Pour certaines maladies causées par des agents chimiques, biologiques, radiologiques et nucléaires (CBRN), il n’existe pas de contre-mesures médicales (MedCM) et bon nombre de celles qui existent pourraient ne pas être disponibles en cas de besoin. En cas d’accident CBRN, des efforts inadéquats de financement de la R&D et de mise à disposition par les gouvernements peuvent avoir de graves conséquences économiques nettement supérieures aux coûts d’initiatives préventives. Compte-tenu des contraintes budgétaires auxquelles de nombreux gouvernements sont confrontés, il est nécessaire de définir des priorités. Parallèlement à la mise en place d’indicateurs de décision de santé efficaces qui identifient et mesurent les effets de causalité de l’impact négatif sur la santé, le processus de décision doit également prendre en considération le rapport coût-efficacité pour rendre le financement durable.Cette thèse a pour objectif de définir une voie vers une politique économique de santé publique visant à renforcer la disponibilité des MedCM pour les agents CBRN. Dans la première partie, les causes des défaillances du marché sont identifiées (lorsque les opportunités de profit ne compensent pas l’effort de R&D nécessaire). Dans la deuxième partie, des études de cas illustrent les caractéristiques et les conséquences économiques d’exemples d’accidents CBRN et des scénarios sont analysés afin de mettre en évidence comment la disponibilité de MedCM pourrait potentiellement devenir rentable. Enfin, la troisième partie propose des approches plus complètes pour mesurer et compenser les facteurs contribuant à la défaillance du marché en appliquant des modèles économiques spécifiques. / For some diseases caused by chemical, biological, radiological, and nuclear (CBRN) agents, innovative medical countermeasures (MedCMs) do not exist while many of those that do might not be readily available. In case of a CBRN event, inappropriate medical research and development (R&D) funding and government procurement efforts can result in adverse economic consequences (e.g. lost income) far exceeding the costs of strong and comprehensive preparedness initiatives. Given the budgetary constraints many governments face, priorities must be defined. Parallel to determining effective health decision metrics that identify and weigh the causal effects of negative health impact, decision making must also consider cost-effectiveness to make funding sustainable. Moreover, international cooperation is necessary since the risks increasingly transcend borders due to global travel and the global threat of terrorism. This dissertation ultimately seeks to define a path to public health economic policy to enhance the international availability of CBRN MedCMs. In Part I, the root causes of market failure are identified and depicted (i.e., where rewards for supply do not adequately compensate for the R&D effort). In Part II, case study examples illustrate the characteristics and economic consequences of CBRN incidents. Scenarios for each case are outlined to show where the availability of MedCMs in these situations could potentially be cost-effective. Finally, Part III construes more comprehensive approaches for gauging and offsetting the deterrence factors of market supply and demand by compiling and applying additional economic models and frameworks.

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2015-12-09T19:00:22Z No. of bitstreams: 1 Simone Pereira Lermontov.pdf: 27639825 bytes, checksum: 8e739b8c382c9f2fc847de9ba00bbec9 (MD5) / Made available in DSpace on 2015-12-09T19:00:22Z (GMT). No. of bitstreams: 1 Simone Pereira Lermontov.pdf: 27639825 bytes, checksum: 8e739b8c382c9f2fc847de9ba00bbec9 (MD5) Previous issue date: 2010 / Mestrado Acadêmico em Ciências do Cuidado em Saúde / Este estudo objetivou avaliar os custos e consequências do tratamento da pseudartrose com aplicação de células-tronco. A metodologia correspondeu à avaliação econômica parcial do custo e das consequências desse tratamento. O cenário do estudo foi o Hospital Universitário Antonio Pedro e os sujeitos foram oito pacientes operados entre setembro de 2008 e maio de 2009. A perspectiva do estudo foi a do Sistema Único de Saúde, principal fonte de financiamento da assistência médica no Brasil. Para o tratamento estatístico dos dados foram utilizados o software STATISTICA 6.0 e o teste não paramétrico de Spearman. A análise estatística apresentou resultados satisfatórios dentro de uma margem aceitável. O custo total médio do tratamento foi de R$ 1243.199 e o tempo de consolidação foi em média 14.71429 semanas. Observamos através do teste não paramétrico de Spearman que a correlação entre o custo total e o tempo de consolidação é - 0, 5078, uma