Assessment of the Indirect Cost of Drug Resistant Tuberculosis Treatment to Patients in a High Burden, Low Income Setting in Mozambique

Introduction: Tuberculosis is closely linked to poverty, with patients facing significant indirect treatment costs. Treating drug-resistant tuberculosis further increases these expenses. Notably, there is a lack of published data on the indirect costs incurred by patients with drug-resistant tuberculosis in Mozambique. Objective: To assess the indirect costs, income reduction, and work productivity incurred by patients undergoing diagnosis and treatment for Drug-Resistant Tuberculosis (DRTB) in Mozambique during their TB treatment. Methods: As part of a comprehensive mixed-methods study conducted from January 2021 to April 2023, this research utilized a descriptive cross-sectional approach, incorporating both quantitative and qualitative methods. The primary goal was to evaluate the costs incurred by the national health system due to drug-resistant TB. Additionally, to explore the indirect costs experienced by patients and their families during treatment, semi-structured interviews were conducted with 27 individuals who had been undergoing treatment for over six months. Results: All survey participants unanimously reported a significant decline in labour productivity, with 70.3% experiencing a reduction in their monthly income. Before falling ill, the majority of respondents (33.3%) earned up to $76.92 monthly, representing the minimum earnings range, while 29.2% had a monthly income above $230.77, the maximum earnings range. Among those who experienced income loss, the majority (22.2%) reported a decrease of up to $76.92 per month, and 18.5% cited a loss exceeding $230.77 per month. Notably, patients with Drug-Resistant Tuberculosis (DRTB) have not incurred the direct costs of the disease, as these are covered by the government. Conclusion: The financial burden of treating Drug-Resistant Tuberculosis (DRTB), along with the income reduction it causes, is substantial. Implementing a patient-centred, multidisciplinary, and multisector approach, coupled with strong psychosocial support, can significantly reduce the catastrophic costs DRTB patients incur.

Is Tuberculosis Treatment Truly Free? A Study to Identify Key Factors Contributing to the Catastrophic Cost of TB Care in Pakistan

Background: The interplay between financial deprivation and tuberculosis (TB) is considered one of the vital socio-economic determinants of disease. This is the first study of its kind to be carried in Pakistan, which aims to identify leading factors contributing towards catastrophic costs of TB diagnosis and management in order to help policy makers. Methodology: From four tertiary care hospitals (TCH) in Islamabad and Rawalpindi, 400 TB patients were interviewed through a cross-sectional survey. The patient’s pre and post-TB income and direct and indirect costs for treatment were analysed following WHO recommendations. Multivariable logistic regression model was used to identify the determinants of catastrophic total cost. Results: For TB management expenditures, the median (interquartile range) of total costs by households was Rs. 58,175 Rs (32,050 - 97,500). At 20% threshold, 67% of TB patient’s households were affected by catastrophic costs. The determinants of the catastrophic total cost were as follows: patient/guardian employed (adjusted odds ratio [aOR] = 3.428, 95% confidence interval [CI]: 1.900 - 6.186), patient/guardian the only breadwinner (aOR = 1.751, 95% CI: 1.011 - 3.032), follow-up visits at current health facility (aOR = 1.352, 95% CI: 1.223 - 1.494), job loss (aOR = 3.381, 95% CI: 1.512 - 7.561), and unpaid sick leaves (aOR = 2.862, 95% CI: 1.249 - 6.558). Conclusion: The financial deprivation experienced by patients of low socio-economic status increases as TB treatment proceeds. This negatively impacts the treatment adherence, resulting in poor treatment outcomes due to income and job loss. Outcomes are exacerbated if the family has single breadwinner and treatment requires follow-up visits.

