| 1. |
- Ahmad Kiadaliri, Aliasghar, et al.
(author)
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Geographic distribution of need and access to health care in rural population: an ecological study in Iran
- 2011
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In: International Journal for Equity in Health. - : Springer Science and Business Media LLC. - 1475-9276. ; 10:39
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Journal article (peer-reviewed)abstract
- Introduction: Equity in access to and utilization of health services is a common goal of policy-makers in most countries. The current study aimed to evaluate the distribution of need and access to health care services among Iran's rural population between 2006 and 2009. Methods: Census data on population's characteristics in each province were obtained from the Statistical Centre of Iran and National Organization for civil registration. Data about the Rural Health Houses (RHHs) were obtained from the Ministry of Health. The Health Houses-to-rural population ratio (RHP), crude birth rate (CBR) and crude mortality rate (CMR) in rural population were calculated in order to compare their distribution among the provinces. Lorenz curves of RHHs, CMR and CBR were plotted and their decile ratio, Gini Index and Index of Dissimilarity were calculated. Moreover, Spearman rank-order correlation was used to examine the relation between RHHs and CMR and CBR. Results: There were substantial differences in RHHs, CMR and CBR across the provinces. CMR and CBR experienced changes toward more equal distributions between 2006 and 2009, while inverse trend was seen for RHHs. Excluding three provinces with markedly changes in data between 2006 and 2009 as outliers, did not change observed trends. Moreover; there was a significant positive relationship between CMR and RHP in 2009 and a significant negative association between CBR and RHP in 2006 and 2009. When three provinces with outliers were excluded, these significant associations were disappeared. Conclusion: Results showed that there were significant variations in the distribution of RHHs, CMR and CBR across the country. Moreover, the distribution of RHHs did not reflect the needs for health care in terms of CMR and CBR in the study period.
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| 2. |
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| 3. |
- Ahmad Kiadaliri, Aliasghar, et al.
(author)
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Overall, gender and social inequalities in suicide mortality in Iran, 2006-2010: a time trend province-level study.
- 2014
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In: BMJ Open. - : BMJ. - 2044-6055. ; 4:8, s. 005227-005227
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Journal article (peer-reviewed)abstract
- Suicide is a major global health problem imposing a considerable burden on populations in terms of disability-adjusted life years. There has been an increasing trend in fatal and attempted suicide in Iran over the past few decades. The aim of the current study was to assess overall, gender and social inequalities across Iran's provinces during 2006-2010.
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| 4. |
- Ahmad Kiadaliri, Aliasghar, et al.
(author)
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Pure and social disparities in distribution of dentists: a cross-sectional province-based study in iran.
- 2013
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In: International Journal of Environmental Research and Public Health. - : MDPI AG. - 1660-4601. ; 10:5, s. 1882-1894
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Journal article (peer-reviewed)abstract
- During past decades, the number of dentists has continuously increased in Iran. Beside the quantity, the distribution of dentists affects the oral health status of population. The current study aimed to assess the pure and social disparities in distribution of dentists across the provinces in Iran in 2009. Data on provinces' characteristics, including population and social situation, were obtained from multiple sources. The disparity measures (including Gini coefficient, index of dissimilarity, Gaswirth index of disparity and relative index of inequality (RII)) and pairwise correlations were used to evaluate the pure and social disparities in the number of dentists in Iran. On average, there were 28 dentists per 100,000 population in the country. There were substantial pure disparities in the distribution of dentists across the provinces in Iran. The unadjusted and adjusted RII values were 3.82 and 2.13, respectively; indicating area social disparity in favor of people in better-off provinces. There were strong positive correlations between density of dentists and better social rank. It is suggested that the results of this study should be considered in conducting plans for redistribution of dentists in the country. In addition, further analyses are needed to explain these disparities.
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| 5. |
- Allel, Kasim, et al.
