Addressing London's modern urban health challenges: learning from other global cities.

Around 150 cities have emerged as notable at a global scale. With a global population of fewer than 12%, they generate 46% of world gross domestic product. There is growing interest in how cities can accelerate health improvements through wider social and economic collaboration. A team led by Public Health England in London visited counterparts in New York City and Paris to examine how city health leaders addressed public health challenges. The three cities have similar health challenges but different legal, political and fiscal resources for promoting and protecting health. Consequently, there is no single model that every city could adopt. Organizational structures, interpersonal relationships and individual skills can play an important part in effective delivery of better city health. Lack of access to published evidence on how practice has been influenced by city health policies hampers learning between cities. There is little easily comparable data to guide those interested in such learning. Municipal governments are ideally situated to join researchers to fill this gap in the literature.

Smart dental practice: capitalising on smart mobile technology.

To keep pace with consumer adoption of smart mobile devices, such as smartphones and tablets, and the applications ('apps') developed for these devices, dental professionals should consider how this technology could be used to simultaneously improve both patient service experiences and dental practice management. Using U-Commerce as a theoretical lens, this article discusses the potential value of smart mobile technology to the dental practice context, with a particular focus on the unique and customisable capabilities of apps. To take full advantage of this technology, a process is outlined for identifying and designing bespoke dental apps that takes into account the unique advantages of these devices. Dental practices, with increasing financial and competitive pressures, may improve the efficiency and profitability of operations and better manage patients, employees and stakeholders by integrating smart mobile technology.

National decision-making on adopting new vaccines: a systematic review.

In recent years numerous new vaccines have been developed, offering potential reductions in the morbidity and mortality caused by a range of diseases. This has led to increased interest in decision-making about the adoption of new vaccines into national immunization programmes. This paper aims to systematically review the literature on national decision-making around the adoption of new vaccines. A thematic framework was developed inductively through analysis of the vaccine adoption decision-making frameworks included in the review. This thematic framework was then applied to the remaining studies included in the review. In total, 85 articles were included in the review: 39 articles describing examples of vaccine adoption decision-making, 26 presenting vaccine decision-making frameworks, 21 empirical articles of decision-making relating to vaccine adoption and 19 theoretical essays. An analysis of vaccine adoption decision-making frameworks identified nine broad categories of criteria: the importance of the health problem; vaccine characteristics; immunization programme considerations; acceptability; accessibility, equity and ethics; financial/economic issues; impact; alternative interventions and the decision-making process. The quality of the empirical studies was varied. Although some of the issues included in the frameworks were similar to those considered in the studies, there were also some notable differences. On the whole, the frameworks were more comprehensive than the studies, including a greater range of criteria. The existing literature provides a good foundation for further research into vaccine adoption decision-making. The current review, in pulling together what is already known and by identifying strengths, weaknesses and gaps in the existing evidence base, aims to encourage a more focused and rigorous approach to the topic in future. This could help to identify the most appropriate ways to develop vaccine adoption decision-making, so as to improve decisions and, ultimately, health outcomes.

Cost-effectiveness of artesunate for the treatment of severe malaria.

OBJECTIVE: To explore the cost-effectiveness of artesunate against quinine based principally on the findings of a large multi-centre trial carried out in Southeast Asia. METHODS: Trial data were used to compare mortality of patients with severe malaria, treated with either artesunate or quinine. This was combined with retrospectively collected cost data to estimate the incremental cost per death averted with the use of artesunate instead of quinine. RESULTS: The incremental cost per death averted using artesunate was approximately 140 USD. Artesunate maintained this high level of cost-effectiveness also when allowing for the uncertainty surrounding the cost and effectiveness assessments. CONCLUSION: This analysis confirms the vast superiority of artesunate for treatment of severe malaria from an economic as well as a clinical perspective.

Changing the first line drug for malaria treatment--cost-effectiveness analysis with highly uncertain inter-temporal trade-offs.

Access to effective treatment would substantially reduce the burden of malaria in sub-Saharan Africa, but resistance to chloroquine, the most commonly used first line drug, is now widespread. There has been considerable debate over the level of chloroquine resistance at which a new first line drug should be adopted. Two issues make this an extremely complex decision: it involves trade-offs in costs and health outcomes over time; and many of the parameters are uncertain. A modelling approach was identified as appropriate for addressing these issues. The costs and effects of changing from chloroquine to sulphadoxine-pyrimethamine (SP) as the first line drug were modelled over 10 years, allowing for growth in drug resistance. Probabilistic sensitivity analysis was used to allow for the high levels of parameter uncertainty. The optimal year of switch was highly dependent on both empirical values, such as initial resistance and resistance growth rates, and on subjective values, such as the time preferences of policy-makers. It was not possible to provide policy-makers with a definitive threshold resistance level at which to switch, but the model can be used as an analytical tool to structure the problem, explore trade-offs, and identify areas for which data are lacking.

The cost-effectiveness of antenatal malaria prevention in sub-Saharan Africa.

