Per-capita Health Expenditure Research Articles

Identifying determinants of spatial agglomeration of healthcare resources by using spatial econometric methods: a longitudinal study in China.

Healthcare resources are necessary for individuals to maintain their health. The Chinese government has implemented policies to optimize the allocation of healthcare resources and achieve the goal of equality in healthcare for the Chinese people since the implementation of the new medical reform in 2009. Given that no study has investigated regional differences from the perspective of healthcare resource agglomeration, this study aimed to investigate China's healthcare agglomeration from 2009 to 2017 in China and identify its determinants to provide theoretical evidence for the government to develop and implement scientific and rational healthcare policies. The study was conducted using 2009-2017 data to analyze health-resource agglomeration on institutions, beds, and workforce in China. An agglomeration index was applied to evaluate the degree of regional differences in healthcare resource allocation, and spatial econometric models were constructed to identify determinants of the spatial agglomeration of healthcare resources. From 2009 to 2017, all the agglomeration indexes of healthcare exhibited a downward trend except for the number of institutions in China. Population density (PD), government health expenditures (GHE), urban resident's disposable income (URDI), geographical location (GL), and urbanization level (UL) all had positive significant effects on the agglomeration of beds, whereas both per capita health expenditures (PCHE), number of college students (NCS), and maternal mortality rate (MMR) had significant negative effects on the agglomeration of institutions, beds, and the workforce. In addition, population density (PD) and per capita gross domestic product (PCGDP) in one province had negative spatial spillover effects on the agglomeration of beds and the workforce in neighboring provinces. However, MMR had a positive spatial spillover effect on the agglomeration of beds and the workforce in those regions. The agglomeration of healthcare resources was observed to remain at an ideal level in China from 2009 to 2017. According to the significant determinants, some corresponding targeted measures for the Chinese government and other developing countries should be fully developed to balance regional disparities in the agglomeration of healthcare resources across administrative regions.

Global, regional, and national progress in financial risk protection towards universal health coverage, 2000–2030

IntroductionComplete (100%) protection against catastrophic health expenditure (CHE) and impoverishment is the main target of universal health coverage (UHC). Evidence-based estimates must be at the heart of policy development for UHC, further research using updated data is essential to monitor, track, and compare country progress up to 2030. We estimate global, regional, and country-level CHE and impoverishment during 2000–2030. MethodsWe aggregated 636 data points from 140 countries that were conducted between 2000 and 2021. We used Bayesian hierarchical model for trend and projection analysis. Furthermore, we constructed scenario-based projections of CHE and impoverishment based on 5% GDP spending on health and per capita health expenditure (PCHE) of $86. ResultsMost countries fail to achieve financial protection targets by 2030, with the global incidence of CHE predicted to persist around 7% at 10% threshold. CHE is predicted to increase in most of Asia (Southern: 8.1% in 2000 to 13.4% in 2030; Central: 3.6%–23.2%; Eastern: 8.3%–14.4%; and Western: 7.3%–20.2%), Northern Africa (12.4%–27.2%), Eastern (7.1%–14.9%) and Northern Europe (6.6%–13.2%). In contrast, a decrease is predicted in Oceania, Latin America and the Caribbean, and Northern America. By 2030, incidence of impoverishment is predicted to be 0% worldwide at $3.10 poverty line, however in several African and Soth Asian countries is predicted to be high impoverishment. The scenario-based analysis indicated that CHE and impoverishment is expected to decrease in 41 and 42 countries for GDP increase and 43 and 62 for PCHE increase respectively compared to current spending on health. ConclusionTo accelerate progress towards reducing financial protection, governments should carefully assess the country context to determine how health can be prioritised through government spending to reduce out-of-pocket payments.

Lessons for Developing Countries From Outlier Country Health Systems.