(author)
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The contributions of public health policies and healthcare quality to gender gap and country differences in life expectancy in the UK
- 2021
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In: Population Health Metrics. - : Springer Science and Business Media LLC. - 1478-7954. ; 19
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Journal article (peer-reviewed)abstract
- Background: In many high-income countries, life expectancy (LE) has increased, with women outliving men. This gender gap in LE (GGLE) has been explained with biological factors, healthy behaviours, health status, and sociodemographic characteristics, but little attention has been paid to the role of public health policies that include/affect these factors. This study aimed to assess the contributions of avoidable causes of death, as a measure of public health policies and healthcare quality impacts, to the GGLE and its temporal changes in the UK. We also estimated the contributions of avoidable causes of death into the gap in LE between countries in the UK.Methods: We obtained annual data on underlying causes of death by age and sex from the World Health Organization mortality database for the periods 2001-2003 and 2014-2016. We calculated LE at birth using abridged life tables. We applied Arriaga's decomposition method to compute the age- and cause-specific contributions into the GGLE in each period and its changes between two periods as well as the cross-country gap in LE in the 2014-2016 period.Results: Avoidable causes had greater contributions than non-avoidable causes to the GGLE in both periods (62% in 2001-2003 and 54% in 2014-2016) in the UK. Among avoidable causes, ischaemic heart disease (IHD) followed by injuries had the greatest contributions to the GGLE in both periods. On average, the GGLE across the UK narrowed by about 1.0 year between 2001-2003 and 2014-2016 and three avoidable causes of IHD, lung cancer, and injuries accounted for about 0.8 years of this reduction. England & Wales had the greatest LE for both sexes in 2014-2016. Among avoidable causes, injuries in men and lung cancer in women had the largest contributions to the LE advantage in England & Wales compared to Northern Ireland, while drug-related deaths compared to Scotland in both sexes.Conclusion: With avoidable causes, particularly preventable deaths, substantially contributing to the gender and cross-country gaps in LE, our results suggest the need for behavioural changes by implementing targeted public health programmes, particularly targeting younger men from Scotland and Northern Ireland.
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| 6. |
- Batura, Neha, et al.
(author)
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Collecting and analysing cost data for complex public health trials : reflections on practice
- 2014
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In: Global Health Action. - : CoAction Publishing. - 1654-9716 .- 1654-9880. ; 7, s. 23257-
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Journal article (peer-reviewed)abstract
- BACKGROUND: Current guidelines for the conduct of cost-effectiveness analysis (CEA) are mainly applicable to facility-based interventions in high-income settings. Differences in the unit of analysis and the high cost of data collection can make these guidelines challenging to follow within public health trials in low- and middle- income settings.OBJECTIVE: This paper reflects on the challenges experienced within our own work and proposes solutions that may be useful to others attempting to collect, analyse, and compare cost data between public health research sites in low- and middle- income countries.DESIGN: We describe the generally accepted methods (norms) for collecting and analysing cost data in a single-site trial from the provider perspective. We then describe our own experience applying these methods within eight comparable cluster randomised, controlled, trials. We describe the strategies used to maximise adherence to the norm, highlight ways in which we deviated from the norm, and reflect on the learning and limitations that resulted.RESULTS: When the expenses incurred by a number of small research sites are used to estimate the cost-effectiveness of delivering an intervention on a national scale, then deciding which expenses constitute 'start-up' costs will be a nontrivial decision that may differ among sites. Similarly, the decision to include or exclude research or monitoring and evaluation costs can have a significant impact on the findings. We separated out research costs and argued that monitoring and evaluation costs should be reported as part of the total trial cost. The human resource constraints that we experienced are also likely to be common to other trials. As we did not have an economist in each site, we collaborated with key personnel at each site who were trained to use a standardised cost collection tool. This approach both accommodated our resource constraints and served as a knowledge sharing and capacity building process within the research teams.CONCLUSIONS: Given the practical reality of conducting randomised, controlled trials of public health interventions in low- and middle- income countries, it is not always possible to adhere to prescribed guidelines for the analysis of cost effectiveness. Compromises are frequently required as researchers seek a pragmatic balance between rigor and feasibility. There is no single solution to this tension but researchers are encouraged to be mindful of the limitations that accompany compromise, whilst being reassured that meaningful analyses can still be conducted with the resulting data.
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| 7. |
- Batura, Neha, et al.
(author)
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Highlighting the evidence gap : how cost-effective are interventions to improve early childhood nutrition and development?
