| 1. |
- Ahmed, Sayem, et al.
(författare)
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Cost-effectiveness of a market-based home fortification of food with micronutrient powder programme in Bangladesh.
- 2021
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Ingår i: Public health nutrition. - 1475-2727. ; 24:S1, s. 59-70
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Tidskriftsartikel (refereegranskat)abstract
- We estimated the cost-effectiveness of home fortification with micronutrient powder delivered in a sales-based programme in reducing the prevalence of Fe deficiency anaemia among children 6-59 months in Bangladesh.Cross-sectional interviews with local and central-level programme staff and document reviews were conducted. Using an activity-based costing approach, we estimated start-up and implementation costs of the programme. The incremental cost per anaemia case averted and disability-adjusted life years (DALY) averted were estimated by comparing the home fortification programme and no intervention scenarios.The home fortification programme was implemented in 164 upazilas (sub-districts) in Bangladesh.Caregivers of child 6-59 months and BRAC staff members including community health workers were the participants for this study.The home fortification programme had an estimated total start-up cost of 35·46 million BDT (456 thousand USD) and implementation cost of 1111·63 million BDT (14·12 million USD). The incremental cost per Fe deficiency anaemia case averted and per DALY averted was estimated to be 1749 BDT (22·2 USD) and 12 558 BDT (159·3 USD), respectively. Considering per capita gross domestic product (1516·5 USD) as the cost-effectiveness threshold, the home fortification programme was highly cost-effective. The programme coverage and costs for nutritional counselling of the beneficiary were influential parameters for cost per DALY averted in the one-way sensitivity analysis.The market-based home fortification programme was a highly cost-effective mechanism for delivering micronutrients to a large number of children in Bangladesh. The policymakers should consider funding and sustaining large-scale sales-based micronutrient home fortification efforts assuming the clear population-level need and potential to benefit persists.
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| 2. |
- Lozano, Rafael, et al.
(författare)
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Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017
- 2018
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Ingår i: The Lancet. - : Elsevier. - 1474-547X .- 0140-6736. ; 392:10159, s. 2091-2138
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Tidskriftsartikel (refereegranskat)abstract
- Background: Efforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of “leaving no one behind”, it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990–2017, projected indicators to 2030, and analysed global attainment. Methods: We measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the health-related SDG index, we transformed the value for each indicator on a scale of 0–100, with 0 as the 2·5th percentile and 100 as the 97·5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator. Findings: The global median health-related SDG index in 2017 was 59·4 (IQR 35·4–67·3), ranging from a low of 11·6 (95% uncertainty interval 9·6–14·0) to a high of 84·9 (83·1–86·7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030. Interpretation: The GBD study offers a unique, robust platform for monitoring the health-related SDGs across demographic and geographic dimensions. Our findings underscore the importance of increased collection and analysis of disaggregated data and highlight where more deliberate design or targeting of interventions could accelerate progress in attaining the SDGs. Current projections show that many health-related SDG indicators, NCDs, NCD-related risks, and violence-related indicators will require a concerted shift away from what might have driven past gains—curative interventions in the case of NCDs—towards multisectoral, prevention-oriented policy action and investments to achieve SDG aims. Notably, several targets, if they are to be met by 2030, demand a pace of progress that no country has achieved in the recent past. The future is fundamentally uncertain, and no model can fully predict what breakthroughs or events might alter the course of the SDGs. What is clear is that our actions—or inaction—today will ultimately dictate how close the world, collectively, can get to leaving no one behind by 2030.
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| 3. |
- Murray, Christopher J. L., et al.
