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This chapter traces the history of election organization in Ghana, Kenya, and Uganda. It identifies a common pattern of technical and institutional elaboration, driven by a desire to produce procedurally perfect elections through the combination of new technologies and more professional personnel. The chapter argues that this elaboration has come at a significant financial cost, but that it has had some effect in shaping the subjectivities of those involved as electoral officials and of voters. Yet this determined attempt to promote civic virtue through electoral performance – which has attracted much support from donors - has always been challenged by forms of patrimonial claims-making that persistently intrude into the imagined order of the electoral process. Intimidation and bribery, as well as pursuit of particular interest, drive malpractice; logistical failures and errors encourage the suspicion that others may not follow the rules. Ghana, Kenya and Uganda may seem to offer different stories: Ghana’s Electoral Commission attracts international praise, while Uganda’s has been heavily criticised. Yet that difference may be overstated: there is widespread suspicion of the electoral management bodies in all three countries. The production of citizens and state through electoral performance may be powerful, but it is very far from unquestioned.
To identify the most cost-effective options/contributors of under-consumed food groups and nutrients in the USA.
Twenty-four-hour dietary recall data were used for the dietary sources of under-consumed food groups and nutrients. Costs were estimated using USDA National Food Price Database 2001–2004 after adjustments for inflation using Consumer Price Index.
National Health and Nutrition Examination Survey, 2013–2016.
A total of 10 112 adults aged 19+ years.
Top five cost-effective options for food groups were apple and citrus juice, bananas, apples, and melons for fruit; baked/boiled white potatoes, mixtures of mashed potatoes, lettuce, carrots and string beans for vegetables; oatmeal, popcorn, rice, yeast breads and pasta/noodles/cooked grains for whole grain; and reduced-fat, low-fat milk, flavoured milk and cheese for dairy. Top five cost-effective sources of under-consumed nutrients were rice, tortillas, pasta/noodles/cooked grains, rolls and buns, and peanut butter–jelly sandwiches for Mg; grits/cooked cereals, low- and high-sugar ready-to-eat (RTE) cereal, rolls and buns, and rice for Fe; low- and high-sugar RTE cereals, rice, protein and nutritional powders, and rolls and buns for Zn; carrots, margarine, other red and orange vegetables, liver and organ meats, butter and animal fats for vitamin A; and citrus juice, other fruit juice, vegetable juice, mustard and other condiments, and apple juice for vitamin C.
Apple/citrus juice, white potatoes/carrots, oatmeal, RTE cereals and milk were the most cost-effective food sources of multiple under-consumed food groups and nutrients and can help promote healthy eating habits at minimal cost.
Research and development (R&D) planners in homeland security agencies would like to be able to prioritize investments in projects based on costs versus future safety and security benefits. While costs are often readily available, estimates of safety and security benefits are fraught with uncertainty. To address these challenges, a benefit–cost model of technological change is adapted to the homeland security context. Data are sparse; therefore, estimation is facilitated by developing a familiar linear welfare model using derivatives of cost and risk reduction functions to estimate areas of costs and benefits. The theoretical model is applied to two homeland security projects involving airport patrols and the assignment of U.S. federal air marshals to international flights. Retrospective data are available for most periods. Welfare-based rates of return are reported for the two cases, each of which is estimated to return large present value net benefits. Extensive sensitivity and Monte Carlo simulation explores uncertainties. Two important findings are that (i) given the rationality assumption, relative increases in security levels can be valued, even if the absolute level of security is not known; and (ii) large uncertainties about risk reduction exist but can be bounded by parametric sensitivity and uncertainty analysis.
The yeast, Brettanomyces bruxellensis (Brett) is a significant cause of quality defects associated with red wine spoilage. At least some wine producers spend significant resources to prevent, detect, and mitigate damage from Brett, and many express concern about it, but some producers and consumers say they like it in small doses. Brett damage is especially of concern in premium red wine and has become more of a concern to producers in recent years as consumers have become better informed about it. We combine information from diverse sources to develop an initial understanding of the economics of Brettanomyces and management practices to mitigate its consequences. An analysis of detailed confidential data from three wineries in California reveals that at least some wineries are incurring significant costs to reduce the risk of infection with Brettanomyces. Some other wineries that opt not to spend so much on prevention are incurring higher costs in treating infected wines and in lost value from wines being downgraded to lower-valued blends. Results from an online survey of industry participants reinforce the analysis of the detailed data from the three wineries and suggest that the findings may be indicative of conditions more generally across the industry. (JEL Classifications: D22, D24, L66)
Studies have suggested 5–20% of paediatric ICU patients may receive care felt to be futile. No data exists on the prevalence and impact of futile care in the Paediatric Cardiac ICU. The aim is to determine the prevalence and economic impact of futile care.