Antimalarial chemoprophylaxis during pregnancy significantly increases the birth weight of babies born to primigravidae, but coverage in sub-Saharan Africa is very limited. This analysis assessed whether increasing coverage is justified on cost-effectiveness grounds. A standardized modeling framework was used to estimate ranges for the cost per discounted year of life lost averted by weekly chloroquine chemoprophylaxis and intermittent sulfadoxine-pyrimethamine (SP) treatment for primigravidae in an operational setting with moderate to high malaria transmission. The SP regimen was found to be more cost-effective than the chloroquine regimen, because of both lower costs and higher compliance. Both regimens appear to be a good value for money in comparison with other methods of malaria control and based on rough cost-effectiveness guidelines for low-income countries, even with high levels of drug resistance. However, extending the SP regimen to all gravidae and increasing the number of doses per pregnancy could make the intervention significantly less cost-effective.

Cost-effectiveness of malaria control in sub-Saharan Africa.

BACKGROUND: Information on the cost-effectiveness of malaria control is needed for the WHO Roll Back Malaria campaign, but is sparse. We used mathematical models to calculate cost-effectiveness ratios for the main prevention and treatment interventions in sub-Saharan Africa. METHODS: We analysed interventions to prevent malaria in childhood (insecticide-treated nets, residual spraying of houses, and chemoprophylaxis) and pregnancy (chloroquine chemoprophylaxis and sulfadoxine-pyrimethamine intermittent treatment), and to improve malaria treatment (improved compliance, improved availability of second-line and third-line drugs, and changes in first-line drug). We developed models that included probabilistic sensitivity analysis to calculate ranges for the cost per disability-adjusted life year (DALY) averted for each intervention in three economic strata. Data were obtained from published and unpublished sources, and consultations with researchers and programme managers. FINDINGS: In a very-low-income country, for insecticide treatment of existing nets, the cost-effectiveness range was US$4-10 per DALY averted; for provision of nets and insecticide treatment $19-85; for residual spraying (two rounds per year) $32-58; for chemoprophylaxis for children $3-12 (assuming an existing delivery system); for intermittent treatment of pregnant women $4-29; and for improvement in case management $1-8. Although some interventions are inexpensive, achieving high coverage with an intervention to prevent childhood malaria would use a high proportion of current health-care expenditure. INTERPRETATION: Cost-effective interventions are available. A package of interventions to decrease the bulk of the malaria burden is not, however, affordable in very-low-income countries. Coverage of the most vulnerable groups in Africa will require substantial assistance from external donors.

PIP: This paper examines the cost-effectiveness of malaria control using an innovative modeling approach based on probabilistic sensitivity analysis in sub-Saharan Africa. The variables included in the study were interventions for preventing malaria in childhood (insecticide-treated nets, residual spraying of houses and chemoprophylaxis), preventing malaria in pregnancy (chloroquine chemoprophylaxis and sulfadoxine-pyrimethamine intermittent treatment), and improving treatment for uncomplicated malaria (better compliance, improved availability of second- and third-line drugs, and changes in first-line drugs). Effectiveness was calculated in terms of disability-adjusted life years (DALY) formula. The cost data were obtained through published and unpublished literature, program budgets, price catalogues, and consultation with researchers and program managers. Results showed that in a very-low-income country, the cost-effectiveness range of insecticide-treated nets was US$19-85. If only insecticide treatment was required, the range would be decreased to US$4-10 per DALY averted. Cost effectiveness was $32-58 for residual spraying (two rounds per year), $3-12 for children's chemoprophylaxis, $4-29 for intermittent treatment of pregnant women, and $1-8 for improvement in case management. Cost-effectiveness analysis helped identify interventions that would result in the effective use of resources, but information on total costs was also needed in order to assess affordability. Furthermore, coverage of the most vulnerable groups in Africa would require substantial assistance from external donors.

The evidence base on the cost-effectiveness of malaria control measures in Africa.

This review assesses the range and quality of the evidence base on the cost-effectiveness of malaria prevention and treatment in sub-Saharan Africa. Fourteen studies are reviewed, covering insecticide-treated nets, residual spraying, chemoprophylaxis for children, chemoprophylaxis or intermittent treatment for pregnant women, a hypothetical vaccine, and changing the first line drug for treatment. The available evidence provides some guidance to decision-makers. However, the potential to inform policy debates is limited by the gross lack of information on the costs and effects of many interventions, the very small number of cost-effectiveness analyses available, the lack of evidence on the costs and effects of packages of measures, and the problems in generalizing or comparing studies that relate to specific settings and use different methodologies and outcome measures.

