis questions the assumption that health outcome is the only relevant argument in the patient's utility function. Following this, consideration is given to deciding which methods to use to establish what attributes there are in the patient's utility function and the relative weights to these attributes. Two methods are assessed and considered appropriate: contingent valuation and conjoint analysis. These methods are applied to assess the benefits from assisted reproductive techniques. An attempt is made to determine both the presence and relative importance of health and non-health attributes in the infertile person's utility function. The results from these empirical studies provide evidence of both the potential importance of factors beyond having a child and the sensitivity and applicability of the tools used to establish the relative importance of possible utility bearing attributes in the infertile person's utility function. The factors identified include: knowing you have done everything possible to have a child, the psychological feeling of disappointment, overall satisfaction with life following involvement with assisted reproductive techniques, the provision of follow-up support, and process type attributes such as continuity of care, attitudes of medical staff, waiting time and cost. Health economists concerned with developing economic instruments to measure utility from assisted reproductive techniques, and health care interventions more generally, should find the results useful. So too should those concerned with policy issues around the provision of assisted reproductive techniques and health care interventions more generally.

This dissertation consists of three independent essays evaluating the impact of public health interventions in two countries, Indonesia and Australia. The first two essays concern the national pro-poor health card program in Indonesia, which fully subsidises health care purchases by its recipients. In quantifying the impact of the program, the combination of propensity score matching and difference-in-differences techniques is used to address bias due to non-random assignment. Covariates to match include both variables affecting demand and eligibility and variables measuring local health care supply. Using data from the single, nationally-representative longitudinal study of Indonesian households, the program is found to have limited impact. The second essay evaluates the program??s impact on supply variables. In the absence of a wage revision or additional staff, the program lowers the incentives for health workers to maintain their public position. This is particularly true for those workers providing outpatient care as patients can not be controlled by waiting lists. The analysis finds some evidence of reduced number of full-time doctors in areas where the distribution of health cards were most extensive. The final essay uses Australian data to investigate changes in women??s preferences for cervical screening following a screening promotion campaign and a vaccination program. Discrete choice experiments were used to elicit preferences, and results from experiments conducted prior and after the interventions were compared. Several additional comparison groups were created based on spatial variations and by variation induced by randomisation. The study finds that the interventions have minor impact on how women valued various screening attributes. However, there was a general reduction in the willingness to screen, which was unexpected given the awareness campaign. Through simulation, it is shown that an effective way to increase the screening rate is through encouraging a more active role of the provider.

This dissertation consists of three independent essays evaluating the impact of public health interventions in two countries, Indonesia and Australia. The first two essays concern the national pro-poor health card program in Indonesia, which fully subsidises health care purchases by its recipients. In quantifying the impact of the program, the combination of propensity score matching and difference-in-differences techniques is used to address bias due to non-random assignment. Covariates to match include both variables affecting demand and eligibility and variables measuring local health care supply. Using data from the single, nationally-representative longitudinal study of Indonesian households, the program is found to have limited impact. The second essay evaluates the program??s impact on supply variables. In the absence of a wage revision or additional staff, the program lowers the incentives for health workers to maintain their public position. This is particularly true for those workers providing outpatient care as patients can not be controlled by waiting lists. The analysis finds some evidence of reduced number of full-time doctors in areas where the distribution of health cards were most extensive. The final essay uses Australian data to investigate changes in women??s preferences for cervical screening following a screening promotion campaign and a vaccination program. Discrete choice experiments were used to elicit preferences, and results from experiments conducted prior and after the interventions were compared. Several additional comparison groups were created based on spatial variations and by variation induced by randomisation. The study finds that the interventions have minor impact on how women valued various screening attributes. However, there was a general reduction in the willingness to screen, which was unexpected given the awareness campaign. Through simulation, it is shown that an effective way to increase the screening rate is through encouraging a more active role of the provider.

This study focuses on the possible ways to improve healthcare services around the world, which increase the life expectancy for aging people. Utilizing a cost-effective analysis, the relationship between various healthcare expenditures and conditional life expectancy for people aged 60 and above was examined. A linear regression model was used to analyze data from 122 WHO (World Health Organization) countries obtained from the year 2000. The model included additional health-adjusted life years (HALE) at age 60 as the dependent variable and healthcare cost indicators as the independent variables. Regression results revealed that cost of healthcare was overall significant in contributing to HALE at age 60. The independent cost variables that were individually significant in the model consisted of government expenditure, private healthcare expenditure, out-of-pocket expenditure, and social security funding. While public healthcare costs such as government expenditure and social security funding positively impacted HALE, private healthcare expenditure negatively impacted HALE years at age 60. This finding suggests that countries with higher private healthcare expenditure than public healthcare expenditure decreased their chances of improving life expectancy for senior citizens. Through a cost-effective lens, in order to increase the quality and quantity of healthy life years for the elderly, countries should focus on instating policies that fund more public healthcare services.