(författare)
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Population and fertility by age and sex for 195 countries and territories, 1950–2017: a systematic analysis for the Global Burden of Disease Study 2017
- 2018
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Ingår i: The Lancet. - 1474-547X .- 0140-6736. ; 392:10159, s. 1995-2051
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Tidskriftsartikel (refereegranskat)abstract
- Background: Population estimates underpin demographic and epidemiological research and are used to track progress on numerous international indicators of health and development. To date, internationally available estimates of population and fertility, although useful, have not been produced with transparent and replicable methods and do not use standardised estimates of mortality. We present single-calendar year and single-year of age estimates of fertility and population by sex with standardised and replicable methods. Methods: We estimated population in 195 locations by single year of age and single calendar year from 1950 to 2017 with standardised and replicable methods. We based the estimates on the demographic balancing equation, with inputs of fertility, mortality, population, and migration data. Fertility data came from 7817 location-years of vital registration data, 429 surveys reporting complete birth histories, and 977 surveys and censuses reporting summary birth histories. We estimated age-specific fertility rates (ASFRs; the annual number of livebirths to women of a specified age group per 1000 women in that age group) by use of spatiotemporal Gaussian process regression and used the ASFRs to estimate total fertility rates (TFRs; the average number of children a woman would bear if she survived through the end of the reproductive age span [age 10–54 years] and experienced at each age a particular set of ASFRs observed in the year of interest). Because of sparse data, fertility at ages 10–14 years and 50–54 years was estimated from data on fertility in women aged 15–19 years and 45–49 years, through use of linear regression. Age-specific mortality data came from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 estimates. Data on population came from 1257 censuses and 761 population registry location-years and were adjusted for underenumeration and age misreporting with standard demographic methods. Migration was estimated with the GBD Bayesian demographic balancing model, after incorporating information about refugee migration into the model prior. Final population estimates used the cohort-component method of population projection, with inputs of fertility, mortality, and migration data. Population uncertainty was estimated by use of out-of-sample predictive validity testing. With these data, we estimated the trends in population by age and sex and in fertility by age between 1950 and 2017 in 195 countries and territories. Findings: From 1950 to 2017, TFRs decreased by 49·4% (95% uncertainty interval [UI] 46·4–52·0). The TFR decreased from 4·7 livebirths (4·5–4·9) to 2·4 livebirths (2·2–2·5), and the ASFR of mothers aged 10–19 years decreased from 37 livebirths (34–40) to 22 livebirths (19–24) per 1000 women. Despite reductions in the TFR, the global population has been increasing by an average of 83·8 million people per year since 1985. The global population increased by 197·2% (193·3–200·8) since 1950, from 2·6 billion (2·5–2·6) to 7·6 billion (7·4–7·9) people in 2017; much of this increase was in the proportion of the global population in south Asia and sub-Saharan Africa. The global annual rate of population growth increased between 1950 and 1964, when it peaked at 2·0%; this rate then remained nearly constant until 1970 and then decreased to 1·1% in 2017. Population growth rates in the southeast Asia, east Asia, and Oceania GBD super-region decreased from 2·5% in 1963 to 0·7% in 2017, whereas in sub-Saharan Africa, population growth rates were almost at the highest reported levels ever in 2017, when they were at 2·7%. The global average age increased from 26·6 years in 1950 to 32·1 years in 2017, and the proportion of the population that is of working age (age 15–64 years) increased from 59·9% to 65·3%. At the national level, the TFR decreased in all countries and territories between 1950 and 2017; in 2017, TFRs ranged from a low of 1·0 livebirths (95% UI 0·9–1·2) in Cyprus to a high of 7·1 livebirths (6·8–7·4) in Niger. The TFR under age 25 years (TFU25; number of livebirths expected by age 25 years for a hypothetical woman who survived the age group and was exposed to current ASFRs) in 2017 ranged from 0·08 livebirths (0·07–0·09) in South Korea to 2·4 livebirths (2·2–2·6) in Niger, and the TFR over age 30 years (TFO30; number of livebirths expected for a hypothetical woman ageing from 30 to 54 years who survived the age group and was exposed to current ASFRs) ranged from a low of 0·3 livebirths (0·3–0·4) in Puerto Rico to a high of 3·1 livebirths (3·0–3·2) in Niger. TFO30 was higher than TFU25 in 145 countries and territories in 2017. 33 countries had a negative population growth rate from 2010 to 2017, most of which were located in central, eastern, and western Europe, whereas population growth rates of more than 2·0% were seen in 33 of 46 countries in sub-Saharan Africa. In 2017, less than 65% of the national population was of working age in 12 of 34 high-income countries, and less than 50% of the national population was of working age in Mali, Chad, and Niger. Interpretation: Population trends create demographic dividends and headwinds (ie, economic benefits and detriments) that affect national economies and determine national planning needs. Although TFRs are decreasing, the global population continues to grow as mortality declines, with diverse patterns at the national level and across age groups. To our knowledge, this is the first study to provide transparent and replicable estimates of population and fertility, which can be used to inform decision making and to monitor progress. Funding: Bill & Melinda Gates Foundation.
