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In 2009, the Democratic Republic of Congo (DRC) started its journey towards achieving Universal Health Coverage (UHC). This study examines the evolution of financial risk protection and health outcomes indicators in the context of the commitment of DRC to UHC. To measure the effects of such a commitment on financial risk protection and health outcomes indicators, we analyse whether changes have occurred over the last two decades and, if applicable, when these changes happened. Using five variables as indicators for the measurement of the financial risk protection component, there as well retained three indicators to measure health outcomes. To identify time-related effects, we applied the parametric approach of breakpoint regression to detect whether the UHC journey has brought change and when exactly the change has occurred.
Although there is a slight improvement in the financial risk protection indicators, we found that the adopted strategies have fostered access to healthcare for the wealthiest quantile of the population while neglecting the majority of the poorest. The government did not thrive persistently over the past decade to meet its commitment to allocate adequate funds to health expenditures. In addition, the support from donors appears to be unstable, unpredictable and unsustainable. We found a slight improvement in health outcomes attributable to direct investment in building health centres by the private sector and international organizations. Overall, our findings reveal that the prevention of catastrophic health expenditure is still not sufficiently prioritized by the country, and mostly for the majority of the poorest. Therefore, our work suggests that DRC’s UHC journey has slightly contributed to improve the financial risk protection and health outcomes indicators but much effort should be undertaken.
The key objective of this dissertation is to study the expected impact of the introduction of the Social Health Insurance (SHI) on the public hospital management and to develop recommendations that will improve this management. In addition to the key objective, this study aims to analyze the health sector financing in Syria, to outline problems affecting on management of public hospitals in Syria. Furthermore, it aims to study the various countries' experience with SHI and analyze key components of the Syrian SHI.
Although End Stage Renal Disease (ESRD) is a disease of increasing epidemiological relevance very little is known about the cost of providing the respective dialysis services in Tanzania. This study analyses the cost of outpatient dialysis at Muhimbili National Hospital (MNH) in Tanzania in the year 2014 in order to address the question weather or not dialysis treatment should be a priority intervention in a poor resource country like Tanzania. Cost analyses were performed based on the provider’s perspective including only direct costs of dialysis treatment. Cost of drugs and consumables were obtained from the price list of Medical Stores Department in Tanzania. Overhead were collected from the respective departments and allocated to the final cost centres through step down approach. The results indicates that MNH performs on average 442 hemodialyses per month (34 patients, with three sessions per week) with a personnel placement of 20 nurses, four nephrologists, eight registrars, one nutritionist, two biomedical engineers, four health attendants and nine dialysis machines. The respective average unit cost per haemodialysis is 175.91 US$. Consequently, an average patient requiring three dialyses per week (i.e. 156 dialyses per year) will cause annual costs of 27,441.95 US$. The annual cost of dialysis is enormous for a least developed country like Tanzania where resources and technology are rather limited. Infectious diseases (such as malaria and tuberculosis) are the major health problems. Therefore, from the economic point of view, it seems rational to allocate health care budgets towards diseases that are curable, have higher cost- effectiveness and cater for the majority of the population. However, before a final decision on allocation of budget towards dialysis is made, all efforts that could improve technical efficiency and reduce the costs of materials in Tanzania must be invested. For instance, reducing the nursing time per dialysis.
Background
Medical research is increasingly interdisciplinary. However, not all projects are successful and cooperation is not always sustained beyond the end of funding. This study empirically assesses the effect of control and trust on the sustainability of interdisciplinary medical research in terms of its performance and satisfaction.
Methods
The sample consists of 100 German publicly funded medical research collaborations with scientists from medicine, natural and social sciences (N = 364). We develop a system model to analyze the influence of trust and control on performance and satisfaction of the cooperation.
Findings
Both control and trust are important prerequisites for sustainability, control mainly for the performance of the collaboration, and trust primarily for its satisfaction. While the level of interdisciplinarity is a positive moderator for performance, expectation of continuity is a negative intervening variable for the effect of trust and control on satisfaction. Moreover, trust principally adds to the positive impact of control on sustainability.
Conclusions
Interdisciplinary medical research requires a participative but systematic management of the respective consortium.
