In Southern Africa, as elsewhere, public-private engagement (PPE) for the provision and financing of healthcare is considered a pervasive and valuable mechanism for meeting the health needs of the population. A wide range of mechanisms for engagement are available, each with organisational models that make them suited to overcoming particular barriers in particular health system contexts. The extent to which a PPE initiative produces the desired outcome is largely dependent on the organisational structure of the collaboration. This study uses scoping and systematic review methods to develop a typology of PPE models visible in Southern Africa and investigate the organisational variations between them. While a variety of PPE models are utilised in the current Southern African context, donor-dependency remains high and there is room to expand engagement of this sort by adopting more innovative mechanisms for engagement and organisational models. An account of the models of PPE being initiated in the Southern African context constitutes a first step toward an analysis of the effectiveness of various mechanisms, and points the way to areas of possible expansion of efforts to engage with the non-state health sector to more effectively align goals in the interest of public health. To some extent, possible models are determined by country context and state capacity. Nonetheless private resources for health, including capital, human resources and technical capacity of for-profit and not-for-profit non-state health sector organisations, represent a rich source of health systems resources that could be more fully utilised through more innovative PPE initiatives for delivery and financing of health care.

Despite advances in recent years, human immunodeficiency virus (HIV) and tuberculosis (TB) are major contributors to global morbidity and mortality. Progress in mitigating the spread and impact of both infectious diseases is being made in many settings, but there is an ongoing gap in hard- to-reach and marginalized populations. Early diagnosis and treatment of infectious diseases is a core component of global efforts to mitigate infectious disease burden. The cost effectiveness of enhanced screening through systematic screening and self-testing (ST) is imperative prior to scaling up these programs given the reality of finite resources within any health care setting. We have undertaken a systematic review to summarize the current economic literature around systematic screening for active TB and ST for HIV. The inputs from the HIVST systematic review were used to create a combined decision tree and Markov model to evaluate the cost utility of HIVST along with digital and community-based programs to support downstream linkage to care.

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This thesis addresses health-policy relevant questions regarding quantity and quality of service delivery in primary healthcare using health administrative data from the province of Ontario. It is comprised of four chapters that explore the following questions: (1) What is the impact of switching from an enhanced fee-for-service (EFFS) payment model to a blended capitation payment model on the specialist referral rates of primary care physicians? (2) What are the rates of inappropriate laboratory testing in the province of Ontario? (3) What are the costs and determinants (physician and practice characteristics) of these inappropriate tests? (4) What is the impact of primary care payment structure on the quantity (number and cost) and the quality (appropriateness) of clinical laboratory testing? Fee-for-service (FFS) payment systems give physicians an incentive to treat patients on the margin of being referred, whereas in capitation systems physicians do not have a financial incentive to treat such marginal patients. Chapter 1 empirically examines how these two payment systems affect referral rates. The results show an increase in specialist visits upon a switch from an EFFS model to a blended capitation model when the physician is listed as the referring physician in the data, but no change in total specialist visits for these physicians’ patients. This change is not observed immediately upon switching payment models. Physicians paid by blended capitation who practice in an interdisciplinary health team have fewer specialist visits per rostered patient compared to EFFS physicians, despite an increase in their patients’ specialist visits after joining the interdisciplinary team. Using a definition of inappropriateness that quantifies ordering clinical laboratory tests too often or too soon following a previous test, Chapter 2 examines the rates of inappropriate laboratory testing for nine selected analytes in Ontario. The chapter finds that the percentage of inappropriate tests ranges from 6% to 20%. Moreover, between 60% and 85% of the time, the physician ordering an inappropriate test is the same physician who ordered the previous test. The findings also show that specialists are more likely than primary care physicians to order repeat tests too soon. Chapter 3 examines the costs and determinants associated with the rates of inappropriate laboratory utilization. The associated costs of inappropriate/redundant laboratory testing for the selected analytes ranges between 6 – 20% of the total cost of each test. Statistical analyses of the association of physician and practice characteristics with inappropriate testing are done using a logit model. Conditional upon the variables within the model, male physicians, physicians trained outside of Canada, older physicians, and a younger patient population are all shown to be associated with less inappropriate testing. Primary care physicians in group practices and in payment models with pay-for-performance (P4P) incentives are less likely to order inappropriate tests and specialist physicians are twice as likely to order inappropriately compared to FFS primary care physicians. Differences in physician, practice and patient characteristics, however, explain only a small amount of the variation in inappropriate utilization. Chapter 4 examines how physicians’ laboratory test ordering patterns change following a switch from an FFS payment model enhanced with P4P to a blended capitation payment model, and the differences in ordering patterns between traditional staffing and interdisciplinary teams within the blended capitation model. Using a propensity score weighted fixed-effects specification to address selection, the chapter estimates that a mandatory switch to capitation would lead to an average of 3% fewer laboratory requisitions per patient. Patients’ laboratory utilization also becomes more concentrated with the rostering physician. More importantly, using diabetes-related laboratory tests as a case study, physicians order 3% fewer inappropriate/redundant tests after joining the blended model and 9% fewer if they joined an interdisciplinary care team within the blended model. / Thesis / Doctor of Philosophy (PhD)