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| 4. |
- Ahmed, Sayem, et al.
(författare)
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Technical efficiency of public district hospitals in Bangladesh : a data envelopment analysis
- 2019
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Ingår i: Cost Effectiveness and Resource Allocation. - : Springer Science and Business Media LLC. - 1478-7547. ; 17
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Tidskriftsartikel (refereegranskat)abstract
- Background: District hospitals (DHs) provide secondary level of healthcare to a wide range of population in Bangladesh. Efficient utilization of resources in these secondary hospitals is essential for delivering health services at a lower cost. Therefore, we aimed to estimate the technical efficiency of the DHs in Bangladesh. Methods: We used input-oriented data envelopment analysis method to estimate the variable returns to scale (VRS) and constant returns to scale (CRS) technical efficiency of the DHs using data from Local Health Bulletin, 2015. In this model, we considered workforce as well as number of inpatient beds as input variables and number of inpatient, outpatient, and maternal services provided by the DHs as output variables. A Tobit regression model was applied for assessing the association of institutional and environmental characteristics with the technical efficiency scores. Results: The average scale, VRS, and CRS technical efficiency of the DHs were estimated to 85%, 92%, and 79% respectively. Population size, poverty headcount, bed occupancy ratio, administrative divisions were significantly associated with the technical efficiency of the DHs. The mean VRS and CRS technical efficiency demonstrated that the DHs, on an average, could reduce their input mix by 8% and 21% respectively while maintaining the same level of output. Conclusion: Since the average technical efficiency of the DHs was 79%, there is little scope for overall improvements in these facilities by adjusting inputs. Therefore, we recommend to invest further in the DHs for improvement of services. The Ministry of Health and Family Welfare (MoHFW) should improve the efficiency in resource allocation by setting an input-mix formula for DHs considering health and socio-economic indicators (e.g., population density, poverty, bed occupancy ratio). The formula can be designed by learning from the input mix in the more efficient DHs. The MoHFW should conduct this kind of benchmarking study regularly to assess the efficiency level of health facilities which may contribute to reduce the wastage of resources and consequently to provide more affordable and accessible public hospital care.
