Li-Wei Chao

Does Regulation Drive out Competition in Pharmaceutical Markets

Most countries regulate pharmaceutical prices, either directly or indirectly, on the assumption that competition is at best weak in this industry. This paper tests the hypothesis that regulation of manufacturer prices and retail pharmacy margins undermines price competition. We use data from seven countries for 1992 to examine price competition between generic competitors (different manufacturers of the same compound) and therapeutic substitutes (similar compounds) under different regulatory regimes. We find that price competition between generic competitors is significant in unregulated or less regulated markets (United States, United Kingdom, Canada, and Germany) but that regulation undermines generic competition in strict regulatory systems (France, Italy, and Japan). Regulation of retail pharmacy further constrains competition in France, Germany, and Italy. Regulation thus undermines the potential for significant savings on off‐patent drugs, which account for a large and growing share of drug expenditures. Evidence of competition between therapeutic substitutes is less conclusive owing to data limitations.

Family Planning Among HIV Positive and Negative Prevention of Mother to Child Transmission (PMTCT) Clients in a Resource Poor Setting in South Africa

The purpose of this study was to investigate family planning needs, knowledge of HIV transmission and HIV disclosure in a cohort sample that had undergone PMTCT in a resource poor setting. Five public clinics implementing PMTCT from Qaukeni Local Service Area, O.R. Tambo District in the Eastern Cape. The sample at postnatal care consisted of 758 women with known HIV status. From 116 HIV positive women 76.3% and from 642 HIV negative women 85.2% got counseling on safe sex during pregnancy but only 65.8% and 62.3% of the women respectively practiced safe sex during pregnancy, which did not differ by HIV status. Postnatally, almost all women received counseling on family planning, yet use of contraceptives and condoms were low. Among HIV positive women PMTCT knowledge and younger age of the mother were associated with pregnancy desire, and among HIV negative women HIV disclosure to the partner, younger age of the mother and having a lower number of children were associated with pregnancy desire. High pregnancy desires (yet lower than for HIV negative women); low contraceptive and condom use were found among HIV positive women. HIV prevention and family planning must acknowledge the reproductive desires of HIV positive women and men.

End-of-Life Medical Treatment Choices: Do Survival Chances and Out-of-Pocket Costs Matter?

Background . Out-of-pocket medical expenditures incurred prior to the death of a spouse could deplete savings and impoverish the surviving spouse. Little is known about the publics opinion as to whether spouses should forego such end-of-life (EOL) medical care to prevent asset depletion. Objectives . To analyze how elderly and near elderly adults assess hypothetical EOL medical treatment choices under different survival probabilities and out-of-pocket treatment costs. Methods . Survey data on a total of 1143 adults, with 589 from the Asset and Health Dynamics Among the Oldest Old (AHEAD) and 554 from the Health and Retirement Study (HRS), were used to study EOL cancer treatment recommendations for a hypothetical anonymous married woman in her 80s. Results . Respondents were more likely to recommend treatment when it was financed by Medicare than by the patients own savings and when it had 60% rather than 20% survival probability. Black and male respondents were more likely to recommend treatment regardless of survival probability or payment source. Treatment uptake was related to the order of presentation of treatment options, consistent with starting point bias and framing effects. Conclusions . Elderly and near elderly adults would recommend that the hypothetical married woman should forego costly EOL treatment when the costs of the treatment would deplete savings. When treatment costs are covered by Medicare, respondents would make the recommendation to opt for care even if the probability of survival is low, which is consistent with moral hazard. The sequence of presentation of treatment options seems to affect patient treatment choice.

Perceptions of Community HIV Prevalence, Own HIV Infection, and Condom Use among Teachers in KwaZulu-Natal, South Africa

A total of 120 teachers from KwaZulu-Natal, South Africa, underwent HIV/AIDS training. As part of the study, the teachers were surveyed, before and after the training, about their perceptions of HIV prevalences among pupils, other teachers, and community members, and about their perceptions of their own HIV status. Before the training, the teachers estimated average HIV prevalences among pupils, other teachers, and other community members to be 36%, 48%, and 61%, respectively. One-third of the teachers believed that they had a 50% or greater chance of currently being infected with HIV. Male teachers and teachers with a university degree gave lower HIV prevalence estimates for other people but not for themselves. Frequency of condom use was positively related to teachers’ HIV prevalence estimates for other people. Teachers’ estimates of HIV prevalence and perceived risk of own HIV infection increased significantly after the HIV/AIDS training.

