Health economists, national decision-makers and global health specialists have been interested in calculating the cost of a disease for many years. Only more recently they started to generate more comprehensive frameworks and tools to estimate the full range of healthcare related costs of illness in a user’s perspective in resource-poor settings. There is now an ongoing trend to guide health policy, and identify the most effective ways to achieve universal health coverage. The user fee exemptions health financing schemes, which grounded the tuberculosis control strategy, have been designed to improve access to essential care for ill individuals with a low capacity to pay. After decades of functioning and substantial progress in tuberculosis detection rate and treatment success, this thesis analyses the extent of the coverage (financial and social protection) of two disease control programs in West Africa. Learning from the concept of the medical poverty trap (Whitehead, Dahlgren, et Evans 2001) and available framework related to the economic consequences of illness (McIntyre et al. 2006), a conceptual framework and a data collection tool have been developed to incorporate the direct, indirect and intangible costs and consequences of illness incurred by chronic patients. In several ways, we have sought to provide baseline for comprehensive analysis and standardized methodology to allow comparison across settings, and to contribute to the development of evidence-based knowledge.<p><p>To begin, filling a knowledge gap (Russell 2004), we have performed microeconomic research on the households’ costs-and-consequences-of-tuberculosis in Burkina Faso and Benin. The two case studies have been conducted both in rural and urban resource-poor settings between 2007 and 2009. This thesis provides new empirical findings on the remaining financial, social and ‘healthcare delivery related organizational’ barriers to access diagnosis and treatment services that are delivered free-of-charge to the population. The direct costs associated with illness incurred by the tuberculosis pulmonary smear-positive patients have constituted a severe economic burden for these households living in permanent budget constraints. Most of these people have spent catastrophic health expenditure to cure tuberculosis and, at the same time, have faced income loss caused by the care-seeking. To cope with the substantial direct and indirect costs of tuberculosis, the patients have shipped their families in impoverishing strategies to mobilize funds for health such as depleting savings, being indebted and even selling livestock and property. Damaging asset portfolios of the disease-affected households on the long run, the coping strategies result in a public health threat. In resource-poor settings, the lack of financial protection for health may impose inability to meet basic needs such as the rights to education, housing, food, social capital and access to primary healthcare. Special feature of our work lies in the breakdown of the information gathered. We have been able to demonstrate significant differences in the volume and nature of the amounts spent across the successive stages of the care-seeking pathway. Notably, pre-diagnosis spending has been proved critical both in the rural and urban contexts. Moreover, disaggregated cost data across income quintiles have highlighted inequities in relation to the direct costs and to the risk of incurring catastrophic health expenditure because of tuberculosis. As part of the case studies, the tuberculosis control strategies have failed to protect the most vulnerable care users from delayed diagnosis and treatment, from important spending even during treatment – including significant medical costs, and from hidden costs that might have been exacerbated by poor health systems. To such devastating situations, the tuberculosis patients have had to endure other difficulties; we mean intangible costs such as pain and suffering including stigmatization and social exclusion as a result of being ill or attending tuberculosis care facilities. The analysis of all the social and economic consequences for tuberculosis-affected households over the entire care-seeking pathway has been identified as an essential element of future cost-of-illness evaluations, as well as the need to conduct benefit incidence assessment to measure equity.<p><p>This work has allowed identifying a series of policy weaknesses related to the three dimensions of the universal health coverage for tuberculosis (healthcare services, population and financial protection coverage). The findings have highlighted a gap between the standard costs foreseen by the national programs and the costs in real life. This has suggested that the current strategies lack of patient-centered care, context-oriented approaches and systemic vision resulting in a quality issue in healthcare delivery system (e.g. hidden healthcare related costs). Besides, various adverse effects on households have been raised as potential consequences of illness; such as illness poverty trap, social stigma, possible exclusion from services and participation, and overburdened individuals. These effects have disclosed the lack of social protection at the country level and call for the inclusion of tuberculosis patients in national social schemes. A last policy gap refers to the lack of financial protection and remaining inequities with regards to catastrophic health expenditure still occurring under use fee exemptions strategies. Thereby, one year before 2015 – the deadline set for the Millennium Development Goals – it is a matter of priority for Benin and Burkina Faso and many other countries to tackle adverse effects of the remaining social, economic and health policy and system related barriers to tuberculosis control. These factors have led us to emphasize the need for countries to develop sustainable knowledge. <p><p>National decision-makers urgently need to document the failures and bottlenecks. Drawing on the findings, we have considered different ways to strengthen local capacity and generate bottom-up decision-making. To get there, we have shaped a decision framework intended to produce local evidence on the root causes of the lack of policy responsiveness, synthesize available evidence, develop data-driven policies, and translate them into actions.<p><p>Beyond this, we have demonstrated that controlling tuberculosis was much more complex than providing free services. The socio-economic context in which people affected by this disease live cannot be dissociated from health policy. The implications of microeconomic research on the households’ costs and responses to tuberculosis may have a larger scope than informing implementation and adaptation of national disease-specific strategies. They can be of great interest to support the definition of guiding principles for further research on social protection schemes, and to produce evidence-based targets and indicators for the reduction and the monitoring of economic burden of illness. In this thesis, we have build on prevailing debates in the field and formulated different assumptions and proposals to inform the WHO Global Strategy and Targets for Tuberculosis Prevention, Care and Control After 2015. For us, to reflect poor populations’ needs and experiences, global stakeholders should endorse bottom-up and systemic policy-making approaches towards sustainable people-centered health systems.<p><p>The findings of the thesis and the various global and national challenges that have emerged from case studies are crucial as the problems we have seen for tuberculosis in West Africa are not limited to this illness, and far outweigh the geographical context of developing countries.<p><p><p>Keywords: Catastrophic health expenditure, Coping strategies, Cost-of-illness studies, Direct, indirect and intangible costs, Evidence-based Public health, Financial and Social protection for health, Health Economics, Health Policy and Systems, Informed Decision-making, Knowledge translation, People-centered policy-making, Systemic approach, Universal Health Coverage<p> / Doctorat en Sciences de la santé publique / info:eu-repo/semantics/nonPublished