- 2015
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In: Health Policy and Planning. - : Oxford University Press. - 0268-1080 .- 1460-2237. ; 30:6, s. 813-821
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Research review (peer-reviewed)abstract
- There is growing evidence of the effectiveness of early childhood interventions to improve the growth and development of children. Although, historically, nutrition and stimulation interventions may have been delivered separately, they are increasingly being tested as a package of early childhood interventions that synergistically improve outcomes over the life course. However, implementation at scale is seldom possible without first considering the relative cost and cost-effectiveness of these interventions. An evidence gap in this area may deter large-scale implementation, particularly in low- and middle-income countries. We conduct a literature review to establish what is known about the cost-effectiveness of early childhood nutrition and development interventions. A set of predefined search terms and exclusion criteria standardized the search across five databases. The search identified 15 relevant articles. Of these, nine were from studies set in high-income countries and six in low- and middle-income countries. The articles either calculated the cost-effectiveness of nutrition-specific interventions (n = 8) aimed at improving child growth, or parenting interventions (stimulation) to improve early childhood development (n = 7). No articles estimated the cost-effectiveness of combined interventions. Comparing results within nutrition or stimulation interventions, or between nutrition and stimulation interventions was largely prevented by the variety of outcome measures used in these analyses. This article highlights the need for further evidence relevant to low- and middle-income countries. To facilitate comparison of cost-effectiveness between studies, and between contexts where appropriate, a move towards a common outcome measure such as the cost per disability-adjusted life years averted is advocated. Finally, given the increasing number of combined nutrition and stimulation interventions being tested, there is a significant need for evidence of cost-effectiveness for combined programmes. This too would be facilitated by the use of a common outcome measure able to pool the impact of both nutrition and stimulation activities.
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| 8. |
- Bidgoli, Hassan Haghparast, et al.
(author)
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Pre-hospital trauma care resources for road traffic injuries in a middle-income country-A province based study on need and access in Iran.
- 2011
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In: Injury. - : Elsevier BV. - 0020-1383 .- 1879-0267. ; 42:9, s. 879-884
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Journal article (peer-reviewed)abstract
- BACKGROUND: Access to pre-hospital trauma care can help minimize many of traffic related mortality and morbidity in low- and middle-income countries with high rate of traffic deaths such as Iran. The aim of this study was to assess if the distribution of pre-hospital trauma care facilities reflect the burden of road traffic injury and mortality in different provinces in Iran. METHODS: This national cross-sectional study is based on ecological data on road traffic mortality (RTM), road traffic injuries (RTIs) and pre-hospital trauma facilities for all 30 provinces in Iran in 2006. Lorenz curves and Gini coefficients were used to describe the distributions of RTM/RTIs and pre-hospital trauma care facilities across provinces. Spearman rank-order correlation was performed to assess the relationship between RTM/RTI and pre-hospital trauma care facilities. RESULTS: RTM and RTIs as well as pre-hospital trauma care facilities were distributed unequally between different provinces. There was no significant association between the rate of RTM and RTIs and the number of pre-hospital trauma care facilities across the country. CONCLUSIONS: The distribution of pre-hospital trauma care facilities does not reflect the needs in terms of RTM and RTIs for different provinces. These results suggest that traffic related mortality and morbidity could be reduced if the needs in terms of RTM and RTIs were taken into consideration when distributing pre-hospital trauma care facilities between the provinces.
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| 9. |
- Colbourn, Tim, et al.
(author)
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Cost-effectiveness and affordability of community mobilisation through women's groups and quality improvement in health facilities (MaiKhanda trial) in Malawi
- 2015
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In: Cost Effectiveness and Resource Allocation. - : BioMed Central (BMC). - 1478-7547. ; 13
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Journal article (peer-reviewed)abstract
- BACKGROUND: Understanding the cost-effectiveness and affordability of interventions to reduce maternal and newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of community mobilisation through women's groups and health facility quality improvement, both aiming to reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted in rural Malawi in 2008-2010. In this paper, we calculate intervention cost-effectiveness and model the affordability of the interventions at scale.METHODS: Bayesian methods are used to estimate the incremental cost-effectiveness of the community and facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi. Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level. Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic product of Malawi in 2013 international $.RESULTS: The incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively). Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292, EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in Malawi.CONCLUSIONS: Community mobilisation through women's groups is a highly cost-effective and affordable strategy to reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.
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| 10. |
- Dickin, Sarah, et al.