基本医保参保人门诊医疗服务利用、费用及风险分析

目的:分析45岁以上人群门诊服务利用、费用和风险。方法:基于CHARLS2018年数据,分别进行单因素分析和多元logit回归。结果:门诊服务利用率明显低于自行购药,门诊费用和自行购药费用月均1 000元以上组占比最高,门诊和购药费用获得医保报销的比例明显低于住院,报销比例亦是如此。门诊保障水平对门诊费用利用影响有统计学意义;门诊服务利用和自行购药都是引致灾难性卫生支出的重要影响因素;随着慢病患者患病种数的增加,未住院患者发生灾难性卫生支出的风险增加。建议:完善基本医保门诊报销政策,引导患者合理利用医疗服务,提高基金支出效率;重新认识门诊费用,重构医保待遇保障组合;提高慢病患者的门诊保障水平,减轻慢病患者门诊费用风险。

考虑动态任务耗时与播种墙容量的移动机器人拣货系统任务分配优化

任务分配是影响移动机器人拣货系统效率的关键决策问题。针对具有差异化客户评级特征的业务场景,考虑系统的动态任务耗时特性和拣选站播种墙容量约束,提出了一种基于混合启发式算法的集中式任务分配方法。首先,在客户订单优先级约束下构建以最大完工时间最小为目标的任务分配优化模型。其次,考虑机器人在任务执行中因加减速、转弯、升降货架、排队等待导致的动态任务耗时以及播种墙容量限制,设计最大完工时间生成方案。随后,开发基于记忆精英种群的灾变自适应大邻域搜索算法(MEPCALNS)对模型进行求解,提高了传统自适应大邻域搜索算法的搜索深度和搜索效率。最后,通过数值实验证明了算法的有效性和稳定性。研究成果有利于提高移动机器人拣货系统的分拣效率。

Cost-Effectiveness of Interventions for Alternate Food to Address Agricultural Catastrophes Globally

The literature suggests there is about a 1 % risk per year of a 10 % global agricultural shortfall due to catastrophes such as a large volcanic eruption, a medium asteroid or comet impact, regional nuclear war, abrupt climate change, and extreme weather causing multiple breadbasket failures. This shortfall has an expected mortality of about 500 million people. To prevent such mass starvation, alternate foods can be deployed that utilize stored biomass. This study developed a model with literature values for variables and, where no values existed,used large error bounds to recognize uncertainty. Then Monte Carlo analysis was performed on three interventions: planning, research, and development. The results show that even the upper bound of USD 400 per life saved by these interventions is far lower than what is typically paid to save a life in a less-developed country. Furthermore, every day of delay on the implementation of these interventions costs 100–40,000 expected lives(number of lives saved multiplied by the probability that alternate foods would be required). These interventions plus training would save 1–300 million expected lives. In general, these solutions would reduce the possibility of civilization collapse, could assist in providing food outside of catastrophic situations, and would result in billions of dollars per year of return.

青岛市大病医疗救助政策实施效果评估

目的:评估青岛市大病救助政策实施成效,为青岛市政策改革提供建议。方法:选取非小细胞肺癌、肝癌作为病种代表,实证分析大病救助政策实施对患者和医疗保险机构的影响,评估政策实施成效。结果:政策出台后,肺癌患者的自付比降幅为40.57%,范围内基金支出的压力显著降低;肝癌患者的自付比降幅为7.13%,范围内基金支出的压力并未得到有效缓解。结论:青岛市大病救助政策不仅减轻了重大疾病或罕见病患者的医疗负担,而且实现了医保基金的精细化管理,提高了基金的使用效率。

自然灾害风险可保性分析及其损失分散机制

自然灾害风险不符合传统精算理论上的可保风险,然而市场—社会效用意义上的可保风险标准拓展了自然灾害风险的可保性。建立在这一理论基础上,文章探讨了如何构建自然灾害保险意义上的整体性、多层次的自然灾害损失分散机制。从直接保险、共同保险、再保险到资本市场和政府的最终保障,居民、保险市场、再保险市场和资本市场是市场化的自然灾害保险损失分散主体,而政府财政救助不应再是"第一保险人"的角色,反之应是承担较高层次的自然灾害损失——"最后再保险人"角色,并以此达到有效的将自然灾害损失分摊到不同主体和个人,最终实现最大限度的损失补偿,为我国的自然灾害保险制度的构建与设计提供参考依据。