A gap exists in the methods used in industry and available in academia that prevents customers and engineers from having a voice when considering engineering risk appetite in the dynamic shaping of early-phase conceptual design trade study outcomes. Current methods used in Collaborative Design Centers either collect risk information after a conceptual design has been created, treat risk as an afterthought during the trade study process, or do not consider risk at all during the creation of conceptual designs. This dissertation proposes a risk-informed decision making framework that offers a new way to account for risk and make decisions based upon risk information within conceptual complex system design trade studies. A meaningful integration of the consideration of risk in trade studies is achieved in this framework thus elevating risk to the same level as other important system-level design parameters. Trade-offs based upon risk appetites of individuals are explicitly allowed under the framework, enabled by an engineering-specific psychometric risk survey that provides aspirational information to use in utility functions. This dissertation provides a novel framework and supporting methodologies for risk-informed design decisions and trades to be made that are based upon engineering risk appetites in conceptual design trade studies. / Graduation date: 2012

Research and Development engineering is at the corner stone of humanity’s evolution. It is perceived to be a systematic creative process which ultimately improves the living standard of a society through the creation of new applications and products. The commercial paradigm that governs project selection, resource allocation and market penetration prevails when the focus shifts from pure research to applied research. Furthermore, the road to success through commercialisation is difficult for most inventors, especially in a vast and isolated country such as Australia which is located a long way from wealthy and developed economies. While market leading products are considered unique, the actual process to achieve these products is essentially the same; progressing from an idea, through development to an outcome (if successful). Unfortunately, statistics indicate that only 3% of ‘ideas’ are significantly successful, 4% are moderately successful, and the remainder ‘evaporate’ in that form (Michael Quinn, Chairman, Innovation Capital Associates Pty Ltd). This study demonstrates and analyses two techniques developed by the author which reduce uncertainty in the engineering design and development phase of new product development and therefore increase the probability of a successful outcome. This study expands the existing knowledge of the engineering design and development stage in the new product development process and is couched in the identification of practical methods, which have been successfully used to develop new products by Australian Small Medium Enterprise (SME) Excel Technology Group Pty Ltd (ETG). Process theory is the term most commonly used to describe scientific study that identifies occurrences that result from a specified input state to an output state, thus detailing the process used to achieve an outcome. The thesis identifies relevant material and analyses recognised and established engineering processes utilised in developing new products. The literature identified that case studies are a particularly useful method for supporting problem-solving processes in settings where there are no clear answers or where problems are unstructured, as in New Product Development (NPD). This study describes, defines, and demonstrates the process of new product development within the context of historical product development and a ‘live’ case study associated with an Australian Government START grant awarded to Excel Technology Group in 2004 to assist in the development of an image-based vehicle detection product. This study proposes two techniques which reduce uncertainty and thereby improve the probability of a successful outcome. The first technique provides a predicted project development path or forward engineering plan which transforms the initial ‘fuzzy idea’ into a potential and achievable outcome. This process qualifies the ‘fuzzy idea’ as a potential, rationale or tangible outcome which is within the capability of the organisation. Additionally, this process proposes that a tangible or rationale idea can be deconstructed in reverse engineering process in order to create a forward engineering development plan. A detailed structured forward engineering plan reduces the uncertainty associated with new product development unknowns and therefore contributes to a successful outcome. This is described as the RETRO technique. The study recognises however that this claim requires qualification and proposes a second technique. The second technique proposes that a two dimensional spatial representation which has productivity and consumed resources as its axes, provides an effective means to qualify progress and expediently identify variation from the predicted plan. This spatial representation technique allows a quick response which in itself has a prediction attribute associated with directing the project back onto its predicted path. This process involves a coterminous comparison between the predicted development path and the evolving actual project development path. A consequence of this process is verification of progress or the application of informed, timely and quantified corrective action. This process also identifies the degree of success achieved in the engineering design and development phase of new product development where success is defined as achieving a predicted outcome. This spatial representation technique is referred to as NPD Mapping. The study demonstrates that these are useful techniques which aid SMEs in achieving successful new product outcomes because the technique are easily administered, measure and represent relevant development process related elements and functions, and enable expedient quantified responsive action when the evolving path varies from the predicted path. These techniques go beyond time line representations as represented in GANTT charts and PERT analysis, and represent the base variables of consumed resource and productivity/technical achievement in a manner that facilitates higher level interpretation of time, effort, degree of difficulty, and product complexity in order to facilitate informed decision making. This study presents, describes, analyses and demonstrates an SME focused engineering development technique, developed by the author, that produces a successful new product outcome which begins with a ‘fuzzy idea’ in the mind of the inventor and concludes with a successful new product outcome that is delivered on time and within budget. Further research on a wider range of SME organisations undertaking new product development is recommended.