The health impact of economic sanctions.

Embargoes and sanctions are tools of foreign policy. They can induce a decline in economic activity in addition to reducing imports and untoward health effects can supervene, especially among older persons and those with chronic illnesses. Often, violations of the rights of life, health, social services, and protection of human dignity occur among innocent civilians in embargoed nations. This paper examines the effects of embargoes and sanctions against several nations, and calls for studies to determine ways in which economic warfare might be guided by the rule of humanitarian international law, to reduce the effects on civilians. It suggests that the ability to trade in exempted goods and services should be improved, perhaps by establishing uniform criteria and definitions for exemptions, operational criteria under which sanctions committees might function, and methods for monitoring the impact of sanctions on civilian populations in targeted states, particularly with regard to water purity, food availability, and infectious-disease control. Prospective studies are advocated, to generate the data needed to provide better information and monitoring capacity than presently exists.     

The health and economic impact of dengue in Latin America

In the last two decades, all countries in the tropical regions of Latin America have experienced marked increases in the incidence of both classic dengue and dengue hemorrhagic fever. Major risk factors for the occurrence of dengue in the region, as well as some regional peculiarities in its clinical expression, such as the extensive involvement of older age groups, have been defined. While little information exists on the economic impact of dengue in the region in terms of disease burden, the estimated loss associated with the disease is on the same order of magnitude as tuberculosis, sexually transmitted diseases (excluding HIV/AIDS), Chagas disease, leishmaniasis, or intestinal helminths. Therefore, similar priority should be given in the allocation of resources for dengue research and control. Data on cost-efficacy and cost-benefit analysis of dengue control programs in Latin America are scarce; however, the cost per DALY averted by control programs during endemic periods appears low, as compared to other mosquito-borne diseases like yellow fever, leishmaniasis, or malaria. Additionally, the cost-benefit ratio of the control programs has proven to be positive.     

The impact of inclusion criteria in health economic assessments

The debate surrounding whether the findings of efficacy studies are applicable to real-world treatment situations is ongoing. The issue of lack of applicability due to a lack of clinical heterogeneity could be addressed by employing less restrictive inclusion criteria. Given that health economic assessments based on cost-effectiveness measures are required by many governments and insurance providers, the impact of this choice may be far reaching. The objective of this article was to explore the use of a pilot study to examine the impact of inclusion criteria on cost-effectiveness results and clinical heterogeneity. A health economic assessment was conducted using QRISK®2 and simulation modelling of different population groups within the pilot study in Lower Austria. Patients were referred by their family physicians to ‘Active Prevention’ (Vorsorge Aktiv), a community-based lifestyle intervention focused on exercise and nutritional programmes. Cardiovascular risk factors were recorded before and after the intervention and translated to cardiovascular events. As expected, enforcing restrictive inclusion criteria produced stronger and more irrefutable computations — in the expected number of events, the number of deaths, the incremental cost per life-year saved and in the 95% confidence interval. These findings provide insight into the issues surrounding clinical heterogeneity and the need for restrictive inclusion criteria. This is not a full health economic assessment of the intervention. While inclusion criteria provide stronger results by limiting populations to those who would benefit the most, they must be enforced, both within and outside the clinical trial setting. Enforcement has costs, both monetary and arising from unintended negative consequences of enforcement mechanisms. All these considerations will affect the results realized by the payer organization. A pilot study can reveal whether an intervention may be cost effective ‘enough’ without restrictive inclusion criteria and can enable researchers to search for population subgroups in which the intervention remains cost effective. When the pilot study does not indicate sufficiently strong cost-effectiveness results, the broader trade-offs between clinical heterogeneity and the strength of the submission package to the reimbursement agency can be discussed by all parties. Payer concerns about the ability to generalize the results beyond the clinical trial can also be discussed at this time. Applicability then depends on the ability to enforce inclusion criteria similar to those used in the trials in the real world.     

The impact of public performance reporting on health plan selection and switching: A systematic review and meta-analysis

The dissemination of public performance reporting (PPR) cards aims to increase utilisation of information on quality of care by consumers when making health plan choices. However, evaluations of PPR cards show that they have little impact on consumer choices. The aim of this study is to undertake a systematic review and meta-analysis of the impact of PPR cards in promoting health plan selection and switching between health plans by consumers. We searched five online databases and eight previous reviews for studies reporting findings on PPR and health plans. We extracted data and conducted quality assessment, systematic critical synthesis and meta-analyses on the included studies. We identified eight relevant health plan articles related to selection (n?=?2), switching (n?=?4), selection/switching (n?=?2). Meta-analyses showed that PPR was associated with an improvement in health plan selection and a very small deterioration in switching health plans though these changes were not statistically significant. Differences were observed between employer-sponsored health insurance and Medicare/Medicaid insurance. Given the small number of studies included in the review, further research examining the impact of PPR on health plan selection and switching in a range of insurance markets is required.     

A rural hospital's impact on a community's economic health.