国家组织药品集中采购对耐药结核病患者药物可负担性的影响

目的探讨国家组织药品集中采购(简称集采)政策对耐药结核病患者药物可负担性的影响。方法根据《耐药结核病化学治疗指南(2019年简版)》和药品说明书,按体质量50 kg成年人估算服药日剂量,参照北京市药品阳光采购平台和医院信息系统中的药品价格,测算集采政策实施前后耐药结核病患者的疗程费用,以灾难性医疗支出(指家庭的医疗支出占家庭可支付能力的比重≥40%)为指标评估耐药结核病患者的药物可负担性。结果对利福平敏感的耐药结核病患者的疗程费用为(0.40~0.88)万元,乙胺丁醇的价格在集采政策实施后下降了42.86%,但组合治疗方案的总疗程费用相差不大;耐多药结核病患者的疗程费用由集采政策实施前的(3.38~42.83)万元降为集采政策实施后的(2.85~21.04)万元,其中含有利奈唑胺的治疗方案的疗程费用降幅为31.68%~50.88%。48个耐多药结核病治疗组合方案中,造成灾难性医疗支出的组合方案由集采政策实施前的38个降至集采政策实施后的17个。城镇患者的药品支出占家庭可支配收入的比例由集采政策实施前的20.77%~102.43%降至集采政策实施后的19.74%~48.51%,造成灾难性医疗支出的治疗方案由集采政策实施前的9个降至集采政策实施后的5个;农村患者的药品支出占家庭可支配收入的比例由集采政策实施前的54.91%~270.83%降至集采政策实施后的52.19%~128.27%,但所有组合方案均会造成灾难性医疗支出。结论国家集采政策可在降低药品费用的同时降低个人自付费用,但二线抗结核药品价格仍较高,给耐多药结核病患者带来了较大的经济负担,且农村患者的情况更严峻。

基于突变级数法的煤炭企业安全投入评价

安全生产的实现要以安全投入为基础,明晰的安全成本构成体系和科学合理的安全投入效果评价方法是提高煤炭企业安全费用使用精准度、提升安全投入效益的关键。为科学合理地评价煤炭企业安全投入效果,提高煤炭企业安全管理水平,将安全成本划分为保证性安全成本和损失性安全成本两大类,再将这两大类细分为不同的小科目单元,提出了更加完善的煤炭企业安全成本构成体系。基于突变理论构建煤炭企业安全投入评价模型,引入突变级数法分析并评价陕煤集团2012—2018年安全投入效果。首先选择保证性安全成本的4项评价指标,损失性安全成本选取直接损失成本和间接损失成本;其次确定突变系统模型并进行归一化处理;最后根据3个评价标准等级分析该煤炭企业的安全投入水平。结果表明:通过构建完善的煤炭企业安全成本体系,安全投入结构更加合理,安全会计业务更加清晰,为安全成本核算提供了理论基础;选用突变级数法评价陕煤集团安全投入效果,该煤炭企业的安全等级为良好,验证了突变级数法适用于煤炭企业的安全投入评价,为煤炭企业安全投入效果评价提供了新思路。

建筑企业施工安全成本分析

在对建筑企业安全成本构成进行分析的基础上,运用突变级数的方法建立安全成本投入的评价模型,并以此模型对福建省福州市闽侯县国宾大道龙江云山墅项目的安全成本投入进行实例分析,评价结果表明其安全成本投入是可行的.该方法克服了模糊数学法、主成分分析法等主观性较大、计算较复杂的缺点,更具有实用价值.

规治大病政策 回归制度本位

建立大病保险制度,是落实中央要求、回应社会呼声、化解灾难性卫生支出风险的具体举措。大病保险已经覆盖城乡居民医保所有参保人员,一定程度上提高了总体支付水平,但由于实行人人有份的平均主义、各类保障措施内涵和边界含混不清、对罕见病缺乏保障等原因,并不能有效解决灾难性卫生支出风险、实现制度初衷。现在应当进行必要的反思,系统考量构建真正意义上的重特大疾病保障和救助机制。要逐步将大病保险纳入基本医疗保险制度框架,使其回归制度本位,发挥政府主体责任和"兜底"作用,承担"补齐短板"的制度功能,完善城乡医疗救助制度,着重解决居民因医疗行为而产生的间接费用,探索多元化的医疗保障各类制度的经办方式。