(author)
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Implementation of the Afya conditional cash transfer intervention to retain women in the continuum of care : a mixed-methods process evaluation
- 2022
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In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 12:9
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Journal article (peer-reviewed)abstract
- Objectives: We report the results of a mixed-methods process evaluation that aimed to provide insight on the Afya conditional cash transfer (CCT) intervention fidelity and acceptability.Intervention, setting and participants: The Afya CCT intervention aimed to retain women in the continuum of maternal healthcare including antenatal care (ANC), delivery at facility and postnatal care (PNC) in Siaya County, Kenya. The cash transfers were delivered using an electronic card reader system at health facilities. It was evaluated in a trial that randomised 48 health facilities to intervention or control, and which found modest increases in attendance for ANC and immunisation appointments, but little effect on delivery at facility and PNC visits.Design: A mixed-methods process evaluation was conducted. We used the Afya electronic portal with recorded visits and payments, and reports on use of the electronic card reader system from each healthcare facility to assess fidelity. Focus group interviews with participants (N=5) and one-on-one interviews with participants (N=10) and healthcare staff (N=15) were conducted to assess the acceptability of the intervention. Data analyses were conducted using descriptive statistics and qualitative content analysis, as appropriate.Results: Delivery of the Afya CCT intervention was negatively affected by problems with the electronic card reader system and a decrease in adherence to its use over the intervention period by healthcare staff, resulting in low implementation fidelity. Acceptability of cash transfers in the form of mobile transfers was high for participants. Initially, the intervention was acceptable to healthcare staff, especially with respect to improvements in attaining facility targets for ANC visits. However, acceptability was negatively affected by significant delays linked to the card reader system.Conclusions: The findings highlight operational challenges in delivering the Afya CCT intervention using the Afya electronic card reader system, and the need for greater technology readiness before further scale-up.
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| 11. |
- Haghparast-Bidgoli, Hassan, et al.
(author)
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Do economic evaluation studies inform effective healthcare resource allocation in Iran? A critical review of the literature.
- 2014
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In: Cost Effectiveness and Resource Allocation. - : Springer Science and Business Media LLC. - 1478-7547. ; 12:Jul 11
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Research review (peer-reviewed)abstract
- To aid informed health sector decision-making, data from sufficient high quality economic evaluations must be available to policy makers. To date, no known study has analysed the quantity and quality of available Iranian economic evaluation studies. This study aimed to assess the quantity, quality and targeting of economic evaluation studies conducted in the Iranian context. The study systematically reviewed full economic evaluation studies (n = 30) published between 1999 and 2012 in international and local journals. The findings of the review indicate that although the literature on economic evaluation in Iran is growing, these evaluations were of poor quality and suffer from several major methodological flaws. Furthermore, the review reveals that economic evaluation studies have not addressed the major health problems in Iran. While the availability of evidence is no guarantee that it will be used to aid decision-making, the absence of evidence will certainly preclude its use. Considering the deficiencies in the data identified by this review, current economic evaluations cannot be a useful source of information for decision makers in Iran. To improve the quality and overall usefulness of economic evaluations we would recommend; 1) developing clear national guidelines for the conduct of economic evaluations, 2) highlighting priority areas where information from such studies would be most useful and 3) training researchers and policy makers in the calculation and use of economic evaluation data.
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| 12. |
- Haghparast-Bidgoli, Hassan, et al.
(author)
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Factors affecting hospital length of stay and hospital charges associated with road traffic-related injuries in Iran
- 2013
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In: BMC Health Services Research. - : Springer Science and Business Media LLC. - 1472-6963. ; 13, s. Article Number: 281-
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Journal article (peer-reviewed)abstract
- Background: Road traffic injuries (RTIs) are a substantial cause of mortality and disability globally. There is little published information regarding healthcare resource utilization following RTIs, especially in low and middle-income countries (LMICs). The aim of this study was to assess total hospital charges and length of stay (LOS) associated with RTIs in Iran and to explore the association with patients' socio-demographic characteristics, insurance status and injury-related factors (e. g. type of road users and safety equipment). Method: The study was based on the Iranian National Trauma Registry Database (INTRD), which includes data from 14 general hospitals in eight major cities in Iran, for the years 2000 to 2004. 8,356 patients with RTI admitted to the hospitals were included in the current study. The variables extracted for the analysis included total hospital charges and length of stay, age, gender, socio-economic and insurance status, injury characteristics, medical outcome and use of safety equipment among the patients. Univariable analysis using non-parametric methods and multivariable regression analysis were performed to identify the factors associated with total hospital charges and LOS. Results: The mean hospital charges for the patients were 1,115,819 IRR (SD=1,831,647 IRR, US$128 +/- US$210). The mean LOS for the patients was 6.8 (SD =8 days). Older age, being a bicycle rider, higher injury severity and longer LOS were associated with higher hospital charges. Longer LOS was associated with being male, having lower education level, having a medical insurance, being pedestrian or motorcyclist, being a blue-collar worker and having more severe injuries. The reported use of safety equipment was very low and did not have significant effect on the hospital charges and LOS. Conclusion: The study demonstrated that the hospital charges and LOS associated with RTI varied by age, gender, socio-economic status, insurance status, injury characteristics and health outcomes of the patients. The results of the study provide information that can be of importance in the planning and design of road traffic injury control strategies.