Materials and method:
Retrospective cohort of patients with congenital cardiac disease 0–21 years old, with length of stay >30 days and died (2015–2018). Documentation of futility by the medical team was retrospectively and independently reviewed.
Of the 127 deaths during the study period, 51 (40%) had hospitalisation >30 days, 13 (25%) had received futile care and 26 (51%) withdrew life-sustaining treatment. Futile care comprised 0.69% of total patient days with no difference in charges from patients not receiving futile care. There was no difference in insurance, single motherhood, education, income, poverty, or unemployment in families continuing futile care or electing withdrawal of life-sustaining treatment. Black families were less likely than White families to elect for withdrawal (p = 0.01), and Hispanic families were more likely to continue futile care than non-Hispanics (p = 0.044).
This is the first study to examine the impact of futile care and characteristics in the paediatric cardiac ICU. Black families were less likely to elect for withdrawal, while Hispanic families more likely to continue futile care. Futile care comprised 0.69% of bed days and little burden on resources. Cultural factors should be investigated to better support families through end-of-life decisions.
To estimate the economic burden of overweight in Bangladesh.
We used data from Household Income and Expenditure Survey, 2010. A prevalence-based approach was used to calculate the population attributable fraction (PAF) for diseases attributable to overweight. Cost of illness methodology was used to calculate annual out of pocket (OOP) expenditure for each disease using nationally representative survey data. The cost attributable to overweight for each disease was estimated by multiplying the PAF by annual OOP expenditure. The total cost of overweight was estimated by adding PAF-weighted costs of treating the diseases.
Nationwide, covering the whole of Bangladesh.
Individuals whose BMI ≥ 25 kg/m2.
The total cost attributable to overweight in Bangladesh in 2010 was estimated at US$147·38 million. This represented about 0·13 % of Bangladesh’s Gross Domestic Product and 3·69 % of total health care expenditure in 2010. The sensitivity analysis revealed that the total cost could be as high as US$334 million or as low as US$71 million.
A substantial amount of health care resource is devoted to the treatment of overweight-related diseases in Bangladesh. Effective national strategies for overweight prevention programme should be established and implemented.
To cope with the pressure of modern life, consumer demand for convenience foods has increased in the last decades. The current study set out to compare the costs of buying industrially processed dishes and of preparing them at home.
Direct purchase costs of industrially processed dishes frequently consumed in France (n 19) and of the ingredients needed for their home-prepared counterparts (n 86) were collected from four major food retailers’ websites in Montpellier, France. Mean prices and energy density were calculated for four portions. Costs related to energy used by cooking appliances and time spent preparing dishes were further estimated.
Based on the costs of ingredients and energy used for cooking, dishes prepared at home cost less (–0·60 € per four portions, P < 0.001) than industrially processed dishes, but when the cost of time was taken into account, the industrially processed dishes were much cheaper (–5·34 € per four portions, P < 0.001) than their home-prepared counterparts. There was no difference in energy density between industrially processed and home-prepared dishes.
Our findings suggest that industrially processed dishes are more profitable to consumers when the cost of time for preparing dishes at home is valued. Given the ever greater demands of everyday life, more account should be taken of the additional cost to consumers of the time they spend preparing meals at home.
This paper examines the costs and cost-effectiveness of psychosocial treatment for personality disorder in a controlled study. Using well-validated cost and outcome measures three groups are compared: the One-Stage group (n = 32) received 12 months of inpatient treatment; the Step-Down group (n = 29) received 6 months of inpatient treatment followed by 12 months of outpatient therapy; and the control group of 47 people used routinely available services. Both specialist programmes were more effective than routine psychiatric services but more costly. Using an extended dominance approach the incremental cost-effectiveness ratio showed that achieving one extra person with clinically relevant outcomes required an investment in the Step-Down programme of around £3400 over 18 months. Small sample sizes and non-random allocation to programmes are limitations of this study but the costs and effectiveness findings consistently point to advantages for the shorter residential programme followed by community-based psychotherapeutic support.