Strategic Management in Healthcare: A Call for Long-Term and Systems-Thinking in an Uncertain System
(2022)
Strategic management is becoming increasingly important for sustainable management in healthcare. The reasons for this can be seen in the increasing complexity, dynamics and uncertainty of the system’s regimes and the resulting need for strategic thinking in a long-term period. The scientific discussion of this issue is the aim of the present analytical framework. The starting point is the definition of the term strategic management itself, followed by a reflection on the requirements resulting from the changes in the political, social and economic value systems of our post-industrial society. In this context, Dynaxity Zone III is used to explain the long-term perspective, the high levels of complexity and uncertainty and the responsibility of strategic management as important parameters. For a practical illustration, we demonstrate two selected applications (German hospital financing systems and development process of implants) and how the implementation of strategic management in the health care system shows success.
Abstract
This paper focuses on the expectation formation process of professional forecasters by relying on survey data on forecasts regarding gross domestic product growth, consumer price index inflation and 3‐month interest rates for a broad set of countries. We examine the interrelation between macroeconomic forecasts and also the impact of uncertainty on forecasts by allowing for cross‐country interdependencies and time variation in the coefficients. We find that professional forecasts are often in line with the Taylor rule and identify significant expectation spillovers from monetary policy in the USA.
Background
This study aimed to analyze the impact of low-value medications (Lvm), that is, medications unlikely to benefit patients but to cause harm, on patient-centered outcomes over 24 months.
Methods
This analysis was based on longitudinal data of patients with dementia. The impact of Lvm on health-related quality of life (HRQoL), hospitalizations, and health care costs were assessed using multiple regression models.
Results
Over 24 months, Lvm was highly prevalent and significantly increased the risk of hospitalization, increased health care costs, and reduced patients' HRQoL.
Conclusion
More than every second patient received Lvm, negatively impacting patient-reported HRQoL, hospitalizations, and costs. Innovative approaches are needed to encourage prescribers to avoid and replace Lvm in dementia care.
Parental gender preferences in Central and Eastern Europe and differential early life disadvantages
(2023)
Parental gender preferences may affect partnership decisions and as a result lead to early life disadvantages. We study these preferences in five post-communist countries of Central and Eastern Europe, a region with strong traditional gender norms and persisting inequalities between women and men in labour market outcomes. Using subsamples of census from Belarus, Hungary, Poland, Romania and Russia around 2000 and 2010, we follow Dahl and Moretti (2008), The demand for sons, to examine the effect of the gender of the first-born child(ren) on fertility decisions and relationship stability of their parents. We only find strong evidence of ‘boy preferences’ in fertility decisions in the cases of Romania and Russia. However, unlike Dahl and Moretti (2008), The demand for sons, for the US, we cannot confirm a relationship between the children's gender and parental partnership decisions. This is the case for all examined Central and Eastern European countries, as well as for a number of countries from Western Europe. The cases of Romania and Russia raise questions about other potential consequences of the documented gender preferences. We argue that our approach can be applied more broadly to identify other countries characterised by parental gender preferences, and to motivate further examination of different forms of gender driven early life disadvantages.
Background and objective
Political, economic, communicative and cultural borders still limit the accessibility of acute healthcare services for patients so that they frequently have to accept longer distances to travel to the next provider within their own country. In this paper, we analyze the impact of borders and opening of borders on acute medical care in hospitals and on patients in border regions.
Methods
We develop a conceptual framework model of cross-border healthcare and apply it to the Polish–German border area. The model combines the distance decay effect, a catchment area analysis, economies of scale and the learning curve.
Results
Borders have a major impact on acute medical care in hospitals and on patients. Setting of new borders will reduce the accessibility of health facilities for patients or require the establishment of new hospitals. Reopening borders might induce a vicious circle leading to the insolvency of a hospital which might result in poorer health for some patients.
Conclusion
Strong effort should be invested to overcome political and cultural borders to improve the health of the population in border regions. Similarly, increased cross-border acute healthcare must be seen in the context of rural health and the special situation of small rural hospitals in rural peripheral areas.