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| 13. |
- Haghparast-Bidgoli, Hassan, et al.
(author)
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Inequity in costs of seeking sexual and reproductive health services in India and Kenya
- 2015
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In: International Journal for Equity in Health. - : BioMed Central. - 1475-9276. ; 14
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Journal article (peer-reviewed)abstract
- Objective: This study aims to assess inequity in expenditure on sexual and reproductive health (SRH) services in India and Kenya. In addition, this analysis aims to measure the extent to which payments are catastrophic and to explore coping mechanisms used to finance health spending. Methods: Data for this study were collected as a part of the situational analysis for the "Diagonal Interventions to Fast Forward Enhanced Reproductive Health" (DIFFER) project, a multi-country project with fieldwork sites in three African sites; Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique), and Mysore in India. Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya) (n = 250). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income. Results: The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.02 to 6.2 % and 0.03-7.5 % in India and Kenya, respectively. There was a statistically significant difference in the proportion of spending on SRH services across income quintiles in both settings. In India, the poorest households spent two times, and in Kenya ten times, more on seeking care than the least poor households. The most common coping mechanisms in India and Kenya were "receiving [money] from partner or household members" (69 %) and "using own savings or regular income" (44 %), respectively. Conclusion: Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings such as India and Kenya. The large proportion of service users, particularly in India, relying on money received from family members to finance care seeking suggests that access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family - although this requires further study.
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| 14. |
- Haghparast-Bidgoli, Hassan
(author)
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Road traffic injuries in the context of rapid motorization : studies on access, provision and utilization of trauma care in Iran
- 2011
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Doctoral thesis (other academic/artistic)abstract
- Background: Iran has one of the highest traffic-related mortality and morbidity rates in the world. Evidence shows that improvements in trauma care can prevent a substantial number of road traffic deaths and disabilities. Aim: The overall aim of this thesis is to explore factors influencing access, provision and utilization of trauma care for road traffic injuries (RTIs) in Iran. Methods: The thesis is based on four studies. Study I is a national ecological study in order to assess if the distribution of pre-hospital trauma care resources reflects the needs in terms of traffic-related mortality and morbidity in different provinces in Iran. Inequality measures and correlation analysis were used in the analysis. In Study II, qualitative interviews were conducted with 15 health professionals to explore factors influencing the provision of pre-hospital trauma care for RTI victims. In Study III, qualitative interviews were conducted with 15 health professionals and 20 RTI victims to explore factors influencing an effective trauma care delivery at emergency departments (EDs). The grounded theory approach was used in both Study II and III. Study IV utilized the Iranian National Trauma Registry Database to assess hospital resource utilization (hospital charges and length of stay (LOS)) associated with RTIs in Iran and also to evaluate the association with the patients’ socio-demographic characteristics, insurance status and injury-related factors. Univariable and multivariable analysis were used in this study. Findings: There was no significant association between traffic-related mortality and morbidity and pre-hospital trauma care resources (I). Seven main factors that could hinder or facilitate an effective pre-hospital trauma care process were identified: administration and organization; staff qualifications and competences; availability and distribution of resources; communication and transportation; involved organizations; laypeople; and infrastructure (II). Lack of a systematic approach to providing trauma care at EDs emerged as the core category in Study III. Unclear national policies and poor organization of care at the ED were perceived as the main factors contributed to non-systematic approach but the contextual factors in the hospitals and those specific to the context of Iran also played a role. The mean (SD) total hospital charges and LOS for the patients were US$ 165 (US$ 290) and 6.8 days (8), respectively. Older age, being female, lower level of education, higher injury severity and longer LOS were associated with higher hospital charges. Longer LOS was associated with being male, lower education, having a medical insurance, being a farmer or a blue-collar worker and having more severe injuries (IV). Conclusion: Pre-hospital trauma care resources across the country were not distributed based on needs in terms of traffic-related mortality and morbidity. For the provision of trauma care, the studies identified that there is a lack of interaction and common understanding among different actors involved in the pre-hospital trauma care and a non-systematic approach as the main barrier to managing trauma patients in the EDs. The findings indicated that the hospital resource utilization associated with RTI victims is substantial and varied based on the victims’ socio-demographic characteristics, insurance status and injury-related factors. Both the pre-hospital and hospital organization, and interaction between them, need to be considered in order to reduce the high burden of RTIs in Iran.