indicação fraca de que o custo total é inversamente proporcional ao tempo de consolidação. A partir deste estudo, podemos concluir que o custo com o tratamento não foram exorbitantes. O pequeno tamanho da amostra não afetou os resultados de forma significativa, sendo que os achados em relação à idade são parecidos com os de outros estudos, o que nos leva a concluir que a população acometida pela pseudartrose é a economicamente ativa. A criação de um protocolo foi primordial para o levantamento do custo com o tratamento, possibilitando a consolidação dos dados e nos permitindo visualizar de forma mais abrangente o tratamento. O tempo de consolidação foi igual aos melhores resultados vistos em estudo internacionais e o procedimento se mostrou seguro e eficaz. Constatamos que o questionário SF36 é um instrumento de fácil aplicação e foi de confiabilidade no acompanhamento ambulatorial de pacientes submetidos ao tratamento. / The purpose of this study was to evaluate the costs and consequences of the use of stem cells in the treatment of pseudarthrosis. The methodology involved a partial economic assessment of the cost and consequences of this treatment. The study scenario was the Hospital Universitário Antonio Pedro and the subjects were eight patients operated between September 2008 and May 2009. The study perspective was that of the Sistema Único de Saúde, the main financial resource for medical assistance in Brazil. Statistical treatment of the data was performed using the STATISTICA 6.0 application and the Spearman nonparametric test. The results were statistically significant within an acceptable margin of error. The average treatment cost was R$ 1.247,21 and the average time for consolidation was 12.875 weeks. The Spearman nonparametric test showed that the correlation between the total cost and the time for was -0.25, a weak indication that the total cost is inversely proportional to the time for consolidation. From this study, we can conclude that the treatment costs were not prohibitive. The small size of the sample had no significant influence on the results; the agerelated findings are similar to those of other studies and lead to the conclusion that population affected by pseudarthrosis is economically active. The creation of a protocol was essential for cost evaluation, providing a framework for data consolidation and yielding a more general view of the treatment. The time for consolidation was about the same as for the best results reported in the international literature and the procedure was observed to be safe and effective. We concluded that the SF36 questionnaire is an easily applied tool that can be reliably used in the post-treatment follow-up of the patients.

Abstracts in English and Zulu / Immunisation is a cost-effective public health intervention that contributes to the attainment of the Sustainable Development Goals (SDGs). About 40% of children under the age of five years die from vaccine-preventable diseases in Nigeria. Routine immunisation has been quite low in Nigeria, where national coverage is estimated to be 33%, according to a 2016–2017 survey. This empirical research was aimed at determining the key socio-economic and gender determinants of immunisation in the Federal Capital Territory (FCT), identifying gaps and proffering solutions. Mixed methods of data collection and analysis were used. Data were gathered from several secondary sources and from 11 key informants using semi-structured interviews and 501 household and 26 health-facility surveys using questionnaires mounted on Open Data Kit. Lot quality assurance sampling and probability to population size methodology were used to size the samples and identify survey locations. Odds ratio analysis and logistic regression analysis were conducted to gauge the statistical association between the determinants and the coverage of immunisation. The main finding that was reached on the basis of the documents reviewed and the feedback received from the key informants was that they were gender blind at worst and gender neural at best. Most of the current strategies give little attention to socio-economic and gender barriers. Over 40 immunisation variables were identified. The analysis, particularly using the 2x2 odds ratio, yielded mixed results. The majority of the variables exhibited a close statistical association as far as immunisation indices were concerned. These variables included urban residency, married couples, literacy, birth at a health facility, antenatal care experience, vaccination card possession, immunisation knowledge, child health information, non-farming earnings, socio-economic status and tolerance of spouse beating. On the other hand, variables that were found to have