Abstract
This article takes a novel look at the relationship between government activity, partisan preferences and varieties of capitalism. Evidence from panel regressions for 25 EU countries from 1990 to 2014 suggests that there are major divides among European countries in terms of the drivers of government activity, that is, government spending and government regulation. The European divide appears to be even more pronounced between liberal and coordinated economic systems than between the classical geographical divide of east and west, which is typically used in most contributions. While both divides apply to the determinants of government activity in general, a reversal of the classical partisan effect for the east is to be found only in specific cases and, is most likely in government spending in liberal eastern countries.
Background
Despite the current undersupply of cochlear implants (CIs) with simultaneously increasing indication, CI implantation numbers in Germany still are at a relatively low level.
Methods
As there are hardly any solid forecasts available in the literature, we develop a System Dynamics model that forecasts the number and costs of CI implantations in adults for 40 years from a social health insurance (SHI) perspective.
Results
CI demand will grow marginally by demographic changes causing average annual costs of about 538 million €. Medical-technical progress with following relaxed indication criteria and patients’ increasing willingness for implantation will increase implantation numbers significantly with average annual costs of 765 million €.
Conclusion
CI demand by adults will increase in the future, thus will the costs for CI supply. Continuous research and development in CI technology and supply is crucial to ensure long-term financing of the growing CI demand through cost-reducing innovations.
Background and objective
The COVID-19 pandemic started in Wuhan, China, in December 2019. Although there are some doubts about the reporting of cases and deaths in China, it seems that this country was able to control the epidemic more effectively than many other countries. In this paper, we would like to analyze the measures taken in China and compare them with other countries in order to find out what they can learn from China.
Methods
We develop a system dynamics model of the COVID-19 pandemic in Wuhan. Based on a number of simulations we analyze the impact of changing parameters, such as contact rates, on the development of a second wave.
Results
Although China’s health care system seems to be poorly financed and inefficient, the epidemic was brought under control in a comparably short period of time and no second wave was experienced in Wuhan until today. The measures to contain the epidemic do not differ from what was implemented in other countries, but China applied them very early and rigorously. For instance, the consequent implementation of health codes and contact-tracking technology contributed to contain the disease and effectively prevented the second and third waves.
Conclusions
China’s success in fighting COVID-19 is based on a very strict implementation of a set of measures, including digital management. While other countries discuss relaxing the lock-down at a rate of 50 per 100,000 inhabitants, China started local lock-downs at a rate of 1.59 per 100,000. We call for a public debate whether this policy would be feasible for more liberal countries as well.
District hospitals are the only solution to guarantee basic health care including life-saving surgeries and hospitalisations in rural SSA areas. Neither regional nor national hospitals, financially and geographically out of reach for the majority of the population, nor rural health care centres, mostly staffed with a nurse only, can cover these tasks adequately. However, only little research exists on care giving processes, cost and efficiency of district hospitals in SSA. The general problem in health economics is that limited resources should be used in order to maximise health effects. This dissertation evaluates the actual treatment pathways and their average provider’s cost per patient for four different diagnoses at Nouna district hospital in Burkina Faso. A total of 95 patient records was analysed in detail and discussed with the health personnel in charge. Cost information for the year 2005 was taken from the well-established provider cost information system. Cost were broken down to the different sequences of the treatment pathway and summed up at the end. Average provider’s cost for paediatric Malaria were U$ 6.71 for outpatients, US$ 60.59 for inpatients with anaemia and US$ 75.11 for inpatients with neurological affection. Average provider’s cost for treating hypertension were US$ 67.94 per year. Average cost for hernia cure were US$ 146.85 under local anaesthesia, US$ 153.08 under spinal anaesthesia and US$ 169.78 under general anaesthesia. Average provider’s cost for Caesarean sections were US$ 140.15 under spinal anaesthesia and US$ 180.41 under general anaesthesia. This means that cost per patient are comparable to or even lower than provider’s cost found for other SSA setting in the literature. Cost would decrease between 20% (a hypertensive outpatient) and 46% for Malaria with neurological affection as complication, if utilisation rates rose from actually 20 to 80%. Patients paid between 35 and 94% of total provider’s cost in form of user fees. If fees would not change and the utilisation rate increased to 80%, cost-recovery for the considered diseases would then be between 63 and 117%. Although this would not allow the hospital to break even in its current configuration, the cost-recovery rate would be considerably higher, especially when taking into account that a full cost analysis was done including all investment cost. The introduction of clinical pathways based on the actual treatment pathways is suggested to improve process structure and documentation and to standardise the treatment according to national and international guidelines.