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| 15. |
- Haghparast-Bidgoli, Hassan, et al.
(author)
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Socio-demographic and economics factors associated with suicide mortality in Iran, 2001-2010 : application of a decomposition model
- 2018
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In: International Journal for Equity in Health. - : Springer Science and Business Media LLC. - 1475-9276. ; 17:1, s. 1-7
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Journal article (peer-reviewed)abstract
- BACKGROUND: Suicide is a major global health problem, especially among youth. Suicide is known to be associated with a variety of social, economic, political and religious factors, vary across geographical and cultural regions. The current study aimed to investigate the effects of socioeconomic factors on suicide mortality rate across different regions in Iran.METHODS: The data on distribution of population and socio-economic factors (such as unemployment rate, divorce rate, urbanization rate, average household expenditure etc.) at province level were obtained from the Statistical Centre of Iran and the National Organization for Civil Registration. The data on the annual number of deaths caused by suicide in each province was extracted from the published reports of the Iranian Forensic Medicine Organization. We used a decomposition model to distinguish between spatial and temporal variation in suicide mortality.RESULTS: The average rate of suicide mortality was 5.5 per 100,000 population over the study period. Across the provinces (spatial variation), suicide mortality rate was positively associated with household expenditure and the proportion of people aged 15-24 and older than 65 years and was negatively associated with the proportion of literate people. Within the provinces (temporal variation), higher divorce rate was associated with higher suicide mortality. By excluding the outlier provinces, the results showed that in addition to the proportion of people aged 15-24 and older than 65, divorce and unemployment rates were also significant predictors of spatial variation in suicide mortality while divorce rate was associated with higher suicide mortality within provinces.CONCLUSION: The findings indicate that both spatial and temporal variations in suicide mortality rates across the provinces and over time are determined by a number of socio-economic factors. The study provides information that can be of importance in developing preventive strategies.
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| 16. |
- Kim, Sung Wook, et al.
(author)
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Socio-economic inequity in HIV testing in Malawi
- 2016
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In: Global Health Action. - : Informa UK Limited. - 1654-9716 .- 1654-9880. ; 9, s. 1-15
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Journal article (peer-reviewed)abstract
- BACKGROUND: Human immunodeficiency virus (HIV) is a significant contributor to Malawi's burden of disease. Despite a number of studies describing socio-economic differences in HIV prevalence, there is a paucity of evidence on socio-economic inequity in HIV testing in Malawi.OBJECTIVE: To assess horizontal inequity (HI) in HIV testing in Malawi.DESIGN: Data from the Demographic and Health Surveys (DHSs) 2004 and 2010 in Malawi are used for the analysis. The sample size for DHS 2004 was 14,571 (women =11,362 and men=3,209), and for DHS 2010 it was 29,830 (women=22,716 and men=7,114). The concentration index is used to quantify the amount of socio-economic-related inequality in HIV testing. The inequality is a primary method in this study. Corrected need, a further adjustment of the standard decomposition index, was calculated. Standard HI was compared with corrected need-adjusted inequity. Variables used to measure health need include symptoms of sexually transmitted infections. Non-need variables include wealth, education, literacy and marital status.RESULTS: Between 2004 and 2010, the proportion of the population ever tested for HIV increased from 15 to 75% among women and from 16 to 54% among men. The need for HIV testing among men was concentrated among the relatively wealthy in 2004, but the need was more equitably distributed in 2010. Standard HI was 0.152 in 2004 and 0.008 in 2010 among women, and 0.186 in 2004 and 0.04 in 2010 among men. Rural-urban inequity also fell in this period, but HIV testing remained pro-rich among rural men (HI 0.041). The main social contributors to inequity in HIV testing were wealth in 2004 and education in 2010.CONCLUSIONS: Inequity in HIV testing in Malawi decreased between 2004 and 2010. This may be due to the increased support to HIV testing by global donors over this period.