Examining the relationship between alcohol use and high-risk sex practices in a population of women with high HIV incidence despite high levels of HIV-related knowledge

Objectives Alcohol use has been linked to risky sexual behaviour and it has been identified as an important modifiable factor to prevent HIV infection. However, the evidence of a link between alcohol use and risky sexual behaviour is mixed. In this paper, we examine the role of alcohol use in sexual risk taking among women in Botswana. Methods Participants were recruited by stratified proportional random sampling and were administered a survey interview that collected information on HIV/AIDS knowledge, risky sexual behaviour and alcohol use. Logistic regression and bivariate probit analyses were used to examine the association between alcohol use and high-risk sexual behaviour. Results 239 women were interviewed. 168 (70%) had high levels of HIV/AIDS knowledge. We found no significant protective effect of good HIV/AIDS knowledge over high-risk sex behaviour (adjusted OR 0.74, 95% CI 0.38 to 1.42). However, alcohol use before sex was associated with high-risk sex behaviour (adjusted OR 3.04, 95% CI 1.11 to 6.45). However, bivariate probit analysis that simultaneously estimates risky sexual behaviour and alcohol use revealed an insignificant association between alcohol use and risky sex, highlighting the potential presence of other unobserved individual factors that are associated with alcohol use and risky sex. Conclusions Knowledge about HIV may not be sufficient to decrease risky sexual behaviour. Alcohol consumption was associated with an increased probability of high-risk sexual intercourse. However, the relationship between alcohol use and risky sex may also be a marker of a third omitted variable (such as overall risk-taking propensity). Further research is needed to identify factors associated with alcohol use and high-risk sex.

TOO SICK TO START: ENTREPRENEUR’S HEALTH AND BUSINESS ENTRY IN TOWNSHIPS AROUND DURBAN, SOUTH AFRICA

Unlike large firms with management teams, small businesses are usually run by one key person, the owner-entrepreneur, who bears almost all of the risks and makes almost all of the decisions related to the business. Because the owner-entrepreneur also embodies most of the firm-specific knowledge capital, health of the owner-entrepreneur is an important factor in the production process. Following a cohort of respondents in townships around Durban, South Africa, over a three-year period, we examined the relationship between an individuals physical health and the decision to start a business. Our results suggest that respondents who were recent business entrants were in better health than respondents who did not start new businesses. Moreover, respondents without a business at the beginning of the study who later opened businesses during the three-year study interval were significantly more likely to have better baseline health than those respondents who never started a new business. Hence, good health among entrepreneurs seems to be an important prerequisite to small business entry.

Depression and social functioning among HIV-infected and uninfected persons in South Africa

Depression and other health problems are common co-morbidities among persons living with human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS). The aim of this study was to investigate depression, health status, and substance use in relation to HIV-infected and uninfected individuals in South Africa. Using a cross-sectional case-control design, we compared depression, physical health, mental health, problem alcohol use, and tobacco use in a sample of HIV-infected (N = 143) and HIV-uninfected (N = 199) respondents who had known their HIV status for two months. We found that depression was higher, and physical health and mental health were lower in HIV-positive than HIV-negative individuals. Poor physical health also moderated the effect of HIV infection on depression; HIV-positive individuals were significantly more depressed than HIV-negative controls, but only when general physical health was also poor. We did not find an association between alcohol or tobacco use and HIV status. These results suggest the importance of incorporating the management of psychological health in the treatment of HIV.

Do Customers Flee From HIV? A Survey of HIV Stigma and Its Potential Economic Consequences on Small Businesses in Tshwane (Pretoria), South Africa

HIV stigma and discrimination affect care-seeking behavior and may also affect entrepreneurial activity. We interview 2382 individuals in Pretoria, South Africa, and show that respondents believe that businesses with known HIV+ workers may lose up to half of their customers, although the impact depends on the type of business. Survey respondents’ fear of getting HIV from consuming everyday products sold by the business—despite a real infection risk of zero—was a major factor driving perceived decline in customers, especially among food businesses. Respondents’ perceptions of the decline in overall life satisfaction when one gets sick from HIV and the respondent’s dislike of people with HIV were also important predictors of potential customer exit. We suggest policy mechanisms that could improve the earnings potential of HIV+ workers: reducing public health scare tactics that exacerbate irrational fear of HIV infection risk and enriching public health education about HIV and ARVs to improve perceptions about people with HIV.ResumenEl efecto discriminatorio y estigma hacia el VIH puede afectar a la búsqueda de ayuda y a la actividad emprendedora. Entrevistamos a 2.382 personas en Pretoria, Sudáfrica. Los encuestados creen que los empresarios con trabajadores con VIH+ conocido pueden perder hasta la mitad de sus clientes, aunque el impacto depende del tipo de negocio. El que los encuestados teman adquirir VIH por el consumo diarios de productos de un negocio, a pesar del riesgo de infección ser nulo, es un factor importante para el declive en el número de clientes, especialmente en el sector alimentario. Otros de los factores que predicen la pérdida de clientes son la percepción de los encuestados de que la satisfacción general de la vida disminuye cuando uno se enferma a causa del VIH y la aversión a las personas con VIH. Sugerimos mecanismos políticos que puedan mejorar el potencial de ingresos de los trabajadores con VIH+: tácticas de reducción de alarma sanitaria que exacerba el miedo irracional de riesgo de infección de VIH y enriquecer la educación de la sociedad en salud sobre el VIH y los ARV para mejorar las percepciones sobre las personas con VIH.