This research illustrates the importance of a hospital to the economic health of a community. A simulation model of a rural community in Oklahoma is used to demonstrate how the implementation of the DRG reimbursement policy has impacted a rural community, and to project how the closing of the hospital would impact the economy of the community. The results indicate that rural hospitals play a vital role in the economics of their communities. The closing of a rural hospital has a devastating impact on the community, while the DRG reimbursement policy has had a significant impact on the community.     

Climate change and vector-borne diseases: an economic impact analysis of malaria in Africa

A semi-parametric econometric model is used to study the relationship between malaria cases and climatic factors in 25 African countries. Results show that a marginal change in temperature and precipitation levels would lead to a significant change in the number of malaria cases for most countries by the end of the century. Consistent with the existing biophysical malaria model results, the projected effects of climate change are mixed. Our model projects that some countries will see an increase in malaria cases but others will see a decrease. We estimate projected malaria inpatient and outpatient treatment costs as a proportion of annual 2000 health expenditures per 1,000 people. We found that even under minimal climate change scenario, some countries may see their inpatient treatment cost of malaria increase more than 20%.     

The economic crisis and its impact on health and health care in Latin America and the Caribbean

The economic crisis that struck most Latin American and Caribbean countries beginning in 1982 has caused sharp reductions in domestic investment and in imports; domestic consumption has been less affected, while public sector spending has responded in different degrees in different countries. In general, public spending on health decreased, sometimes quite dramatically, but some countries were able to maintain the real value of noninvestment spending for health by central governments. It is much harder to tell what may have happened to output of health services, and still harder to know how health status has been affected. Scattered evidence suggests two conclusions. First, worsened economic conditions can seriously damage health status, with effects on infant mortality and on the patterns of disease and death, especially for children. Second, these repercussions do not have to occur, and public programs designed specifically to maintain basic health services and to assure adequate nutrition are effective in offsetting the worst consequences of economic hardship.     

World health dilemmas: Orphan and rare diseases,orphan drugs and orphan patients

According to global annual estimates hunger/malnutrition is the major cause of death (36 of 62 million). Cardiovascular diseases and cancer (5.44 of 13.43 million) are the major causes of death in developed countries, while lower respiratory tract infections, human immunodeficiency virus infection/acquired immunodeficiency syndrome, diarrhoeal disease, malaria and tuberculosis (10.88 of 27.12 million) are the major causes of death in developing countries with more than 70% of deaths occurring in children. The majority of approximately 800 million people with other rare diseases, including 100000 children born with thalassaemia annually receive no treatment. There are major ethical dilemmas in dealing with global health issues such as poverty and the treatment of orphan and rare diseases. Of approximately 50000 drugs about 10% are orphan drugs, with annual sales of the latter approaching 100 billion USD. In comparison, the annual revenue in 2009 from the top 12 pharmaceutical companies in Western countries was 445 billion USD and the top drug, atorvastatin, reached 100 billion USD. In the same year, the total government expenditure for health in the developing countries was 410 billion USD with only 6%-7% having been received as aid from developed countries. Drugs cost the National Health Service in the United Kingdom more than 20 billion USD or 10% of the annual health budget. Uncontrollable drug prices and marketing policies affect global health budgets, clinical practice, patient safety and survival. Fines of 5.3 billion USD were imposed on two pharmaceutical companies in the United States, the regulatory authority in France was replaced and clinicians were charged with bribery in order to overcome recent illegal practises affecting patient care. High expenditure for drug development is mainly related to marketing costs. However, only 2 million USD was spent developing the drug deferiprone (L1) for thalassaemia up to the stage of multicentre clinical trials. The criteria for drug development, price levels and use needs to be readdressed to improve drug safety and minimise costs. New global health policies based on cheaper drugs can help the treatment of many categories of orphan and rare diseases and millions of orphan patients in developing and developed countries.     

The impact of the 1997-98 East Asian economic crisis on health and health care in Indonesia

This article identifies the effects of the 1997-98 East Asian economic crisis on health care use and health status in Indonesia. The article places the findings in the context of a framework showing the complex cause and effect relationships underlying the effects of economic downturns on health and health care. The results are based on primary analysis of Indonesian household survey data and review of a wide range of sources from the Indonesian government and international organizations. Comparisons are drawn with the effects of the crisis in Thailand. The devaluation of the Indonesian currency, the Rupiah, led to inflation and reduced real public expenditures on health. Households' expenditures on health also decreased, both in absolute terms and as a percentage of overall spending. Self-reported morbidity increased sharply from 1997 to 1998 in both rural and urban areas of Indonesia. The crisis led to a substantial reduction in health service utilization during the same time period, as the proportion of household survey respondents reporting an illness or injury that sought care from a modern health care provider declined by 25%. In contrast to Indonesia, health care utilization in Thailand actually increased during the crisis, corresponding to expansion in health insurance coverage. The results suggest that social protection programmes play a critical role in protecting populations against the adverse effects of economic downturns on health and health care.     

