Malaria prevention in The Gambia: patterns of expenditure and determinants of demand at the household level.

OBJECTIVE: To provide a better understanding of (1) the amounts households in The Gambia spend on a wide variety of malaria prevention measures, (2) how expenditure fluctuates throughout the year and (3) the main determinants of expenditure. METHODS: A random sample of 1700 households from the Farafenni region were interviewed about their expenditure on malaria prevention over the past 2 weeks. Interviews were staggered over 12 months. Expenditure was measured for bed nets, treating and repairing bed nets, aerosols, coils, indoor spraying, smoke and other prevention strategies such as drinking herbs and cleaning the outside environment. Results Expenditure on bed nets, including treatment and repair, constituted only 10% of total expenditure on malaria prevention. Every fortnight, households spent an average of 8.40 Dalasis (D) on coils, 4.20 D on indoor sprays, 3.09 D on smoke and 3.06 D on aerosols, together making up 81% of total fortnightly expenditure. Of the 442 households that did not own a bed net, 68% said it was because they could not afford one. Every 2 months, the same households spent an average of US 5 dollars, the equivalent to the cost of an insecticide treated bed net, on other forms of prevention. Total expenditure was 42% higher during the wet season than for the rest of the year. For every month of the year, coils were the dominant form of prevention expenditure. Wealth, age, occupation of household head, location of residence and month of the year were significant determinants of prevention expenditure. CONCLUSIONS: Households in The Gambia spend considerable amounts on a range of malaria prevention products and activities throughout the year. Bed nets represent a relatively small proportion of this expenditure even though they are perceived to be the most efficient and effective method of malaria control. A more concerted effort is needed to develop appropriate targeting strategies to encourage bed net use especially for children <5 years of age. Equal emphasis should be given to addressing barriers to purchasing nets such as their relative high upfront cost.

Cost-Effectiveness Study of Three Antimalarial Drug Combinations in Tanzania

Background: As a result of rising levels of drug resistance to conventional monotherapy; the World Health Organization (WHO) and other international organisations have recommended that malaria endemic countries move to combination therapy; ideally with artemisinin-based combinations (ACTs). Cost is a major barrier to deployment. There is little evidence from field trials on the cost-effectiveness of these new combinations. Methods and Findings: An economic evaluation of drug combinations was designed around a randomised effectiveness trial of combinations recommended by the WHO; used to treat Tanzanian children with non-severe slide-proven malaria. Drug combinations were: amodiaquine (AQ); AQ with sulfadoxine-pyrimethamine (AQ+SP); AQ with artesunate (AQ+AS); and artemether-lumefantrine (AL) in a six-dose regimen. Effectiveness was measured in terms of resource savings and cases of malaria averted (based on parasitological failure rates at days 14 and 28). All costs to providers and to patients and their families were estimated and uncertain variables were subjected to univariate sensitivity analysis. Incremental analysis comparing each combination to monotherapy (AQ) revealed that from a societal perspective AL was most cost-effective at day 14. At day 28 the difference between AL and AQ+AS was negligible; both resulted in a gross savings of approximately US$1.70 or a net saving of US$22.40 per case averted. Varying the accuracy of diagnosis and the subsistence wage rate used to value unpaid work had a significant effect on the number of cases averted and on programme costs; respectively; but this did not change the finding that AL and AQ+AS dominate monotherapy.Conclusions: In an area of high drug resistance; there is evidence that AL and AQ+AS are the most cost-effective drugs despite being the most expensive; because they are significantly more effective than other options and therefore reduce the need for further treatment. This is not necessarily the case in parts of Africa where recrudescence following SP and AQ treatment (and their combination) is lower so that the relative advantage of ACTs is smaller; or where diagnostic services are not accurate and as a result much of the drug goes to those who do not have malaria

Using diaries to collect data in resource-poor settings: questions on design and implementation.

Diaries, as a tool for data collection, have been around for some time. Lessons shared to date come from disparate settings and there remains a degree of ambiguity regarding the value of diaries, particularly in resource-poor settings where populations are often illiterate and highly mobile. We recently designed a pictorial diary for the collection of data on household consumption and expenditure in Tanzania and The Gambia. A random sample of 361 diary keepers in The Gambia and 308 in Tanzania maintained diaries for a period of 12 months. The aim of this paper is to share some of the lessons learnt in developing and applying this instrument. It is structured around a series of questions about diaries that we found relatively few answers to when we first embarked on this study. These questions include: how should a diary be designed? How long should a diary be maintained? When should entries be recorded? Who should keep the diary? The motive behind this paper is simple: to provide future researchers who are contemplating using diaries in resource-poor settings with some practical information that may guide them through this process.

Involving the general public in priority setting: experiences from Australia.

The discussion over whether community preferences have a legitimate role to play in priority setting has been highly polarised. Skeptics warn of the risk of establishing a 'dictatorship of the uninformed', while advocates proclaim the legitimacy of the participatory process. The one group who appears not to be consulted in this debate is the citizens themselves. In this study, a convenience sample of 373 citizens attending two medical clinics in central Sydney were surveyed about whether the general public has a legitimate role to play in informing priority setting in health care. Respondents were presented with three different levels of priority setting: across health care programmes, across medical procedures, and at a global level. To assist respondents in understanding the choices and trade-offs involved, they were given information about current levels of funding and the cost-effectiveness of each alternative. Respondents were asked whether they felt the preferences of the general public should be used to inform priority setting at each level. Of particular interest was the question of whether their willingness to use public preferences depended on the level of priority setting. Respondents were also asked about who else's preferences should be used to inform priority setting at each level. The results suggest that the public overwhelmingly want their preferences to inform priority-setting decisions in health care. This was seen to be particularly important in informing decisions about how to prioritise across broad health care programmes and about the criteria to be used to allocate funds across different population groups. In contrast, the preferences of medical professionals and health service managers were rated most highly in relation to the prioritisation of different treatments and medical procedures. In most cases, however, respondents did not advocate the use of one particular group's preferences. Even when the preferences of the general public were considered most important, it was felt that any decision-making process needed to be informed by the preferences of a range of groups. The preferences of politicians were viewed as least important to processes of priority setting in health care.