no statistical significance included sex, marital status, marriage type, age, religion, tetanus toxoid (TT) vaccination and adequacy of income. Immunisation and gender are intertwined, particularly because of mothers’ biological and social attachment to their children. At the same time, conducting vaccination avails the opportunity to access almost all households. Moreover, it is important to recognise that socio-economic and gender determinants are not totally in control of one ministry. Single agenda interventions will not produce the desired result. A paradigm shift and the concerted effort of various sectors and partners are required. Therefore, the Nigerian government should galvanise the relevant stakeholders to bring gender and socio-economic variables into the mainstream throughout the immunisation ecosystem and to implement integrated development initiatives by prioritising vulnerable communities. / Ugonyo yindlela engcono yokungenela kwezempilo yabantu engathela esivivaneni ekufinyeleleni izinhloso zentuthuko eqhubekela phambili ezaziwa ngelokuthi yi- Sustainable Development Goals (SDGs). Cishe izingane ezifinyelela ku 40% ezingaphansi kweminyaka emihlanu zibulawa yizifo ezivimbelekayo ngomgcabo emitholampilo eNigeria. Ukugonya njalo kusezingeni eliphansi eNigeria, laphokhona ukwengamela kuzwelonke kulinganiselwa ku 33%, ngokuya kocwaningo olwenziwe phakathi kuka 2016-2017. Ucwaningo lokuthola ubufakazi lwalunenhloso yokubona imithelela yezesimo sabantu nomnotho (socio-economic) kanye nobulili ngokugonya kwi-Federal Capital Territory (FCT) ukubona amagebe kanye nokutholakala kwezixazululo. Amamethodi axubene okuqokelela ulwazi kanye nohlaziyo kwasetshenziswa. Ulwazi lwaqokelelwa ngokufunda imithombo yemibhalo (secondary sources) kanye nakubantu ababalulekile abanolwazi (key informants) abangu 11 ngokusebenzisa ama-semi-structured interview kanye nemizi engu 501 kanye namasurvey amafasilithi ezempilo angu 26 ngokusebenzisa uhla lwemibuzo yamaquestionnaire ebifakelwe kwi-Open Data Kit. Kwasetshenziswa nemethodi ye-Lot quality assurance sampling ne-probability, ngemethodoloji yobuningi babantu, ukwenza usayizi wamasampuli kanye nokubona izindawo okumele kwenziwe kuzo ama-survey. Kwenziwa nohlaziyo lwe-Odds ratio analysis kanye ne-logisic regression analysis ukubona ukuhambelana kwamastatistiki phakathi kwezinto eziwumthelela kanye nokunaba kongamelo lokwenziwa kogonyo. Okukhulu okutholakele ngokulandela amadokhumende okufundwe kuwo, kanye nezimpendulo ezivela kulabo abanolwazi ababalulekile (key informants) kube wukuthi bekungaboneleli ubulili (gender blind) kanti futhi bekungachemile ngokulandela ubulili (gender neutral) ngezinga elibi nangokungcono kakhulu. Amasu amaningi amanje awanakekeli kakhulu izihibe ezimayelana nabantu nezomnotho kanye nezobulili. Kwaphawulwa cishe izinto ezehlukene zama-variable ezingu 40 mayelana nogonyo. Uhlaziyo, ikakhulukazi ngokusebenzisa i 2x2 odds ratio, lwaveza imiphumela exubene. Ezinto zama-variable ehlukene eziningi zikhombise ukuhlobana phakathi kwamastatistiki mayelana namaindices ogonyo. Lama variable, abandakanye ukuhlala emadolobheni, abantu abashadile, ikhono lokubhala nokufunda, ukuzalwa kwezingane kumafasilithi ezempilo, izipiliyoni zonakekelo lwengane ngaphambi kokuzalwa, ukuba nekhadi lomgcabo ix wasemitholampilo, ulwazi ngogonyo, ulwazi ngempilo yengane, ukuthola imali ngemisebenzi engeyona eyokulima, isimo sabantu mayelana nezomnotho, kanye nokuqinisela ukuhlukunyezwa ngokushaywa kwabesimame. Kanti ngakolunye uhlangothi, ama-variable atholakale engenakho ukubaluleka ngokwamastatistiki, abandakanya ubulili, isimo ngokomendo, inhlobo yomendo, iminyaka yobudala, inkolo, umgcabo we-tetanus toxoid (TT), kanye nokwenela kwengeniso lemali. Ugonyo kanye nobulili kuyangenelana nokuhambelana, ikakhulukazi ngenxa yokusondelana komama kanye nezingane zabo. Ngaso leso sikhathi, ukwenziwa kogonyo kuhlinzeka ngethuba lokufinyelela cishe kuwo yonke imizi eminingi. Nangaphezu kwalokho, kubalulekile ukwamukela ukuthi isimo sabantu mayelana nezomnotho kanye nobulili kuyizinto ezinomthelela, azinalo ulawulo oluphelele kumnyango kangqongqoshe owodwa. Ungenelo ngento eyodwa ngeke kwaveza imiphumela efiswayo. Ukugudluka ngokomqondo (paradigm shift), kanye nemizamo eqhubekela phambili yemikhakha ehlukene kanye nabasebenzisani kuyadingeka. Ngakho-ke uhulumeni waseNigeria, kumele agqugquzele ababambiqhaza abafanele ukuhlanganisa nokufaka emkhakheni ofanele izinto ezimayelana nabantu nomnotho kanye nobulili, kuyo yonke inqubo yokusebenzisana kwemikhakha okumele isebenzisane nehlangene ukusebenza ngokulandela inqubo yentuthuko ehlangane ngokubonelela imiphakathi ekwizimo ezibucayi / Development Studies / D. Phil. (Development Studies)