Building good health systems is an important objective for policy makers in any country. Developing countries which are just starting out on their journeys need to do this by using their limited resources in the best way possible. The total health expenditure of a country exerts a significant influence on its health outcomes but, given the well-understood failures of price-based market-mechanisms, countries that spend the most money do not necessarily end-up building the best health systems. To help developing country policy makers gain a deeper insight into what factors matter, in this study the contribution of per-capita total, out-of-pocket, and pooled health expenditures, to the cross-country variation in Disability Adjusted Life Years lost per 100,000 population (DALY Rates), a summary measure of health outcomes, is estimated. The country-specific residuals from these analyses are then examined to understand the sources of the rest of the variation. The study finds that these measures are able to explain between 40 and 50% of the variation in the DALY Rates with percentage increases in per-capita out-of-pocket and pooled expenditures being associated with improvements in DALY Rates of about 0.06% and 0.095%, respectively. This suggests that while increases in per-capita total health expenditures do matter, moving them away from out-of-pocket to pooled has the potential to produce material improvements in DALY Rates, and that taken together these financial parameters are able to explain only about half the cross-country variation in DALY Rates. The analysis of the residuals from these regressions finds that while there may be a minimum level of per-capita total health expenditures (> $100) which needs to be crossed for a health system to perform (Bangladesh being a clear and sole exception), it is possible for countries to perform very well even at very low levels of these expenditures. Colombia, Thailand Honduras, Peru, Nicaragua, Jordan, Sri Lanka, and the Krygyz Republic, are examples of countries which have demonstrated this. It is also apparent from the analysis that while very high rates (> 75%) of pooling are essential to build truly high performing health systems (with DALYRates < 20, 000), a high level of pooling on its own is insufficient to deliver strong health outcomes, and also that even at lower levels of pooling it is possible for countries to out-perform their peers. This is apparent from the examples of Ecuador, Mexico, Honduras, Malaysia, Vietnam, Kyrgyz Republic, and Sri Lanka, which are all doing very well despite having OOP% in the region of 40–60%. The analysis of residuals also suggests that while pooling (in any form) is definitely beneficial, countries with single payer systems are perhaps more effective than those with multiple payers perhaps because, despite their best efforts, they have insufficient market power over customers and providers to adequately manage the pulls and pressures of market forces. It can also be seen that countries and regions such as Honduras, Peru, Nicaragua, Jordan, Sri Lanka, Bangladesh, Kerala, and the Kyrgyz Republic, despite their modest levels of per-capita total health expenditures have delivered attractive DALY Rates on account of their consistent prioritization of public-health interventions such as near 100% vaccine coverage levels and strong control of infectious diseases. Additionally, countries such as Turkey, Colombia, Costa Rica, Thailand, Peru, Nicaragua, and Jordan, have all delivered low DALY Rates despite modest levels of per-capita total health expenditures on account of their emphasis on primary care. While, as can be seen from the discussion, several valuable conclusions can be drawn from this kind of analysis, the evolution of health systems is a complex journey, driven by multiple local factors, and a multi-country cross-sectional study of the type attempted here runs the risk of glossing over them. The study attempts to address these limitations by being parsimonious and simple in its approach toward specifying its quantitative models, and validating its conclusions by looking deeper into country contexts.

The Impact of Community-Based Health Insurance on Household's Welfare in Chilga District, Amhara Regional State, Ethiopia.

Household welfare is depleted by catastrophic health expenditure by forcing families to reduce the consumption of necessary goods and services, underutilization of health services, and of finally falling into the poverty trap. To mitigate such problem, the Government of Ethiopia launched CBHI schemes. Therefore, this study investigates the household welfare impact of Community based health insurance (CBHI) in the Chilga district. A multi-stage sampling technique was used to select 531 households (of which 356 were treated and 175 control groups). Probit and propensity score matching (PSM) were used to analyze the data. Probit model revealed the following: Level of education, access to credit, chronic disease, insurance premium, awareness, distance to health service, and health service waiting time are significant determinates for being insured in CBHI. The PSM method revealed that the insured households associated with visits increased by 2.6 times, reduced per-capita health expenditure by 17–14% points, increased the per-capita consumption of non-food items by 12–14% points, increased the per-capita consumption of food items by 12–13% points in a given matching algorithm compared to the counterparts. Therefore, CBHI has enhanced service utilization by reducing per-capita health expenditure and increasing consumption per-capita, in general, it improved household welfare. To this end, the results of this study suggested that the government (ministry of health) and concerned bodies (such as NGOs) should extend the coverage and accessibility of CBHI schemes, create aware to the society about CBHI, and subsidize premium costs of the poor.