This thesis investigates whether variations in wait times for different medical specialties have a significant impact on the proportion of people who choose to opt out of the public insurance system in their country. Canada presents an interesting case study because it is one of the few nations with a single-payer system for all procedures covered by the public health system. As a result, leaving Canada is the equivalent of opting into the private system in other countries where socialized medicine is available side by side to a private market provider. The results provide some evidence of a positive relationship, but are somewhat sensitive to the chosen sample period.

Health disparities between different racial/ethnic groups in the United States are substantial. When reviewed across an extensive body of literature, these disparities have been demonstrated to persist even when socioeconomic status, geographic region, health conditions, treatment methods, and patient access-related variables are controlled. This ultimately leads to higher mortality rates among minority patients, making disparities in health a highly prevalent issue. However, the literature suggests that while racial and ethnic disparities in health have been widely examined, research documenting the evolution of these changes over time is lacking. This motivates the research questions: (1) How has the impact of racial biases on disparities in health outcomes evolved over the past decade?; (2) To what extent do race and ethnicity impact variation in health outcomes?; and (3) To what extent are race and ethnicity correlated with the socioeconomic gradient in health?; Last, (4) How present were these disparities when looking at outcomes related to the COVID-19 Pandemic? This thesis aims to address these questions through a two-part empirical analysis using publicly available data from the National Health Interview Survey (NHIS) and the COVID-19 Case Surveillance Public Use Dataset from the Centers for Disease Control and Prevention (CDC).

<p>This thesis focuses on two important areas of health economics: health dynamics during pre-adulthood, and physician behaviour. The first two essays seek to explore the important factors that determine the health production process during the period of pre-adulthood. The third chapter then turns the focus to physician labour and service provision behaviours.</p> <p>The first chapter examines the impact of family social economic status (SES) and neighbourhood environment on the dynamics of child <em>physical</em> health development. It examines the distribution of health outcomes and health transitions and explores the determinants of these distributions by estimating the contributions of family SES, neighbourhood status, unobserved heterogeneity and pure state dependence.</p> <p>The second chapter extends the research on health development in pre-adulthood by examining the roles of family SES, early childhood life-events, unobserved heterogeneity and pure state dependence in explaining the distribution of depression among adolescents and young adults. It also explicitly models the depression dynamics and quantifies both the mobility and persistence of this type of <em>mental</em> health problem from adolescence to early adulthood.</p> <p>The third chapter examines whether and how pay-for-performance (P4P) payments can motivate physician service provision to improve the quality of health care. It exploits a natural experiment in the province of Ontario, Canada to identify empirically the impact of P4P incentives on the provision of targeted primary care services, and whether physicians’ responses differ by age, practice size and baseline compliance level.</p> / Doctor of Philosophy (PhD)