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| 5. |
- Ahmed, Sayem
(författare)
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Healthcare financing challenges and opportunities to achieving universal health coverage in the low- and middle-income country context
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: In Bangladesh, on an average 62% of total healthcare spending was borne by households through out-of-pocket (OOP) payments annually during 2000- 2015. Because of such high OOP payments, a sizable proportion of households (15.7%) faced catastrophic health expenditure (CHE) and a number of them fell into poverty in 2010. Protecting households from such payments and consequently, the risk of impoverishment are desirable objectives of health systems worldwide. The Sustainable Development Goals (SDGs) resolution emphasized ensuring quality and affordable essential health services through Universal Health Coverage (UHC) by 2030. In order to achieve UHC, the World Health Organization (WHO) recommends to ensure the protection against the risk of large healthcare payments or CHE by spreading the risk among the population through pre-payments e.g., tax, social security contribution, insurance premium. Informal workers in the agricultural and non-agricultural sectors including readymade garments (RMG) workers constitute a large proportion of the total labor force (88%), who contribute to 64% of the total Gross Domestic Products of Bangladesh. Efforts should, therefore, be made to ensure sustainable quality healthcare for this group of workers by bringing them under pre-payment health schemes. Community-Based health insurance (CBHI) and employer-sponsored health insurance (ESHI) schemes were thus piloted among selected informal workers with an aim to increase utilization of medically trained healthcare providers (MTPs) at an affordable price. Objectives: The main objective of this dissertation is twofold: firstly, to study the effect of the current healthcare financing system on the financial risk of households and secondly, to explore potential solutions through pre-payments schemes (CBHI and ESHI) for mitigating such challenges. Methods: Based on both primary and/or secondary data, five studies were conducted. In study I, nationally representative Household Income and Expenditure Survey, 2016 has been used which provide data on household consumption expenditure including health expenses. We calculated the incidence of CHE, which was later predicted by demographic and socio-economic characteristics of the households using multiple regression analysis. The incidence of CHE was defined as the proportion of households having healthcare expenditure of more than a threshold level such as 10% of their total consumption expenditure or 40% of their non-food consumption expenditure. We estimated the impoverishment effect of OOP payments using both the national (cost of basic need approach) and the international (1.90 International dollar per person per day) poverty line. For study II, 557 informal workers were surveyed during 2010-11 in three geographic locations (a metropolitan city, a district town and a sub-district area) to estimate the willingness-to-pay (WTP) for CBHI, using the contingent valuation method. The association between WTP and demographic characteristics was measured by employing the log-normal regression model. Study III adopted a case-control design to estimate the effect of the CBHI scheme on healthcare utilization from MTPs. We, therefore, surveyed 1,292 (646 insured and 646 uninsured) households after 1 year of implementation of the scheme. In order to minimise the unobserved baseline differences between the insured and uninsured groups, a propensity score matching was performed. A multilevel logistic regression model was applied to measure the association between MTP healthcare use and CBHI membership, in comparison to uninsured. Using the same design in study IV, a two-part regression model was applied to assess the relationship between CBHI membership and the OOP expenditure (probability and magnitude) when adjusted for other confounding factors (demographic and socio-economic). Study V utilized a case-control design with cross-sectional pre-and post-intervention surveys among workers from 7 purposely selected RMG factories (6 intervention and 1 comparison factories) in Safipur of Gazipur, Bangladesh. Randomly selected RMG workers were interviewed in pre-(October 2013) and post-intervention phases (April 2015) from insured and uninsured RMG factories. In total, 1,924 workers were interviewed (480 from the insured group and 482 from the uninsured group in pre- and post-intervention periods). We estimated the difference-in-difference (DiD) of the utilization of healthcare and OOP expenditure. The DiD is a counterfactual estimate derived by measuring the change in outcomes in the intervention group, which is deducted from the change in outcomes in the comparison group between the pre- and post-intervention periods. Beside DiD estimation, we used a two-part regression model to measure the association between OOP payments and membership of the ESHI scheme while controlling for workers’ demographic and socio-economic characteristics. Results: Study I found that CHE were faced by 24.6% of households at the 10% threshold level, the incidence was 25.3% and 22.0% among the poorest and the richest households, respectively. The poverty rate rose by 5.5% (9.0 million individuals) due to OOP payments. In study II, we observed that approximately 87% of the informal workers were willing to pay for the CBHI. The average weekly WTP was 22.8 BDT [95% confidence interval (CI): 20.9–24.8] or 0.32 USD. Monthly income, occupation, geographic location and educational level were the main determinants