The Effects of Total Health Expenditure on Economic Growth in Central and Eastern Sub-Sahara African Regions

This study looked at the link connecting the growth of the economy and health spending in Central and Eastern Sub-Saharan Africa. To assess the short and long-term effects of total per capita health expenditure on the growth of the economy across Sub-Saharan African areas (East Africa and Central Africa), the panel data analysis was employed. In the short-term, total per-capita health expenditure (THE_PC) in Central Africa has an upbeat outcome on economic growth (LGDP_PC) at all levels of significance. In the long-term, current health per-capital expenditure (CHE_PC) has an upbeat outcome on the growth of the economy (LGDP_PC) at 5% and 10% significance levels, whereas life expectancy at birth (LEB) has a downbeat outcome on the growth of the economy. In East Africa THE_PC in the short and long-run has a favorable effect on the growth of the economy (LGDP_PC) at 5 and 10% significant levels, whereas CHE_GDP has a downbeat outcome on the growth of the economy (LGDP_PC) at all levels in the long-run. The findings imply that increasing per-capita health spending will boost the growth of the economy in the short term while increasing CHE_PC and LEB will boost economic growth in the long run. More investment in health services is recommended. Keywords: Public Spending, Economic Growth, GDP Per-Capita, Long Run, Mean Group, Dynamic Fixed Effect, Pooled Mean Group/ARDL (Autoregressive Distributed Lags), Short Run

The socioeconomic burden of facioscapulohumeral muscular dystrophy

BackgroundPromising genetic therapies are being investigated in facioscapulohumeral muscular dystrophy (FSHD). However, the current cost of illness is largely unknown.ObjectiveThis study aimed at determining the socioeconomic burden of FSHD.MethodsAdult patients with FSHD from the Dutch FSHD registry were invited to complete a questionnaire on medical consumption, work productivity and health-related quality of life (HR-QoL) using the EQ-5D-5L. Associated costs were calculated from a societal perspective. A generalized linear model was fitted to the data to investigate whether level of mobility was related to annual costs of illness.Results172 patients with FSHD completed the questionnaire (response rate 65%). The per-patient annual direct medical costs of FSHD were estimated at €12,077, direct non-medical costs at €9179 and indirect costs at €5066, adding up to a total cost of illness of €26,322 per patient per year. The direct costs of illness were €21,256, approximately five times higher than the mean per-capita health expenditures in the Netherlands. Major cost-driving factors were formal home care and informal care. A decreased level of mobility was associated with higher direct costs of illness. HR-QoL was significantly reduced in patients with FSHD with a median health utility value of 0.63.ConclusionsWe show that FSHD is associated with substantial direct and indirect socioeconomic costs as well as a reduction in HR-QoL. These findings are important for health care decision makers and aids in allocation of research funds and evaluation of the cost-effectiveness of novel therapies.

Living Longer with Disability: Economic Implications for Healthcare Sustainability

This work focuses on the economic implications of the relationship between life expectancy, the number of years lost to disability and per-capita total health expenditure. The primary goal of the paper is to identify and plot the correlation between healthcare expenditure and the global increase in life expectancy, in order to assess if, and how, the way longer average lifespans are achieved affects healthcare sustainability. Datasets regarding the United States, the European Union and the five largest emerging healthcare systems (i.e., Brazil, the Russian Federation, India, China and South Africa) were obtained from the Institute for Health Metrics and Evaluation and the WHO Health Expenditure Statistics Repository. All analysis was performed on 2017 data. The results of the analysis showed the number of years lost to disability to be a linear function of life expectancy at birth (male R2 = 0.61; female R2 = 0.47), and per-capita total health expenditure to be an exponential function of the number of years lost to disability (male R2 = 0.60; female R2 = 0.65). This implies that improving life expectancy via social policies bears negative consequences in terms of healthcare sustainability, unless the number of years lost to disability is reduced too. Further studies should narrow the sample of countries and causes of years lost due to disability, to better inform future policy efforts.