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| 17. |
- Kittipittayakorn, Cholada
(author)
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Enhancing the Performance and Efficiency of Healthcare Systems Using Industrial Economic Principles and Statistical Techniques
- 2024
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Doctoral thesis (other academic/artistic)abstract
- Optimizing healthcare systems has become more crucial in recent years due to escalating healthcare demands and economic constraints. This dissertation employed industrial economic principles and advanced statistical methods to analyze the performance and efficiency of healthcare systems in Europe. The study provided a detailed analysis of how healthcare systems can enhance service delivery and maintain cost-effectiveness by integrating industrial economic theories with empirical data. The dissertation was organized into a series of analyses, each focusing on different aspects of healthcare system performance, resource allocation, operational efficiency, and forecasting future health demands, as well as evaluating the accuracy of these forecasting models. Statistical techniques such as time series and multilevel regression analyses were used to examine the interplay between healthcare resources, healthcare systems, and health outcomes across European nations. The two main healthcare models in Europe, the Beveridge and Bismarck models, were compared in terms of performance, efficiency, and resource allocation. The main findings revealed that effective resource allocation and efficient management practices can significantly enhance the performance of healthcare systems. The study indicated that a healthcare system's efficiency depends on its ability to adjust resource allocation to changes in demographic and economic conditions. Additionally, this dissertation forecasted future demands for healthcare services, social security benefits, and pensions by incorporating macro-level determinants such as economic growth, unemployment rates, and population density into the forecasting models. The accuracy of these models provided valuable insights for policymakers to effectively plan for future healthcare, social security, and pension needs. Moreover, this dissertation employed an economic evaluation to compare the cost-effectiveness of Beveridge-type and Bismarck-type healthcare systems over the past twenty years. An effectiveness ratio was applied to measure the relationship between inputs (medical spending) and outputs (health outcomes). These effectiveness ratios demonstrated which healthcare system yields better health outcomes for each dollar spent. Furthermore, the findings indicated that the efficiency of healthcare systems varies from country to country, highlighting the challenges of adopting a universal approach to healthcare policy. This dissertation contributes to the academic field by demonstrating how industrial economic principles can be applied to improve the performance and efficiency of healthcare systems. It offered a framework for evaluating healthcare performance and efficiency, which can inform future reforms to achieve sustainable, high-quality healthcare services. This study promotes a dynamic approach to healthcare planning that adapts to technological advancements and demographic changes to enhance population health.
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| 18. |
- Lozano, Rafael, et al.
(author)
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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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In: The Lancet. - : Elsevier. - 1474-547X .- 0140-6736. ; 392:10159, s. 2091-2138
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Journal article (peer-reviewed)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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| 19. |
- Pulkki-Brännström, Anni-Maria, et al.
(author)
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Participatory learning and action cycles with women s groups to prevent neonatal death in low-resource settings : A multi-country comparison of cost-effectiveness and affordability
- 2021
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In: Health Policy and Planning. - : Oxford University Press. - 0268-1080 .- 1460-2237. ; 16:35
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Journal article (peer-reviewed)abstract
- WHO recommends participatory learning and action cycles with women's groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range: $61-$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from $135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women's groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations.
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| 20. |
- Ramani-Chander, Anusha, et al.
(author)
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Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries : protocol for a longitudinal mixed-methods study
- 2022
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In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 12
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Journal article (peer-reviewed)abstract
- Introduction: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions.Methods and analysis: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (T-P), initiation of implementation (T-0) and 1-year postinitiation (T-1). We will extract project-related data from secondary documents at T-P and conduct multistakeholder qualitative interviews to gather data at T-0 and T-1. We will undertake descriptive statistical analysis of T-P data and analyse T-0 and T-1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks.Ethics and dissemination: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.