巨灾风险可保性与损失分担机制研究

巨灾风险不符合传统精算理论上的可保风险,然而市场——社会效用意义上的可保风险标准拓展了巨灾风险的可保性。建立在这一理论基础上,本文探讨了如何构建巨灾保险意义上的整体性、多层次的巨灾损失分担机制。从直接保险、共同保险、再保险到资本市场和政府的最终保障,居民、保险市场、再保险市场和资本市场是市场化的巨灾保险损失分担主体,而政府财政救助不应再是"第一保险人"的角色,反之应是承担较高层次的巨灾损失——"最后再保险人"角色,并以此达到有效的将巨灾损失分摊到不同主体和个人,最终实现最大限度的损失补偿。以此为我国的巨灾保险制度的构建与设计提供参考依据。

大病保障模式比较及发展路径研究:以成本—效益分析为视角

制度发展和国民日益增长的需求都要求提供更加充分的大病保障,但目前我国大病保障相对不足。近年来,全国各地对大病保障实践进行了积极探索,形成多种化解大病经济风险的模式。本文在总结中国大病保障实践模式特点的基础上,应用基于德尔菲等方法构建的成本—效益指标及权重体系,对各典型模式进行了比较分析。研究发现,制度统一、有序就医、拥有健康红利的东莞模式相对最优。借鉴国际上绝对数、相对比、混合式等三种自付封顶方式,在逐步取消基金封顶的条件下,我国可以探索建立多层次绝对值自付封顶模式,并利用"互联网+"及政府购买服务方式,提高大病保障水平,推动医保治理现代化。

间接医疗费用对造成家庭重大医疗支出的影响

目的研究间接医疗费用对增加家庭医疗费用负担以及引起家庭重大医疗支出的作用及其影响因素。方法利用2003年全国卫生服务调查资料，定量测算门诊及住院间接医疗费用及其造成的家庭重大医疗支出发生率，并利用回归模型分析其影响因素。结果间接医疗费用在门诊和住院中都非常普遍，间接医疗费用可以直接导致1％-2％的家庭重大医疗支出发生，特别是在农村地区作用更为明显。影响间接医疗费用的主要因素包括收入状况、保险类型，及家庭与卫生机构的距离。结论间接医疗费用不但可以增加家庭的医疗支出，而且可以直接造成家庭重大医疗支出的发生，特别是对于农村地区和弱势人群的作用更加突出。为了更好的解决“看病难”问题，要对间接医疗费用引起足够的重视，并通过提高卫生服务利用的物理可及性和经济可及性、扩大医疗保障覆盖范围和覆盖力度来加以解决，同时还要特别关注弱势群体和农村地区。

新农合重大疾病保障政策对单病种医药费用的影响分析

目的:探讨新农合重大疾病保障政策对不同费用类型单病种费用的影响。方法:利用医院信息系统(Hospital Information System,HIS)搜集泰州市人民医院肺癌、食管癌、胃癌、结肠癌、直肠癌手术病人医疗费用等资料,分析新农合重大疾病保障政策实施前后的费用变化。结果:新农合重大疾病保障政策实施后,新农合患者单病种费用明显下降,职工医保患者费用未下降。结论:新农合单病种支付方式改革有利于控制单病种医疗费用,但要使整体医疗费用下降,建议实行疾病诊断相关分类(Diagnosis Related Groups,DRGs)支付。

Inequity in catastrophic costs among tuberculosis-affected households in China

Background:There are limited nationally representative studies globally in the post-2015 END tuberculosis(TB)era regarding wealth related inequity in the distribution of catastrophic costs due to TB care.Under the Chinese national tuberculosis programme setting,we aimed to assess extent of equity in distribution of total TB care costs(pre-treatment,treatment and overall)and costs as a proportion of annual household income(AHI),and describe and compare equity in distribution of catastrophic costs(pre-treatment,treatment and overall)across population sub-groups.Methods:Analytical cross-seaional study using data from national TB patient cost survey carried out in 22 counties from six provinces in China in 2017.Drug-susceptible pulmonary TB registered under programme,who had received at least 2 weeks of intensive phase therapy were included.Equity was depiaed using concentration curves and concentration indices were compared using dominance test.Results:Of 1147 patients,the median cost of pre-treatment,treatment and overall care,were USD 283.5,USD 413.1 and USD 965.5,respectively.Richer quintiles incurred significantly higher pre-treatment and treatment costs compared to poorer quintiles.The distribution of costs as a proportion of AHI and catastrophic costs were significantly pro-poor overall as well as during pre-treatment and treatment phase.All the concentration curves for catastrophic costs(due to pre-treatment,treatment and overall care)stratified by region(east,middle and west),area of residence(urban,rural)and type of insurance new rural co-operative medical system[NCMS],non-NCMSalso exhibited a pro-poor pattern with statistically significant(P<0.01)concentration indices.The pro-poor distribution of the catastrophic costs due to TB treatment was significantly more inequitable among rural,compared to urban patients,and NCMS compared to non-NCMS beneficiaries.Conclusions:There is inequity in the distribution of catastrophic costs due to TB care.Universal health coverage,social protection strategies complemented by quality TB care is vital to reduce inequitable distribution of catastrophic costs due to TB care in China.