Age at first marriage and fertility in developing countries: A meta analytical view of 15 Demographic and Health Surveys

BackgroundAdolescent and early marriage increase the marriage duration which ultimately can boost the number of ever born children. On the other hand, when age at first marriage is too high there is a chance to birth complicity. In this study, the researcher has taken an attempt to investigate the structure of the relationship between female age at first marriage and fertility and find out a more precise estimate of the factor on fertility in developing countries. MethodsThis study comprises DHS data of 15 developing countries. A Meta-analysis, sub-group analysis, and meta-regression are used by the researcher to reach a valid conclusion keeping the study purposes in mind. ResultsThis study has found that for the marriage age 18 and above, pooled OR is 0.47 [0.40; 0.56] which is statistically significant for 15 DHS data. A large amount of heterogeneity was found for meta-analysis with I2 = 98%. For Asian countries, the combined OR is 0.3828 [0.27, 0.54] on the contrary Non-Asian countries holds the pooled OR to be 0.4567 [0.39, 0.54]. Also, the variation among different countries fertility performance for age at first marriage is largely explainable by the moderator variable per capita health expenditure (PCHE). PCHE alone is responsible for 57.14% of the heterogeneity among the overall explainable heterogeneity. ConclusionIn summary, our analysis highlights the effect of female age at first marriage on fertility in developing countries. This study explores the effective strategies to the developing countries that are suffering from high fertility.

Empirical Analysis of Relationship between Per Capita Health Expenditure and Economic Growth Based on Vector Autoregressive Model (VAR) in Mongolia

The present research aimed to study the dynamic correlation between per capita health expenditure (PCHE) and economic growth in Mongolia. The data from the period of 1993-2018 were used. A Vector Autoregressive (VAR) model was established between per capita gross domestic product (PGDP) and PCHE. Variance decomposition as well as impulse response function was used to analyze the dynamic relationship among variables. The results revealed that correlation was found between PCHE and PGDP with obvious one-way Granger causality. Moreover, the results showed that economic development had positive impact on PCHE growth for 1 - 3 (short term) years in Mongolia. However, the response of the two variables was gradually eradicated in the long term by impulse response function. The contribution rate of PGDP on PCHE increased from 0% to 18.14% by six periods. This study recommended that Mongolian policymakers not only increase the budget to the health but rather oversee the budget spending, increase public health expenditure and improve private health insurance system, which leads to the upgraded national health and can reduce personal health burden.

GEOGRAPHIC DISPARITIES IN LIFE EXPECTANCY AND MORTALITY IN THE U.S.

Although the US has one of the highest per-capita health expenditures in the world, it noticeably lags behind a number of other industrialized countries in terms of life expectancy (LE). These disparities remain unexplained by individual demographic, socioeconomic, and healthcare factors. Analysis of death certificates for 1999-2016 revealed that diseases contributed most to LE variability are myocardial infarction (explained 12.9% of the difference in mortality), heart failure (10.6%), stroke (8.2%), lung cancer (7.5%) and COPD (7.2%). Analysis of histories of diseased patients in Medicare records showed that septicemia (15.7%), low weight (13.8%), renal disease (13.3%), disorders of electrolyte and fluid balance (9.0%) and heart failure (7.3%) contributed most to the disparities. Diseases that substantially contribute to disparities in LE in the US include both common and less-often-discussed diseases. Future studies of variations in treatment patterns, access-to and quality-of medical care for these diseases could provide important insight in observed patterns.

Measuring the efficiency of health systems in Asia: a data envelopment analysis

ObjectiveThis study aims to estimate the technical efficiency of health systems in Asia.SettingsThe study was conducted in Asian countries.MethodsWe applied an output-oriented data envelopment analysis (DEA) approach to estimate the...