of WTP. Study III suggested that the insured of CBHI were 2.111 (95% CI: 1.458- 3.079) times more likely than uninsured to use MTP for healthcare. Applying the two-part regression model in study IV, we found that in comparison with the uninsured, the average OOP payment was 6.4% (p<0.001) smaller among the insured for such healthcare utilization. Nonetheless, no significant difference was observed in OOP payments for the health service utilization from all types of providers, i.e., both MTPs and non-trained providers though the latter one was not included in the benefit package of the scheme. Study V showed that the ESHI scheme has resulted in a significant 26.1% escalation in the utilization of healthcare (DiD=26.1; p<0.01) from MTPs among the insured relative to uninsured. When accounting for covariates, such utilization fell to 18.4% (p<0.05). The DiD calculation showed that OOP spending for insured group decreased by -3,700 BDT and -1,100 BDT in comparison to uninsured group while utilized MTPs or all types of providers respectively, although not statistically significant. Conclusions: Reliance on OOP payments for healthcare leads to financial hardship and a challenge for securing financial protection to achieve UHC in low- and middle-income country settings with a large informal sector, like in Bangladesh. To mitigate the challenge of healthcare utilization at lower OOP payments, preppayment schemes such as CBHI and ESHI, are useful for increasing utilization of healthcare from MTPs by both informal and RMG workers. These schemes are in considerable demand that was supported by the WTP findings. However, the insured of the CBHI scheme had a significantly lower OOP payment, while worker insured by ESHI did not experience such reduction. Broader healthcare provider networks of ESHI schemes would reduce dependency on external providers (not contracted by ESHI) and consequently reduce OOP payments while increasing utilization of services. In summary, the studies in this dissertation describe the challenges of the current healthcare financing system in Bangladesh and the substantial potential of CBHI and ESHI schemes to mitigate such challenges among the informal and RMG workers.
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| 6. |
- Feldmann, Andreas, 1981-, et al.
(författare)
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Coordination in International Manufacturing: The Role of Competitive Priorities and the Focus of Globally Dispersed Facilities
- 2018
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Ingår i: Sustainability. - : MDPI. - 2071-1050. ; 10:5
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Tidskriftsartikel (refereegranskat)abstract
- In this era of globalization, network integration has received great attention, as it certainly has implications for the competitiveness in international manufacturing. A key issue in integration is to coordinate activities of dispersed facilities in a way to align the target of locating abroad and the priorities to be competitive. This study explores and clarifies the effect of competitive priority and focus of dispersed facilities on coordinating the activities in intra-firm network manufacturing. Based on a multiple case study involving four different companies manufacturing in globally dispersed facilities, the results confirm that both competitive priorities and specific focus of global manufacturing are important for selecting mechanisms to coordinate overseas facilities, with the competitive priorities ‘quality’ and ‘flexibility’ being the more important. Furthermore, the findings reveal that companies place emphasis on informal mechanisms to coordinate the low-cost focused facilities. In turn, the importance of formal mechanisms seems equal for coordinating both low-cost focused facilities and those focused on capturing a local market. Finally, the findings of this paper suggest that elements of competitive priority, as well as the focus of dispersed facilities, should be considered towards making the choice for mechanisms of coordination. The findings bear important implications for the effective coordination of activities in international manufacturing.
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| 7. |
- Sayem, Ahmed, et al.
(författare)
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Investigating the influence of network-manufacturing capabilities to the phenomenon of reshoring : An insight from three case studies
- 2019
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Ingår i: BRQ Business Research Quarterly. - : Elsevier. - 2340-9436 .- 2340-9444. ; 22:1, s. 68-82
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Tidskriftsartikel (refereegranskat)abstract
- After a steady growth in global offshoring activities, it appears now a marked flow in the opposite direction with both a partial and full reversal of offshoring decisions. Research on reshoring put less stresses on the operation of dispersed facilities of an intra-firm network manufacturing. The purpose of this paper is to address the relevance of strategic capabilities for the operation of international manufacturing to the reshoring decision. The paper reports on retrospective studies of three European based companies, which have had recent reshoring experience. We adopt qualitative research using a case-based methodology that includes multiple in-depth interviews based on three companies. The study demonstrates that managerial challenges in the operation of dispersed facilities have played an important role in the reshoring decision. The findings allow understanding how the capability dimensions, 'thriftiness' and 'learning' being the most important, connect with the phenomenon of reshoring.
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