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| 21. |
- Rinaldi, Giulia, et al.
(author)
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Cost effectiveness of HIV and sexual reproductive health interventions targeting sex workers : A systematic review
- 2018
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In: Cost Effectiveness and Resource Allocation. - : Springer Science and Business Media LLC. - 1478-7547. ; 16:1
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Research review (peer-reviewed)abstract
- Background: Sex workers have high incidences of HIV and other sexually transmitted diseases. Although, interventions targeting sex workers have shown to be effective, evidence on which strategies are most cost-effective is limited. This study aims to systematically review evidence on the cost-effectiveness of sexual health interventions for sex workers on a global level. It also evaluates the quality of available evidence and summarizes the drivers of cost effectiveness. Methods: A search of published articles until May 2018 was conducted. A search strategy consisted of key words, MeSH terms and other free text terms related to economic evaluation, sex workers and sexual and reproductive health (SRH) was developed to conduct literature search on Medline, Web of Science, Econlit and the NHS Economic Evaluation Database. The quality of reporting the evidence was evaluated using the CHEERS checklist and drivers of cost-effectiveness were reported. Results: Overall, 19 studies met the inclusion criteria. The majority of the studies were based in middle-income countries and only three in low-income settings. Most of the studies were conducted in Asia and only a handful in Sub-Saharan Africa and Latin America. The reviewed studies mainly evaluated the integrated interventions, i.e. interventions consisted a combination of biomedical, structural or behavioural components. All interventions, except for one, were highly cost-effective. The reporting quality of the evidence was relatively good. The strongest drivers of cost-effectiveness, reported in the studies, were HIV prevalence, number of partners per sex worker and commodity costs. Furthermore, interventions integrated into existing health programs were shown to be most cost-effective. Conclusion: This review found that there is limited economic evidence on HIV and SRH interventions targeting sex workers. The available evidence indicates that the majority of the HIV and SRH interventions targeting sex workers are highly cost-effective, however, more effort should be devoted to improving the quality of conducting and reporting cost-effectiveness evidence for these interventions to make them usable in policy making. This review identified potential factors that affect the cost-effectiveness and can provide useful information for policy makers when designing and implementing such interventions.
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| 22. |
- Skordis-Worrall, Jolene, et al.
(author)
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Protocol for the economic evaluation of a community-based intervention to improve growth among children under two in rural India (CARING trial)
- 2016
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In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 6:11
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Journal article (peer-reviewed)abstract
- INTRODUCTION: Undernutrition affects ∼165 million children globally and contributes up to 45% of all child deaths. India has the highest proportion of global undernutrition-related morbidity and mortality. This protocol describes the planned economic evaluation of a community-based intervention to improve growth in children under 2 years of age in two rural districts of eastern India. The intervention is being evaluated through a cluster-randomised controlled trial (cRCT, the CARING trial).METHODS AND ANALYSIS: A cost-effectiveness and cost-utility analysis nested within a cRCT will be conducted from a societal perspective, measuring programme, provider, household and societal costs. Programme costs will be collected prospectively from project accounts using a standardised tool. These will be supplemented with time sheets and key informant interviews to inform the allocation of joint costs. Direct and indirect costs incurred by providers will be collected using key informant interviews and time use surveys. Direct and indirect household costs will be collected prospectively, using time use and consumption surveys. Incremental cost-effectiveness ratios (ICERs) will be calculated for the primary outcome measure, that is, cases of stunting prevented, and other outcomes such as cases of wasting prevented, cases of infant mortality averted, life years saved and disability-adjusted life years (DALYs) averted. Sensitivity analyses will be conducted to assess the robustness of results.ETHICS AND DISSEMINATION: There is a shortage of robust evidence regarding the cost-effectiveness of strategies to improve early child growth. As this economic evaluation is nested within a large scale, cRCT, it will contribute to understanding the fiscal space for investment in early child growth, and the relative (in)efficiency of prioritising resources to this intervention over others to prevent stunting in this and other comparable contexts. The protocol has all necessary ethical approvals and the findings will be disseminated within academia and the wider policy sphere.TRIAL REGISTRATION NUMBER: ISRCTN51505201; pre-results.
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