中国部分地区高血压患者疾病负担变化的影响因素研究

目的:探讨高血压管理模式对患者疾病负担的影响。方法:采用方便抽样抽取6个省7家县级公立医院的高血压患者进行随访调查。以灾难性卫生支出指标衡量疾病负担,以WHO界定的10%作为灾难性卫生支出发生的标准。以居住地、收入等级、年龄和医保类型为分组描述灾难性卫生支出发生率、平均差距和相对差距变化情况,采用χ2检验比较不同组别患者的灾难性卫生支出发生率。结果:对比2017年基线调查,高血压患者灾难性卫生支出发生率、平均差距和相对差距均明显下降,分别从23.0%降至20.5%,19.4%降至9.6%和84.1%降至47.0%。农村、中等收入以下和新农合高血压患者灾难性卫生支出改善效果显著。年龄分组中大于60岁、江西患者、文化程度分组为文盲或半文盲和收入等级分组为低收入组和中低收入组患者较基线调查时灾难性卫生支出发生率显著降低(P<0.05);省份为甘肃和陕西的患者较基线调查时灾难性卫生支出发生率显著上升(P<0.05),其他组别变化差异无统计学意义。结论:高血压患者规范化管理在抵御灾难性卫生支出方面具有积极作用。在探索与完善高血压管理模式的过程中,应引导政策进一步向农村、老年、低文化和低收入等特定人群患者倾斜,健全医疗补助政策,加强新农合患者的保障力度,必要时适当增加补助,加强加深高血压管理模式在此类人群中的良好效果。

Catastrophic total costs in tuberculosisaffected households and their determinants since Indonesia’s implementation of universal health coverage

Background:As well as imposing an economic burden on affected households,the high costs related to tuberculosis(TB)can create access and adherence barriers.This highlights the particular urgency of achieving one of the End TB Strategy’s targets:that no TB-affected households have to face catastrophic costs by 2020.In Indonesia,as elsewhere,there is also an emerging need to provide social protection by implementing universal health coverage(UHC).We therefore assessed the incidence of catastrophic total costs due to TB,and their determinants since the implementation of UHC.Methods:We interviewed adult TB and multidrug-resistant TB(MDR-TB)patients in urban,suburban and rural areas of Indonesia who had been treated for at least one month or had finished treatment no more than one month earlier.Following the WHO recommendation,we assessed the incidence of catastrophic total costs due to TB.We also analyzed the sensitivity of incidence relative to several thresholds,and measured differences between poor and non-poor households in the incidence of catastrophic costs.Generalized linear mixed-model analysis was used to identify determinants of the catastrophic total costs.Results:We analyzed 282 TB and 64 MDR-TB patients.For TB-related services,the median(interquartile range)of total costs incurred by households was 133 USD(55-576);for MDR-TB-related services,it was 2804 USD(1008-4325).The incidence of catastrophic total costs in all TB-affected households was 36%(43%in poor households and 25%in non-poor households).For MDR-TB-affected households,the incidence was 83%(83%and 83%).In TB-affected households,the determinants of catastrophic total costs were poor households(adjusted odds ratio[aOR]=3.7,95%confidence interval[CI]:1.7-7.8);being a breadwinner(aOR=2.9,95%CI:1.3-6.6);job loss(aOR=21.2;95%CI:8.3-53.9);and previous TB treatment(aOR=2.9;95%CI:1.4-6.1).In MDR-TB-affected households,having an income-earning job before diagnosis was the only determinant of catastrophic total costs(aOR=8.7;95%CI:1.8-41.7).Conclusions:Despite the implementation of UHC,TB-affected households still risk catastrophic total costs and further impoverishment.As well as ensuring access to healthcare,a cost-mitigation policy and additional financial protection should be provided to protect the poor and relieve income losses.

