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1
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84913842017
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Methods exist for estimating multiple output cost functions using flexible functional forms which are capable of capturing a variety of patterns of complementarity in the joint production of these outputs. There is also an extensive literature on controlling for output heterogeneity in hospital cost functions in the United States. The author is unaware of any similar studies that have been attempted for the public health sector of developing countries.
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2
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84913846694
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Most of the population consists of sedentary farmers who inhabit the more fertile southern quarter of the land bordering the Niger River to the southwest and Nigeria to the southeast. However, when rainfall is normal, Fulani (i.e. Peuhl) and Tuareg nomads migrate extensively. The encampments of these nomads are included in the government's goal of reaching every ‘village’, but the technical problems involved in initiating and maintaining contacts with health workers in these encampments have not yet been solved.
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3
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84913835297
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The link between the presence of functioning VHTs and their utilization requires an analysis of the effective demand for their services in the presence of competing sources of care such as traditional healers, home remedies and trips to the closest clinic, pharmacy or hospital. See Akin [4] and Mwabu [5, 6] for examples of such demand studies. The link between utilization and a change in health status requires studies such as those reviewed by Gwatkin et al. [7]. In the absence of detailed studies such as these, some reasonable assumptions may be required to convert a process measure such as functioning VHTs into measures of people served or health status changed.
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5
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33749466997
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A model of household choice among medical treatment alternatives in rural Kenya
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Boston University, Boston, Mass
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(1984)
Doctoral dissertation
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Mwabu1
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8
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84913818860
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See Over [9] for a cost-effectiveness analysis using two process measures to compare the health impacts of two alternative approaches to the implementation of a PHC program.
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10
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84913820102
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The choice of 1 year as the duration which distinguishes an investment from a consumption expenditure is an arbitary, but virtually universal convention. Furthermore, any expenditure during a given budget year which yields services in the next year is typically considered an investment even if the expenditure occurs near the end of the previous period.
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15
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84913858267
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The best choice of an output measure might differ for some of these other cost components. If no single output measure seems appropriate for all parts of a cost projection, more than one can be adopted and cost projections computed separately for the different program components before adding the cost components to estimate total cost.
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17
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84913813622
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The only exception to the principle arises in the situation where the analyst has a strong reason to believe that the relative prices of different categories of project inputs are likely to change over time. For example suppose that a devaluation is predicted with some confidence. The effect of the devaluation on the relative costs of imported vs domestic inputs should be included in the analyst's cost projections for the individual project.
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18
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84913851944
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The public sector cost curves described in this paper all refer to the long run in the sense that all readjustment of factor combinations that could take place to reduce costs has already taken place. The long-run cost curve is an envelope which bounds from below a sequence of short-run curves, each defined by a different level of some factor of production which is fixed in the short run. This is not to say that further cost reductions could not be achieved, but that they are unlikely to be achieved without major changes in the incentive structure inder which health sector officials operate in Niger and other African countries.
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19
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84913831448
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Strictly speaking, the concept of economies of scale discussed in the text is related to only the first of the two cited causes. The second cause is sometimes referred to as ‘learning by doing’ and actually shifts the entire cost curve downwards over time so that costs become lower at every level of output. However, since these shifts tend to occur over time as program output expands, they are correlated with, if not caused by, increasing scale. Two other sources of cost reduction with expanding output are less likely to occur in a publicly owned and operated program than in the private sector. First, the incentive to seek technical improvements might be larger in a firm with larger output because (a) a given savings in cost per unit of output can have a much bigger absolute impact on total costs, (b) there may be economies of scale in the activity of research and development and (c) a larger firm may be able to capture a larger proportion of [[Truncated]]
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20
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84913857959
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For purposes of contacting, recruiting and training, the MES is 10 VHTs by this definition.
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21
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84913836554
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An example of a health care program that was able to achieve universal coverage only at the expense of sharply rising costs per unit of output as it neared completion was the smallpox eradication program. For an anecdotal account that stresses the increased difficulty of vaccinating the last few susceptibles likely to be infected in Bangladesh, see Foster [22].
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23
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84913876445
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The PHC program in Mauritania is an interesting special case, because large numbers of the most influential constituency, the Moorish nomads, inhabit the most remote and least densely populated regions of the country. Despite pressure from this constituency, the leaders bowed to bureaucratic and economic practicalities by launching the PHC program in areas close to the capital where Moors are in the minority. Now government leaders are exerting pressure to assure that regions where Moors are in the majority are among the next regions to be brought into the program—regardless of the higher costs implied by that decision.
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24
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84913851037
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The slope of 35 is estimated as the ratio of the change in investment to the change in existing VHTs 140,000/4000. The intercept is estimated from a point on the line as 160,000 − 35(1000) = 125,000.
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25
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84913871839
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2.
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26
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84913844527
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The policy response to inactive VHWs is not necessarily to replace them. To the extent that a non-functioning VHW is merely an indication of insufficient demand for VHW services in a certain village, perhaps because of the availability of other forms of health care, the appropriate policy may be to allow the village to go without a VHW until it explicitly requests that a new VHT be trained. Perhaps only one in five villages which have dropped out of the system would request a replacement, thus allowing scarce recurrent resources to be allocated to villages where effective demand continues to substain a VHT.
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27
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84913840172
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One project which attempted to experiment in several geographical regions was the Rural Health Project in Mali, which was implemented by the Harvard Institute for International Development under contract to the government of Mali with the support of the U.S. Agency for International Development (Gray and Sankare [28]). The more remote of the two project regions did in fact incur much greater difficulties and higher costs—to the point that it was abandoned.
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