PIP: This article reviews the range and quality of the evidence based on the cost-effectiveness of malaria prevention and treatment in sub-Saharan Africa. About 14 studies were analyzed, covering insecticide-treated nets, residual spraying, chemoprophylaxis for children, chemoprophylaxis or intermittent treatment for pregnant women, a hypothetical vaccine, and changing the first line drug for treatment. Results of the analyses demonstrate that highly cost-effective interventions exist for both prevention and treatment; that approaches to improving treatment are likely to be highly cost-effective; and that given the uncertainty and variation involved, the choice between childhood preventive interventions is not clear-cut due to the considerable overlap in their cost-effectiveness ranges. The review also cites several challenges in using cost-effectiveness estimates for policy-making. In conclusion, evidence from economic evaluations can assist policy-makers in identifying interventions representing the best value for money. Available studies provide some guidance to decision-makers. However, the current potential of economic evaluation to inform policy debates is limited by: the gross lack of information on the costs and effects of many interventions; the very small number of cost-effectiveness analyses available; the lack of evidence on the costs and effects of packages of measures; and the problems generalizing or comparing studies that relate to specific settings and use different methodologies and outcome measures.

The cost of the district hospital: a case study in Malawi.

Described in an analysis of the cost to the Ministry of Health of providing district health services in Malawi, with particular emphasis on the district hospital. District resource allocation patterns were assessed by carefully disaggregating district costs by level of care and hospital department. A strikingly low proportion of district recurrent costs was absorbed by salaries and wages (27-39%, depending on the district) and a surprisingly high proportion by medical supplies (24-37%). The most expensive cost centre in the hospital was the pharmacy. A total of 27-39% of total recurrent costs were spent outside the hospital and 61-73% on hospital services. The secondary care services absorbed 40-58% of district recurrent costs. Unit costs by hospital department varied considerably by district, with one hospital being consistently the most expensive and another the cheapest. A total of 3-10 new outpatients could be treated for the average cost of 1 inpatient-day, while 34-55 could be treated for the average cost of 1 inpatient. The efficiency of hospital operations, the scope for redistributing resources districtwide, and the costing methodology are discussed.

PIP: A detailed analysis of costs in district hospitals in Malawi illustrates that estimation is possible, in spite of the lack of separation between rural facility and hospital expenditures, the poor availability of salary and wage information, and the difficulty in obtaining activity statistics. Routine analysis could be performed with some minor adjustments in the current accounting system. The analysis provided meaningful efficiency measures of total unit costs per outpatient, per inpatient, per inpatient day, and cost of food per inpatient day. Results of the examination of allocation of resources showed that resource utilization in staff time and drugs varied widely between different hospitals and between inpatients and outpatients. Resources should not be apportioned based on an assumed ratio of cost per outpatient to cost per inpatient day. This analysis was conducted among a range of types of district hospitals in order to allocate all costs to departments that provided direct patient care. Diagnostic and support departments were separated, since they provide services to direct care departments. An estimation procedure was used to apportion costs between hospital departments and between hospital and rural facilities. The calculation of the costs of drugs and medical supplies was reflective of annual expenditure and hospital order records from the pharmacy and monthly requisitions from health centers. Total cost included the prices charges at the central medical store and the quantities obtained regardless of whether these were donated. Vaccine costs included cost, insurance, and freight. Departmental records and vehicle logbooks provided data on x-rays and vehicle costs. Salaries distinguished between senior and junior staff. The results revealed low recurrent costs for salaries and wages (27-39%) and high costs for buildings and equipment (46-57%). Costs of drugs and medical supplies accounted for 24-37% and vehicle costs accounted for 11-18% of total recurrent costs. By department, the pharmacy was the most expensive (25-38% of total recurrent costs). Rural services absorbed 27-39% of recurrent costs. Hospital costs reflected primary health care services as well as secondary care services, which were 40-58% of district recurrent costs. The study identified areas where improvements could be made in time allocation and redistribution of resources.

The operational costs of spraying residual insecticides: a case-study from Nepal.

Little attention has been paid to the cost implications of different insecticides for malaria control, particularly to the local (non-insecticide) costs. This study in Nepal explored the significance of operational costs in relation to insecticide cost and examined the extent to which operational costs varied for DDT, malathion and Ficam. A detailed analysis was done of costs relating to spraying, transport and safety. The study found that the operational cost differences were relatively small in comparison with the costs of the chemicals themselves and the cost of transporting them to Nepal, though DDT and Ficam had significantly lower operational costs than malathion. Operational costs were paid mainly by the Nepalese government and insecticide and external freight costs by donors.

Can nutritional criteria help predict outcome in hospitalized patients?

The following nutritional criteria were evaluated for their usefulness in predicting outcome in a prospective study of 66 randomly selected hospitalized patients with a variety of diagnoses: total protein, albumin, and transferrin concentrations in serum, creatinine height index, weight height index, phenylalanine/tyrosine ratio (Phe/Tyr), concentration of branched-chain amino acids in serum, and ratio of essential to nonessential amino acids in serum. The cases were followed from admission to discharge, and were classified into the following three groups: 43 "well"; 14 with "complications" but recovered; and nine "dead". Statistical analysis (Scheffe's s-test) demonstrated the means of "well" and "dead" groups to be different for total protein, albumin, transferrin, and Phe/Tyr. In individual patients the nutritional criteria, even for those with fatal outcome, were poor indicators of outcome. These nutritional criteria are useful in identifying hospitalized groups that are at maximum risk (i.e., death), but are much less useful for individual patients.