Austerity, measles and mandatory vaccination: cross-regional analysis of vaccination in Italy 2000-14.

BackgroundItaly has experienced a resurgence in measles since 2015. Although much emphasis has been placed on the role of individuals opting out of vaccination, here we test the hypothesis that large budget reductions in public health spending were also a contributing factor.MethodsMulti-variate statistical models were used to assess the relationship between measles, mumps and rubella (MMR) coverage and real public health expenditure per-capita across Italy’s 20 regions covering the period 2000–14.ResultsBetween 2010 and 2014 Italy’s public health expenditure fell by over 2%, although varying among regions. Fixed effects models estimate that each 1% reduction in per-capita public health expenditure was associated with a decrease of 0.5 percentage points (95% CI: 0.36–0.65 percentage points) in MMR coverage, after adjusting for time and regional-specific time trends. The consequences can be illustrated by comparing two regions, Lazio, where public health spending fell by 5% and MMR coverage by over 3 percentage points, and Sardinia, a historically deprived region, where public health spending partly rose and MMR rates remained approximately steady.ConclusionAdoption of austerity policies in the Italian health system was found to be significantly associated with declining vaccination rates for MMR. However, the recent introduction of mandatory vaccination for Italian children may help counteract this trend.

NEXUS BETWEEN HUMAN CAPITAL AND ECONOMIC GROWTH: EVIDENCE FROM GROWTH MODEL IN PAKISTAN

In the global economy, every country wants to boost the economic development of the economy in the nation. In this, good governance can play significant role in development of the economy. The present study aims at investigating the impact of human and physical capital on economic growth in Pakistan. Annually time series data is used for analysis during the period of 1980-2016. The data has been taken from the ‘Pakistan Economic Survey’ and ‘A Handbook of Statistics 2015’. The ADF (Augmented Dickey-fuller) test is used for stationary and non-stationary process. For parameters estimation and co-integration, the Engle-Granger approach is used to indicate that there is long-run connection among the study concerned variables. The empirical finding of this study demonstrated that gross fixed capital formation, literacy rate, per-capita health expenditure and secondary school enrolment rate have a significant impact on the economic growth of Pakistan. There is co-integration among variables of the model.

ON THE EXAMINATION OF OUT-OF-POCKET HEALTH EXPENDITURES IN INDIA, PAKISTAN, SRI LANKA, MALDIVES, BHUTAN, BANGLADESH AND NEPAL

The aim of this study is to analyze the healthcare expenditures in seven South Asian countries namely, India, Pakistan, Sri Lanka, Maldives, Bhutan, Bangladesh and Nepal. The longitudinal data has been taken for 19 years from 1995 to 2013. We specifically examine the out-of-pocket healthcare expenditure in these countries. The per-capita health expenditure differences have been compared. We also develop panel data pooled OLS model for out-of-pocket expenditure with the factors affecting it, i.e. per capita health expenditure, household final consumption expenditure and public health expenditure. The work is in line with the earlier studies of determinants of out-of-pocket health expenditures. The results suggest that Maldives has the highest per capita health expenditure while out-of-pocket health expenditure as a percentage of total expenditure on health is highest for the India. The fixed and random effect is evidenced on health expenses across the years and cross section based on various determinants. The novel aspect of the work is that, this is an attempt to explain healthcare financing in the developing economies. The key determinant of out-of-pocket expenditure is the final household expenditures as the percentage of gross domestic product.

Advanced Neonatal Medicine in China: A National Baseline Database.