Effect of financial support on reducing the incidence of catastrophic costs among tuberculosis-affected households in Indonesia:eight simulated scenarios

Background:The World Health Organization's End Tuberculosis Strategy states that no tuberculosis(TB)-affected households should endure catastrophic costs due to TB.To achieve this target,it is essential to provide adequate social protection.As only a few studies in many countries have evaluated social-protection programs to determine whether the target is being reached,we assessed the effect of financial support on reducing the incidence of catastrophic costs due to TB in Indonesia.Methods:From July to Septem ber 2016,we interviewed adult patients receiving treatment for TB in 19 primary health centres in urban,sub-urban and rural area of Indonesia,and those receiving multidrug-resistant(MDR)TB treatment in an Indonesian national referral hospital.Based on the needs assessment,we developed eight scenarios for financial support.We assessed the effect of each simulated scenario by measuring reductions in the incidence of catastrophic costs.Results:We analysed data of 282 TB and 64 MDR-TB patients.The incidences of catastrophic costs in affected households were 36 and 83%,respectively.Patients'primary needs for social protection were financial support to cover costs related to income loss,transportation,and food supplements.The optimum scenario,in which financial support would be provided for these three items,would reduce the respective incidences of catastrophic costs in TB and MDR-TB-affected households to 11 and 23%.The patients experiencing catastrophic costs in this scenario would,however,have to pay high rem aining costs(median of USD 910;[interquartile range(IQR)662]in the TB group,and USD 2613;[IQR 3442]in the MDR-TB group).Conclusions:Indonesia's current level of social protection is not sufficient to mitigate the socioeconom ic im pact of TB.Financial support for income loss,transportation costs,and food-supplem ent costs will substantially reduce the incidence of catastrophic costs,but financial support alone will not be sufficient to achieve the target of 0%TBaffected households facing catastrophic costs.This would require innovative social-protection policies and higher levels of dom estic and external funding.

The role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in Nepal

Background:The World Health Organization(WHO)End TB Strategy has established a milestone to reduce the number of tuberculosis(TB)-affected households facing catastrophic costs to zero by 2020.The role of active case finding(ACF)in reducing patient costs has not been determined globally.This study therefore aimed to compare costs incurred by TB patients diagnosed through ACF and passive case finding(PCF),and to determine the prevalence and intensity of patient-incurred catastrophic costs in Nepal.Methods:The study was conducted in two districts of Nepal:Bardiya and Pyuthan(Province No.5)between June and August 2018.One hundred patients were included in this study in a 1:1 ratio(PCF:ACF,25 consecutive ACF and 25 consecutive PCF patients in each district).The WHO TB patient costing tool was applied to collect information from patients or a member of their family regarding indirect and direct medical and non-medical costs.Catastrophic costs were calculated based on the proportion of patients with total costs exceeding 20%of their annual household income.The intensity of catastrophic costs was calculated using the positive overshoot method.The chi-square and Wilcoxon-Mann-Whitney tests were used to compare proportions and costs.Meanwhile,the Mantel Haenszel test was performed to assess the association between catastrophic costs and type of diagnosis.Results:Ninety-nine patients were interviewed(50 ACF and 49 PCF).Patients diagnosed through ACF incurred lower costs during the pre-treatment period(direct medical:USD 14 vs USD 32,P=0.001;direct non-medical:USD 3 vs USD 10,P=0.004;indirect,time loss:USD 4 vs USD 13,P<0.001).The cost of the pre-treatment and intensive phases combined was also lower for direct medical(USD 15 vs USD 34,P=0.002)and non-medical(USD 30 vs USD 54,P=0.022)costs among ACF patients.The prevalence of catastrophic direct costs was lower for ACF patients for all thresholds.A lower intensity of catastrophic costs was also documented for ACF patients,although the difference was not statistically significant.Conclusions:ACF can reduce patient-incurred costs substantially,contributing to the End TB Strategy target.Other synergistic policies,such as social protection,will also need to be implemented to reduce catastrophic costs to zero among TB-affected households.