Background: Demographic changes are leading to a rapid increase in the number and proportion of the elderly. This goes along with an increase of prevalence of age-associated illnesses, such as dementia. The prevalence of dementia is estimated to amount to 1.5 million in Germany. Up to three-quarter of the persons with dementia (PWD) were living in their own homes. In European countries, dementia is associated with substantial and increasing healthcare costs, which makes dementia one of the most expensive diseases in old age and a serious health care priority. Whereas analyses of total healthcare costs in dementia have been the focus of various cost-of-illness (COI) studies, so far little is known about several cost categories in detail. Firstly, detailed economic analyses of medication cost are currently still missing. Secondly, it is well known that dementia is under-diagnosed, but there is a lack of knowledge about the differences in resource utilization and its costs between dementia patients with and those without a formal dementia diagnosis. Finally, analyses that take the utilization and costs of professional formal and unpaid informal care as well as caregiver’s productivity losses into a consideration are currently missing. Objectives: (1) To determine medication cost, cost per drug and number of drugs taken and analyze their associated factors; to estimate the current price reduction of anti-dementia drugs due to implementation of low-priced generics. (2) To determine health care resource utilisation and costs of patients with a formal diagnosis and those without a formal diagnosis of dementia, and to analyse the association between having received a formal dementia diagnosis and health care costs (3) To determine the utilization and costs of formal and informal care for PwD, indirect costs because of productivity losses of caregivers and the associations between cost, socio-demographic and clinical variables. Methods: The present study is a cross-sectional analysis of health care resource utilization and health care cost of community-dwelling PWD in primary care. Analyses are based on primary data from the ongoing DelpHi-MV trial (Dementia: Life- and person-centered help in Mecklenburg-Western Pomerania, Germany), a population-based, cluster-randomized, controlled intervention trial in the primary care setting (Clinical Trials gov. Identifier: NCT01401582). Eligible patients (older than 70 years, living at home) were screened in participating general practitioner practices for dementia using the DemTect. The utilization of healthcare resources was assessed within the baseline assessment at practitioner’s homes. Costs were calculated from the perspective of the statutory health insurance or the social perspective. Factors associated with healthcare cost were evaluated using multiple regression models. Results: (1) Medication cost and cost per drug were higher and the number of taken drugs lower in advanced stages of cognitive impairment. Prescription of anti-dementia generics could decrease overall medication cost by 28%. Medication cost was associated with number of diagnoses, deficits in activities of daily living and age. Dementia severity was related to cost per drug and number of drugs taken. (2) Patients formally diagnosed with dementia were treated significantly more often by a neurologist, but less often by all other outpatient specialists, and received anti-dementia drugs and day care more often. Diagnosed patients underwent shorter and less frequent planned in-hospital treatments. Dementia diagnosis was significantly associated with higher costs of anti-dementia drug treatment, but significantly associated with less total medical care costs, which valuated to be € 5,123 compared, to € 5,565 for undiagnosed patients. (3) Formal care were utilized less (26.3%) than informal care (85.1%), resulting in a cost ratio of one to ten (1,646 €; 16,473 €, respectively). In total, 29% of caregivers were employed, and every seventh (14.3%) experienced productivity losses, which corresponded to 1,258 € annually. Whereas increasing deficits in daily living activities were associated with higher formal and higher informal costs, living alone was significantly associated with higher formal care costs and the employment of a caregiver was associated with lower informal care costs. Conclusion: (1) Medication cost increases with the number of diagnoses and growing deficits in activities of daily living and decreases with age. Severely cognitively impaired persons are treated with a small number of high-priced drugs, which could suggest inadequate medication of multimorbid persons. (2) There are no significant differences in total health care cost between diagnosed and undiagnosed patients. Dementia diagnosis is beneficial for receiving cost-intensive anti-dementia drug treatments, but is currently insufficient to ensure adequate non-medication treatment for community-dwelling patients. (3) Informal care contributes the most to total care costs. Living alone is a major cost driver for formal costs because of the lower availability of potential informal care. The availability of informal care is limited and productivity losses are increased when a caregiver is employed.