Depression is one of the most common causes of disability and is associated with substantial reductions in the individual's quality of life. The aim of this study was to estimate the economic burden of depression to Swedish society from 1997 to 2005.
Materials and Methods
The study was conducted in a cost-of-illness framework, measuring both the direct cost of providing health care to depressive patients, and the indirect costs as the value of production that is lost due to morbidity or mortality. The costs were estimated by a prevalence and top-down approach.
The cost of depression increased from a total of €1.7 billion in 1997 to €3.5 billion in 2005, representing a doubling of the burden of depression to society. The main reason for the cost increase is found in the significant increase in indirect costs due to sick leave and early retirement during the past decade, whereas direct costs were relatively stable over time. In 2005, indirect costs were estimated at €3 billion (86% of total costs) and direct costs at €500 million (16%). Cost of drugs was estimated at €100 million (3% of total cost).
The cost of depression is substantial to society and the main cost driver is indirect costs due to sick leave and early retirement. The cost of depression has doubled during the past eight years making it a major public health concern for the individuals afflicted, carers and decision makers.
The recent epidemiologic studies report extremely varied rates for social phobia (SP). One of the reasons for this may be the difficulty in diagnosing SP, the boundaries of which are uncertain. A community survey was carried out using doctors with experience in clinical psychiatry as interviewers, and a clinical diagnostic instrument. Two thousand three hundred and fifty-five people (out of the 2,500 randomly selected from the population) living in Sesto Fiorentino, a suburb of Florence, Italy, were interviewed by their own general practitioner, using the MINI plus six additional questions. Six hundred and ten of the 623 subjects that were found positive for any form of psychopathology at the screening interview, and 57 negative subjects, were re-interviewed by residents in psychiatry using the Florence Psychiatric Interview (FPI). The FPI is a validated composite instrument that has the format of a structured clinical research record. It was found that 6.58% of subjects showed social anxiety not attributable to other psychiatric or medical conditions during their life. Social or occupational impairments meeting DSM-IV diagnostic requirements for SP was detected in 76 subjects (lifetime prevalence = 3.27%). Correction for age raises the lifetime expected prevalence to 4%. Sex ratio was approximately (F:M) 2:1. The most common fear was speaking in public (89.4%), followed by entering a room occupied by others (63.1%) and meeting with strangers (47.3%). Eighty-six point nine percent of subjects with SP complained of more than one fear. The mean age of onset (when the subjects first fully met DSM-IV criteria for SP) was 28.8 years, but the first symptoms of SP usually occurred much earlier, with a mean age of onset at 15.5 years. Ninety-two percent of cases with SP also showed at least one other co-morbid psychiatric disorder during their life. Lifetime prevalence of avoidant personality disorder (APD) was 3.6%. Forty-two point nine percent of cases with SP also had APD, whereas 37.9% of cases with APD developed SP.
The increasing cost of pharmaceuticals in the Czech Republic has led to restrictions on the prescription of more expensive atypical antipsychotics. The aim of the study was to compare the costs and outcomes of using risperidone versus classical neuroleptics in treatment of schizophrenia in order to see if there was any cost advantage in restricting use of more recent antipsychotics. Sixty-seven patients (39 women) with a mean age of 34.6 years (S.D. = 9.74) suffering from schizophrenia or schizoaffective disorder were treated with risperidone while 67 patients (39 women) with the same diagnoses with a mean age of 35.7 years (S.D. = 9.91) received standard neuroleptics. Yearly direct medical costs and outcomes (indicated by the average Global Assessment of Functioning score) were assessed retrospectively in an open, intent-to-treat study by abstracting psychiatric outpatient charts. The outcomes were not significantly different between the treatment groups while the risperidone treatment was significantly more expensive than the therapy with standard neuroleptics. This result which appears to be inconsistent with the literature was caused by the cheap labor force in the Czech Republic. The difference between the followed treatments in the direct costs will probably become insignificant in the future when the country’s economy will be more developed.