South African medical schemes spend billions of Rands each year on medical care costs for their beneficiaries near their end of life. Hospi-centric benefit design, fee-for-service reimbursement arrangements and fragmented, silo-based delivery of care result in high, often unnecessary spending near the end of life. Factors including an ageing population, increasing incidence rates of cancer and other non-communicable diseases, and high levels of multi-morbidity among beneficiaries near their end of life further drive end-of-life care costs. Low levels of hospice or palliative care utilisation, a high proportion of deaths in-hospital and chemotherapy use in the last weeks of life point to potentially poor-quality care near the end of life. The usual care pathway for serious illness near the end of life acts like a funnel into private hospitals. This often entails resource intensive care that includes aggressive care interventions right up until death. The result is potentially sub-optimal care and poor healthcare outcomes for many scheme beneficiaries and their surviving relatives. Understanding the complex nature of the end of life, the different care pathways, the available insurance benefits, the interactions between key stakeholders and the multitude of factors that drive end-of-life care costs are vital to setting end-of-life care reform in motion. In order to increase value at the end of life, i.e. to increase quality and/or to reduce costs, benefit design reform, alternative reimbursement strategies, effective communication and multi-stakeholder buy-in is key.

Background: Catastrophic health expenditure (CHE) and impoverishing health expenditure (IHE) are significant barriers to surgical care. Worldwide, 3.7 billion people risk financial catastrophe if they require surgery, mostly affecting the poorest populations in LMICs. Surgical CHE and IHE are not described in the South African context. The objectives of this study were: 1) to determine the proportion of surgical participants at New Somerset Hospital (NSH) ), a second-level public sector South African hospital, who experienced CHE and IHE and 2) to determine the risk factors associated with out-of-pocket (OOP) payments. Methods: This study used a cross-sectional retrospective questionnaire administered to participants admitted to any department of surgery (obstetrics, gynaecology, general surgery, urology, otorhinolaryngology, or orthopaedics) for a surgical procedure at NSH. Direct healthcare expenditure for the surgical admission was defined to be catastrophic according to three definitions: 1) OOP payments 10% or more of annual household expenditure (HHE) (CHE10); 2) OOP payments 25% or more of annual HHE (CHE25); 3) OOP payments 40% or more of capacity to pay (CHE40). IHE was based on the national poverty lines and was defined according to new impoverishment or worsening impoverishment, as a result of OOP expenditure on the surgical admission. Multivariate regression analysis was used to assess the relationship between OOP payments and per capita HHE, age, type of procedure, department to which participant was admitted, distance from NSH, and length of stay. Results: Out of the 274 participants interviewed: 263 were included in the analysis (4% attrition rate). Two (0.8%), five (1.9%), and three (1.1%) participants experienced CHE according to the CHE40, CHE10, and CHE25 definitions, respectively. About 98.5% of participants spent less than 10% of their annual HHE, while 95.4% spent less than 10% of their annual non-food expenditure OOP. Median OOP expenditure was R100 (IQR R15 – R350). About 23% of the participants (n=62) were not charged for their surgical admission. Low per capita HHE (p=0.02), cancer (p=0.001), having a non-generous health insurance plan (p=0.002), and the hospital bill amount (p<0.001) correlated positively with OOP expenditure on healthcare. Linear regression revealed that there was no correlation between the proportion of OOP payments and LOS or distance. One in five patients (n=50, 19%) experienced new or worsening impoverishment and were pushed below the poverty line for receiving surgical care at a public hospital. Furthermore, 65 (25%) patients reported their household was unable to cope or household still recovering from the financial burden of the surgical admission. Discussion: Surgical CHE was not common among this study population, however IHE was substantial and the majority of participants incurred OOP for surgical care, with the main drivers of OOP costs being the hospital bill and transport. Financial catastrophe might have been low because: 1) most participants were protected by the uniform patient fee schedule and therefore did not incur a medical bill and 2) direct non-medical costs did not account for a significant proportion of OOP payments. Understanding the financial impacts of OOP health care expenditure is essential in the planning of the impending National Health Insurance in South Africa.