The purpose of this study was to compare the effect of culture on consumers’ attitudes toward Cause-Related marketing between Iran and Germany by answering the following questions:
A: What is consumer’s response concerning (1) skepticism toward CRM claim (2) attitude toward the CRM strategy, (3) attitude toward CRM brand personality, (4) attitude toward the CRM brand image and (5) CRM purchase intention (6) Warm glow? ; B: Do consumers respond differently to Cause-Related Marketing in Iran in comparison to Germany? C: Can cultural characteristics of the countries explain these differences? To answer the research questions, hypotheses were developed based on the literature which shape the research framework, in total containing 17 hypotheses. The data was gathered by questionnaire to make the research quantitative. By using convenience sampling, 564 responses were generated. The data was analysed by Structural Equation Modeling (SEM) and independent student t-test. Potential differences between Iran and Germany as well as moderation analysis are tested by critical ratio difference test as well as chi-square difference test using multiple- group analysis in AMOS. The results showed the importance of culture in applying CRM strategy. It can be said that CRM in a collectivistic culture like Iran can be successful as well as individualistic country like Germany. Although Iranian consumers were less familiar with this strategy, the benefits of CRM were similar in case of brand image and higher for purchase intention. The research found that emotions play a stronger role in Iran and it is more critical to evoke proper emotions by CRM campaign.
This study validates a newly-developed scale of consumer culture at individual-level in purchase-consumption context. Following unipolar approach in measurement, the applicable-reliable scale for consumer culture analyzes plausible effects of the seven cultural dimensions on three selected consumer-behaviors; anticipated regret, and two further purchase behaviors of variety-seeking and Quality-consciousness, comparing both Hedonic and Utilitarian aspect of consumer decisions. The interaction among the three behavioral variables are also studied. Feeling the necessity of cultural investigations in rather-unknown countries, Iran and Germany are focused.Iran is among the culturally undiscovered markets with an ever increasing demand; also German consumers have several unknown aspects in their purchase behaviors. Finally, the role of contextual elements — nationality, demographic profile and task— in consumer purchase behaviors are separately analyzed.
Purpose: To assess the comparative efficacy and the long-term cost-utility of alternative minimally invasive glaucoma surgeries (MIGSs) when combined with cataract surgery in patients with primary open-angle glaucoma (POAG).
Methods: Treatment effects, as measured by the 1-year reduction in intraocular pressure (IOP), were estimated with an adjusted indirect treatment comparison. Evidence from randomized clinical trials was identified for four different MIGS methods. A disease-transition model was developed by capturing clinically relevant POAG stages and the expected natural disease evolution. Outcomes of the disease-transition model were the comparative utility [quality-adjusted life years (QALYs)], cost and cost-utility of included strategies in a lifetime horizon.
Results: Estimated 1-year IOP reductions were: cataract surgery - 2.05 mmHg (95% CI - 3.38; - 0.72), one trabecular micro-bypass stent - 3.15 mmHg (95% CI - 5.66; - 0.64), two trabecular micro-bypass stents - 4.85 mmHg (95% CI - 7.71; - 1.99) and intracanalicular scaffold - 2.25 mmHg (95% CI - 4.87; 0.37). Discounted outcomes from the disease-transition model appraised the strategy of two trabecular micro-bypass stents with cataract surgery in the moderate POAG stage as the one providing the greatest added value, with 10,955€ per additional QALY. Improved outcomes were seen when assessing MIGS in the moderate POAG stage.
Conclusions: When indirectly comparing alternative MIGS methods combined with cataract surgery, the option of two trabecular micro-bypass stents showed both a superior efficacy and long-term cost-utility from a German perspective. Moreover, outcomes of the disease-transition model suggest POAG patients to beneficiate the most from an earlier intervention in the moderate stage contrary to waiting until an advanced disease is present.