Resource allocation within Australian indigenous communities: a program for implementing vertical equity.

Given the significant disparities in health and health related disadvantage between Aboriginal and non-Aboriginal Australians, the application of some notion of equity has a role to play in the formulation of policy with respect to Aboriginal health. Aboriginal and Torres Strait Islander has been abbreviated to Aboriginal. There has been considerable debate in Australia as to what the principles of equity should be. This paper discusses the relevance of the principle of vertical equity (the unequal, but equitable, treatment of unequals) to Aboriginal health funding. In particular, the paper advocates pursuing procedural justice as the basis for vertical equity where the focus is on the fairness of how things are done rather than on the distribution of outcomes per se (i.e. distributive justice). Particular attention is paid to how the principle of vertical equity might be handled at a practical level. Details of the approach used in a number of Australian indigenous communities are discussed. It is concluded that there are strong arguments for pursuing procedural justice under vertical equity particularly when there are cultural differences in the way health is defined and when there is importance attached to indigenous involvement in the health care decision making process.

Culture, self-rated health and resource allocation decision-making.

It has been observed that some groups in society tend to report their health to be better than would be expected through more objective measures. The available evidence suggests that while variations in self-assessed measures of health may act as good proxies of mortality and morbidity in homogeneous populations, in some groups, such as the Aboriginal and Torres Strait Islander communities of Australia, these subjective measures may provide a misleading picture. Useful insights into the formation of health perceptions can be drawn from a range of disciplines, in particular, from social comparison theories, models of illness behaviour, survey literature and linguistics. These theories and models help to provide an understanding of the different ways in which illness may be perceived, evaluated and acted upon by different kinds of people. Such considerations can have very direct implications for those planning and evaluating public health programs as well as those responsible for funding such programs.

From selfish individualism to citizenship: avoiding health economics' reputed 'dead end'.

Recent interpretations of citizenship are firmly rooted in the value of social membership and social participation. Citizens are described as having a moral right to draw upon the support of the community, but at the same time have a responsibility to contribute to the provision of social services such as health care. In contrast, contemporary health economics has been criticised for taking a narrow and individualistic view of human behaviour. This paper examines the extent to which economic theory and practice have been developed to accommodate a more 'civic' view, namely, the notions of mutual concern for community members, social participation and social rights. It is argued that because the provision of health care is often linked to feelings of compassion and social responsibility and not just to individual well-being, this sort of insight may enrich economic analysis and, in turn, provide a way around health economics' reputed 'dead end'.

Burden of illness estimates for priority setting: a debate revisited.

This paper returns to the debate in this journal about a decade ago on the value of cost of illness (COI) and burden of illness (BOI) estimates in priority setting. Concern is expressed that there has been a resurgence of interest in calculating and using BOI estimates in such priority setting. It is especially concerning that this interest seems to have support from both the World Bank and the World Health Organisation (WHO) (although perhaps less so recently from the latter). It is argued that in terms of priorities for health services, BOI calculations are irrelevant except possibly in the context of some (less than ideal) concept of need in support of equity. If the need basis for equity is set in terms of 'capacity to benefit', then BOI calculations become even less relevant. There is an argument for some research funding being prioritised in terms of BOI but only when it is genuinely the case that there is total ignorance, beyond the size of the problem, about a particular policy or disease area. Such a level of ignorance will happen very seldom and then some fairly approximate estimates of BOI will suffice. It is better to concentrate in priority setting on estimating the costs and benefits of marginal changes than devoting scarce analytical resources to superfluous estimates of BOI.

Caring: the neglected health outcome? or input?

In most forms of evaluation of health care--and it is certainly true of economic evaluation--and is considering the outcomes of such care, caring tends to be omitted, or simply forgotten. It is often the case that little more than lip service is paid to the inclusion of caring as an input. This paper takes a closer look at caring, the neglected outcome of health care. The perspective starts from that of economics but other disciplines are examined briefly along the way to determine whether they deal better with caring than does the dismal science of economics. It is concluded that there is a need for greater consideration of caring as both an outcome and an input in evaluation of health care and that in the specific context of economic evaluation, when considering caring, economists might usefully look to other disciplines to broaden and deepen their conceptualisation of both benefits and costs in their economic evaluation studies.

Examining preferences for allocating health care gains.

This study is part of a programme to elicit and examine community preferences for health care in different contexts. Data were obtained from a group of predominantly Australian health care decision-makers. A short questionnaire contained six valuation questions and four demographic questions. The six valuation questions posed choices where equal health gains were to be allocated to different population groups based upon: age; sex; current health; socio-economic status; across time; and across different numbers of individuals. The results provide some evidence that respondents were prepared to discriminate between health gains derived in different contexts especially where health gains were to be allocated between groups of different health status and over time. Further research is planned and the possible implications for health policy, and in particular for resource allocation in health care, are briefly discussed.