A major challenge in linking conservation science and policy is deciding how, and when, to offer relevant science to decision-makers to have the greatest impact on decisions. This chapter argues it is a question of alignment – of selecting the right knowledge to address the needs of decision-makers, ensuring that knowledge is accessible to them, and articulating it within their decision-making processes. The chapter describes three mechanisms to enhance this alignment: decision support tools; active knowledge exchange mechanisms; and large-scale scientific assessments. For each, we provide examples and draw out guidelines regarding circumstances in which the mechanism is likely to be most effective. No single mechanism is consistently best at aligning evidence with policy and practice. Each has strengths and weaknesses, and can be applied in different circumstances and at different scales. The chapter ends with a call for these mechanisms that link synthesised evidence with policy and practice decisions to be funded sufficiently, alongside environmental research, to enable adherence to core values of salience, legitimacy, credibility and transparency.
We sought to establish if a brief psychoeducational intervention for relatives is effective in improving relatives’ knowledge about schizophrenia and reducing rehospitalization. We evaluated 101 relatives of 55 patients with schizophrenia before and after an 8-week psychoeducational group using a self-report method. We also conducted a matched case-control study of the effects on rehospitalisation for 28 of these patients. We calculated the number of hospital days for each index case and control in the 1 and 2 years before and after the intervention.
Relatives made significant gains in their knowledge about schizophrenia, particularly about medication. Patients whose relatives attended the group had significantly fewer days in hospital and days per admission compared to controls in the year after the programme but the effect waned in the second year after the intervention. Controls were almost four times more likely to be readmitted at 2 years than cases. Median time to readmission was significantly longer in cases compared to controls. We conclude that a psychoeducational group, which is valued by carers, is effective in increasing their knowledge about schizophrenia as well as reducing and forestalling the rehospitalization of their affected relatives. Such programmes deliver what carers frequently request in a cost-effective manner.
Asenapine is the most recent compound that has been FDA- and EMA-approved for treatment of mania. Its efficacy and safety have been assessed in placebo-controlled trials, but little is known about its performance in routine clinical conditions. In this study, we compared features of patients treated with adjunctive asenapine or other adjunctive antipsychotics and the costs of the treatment.
A combined prospective and retrospective data collection and analysis was conducted from January 2011 to December 2013 following a clinical interview and assessment of manic and depressive symptoms (YMRS, HDRS-17), clinical state (CGI-BP-M), psychosocial functioning (FAST), sexual dysfunction (PRSexDQ) and health resource costs associated with treatment with adjunctive asenapine versus other adjunctive antipsychotics.
Hundred and fifty-two patients from different university hospitals were included. Fifty-three patients received adjunctive asenapine and 99 received other adjunctive antipsychotics concomitantly to mood stabilizers. Considering inpatients, those treated with adjunctive asenapine presented a significantly less severe manic episode (P = 0.001), less psychotic symptoms (P = 0.030) and more comorbid personality disorder (P = 0.002). Regarding outpatients, those treated with adjunctive asenapine showed significantly less severe manic episode (P = 0.046), more previous mixed episodes (P = 0.013) and more sexual dysfunction at baseline (P = 0.036). No significant differences were found in mean total costs per day.
Clinicians tended to use adjunctive asenapine in patients with less severe manic symptoms but more complex clinical profile, including more mixed episodes in the past, concomitant personality disorder, and sexual problems. Treatment with adjunctive asenapine was not associated with higher costs when compared to other options.
The final chapter is a largely non-technical overview of economic and political aspects of wind energy policy. The cost of wind energy is assessed in terms of Levelised Cost of Energy (LCoE), with equations given in full and simplified forms. Using a large database, historic installed costs for UK wind both onshore and offshore are given, from the earliest projects to the present day. The observed trends are discussed. Operational and balancing costs are outlined, the latter reflecting the intermittency of wind power. LCoE estimates are made for a range of installed costs and output capacity factors at typical discount rates and compared with current generation prices. The chapter considers the economics of onsite generation with the example of a private business using wind energy to offset demand; the energy displacement and export statistics are extrapolated to compare with a national scenario for 100% renewable electricity generation. The topic of ownership is introduced and examined in the context of the UK’s first community-owned windfarm. The chapter concludes with a brief review of UK renewable energy policy, which originated with legislation to protect the nuclear power industry.
Vestibular schwannoma is the most common neoplasm in the cerebellopontine angle, and fast spin-echo T2-weighted magnetic resonance imaging is the most sensitive test for diagnosing it. This study evaluated the financial and time costs of unnecessary magnetic resonance imaging referrals before and after the application of a magnetic resonance imaging protocol.
A full audit cycle was used for the assessment. The first cycle in January 2012 was retrospective and evaluated the financial impact of current selection criteria for magnetic resonance imaging referral against standard guidelines. The second cycle in January 2014 was prospective after implementation of the protocol.