Valuing health using EQ‐5D: The impact of chronic diseases on the stock of health

Chronic diseases strongly affect individuals' health status. In aggregate terms, this impact is reflected by the stock of health, which measures the amount of health of a population in a given period of time. The objectives of this study were to measure the relative burden of chronic illnesses by assessing health‐related quality of life using the EQ‐5D‐5L instrument, to rank diseases according to their associations with the stock of health, and to calculate the stock of health of the Spanish population and the amount of health loss attributable to each chronic disease from a social perspective. Data were gathered from the Spanish Health Survey (ENSE 2011–2012, N = 20,587). A population weighted least squares model was used. Chronic diseases represent 19.19% of the stock of health losses in Spain compared with a country free from those diseases. In Spain, the stock of health in 2011 was 31.86 million units on the visual analog scale. The diseases with the strongest impact in terms of loss of stock of health at the individual level were mental illness and embolism, stroke, or cerebral hemorrhage. Collectively, the diseases with the largest impact included osteoarthritis, arthritis, or rheumatism; chronic back pain; and high blood pressure.     

The health and economic burden of pertussis in Canada: A microsimulation study

BackgroundDespite excellent vaccine coverage, pertussis persists in Canada, with high incidence during recent outbreaks and non-negligible incidence in non-outbreak years. While Canadian pertussis incidence is well-characterized, the full health and economic impact of pertussis have not been examined in Canada. We estimated age-specific life years (LYs) and quality-adjusted life years (QALYs) lost, and costs due to pertussis in Ontario, Canada, using a model-based approach.MethodsWe developed a microsimulation model to simulate pertussis natural history. Daily probabilities of pertussis complications, hospitalizations, and disease sequelae as well as utilities and costs for health states were literature-derived. A healthcare payer perspective was used with a lifetime time horizon. Model outcomes were compared to those from a model with no pertussis health states. Probabilistic sensitivity analyses were used to generate distributions for estimates. Economic burden was estimated by multiplying case cost estimates by annual age-specific incidence.ResultsOverall, LYs lost per pertussis case was low, with negligible LYs lost in those aged >4 years. Infants (<6 months) had the greatest mean QALY loss per case (0.58), while adults lost only 0.05 QALYs per case. Infants experienced the greatest mean cost per case of $22,768 (95% CI: 21,144–23,406). Case costs generally declined with age, but increased in seniors (aged 65+) with mean cost of $1920 (95% CI: 1800–2033). Based on historic age-specific incidence, pertussis costs the Ontario healthcare system approximately $7.6–$21.5 M annually. In total economic cost estimates with QALYs valued at 1xGDP (3xGDP) per capita, the net impact of pertussis in Ontario was estimated at $21.7–$66.5 M annually ($50.0–$156.3 M). For all of Canada, total economic costs were estimated at $79.6–$241.3 M ($187.5–$580.5 M) annually.ConclusionThe health and economic consequences of pertussis persistence are substantial and highlight the need for improved control strategies.     

Childhood residential mobility and health outcomes: A meta-analysis

This study assesses the association between childhood residential mobility and health-related outcomes by way of a meta-analysis of studies published between 1989 and 2020. The sample includes 844 effect sizes from 64 unique studies. The results point to a negative association (small to medium) between childhood mobility and health. This association is contingent upon the type of health outcome studied, age at outcome assessment, age at moving, and frequency of moves. The major confounders of this association are parental SES, parental marital status, ethnicity, and co-occurring childhood adversities. The implications for future research are discussed.     

The impact of the economic crisis and the US embargo on health in Cuba.

OBJECTIVES: This paper examines the combined effects of a severe economic decline since 1989 and a tightening of the US embargo in 1992 on health and health care in Cuba. METHODS: Data from surveillance systems for nutrition, reportable diseases, and hospital diagnoses were reviewed. These sources were supplemented with utilization data from the national health system and interviews with health leaders. RESULTS: Changes in Cuba include declining nutritional levels, rising rates of infectious diseases and violent death, and a deteriorating public health infrastructure. But despite these threats, mortality levels for children and women remain low. Instead, much of the health impact of the economic decline of Cuba has fallen on adult men and the elderly. CONCLUSIONS: To be consistent with international humanitarian law, embargoes must not impede access to essential humanitarian goods. Yet this embargo has raised the cost of medical supplies and food Rationing, universal access to primary health services, a highly educated population, and preferential access to scarce goods for women and children help protect most Cubans from what otherwise might have been a health disaster.     

Correction: Emotional impact of screening: A systematic review and meta-analysis

The experiences of the past 10 years have shown that it is feasible to treat HIV infected patients with ART even in severely resource constrained settings. Achieving the levels of antiretroviral coverage necessary to impact the course of the HIV epidemic remains a challenge and antiretroviral therapy coverage in most nations remains short of even current recommendations. Though treatment as prevention and seek, test, treat and retain strategies are attractive, realization of the benefits of these strategies will require the ability to successfully engage key hard to reach populations such as sex workers. The successes engaging these populations in research settings as seen in the article by Huet et al are encouraging, however key questions remain regarding the sustainability of these efforts as patients are transitioned back to national HIV control programs, many of which are struggling even to maintain the current panels in care in the face declining external funding for HIV care. To achieve the critical goals of increasing treatment uptake and retention and thereby curtail the epidemic of HIV, advocacy from both medicine and public health providers will be critical to generate the support and political will necessary to sustain and enhance the necessary HIV care programs worldwide.