<p>BACKGROUND</p> <p>For ST-segment elevation myocardial infarction (STEMI) patients received by emergency medical services (EMS), prehospital identification with 12-lead electrocardiogram/cardiography (ECG) and advanced notification of the receiving centre may increase access to primary reperfusion and reduce mortality, compared to standard cardiac monitoring. The lifetime benefits and costs of upgrading to a 12-lead ECG system are uncertain.</p> <p>OBJECTIVE</p> <p>To determine the cost-effectiveness of prehospital identification with 12-lead ECG and advanced notification vs. no prehospital identification and no advanced notification.</p> <p>METHODS</p> <p>A probabilistic Markov model was designed from a government payer perspective. Outcomes were lifetime incremental quality-adjusted life-years (QALYs) and healthcare costs. Type of primary reperfusion, 30-day and one-year mortality were from a cohort study conducted in Ontario. Reinfarction, stroke and revascularization rates were derived from the literature. Inpatient costs and professional fees came from the Ontario government; follow-up costs from published literature. The analysis was stratified by eligibility to bypass to a percutaneous coronary intervention (PCI) centre.</p> <p>RESULTS</p> <p>In bypass eligible settings, prehospital identification and advanced notification led to an average 0.23 additional QALYs and $1,501 additional costs over no prehospital identification and no advanced notification. In bypass ineligible settings, it led to an average 0.15 fewer QALYs and $130 additional costs. It was a cost-effective strategy 87% and 40% of the time in bypass eligible and ineligible settings, respectively, at a willingness-to-pay of $50,000/QALY.</p> <p>CONCLUSIONS</p> <p>In bypass eligible settings, prehospital identification with 12-lead ECG and advanced notification is a cost-effective intervention. In bypass ineligible settings, there is no evidence of cost-effectiveness.</p> / Master of Science (MSc)

The recent advancements in healthcare is extending the lives of older people. However, such advancements come at a cost: higher medical expenses with less financial resources and limited, if not truncated, monetary assistance. The dilemma is further compounded by the unreliable quality of life produced by extending life of the chronically ill. Using the RAND data, I examine three financial transaction outcomes at different points-in-time in context of the onset of a health issue: one, the probability of a transaction occurring, two, how much is given, and three, the frequency of transactions. I also examine how a health issue impacts financial transaction choices within a given year, a year after the health issue occurs, and the longer term impacts on subsequent intergenerational financial transactions. I find no change in financial behavior of an adult child immediately after the health issue occurs and minimal over the longer period of time. However, this study does show a slight and statistically significant shift in financial transactions within the first year after a health issue occurs. Additionally, the results suggest that those who can live in assisted care and near respondent children have higher transactions between family members.

No / Objectives: Poor knowledge of eye health, concerns about the cost of spectacles, mistrust of optometrists and limited geographical access in socio-economically deprived areas are barriers to accessing regular eye examinations and result in low uptake and subsequent late presentation to ophthalmology clinics. Personal Medical Services (PMS) were introduced in the late 1990s to provide locally negotiated solutions to problems associated with inequalities in access to primary care. An equivalent approach to delivery of optometric services could address inequalities in the uptake of eye examinations. Study design: One-way and multiway sensitivity analyses. Methods: Variations in assumptions were included in the models for equipment and accommodation costs, uptake and length of appointments. The sensitivity analyses thresholds were cost-per-person tested below the GOS1 fee paid by the NHS and achieving breakeven between income and expenditure, assuming no cross-subsidy from profits from sales of optical appliances. Results: Cost per test ranged from £24.01 to £64.80 and subsidy required varied from £14,490 to £108,046. Unused capacity utilised for local enhanced service schemes such as glaucoma referral refinement reduced the subsidy needed. / Yorkshire Eye Research, NHS Leeds, RNIB