There were 46 and 112 patients who had magnetic resonance imaging during first and second cycle, respectively. Of the referrals for magnetic resonance imaging, 65 per cent versus 81 per cent of the referrals were appropriate in the first and second cycles, respectively. The relative risk was reduced from 0.5 to 0.2. The waiting times for magnetic resonance imaging scans improved.
Selection criteria for magnetic resonance imaging referral are important in reducing waiting times for scans, patient anxiety and conserving trust resources.
Chapter 2 examines how and why the United States chose to deliver the EITC in one annual payment as a tax refund, and how this is a stark contrast to how other social benefits are administered. One reason is administrative cost – it is relatively inexpensive to allow taxpayers to self-declare eligibility and receive benefits as a tax refund. Because other social benefit programs have direct contact with their recipients prior to payment, those programs have far higher administrative costs and far smaller overpayment rates. Delivery of social benefits through the tax system also avoids the stigma associated with applying for benefits through social welfare workers. This chapter cites empirical studies about taxpayer preferences as to delivery method and timing of refund and evidence as to how EITC recipients spend their refund. It also describes experiments with periodic payment, including the Advance Earned Income Tax Credit.
Equitable access to mental healthcare is a priority for many countries. The National Health Service in England uses a weighted capitation formula to ensure that the geographical distribution of resources reflects need.
To produce a revised formula for estimating local need for secondary mental health, learning disability (intellectual disability) and psychological therapies services for adults in England.
We used demographic records for 43 751 535 adults registered with a primary care practitioner in England linked with service use, ethnicity, physical health diagnoses and type of household, from multiple data-sets. Using linear regression, we estimated the individual cost of care in 2015 as a function of individual- and area-level need and supply variables in 2013 and 2014. We sterilised the effects of the supply variables to obtain individual-need estimates. We aggregated these by general practitioner practice, age and gender to derive weights for the national capitation formula.
Higher costs were associated with: being 30–50 years old, compared with 20–24; being Irish, Black African, Black Caribbean or of mixed ethnicity, compared with White British; having been admitted for specific physical health conditions, including drug poisoning; living alone, in a care home or in a communal environment; and living in areas with a higher percentage of out-of-work benefit recipients and higher prevalence of severe mental illness. Longer distance from a provider was associated with lower cost.
The resulting needs weights were higher in more deprived areas and informed the distribution of some 12% (£9 bn in 2019/20) of the health budget allocated to local organisations for 2019/20 to 2023/24.
The START (STrAtegies for RelaTives) intervention reduced depressive and anxiety symptoms of family carers of relatives with dementia at home over 2 years and was cost-effective.
To assess the clinical effectiveness over 6 years and the impact on costs and care home admission.
We conducted a randomised, parallel group, superiority trial recruiting from 4 November 2009 to 8 June 2011 with 6-year follow-up (trial registration: ISCTRN 70017938). A total of 260 self-identified family carers of people with dementia were randomised 2:1 to START, an eight-session manual-based coping intervention delivered by supervised psychology graduates, or to treatment as usual (TAU). The primary outcome was affective symptoms (Hospital Anxiety and Depression Scale, total score (HADS-T)). Secondary outcomes included patient and carer service costs and care home admission.
In total, 222 (85.4%) of 173 carers randomised to START and 87 to TAU were included in the 6-year clinical efficacy analysis. Over 72 months, compared with TAU, the intervention group had improved scores on HADS-T (adjusted mean difference −2.00 points, 95% CI −3.38 to −0.63). Patient-related costs (START versus TAU, respectively: median £5759 v. £16 964 in the final year; P = 0.07) and carer-related costs (median £377 v. £274 in the final year) were not significantly different between groups nor were group differences in time until care home (intensity ratio START:TAU was 0.88, 95% CI 0.58–1.35).
START is clinically effective and this effect lasts for 6 years without increasing costs. This is the first intervention with such a long-term clinical and possible economic benefit and has potential to make a difference to individual carers.
Declarations of interest
G.L., Z.W. and C.C. are supported by the UCLH National Institute for Health Research (NIHR) Biomedical Research Centre. G.L. and P.R. were in part supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart's Health NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Z.W. reports during the conduct of the study; personal fees from GE Healthcare, grants from GE Healthcare, grants from Lundbeck, other from GE Healthcare, outside the submitted work.