Previous surveys of neonatal medicine in China have not collected comprehensive information on workforce, investment, health care practice, and disease expenditure. The goal of the present study was to develop a national database of neonatal care units and compare present outcomes data in conjunction with health care practices and costs. We summarized the above components by extracting data from the databases of the national key clinical subspecialty proposals issued by national health authority in China, as well as publicly accessible databases. Sixty-one newborn clinical units from provincial or ministerial hospitals at the highest level within local areas in mainland China, were included for the study. Data were gathered for three consecutive years (2008–2010) in 28 of 31 provincial districts in mainland China. Of the 61 newborn units in 2010, there were 4,948 beds (median = 62 [IQR 43–110]), 1,369 physicians (median = 22 [IQR 15–29]), 3,443 nurses (median = 52 [IQR 33–81]), and 170,159 inpatient discharges (median = 2,612 [IQR 1,436–3,804]). During 2008–2010, the median yearly investment for a single newborn unit was US$344,700 (IQR 166,100–585,800), median length of hospital stay for overall inpatient newborns 9.5 (IQR 8.2–10.8) days, median inpatient antimicrobial drug use rate 68.7% (IQR 49.8–87.0), and median nosocomial infection rate 3.2% (IQR1.7–5.4). For the common newborn diseases of pneumonia, sepsis, respiratory distress syndrome, and very low birth weight (<1,500 grams) infants, their lengths of hospital stay, daily costs, hospital costs, ratios of hospital cost to per-capita disposable income, and ratios of hospital cost to per-capita health expenditure, were all significantly different across regions (North China, Northeast China, East China, South Central China, Southwest China, and Northwest China). The survival rate of extremely low birth weight (ELBW) infants (Birth weight <1,000 grams) was 76.0% during 2008–2010 in the five hospitals where each unit had more than 20 admissions of ELBW infants in 2010; and the median hospital cost for a single hospital stay in ELBW infants was US$8,613 (IQR 8,153–9,216), which was 3.0 times (IQR 2.0–3.2) the average per-capita disposable income, or 63 times (IQR 40.3–72.1) the average per-capita health expenditure of local urban residents in 2011. Our national database provides baseline data on the status of advanced neonatal medicine in China, gathering valuable information for quality improvement, decision making, longitudinal studies and horizontal comparisons.

Health inequity and health outcome: a causal linkage study of low and middle income countries

The concept of health equity has received a lot of attention from researchers in recent times. However, the health equity researchers have majorly focused on the measurement of health equity or inequity or the antecedents of health equity. There are no studies until date that explores the effect of health equity on health outcomes. Such a study is relevant specifically for low income countries, as it would enhance the understanding of inequitable distribution of health services that could influence health outcomes in a country. The present study aims to explore the effect of health inequity on a popularly used health outcome indicator: infant mortality rate (IMR). The present study further includes some of the theoretically supported determinants of health outcomes such as health expenditures and health infrastructure measures as control variables. The present study utilizes a cross section pooled data of 72 low and middle income countries for the year 2011. Based on stepwise and robust regression, the findings indicate a significant effect of health inequity, per-capita public health expenditure, out of pocket health expenditure and access to improved water sources on infant mortality. The study is one of its kinds that relates health inequity to a health outcome. The findings have important implications for policy makers and academicians.

The dynamic relationship between health expenditure and economic growth: is the health-led growth hypothesis valid for Turkey?

The well-known health-led growth hypothesis claims a positive correlation between health expenditure and economic growth. The aim of this paper is to empirically investigate the health-led growth hypothesis for the Turkish economy. The bound test approach, autoregressive-distributed lag approach (ARDL) and Kalman filter modeling are employed for the 1975-2013 period to examine the co-integration relationship between economic growth and health expenditure. The ARDL model is employed in order to investigate the long-term and short-term static relationship between health expenditure and economic growth. The results show that a 1% increase in per-capita health expenditure will lead to a 0.434% increase in per-capita gross domestic product. These findings are also supported by the Kalman filter model's results. Our findings show that the health-led growth hypothesis is supported for Turkey.

