Ramanan Laxminarayan

Hospitalizations and Deaths Caused by Methicillin-Resistant Staphylococcus aureus, United States, 1999–2005

MRSA should be a national priority for disease control.

Global investments in TB control: economic benefits.

The Global Plan to Stop TB calls for significant financial resources to meet the Millennium Development Goals for tuberculosis. However, it is unclear whether the economic benefits of TB control exceed the costs. Using an epidemiological model, we find that the economic benefits of the Global Plan relative to sustained DOTS (a commonly used treatment method) were unambiguously greater than the incremental costs in all nine high-burden countries in Africa and in Afghanistan, Pakistan, and Russia. Benefit-cost ratios of sustaining DOTS at current levels relative to having no DOTS exceeded 1 in all twenty-two high-burden, TB-endemic countries and sub-Saharan Africa.

Fiscal and Externality Rationales for Alcohol Policies

Abstract Alcohol taxes are typically justified as a means to address externalities from alcohol abuse and to raise government revenue. Prior literature has focused on measuring the Pigouvian tax but has paid little attention to the fiscal rationale. This paper presents an analytical and simulation framework for assessing the optimal levels, and welfare effects, of alcohol taxes and drunk driver penalties, accounting for both externalities and how policies interact with the broader fiscal system.Under plausible parameter values and recycling possibilities, the fiscal component of the optimal alcohol tax may be as large, or larger, than the externality-correcting component. Therefore, fiscal considerations can significantly strengthen the case for higher alcohol taxes. They also raise the welfare gains from alcohol taxes relative to those from drunk driver penalties, and they warrant differential taxation of individual beverages on an alcohol equivalent basis.

CommentThe Affordable Medicines Facility—malaria: killing it slowly

In 2002, we served on a committee for the Institute of Medicine of the US National Academy of Sciences that was asked to recommend measures for getting new and eff ective, but relatively expensive, artemisininbased antimalarials to poor populations. People were still buying chloroquine because it was cheap and available, but it was becoming less eff ective because of parasite resistance, and malaria mortality was increasing. At that time, artemisinin derivatives were highly eff ective but no other drugs in the pipeline were expected to be as good. Then, as now, most people sought malaria treatment in the private sector. Rapid diagnostic tests were available but were expensive and low quality, and WHO’s recommendation for fever in malaria-endemic areas was presumptive treatment with an antimalarial drug. The threat of resistance to artemisinin was heightened by widespread use of artemisinin mono therapies across Asia and Africa, and WHO’s entreaties to manufacturers to cease production of monotherapies were largely ignored. Only after serious deliberation on the pros and cons of making artemisinin combination treatments (ACTs), which reduce the chances that drug-resistant parasites would arise and spread, widely available—in line with WHO guidelines—did the committee recommend a subsidy to producers to make the life-saving drugs inexpensive. After a further 5 years of discussion, a fi rst phase of the Aff ordable Medicines Facility—malaria (AMFm), designed by many organisations working under the Roll Back Malaria Partnership, was hosted by the Global Fund to Fight AIDS, Tuberculosis and Malaria. AMFm was funded by the UK’s Department for International Development, UNITAID, the Bill & Melinda Gates Foundation, and the Canadian Government. In The Lancet, Sarah Tougher and colleagues report the results of an independent evaluation of an 18-month AMFm pilot in seven countries (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania [including Zanzibar], and Uganda). In the six pilots where the programme was implemented to a substantial degree, AMFm met or exceeded benchmarks for availability, price, and market share of quality-assured ACTs. In private for-profi ts, quality-assured ACT market share at baseline ranged from 2% to 12%. There were increases in all pilots, exceeding 30 percentage points in fi ve pilots. Over 87% of quality-assured ACTs sold in this sector at endpoint were AMFm co-paid in all pilots except Niger. For comparison, executives at multinational drug companies queried before the launch of AMFm indicated that for the launch of a new product in a developing country, a market share of about 10% at 1 year and 20% at 2 years would be considered successful. Price declines in the private for-profi t sector, which accounted for between 49% and 92% of market share in these countries, ranged from US

Disease Control Priorities, Third Edition (Volume 4): Mental, Neurological, and Substance Use Disorders

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Economics of Antibiotic Resistance: A Theory of Optimal Use

4·82 per dose, at an average subsidy cost to donors of a dollar per adult dose. Although AMFm had less eff ect on the public sector where there were substantial delays in ordering drugs and implementing the programme, in four countries the public sector purchased AMFmsubsidised ACTs from the private sector to avoid stockouts. AMFm was also successful in reducing relative market share of artemisinin monotherapy in the two countries where artemisinin monotherapies, which could accelerate the spread of resistance, were signifi cant in the market at baseline. The original AMFm design, already modifi ed in phase 1, must be—and can be—further aligned with the changing needs of malaria control. Declines in malaria incidence in some parts of the world, particularly east Africa, have shrunk the malaria caseload, but the need for prompt malaria treatment near the household remains. Resistance to artemisinin, which had not been detected at the time of the Institute of Medicine Published Online October 31, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)61843-1

Will A Global Subsidy Of New Antimalarials Delay The Emergence Of Resistance And Save Lives

Mental, neurological, and substance use (MNS) disorders contribute approximately 10 percent of the global burden of disease. They often run a chronic course, are highly disabling, and are associated with significant premature mortality. Moreover, beyond their health consequences, the impact of these disorders on the social and economic well-being of individuals, families, and societies is enormous. Despite this burden, MNS disorders have been systematically neglected in most of the world, particularly in low- and middle-income countries (LMICs), with pitifully small contributions to prevention and treatment by governments and development agencies. Systematically compiling the substantial evidence that already exists to address this inequity is the central goal of volume 4 of Disease Control Priorities, third edition (DCP3). The evidence presented in this volume will help to build an evidence-based perspective on which policies and interventions for addressing MNS disorders should be prioritized in resource-constrained settings. The findings of this volume make an emphatic case for a substantially increased investment in the prevention of and care for MNS disorders. We document highly cost-effective strategies for the prevention of some MNS disorders and affordable models of care for the delivery of treatment interventions in routine health care platforms through non-specialist health workers. Such investments make economic sense for two reasons: the interventions we recommend are cost-effective, and the impact of these interventions on social and economic outcomes is immense. The counterfactual situation of not doing enough, which prevails in most populations, is leading to enormous loss of human capital and will hinder the ambition of sustainable development. The evidence in this volume can be translated into practice only with strong political will and commitment from the governments and developmental agencies who now have to make the necessary investments in their scale-up.Childhood mental and developmental disordersencompass neurodevelopmental, emotional, and behavioraldisorders that have broad and serious adverseimpacts on psychological and social well-being. Childrenwith these disorders require significant additional supportfrom families and educational systems; the disordersfrequently persist into adulthood (Nevo and Manassis2009; Polanczyk and Rohde 2007; Shaw and others 2012).These children are more likely to experience a compromiseddevelopmental trajectory, with increased need formedical and disability services, as well as increased riskof contact with law enforcement agencies (Fergusson,Horwood, and Lynskey 1993).