The link between diabetes mellitus and tuberculosis has been recognised for centuries. In recent decades, tuberculosis incidence has declined in high-income countries, but incidence remains high in countries that have high rates of infection with HIV, high prevalence of malnutrition and crowded living conditions, or poor tuberculosis control infrastructure. At the same time, diabetes mellitus prevalence is soaring globally, fuelled by obesity. There is growing evidence that diabetes mellitus is an important risk factor for tuberculosis and might affect disease presentation and treatment response. Furthermore, tuberculosis might induce glucose intolerance and worsen glycaemic control in people with diabetes. We review the epidemiology of the tuberculosis and diabetes epidemics, and provide a synopsis of the evidence for the role of diabetes mellitus in susceptibility to, clinical presentation of, and response to treatment for tuberculosis. In addition, we review potential mechanisms by which diabetes mellitus can cause tuberculosis, the effects of tuberculosis on diabetic control, and pharmacokinetic issues related to the co-management of diabetes and tuberculosis.

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Tuberculosis and diabetes mellitus: convergence of two epidemics

The measurement of efficiency and productivity of health service delivery has become a small industry. This is a review of 317 published papers on frontier efficiency measurement. The techniques used are mainly based on non-parametric data envelopment analysis, but there is increasing use of parametric techniques, such as stochastic frontier analysis. Applications to hospitals and other health care organizations and areas are reviewed and summarised, and some meta-type analysis undertaken. Cautious conclusions are that public provision may be potentially more efficient than private, in certain settings. The paper also considers conceptualizations of efficiency, and points to dangers and opportunities in generating such information. Finally, some criteria for assessing the use and usefulness of efficiency studies are established, with a view to helping both researchers and those assessing whether or not to act upon published results.

The measurement of efficiency and productivity of health care delivery

Iconographies supplémentaires de l'article : Tuberculosis and diabetes mellitus: convergence of two epidemics

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)60550-8.pdf

Diabetes in sub-Saharan Africa

Background
There has been a widely documented and recognized increase in diabetes prevalence, not only in high-income countries (HICs) but also in low- and middle-income countries (LMICs), over recent decades. The economic burden associated with diabetes, especially in LMICs, is less clear.

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The Economic Costs of Type 2 Diabetes: A Global Systematic Review

In 2000, the prevalence of diabetes among the 46 countries of the WHO African Region was estimated at 7.02 million people. Evidence from North America, Europe, Asia, Latin America and the Caribbean indicates that diabetes exerts a heavy health and economic burden on society. Unfortunately, there is a dearth of such evidence in the WHO African Region. The objective of this study was to estimate the economic burden associated with diabetes mellitus in the countries in the African Region. Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health systems and the families in directly addressing the problem; and (b) the indirect costs, i.e. the losses in productivity attributable to premature mortality, permanent disability and temporary disability caused by the disease. Prevalence estimates of diabetes for the year 2000 were used to calculate direct and indirect costs of diabetes mellitus. A discount rate of 3% was used to convert future earnings lost into their present values. The economic burden analysis was done for three groups of countries, i.e. 6 countries whose gross national income (GNI) per capita was greater than 8000 international dollars (i.e. in purchasing power parity), 6 countries with Int$2000–7999 and 33 countries with less than Int$2000. GNI for Zimbabwe was missing. The 7.02 million cases of diabetes recorded by countries of the African Region in 2000 resulted in a total economic loss of Int$25.51 billion (PPP). Approximately 43.65%, 10.03% and 46.32% of that loss was incurred by groups 1, 2 and 3 countries, respectively. This translated into grand total economic loss of Int$11,431.6, Int$4,770.6 and Int$ 2,144.3 per diabetes case per year in the three groups respectively. In spite of data limitations, the estimates reported here show that diabetes imposes a substantial economic burden on countries of the WHO African Region. That heavy burden underscores the urgent need for increased investments in the prevention and management of diabetes.