G.O.14: The burden of Duchenne muscular dystrophy: An international, cross-sectional study

Following the substantial unmet medical need, there has been great interest in recent years to develop novel therapies for Duchenne muscular dystrophy (DMD). As the process for reimbursement of therapies requires evidence of the economic context of the disease, we performed a study to estimate the economic burden of DMD. Patients from Germany, Italy, UK, and US were identified through TREAT-NMD registries and invited to complete a questionnaire online together with a caregiver. Healthcare use, quality of life, work status, informal care, and household expenses data were collected to estimate costs of DMD from the perspective of society and caregiver households. A total of 770 patients (173 German, 122 Italian, 191 UK, and 284 US) completed the questionnaire. DMD care was associated with intensive healthcare utilization, encompassing a wide variety of medical aids, medications, tests, and visits to physicians and other practitioners. Mean per-patient annual direct cost of illness was estimated at between $23920 (95% CI: $20420–$28300) and $54270 ($48740–$62220) (2012 international dollars), eight to sixteen times higher than the mean per-capita health expenditure in these countries. Indirect and informal care costs were substantial, each constituting between 18% and 43% of total costs. The societal burden, including intangible costs, was estimated at between $80120 ($71030–$89190) and $120910 ($111460–$130770) per-patient and annum, and increased markedly with disease progression. The corresponding household burden was estimated at between $58440 ($50200–$68900) and $71900 ($65520–$81520). We show that DMD is associated with a substantial economic burden to society and affected families. Our description of the economic context of DMD serves as important intelligence input to health policy evaluations of intervention programs and novel therapies, financial support schemes put in place for patients and their families, and the design of future rare disease cost studies.

Measuring spatial effects in the presence of institutional constraints: The case of Italian Local Health Authority expenditure

Over the last decades spatial econometric models have represented a common tool for measuring spillover effects across different geographical entities (counties, provinces, regions or nations). The aim of this paper is to investigate the issue of measuring spatial spillovers in the presence of institutional constraints that can be geographically defined. In these cases, assuming that spatial effects are not affected by the institutional setting may produce biased estimates due to the composition of twodistinct sources of spatial dependence. Our approach is based on redefining the contiguity structure so as to account for the institutional constraints using two different contiguity matrices: the within matrix, which defines contiguity among units obeying the same institutional setting, and the between matrix, which traces spatial linkages among contiguous units across different jurisdictions. This approach allows to disentangle the two sources of spatial correlation and to easily test for the existence of binding institutional constraints. From the econometric perspective, we extend Lacombe (2004) approach to incorporate the aforementioned institutional constraints in a spatial Durbin model with individual specific slopes, while inference is conducted using a two-way cluster robust variance–covariance matrix controlling for both spatial and time correlations. We apply this methodology to analyze spatial dependence of per-capita public health expenditures in Italyat Local Health Authority level using a balanced panel dataset from 2001 to 2005. Our results show robust evidence of a significant and positive spatial coefficient for the within effect, while the between effect, although significant, is very close to zero, thus confirming the importance and validity of the proposed approach.

The burden of Duchenne muscular dystrophy: an international, cross-sectional study.

Objective:The objective of this study was to estimate the total cost of illness and economic burden of Duchenne muscular dystrophy (DMD).Methods:Patients with DMD from Germany, Italy, United Kingdom, and United States were identified through Translational Research in Europe–Assessment & Treatment of Neuromuscular Diseases registries and invited to complete a questionnaire online together with a caregiver. Data on health care use, quality of life, work status, informal care, and household expenses were collected to estimate costs of DMD from the perspective of society and caregiver households.Results:A total of 770 patients (173 German, 122 Italian, 191 from the United Kingdom, and 284 from the United States) completed the questionnaire. Mean per-patient annual direct cost of illness was estimated at between $23,920 and $54,270 (2012 international dollars), 7 to 16 times higher than the mean per-capita health expenditure in these countries. Indirect and informal care costs were substantial, each constituting between 18% and 43% of total costs. The total societal burden was estimated at between $80,120 and $120,910 per patient and annum, and increased markedly with disease progression. The corresponding household burden was estimated at between $58,440 and $71,900.Conclusions:We show that DMD is associated with a substantial economic burden. Our results underscore the many different costs accompanying a rare condition such as DMD and the considerable economic burden carried by affected families. Our description of the previously unknown economic context of a rare disease serves as important intelligence input to health policy evaluations of intervention programs and novel therapies, financial support schemes for patients and their families, and the design of future cost studies.