The purpose of the current study was to assess how RBF performed in terms of efficiency, effectiveness, equity and governance in the Zimbabwean context. It outlines the evolution of health systems thinking and health funding models over time to show the history and changing landscape of health care financing and their actors. General consensus is there is need to focus on results of health care investments against a background of prodigious amounts of foreign aid with marginal or no improvements in heath care delivery for decades of development assistance in developing countries. Health systems in developing countries are beset with burgeoning domestic and foreign debts as well as diminishing fiscal space that has more often put the primary health delivery system in developing nations in "comatose". The research made use of both qualitative and quantitative dimensions. Findings indicate that the pre-RBF era was characterised by poor primary health outcomes, unsound governance and a lack of confidence in the public health delivery system. However, since RBF implementation, access to health care by marginalised groups has increased, with incentives and community participation liberalising health systems to greater efficiency as shown by slight increases in post-natal care visits in rural health care centres. A trade-off between achieving efficiency and equity was found especially when scaling up health programmes under the RBF initiative. Through embracing RBF, the primary health delivery system is poised for future development attributed to community buy-in and people-centric empowerment approaches.

Background: According to the National Cancer Registry of South Africa 600-700 new cases of paediatric cancers have been reported every year for the past 25 years. While in the year 2000 HIV/AIDS was responsible for 42 479 deaths in children under five. However support for and research in general for the paediatric intermediate care (encompasses palliative, sub-acute and respite care) needed by these children remains sparse. Costing studies are even rarer, with the few studies conducted in South Africa reporting a broad range of average costs per inpatient day. Methods: A retrospective cost analysis for the period April 2014-March 2015 was undertaken from the provider perspective. Costs of paediatric intermediate care were estimated for an intermediate stepdown facility and a tertiary hospital in Cape Town, South Africa. A step down costing approach was employed, and the costs were inflated to 2016 values and expressed in Rand and USD using an exchange rate of 1 USD = R14.87. Results: Cost per inpatient day was USD 713.09 at the hospital and USD 695.17 at the step-down facility. The cost for a paediatric patient who is HIV/TB co-infected was USD 7130.94 and USD 6951.67 at the hospital and step-down facility respectively, assuming an average length of stay (ALOS) of 10 days. For a patient who has a terminal brain carcinoma the cost was USD 19966.63 and USD 19464.69 at the hospital and step-down facility respectively, assuming an ALOS of 28 days. Personnel costs accounted for 60% of the total cost at the hospital, compared to only 17% of the total costs at the step-down facility. Overhead costs accounted for 12.33% at the step-down facility, almost 3 times that of the hospital (4.48%). Conclusions: The study highlights that the drivers of cost are not uniform across settings. Providing intermediate care at a step-down facility can be more cost-saving than providing this care at a hospital, there are however areas in which more savings could be realized. The costs presented in this study were considerably higher than those found in other studies, however, the paucity of cost data available in the area of paediatric intermediate care makes comparisons difficult.

Individuals with Lynch Syndrome (LS) have a 25% to 75% lifetime risk of colorectal cancer and the cancer generally presents at an early age. Establishing the costs of strategies to prevent or delay the onset of cancer is, thus, desirable. This study compared the cost of two screening approaches - colonoscopy only (Strategy 1) versus genetic testing for LS followed by colonoscopy for the individuals that tested positive for LS (Strategy 2). A comparative cost analysis was conducted at a tertiary hospital, from the health provider perspective, using a micro-costing, ingredient approach. Probands that were selected, according to the Revised Bethesda Criteria, for genetic testing between 01 November 2014 and 30 October 2015, and their first degree relatives (high risk relatives) were evaluated according to Strategy 1 and Strategy 2. Total costs per strategy were estimated and compared. Sensitivity analyses were performed on adherence rates to colonoscopy, positivity rates of relatives and discount rates. A total of 40 families were studied. The total cost for Strategy 1 amounted to R4 932 718 ($332 617) compared to R390 308 ($26 319) for Strategy 2 (Discount rate 3%; Adherence 75% and Positivity rate of relatives 45%). Base case analysis indicated a difference of 92% less in the total cost for Strategy 2 compared to Strategy 1. Univariate sensitivity analyses showed that the difference in cost between the two strategies was not sensitive to changes in discount rates, adherence rates or positivity rates of relatives. Compared to colonoscopy screening only, colonoscopy combined with genetic testing presented a less costly option by identifying patients at high risk of colorectal cancer for screening. Testing of relatives should be facilitated since, compared to probands, genetic testing of relatives is less costly and is likely to have more benefit. Effectiveness of the screening programmes should be established through further research.