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Economic burden of diabetes mellitus in the WHO African region

Over 60% of the recurrent budget of the Ministry of Health (MoH) in Angola is spent on the operations of the fixed health care facilities (health centres plus hospitals). However, to date, no study has been attempted to investigate how efficiently those resources are used to produce health services. Therefore the objectives of this study were to assess the technical efficiency of public municipal hospitals in Angola; assess changes in productivity over time with a view to analyzing changes in efficiency and technology; and demonstrate how the results can be used in the pursuit of the public health objective of promoting efficiency in the use of health resources. The analysis was based on a 3-year panel data from all the 28 public municipal hospitals in Angola. Data Envelopment Analysis (DEA), a non-parametric linear programming approach, was employed to assess the technical and scale efficiency and productivity change over time using Malmquist index.The results show that on average, productivity of municipal hospitals in Angola increased by 4.5% over the period 2000---2002; that growth was due to improvements in efficiency rather than innovation.

A Performance Assessment Method for Hospitals: The Case of Municipal Hospitals in Angola

The Data Envelopment Analysis (DEA) method has been fruitfully used in many countries in Asia, Europe and North America to shed light on the efficiency of health facilities and programmes. There is, however, a dearth of such studies in countries in sub-Saharan Africa. Since hospitals and health centres are important instruments in the efforts to scale up pro-poor cost-effective interventions aimed at achieving the United Nations Millennium Development Goals, decision-makers need to ensure that these health facilities provide efficient services. The objective of this study was to measure the technical efficiency (TE) and scale efficiency (SE) of a sample of public peripheral health units (PHUs) in Sierra Leone. This study applied the Data Envelopment Analysis approach to investigate the TE and SE among a sample of 37 PHUs in Sierra Leone. Twenty-two (59%) of the 37 health units analysed were found to be technically inefficient, with an average score of 63% (standard deviation = 18%). On the other hand, 24 (65%) health units were found to be scale inefficient, with an average scale efficiency score of 72% (standard deviation = 17%). It is concluded that with the existing high levels of pure technical and scale inefficiency, scaling up of interventions to achieve both global and regional targets such as the MDG and Abuja health targets becomes far-fetched. In a country with per capita expenditure on health of about US$7, and with only 30% of its population having access to health services, it is demonstrated that efficiency savings can significantly augment the government's initiatives to cater for the unmet health care needs of the population. Therefore, we strongly recommend that Sierra Leone and all other countries in the Region should institutionalise health facility efficiency monitoring at the Ministry of Health headquarter (MoH/HQ) and at each health district headquarter.

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Technical efficiency of peripheral health units in Pujehun district of Sierra Leone: a DEA application

Africa is confronted by a heavy burden of communicable and non-communicable diseases. Cost-effective interventions that can prevent the disease burden exist but coverage is too low due to health systems weaknesses. This editorial reviews the challenges related to leadership and governance; health workforce; medical products, vaccines and technologies; information; financing; and services delivery. It also provides an overview of the orientations provided by the WHO Regional Committee for Africa for overcoming those challenges. It cautions that it might not be possible to adequately implement those orientations without a concerted fight against corruption, sustained domestic and external investment in social sectors, and enabling macroeconomic and political (i.e. internally secure) environment.

https://link.springer.com/content/pdf/10.1186%2F1755-7682-1-27.pdf

Health challenges in Africa and the way forward

Objectives: To describe a comprehensive analytical framework for assessing health sector reforms and demonstrates use of the analysis framework using cost-recovery mechanisms as a case study in the WHO African Region. Data sources: Health sector reforms published literature review. Study selection: No selection involved. Data extraction: This paper draws from previous published literature to describe a comprehensive framework to assess the performance of health sector reforms in the African region. Using this framework, it goes on to illustrate how it may be used to analyze cost recovery reforms as a case study. The major elements for the analysis include a description of the context, design, process and intended results. Data synthesis: In terms of context and design of the cost recovery reform, there were gaps in the stewardship role of governments as evidenced by the lack of appropriate policies and information to monitor and/or influence the process. Regarding the cost recovery implementation, it is not clear from the literature reviewed in this paper that there was a comprehensive stakeholder coordination mechanism that catered for all who were involved. Concerning results of the expected results of implementing cost recovery reforms such as improved quality of health services; equitable service utilisation; social sustainability through active community participation; and gains in efficiency were not always realised. Conclusions: Given that the aspects of the analysis framework described in this paper are interrelated, reviewing one without another provides an answer to a specific question but is insufficient for a comprehensive assessment.

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SP Barry

Papers

Economic burden of diabetes mellitus in the WHO African region

A Performance Assessment Method for Hospitals: The Case of Municipal Hospitals in Angola

Technical efficiency of peripheral health units in Pujehun district of Sierra Leone: a DEA application

Health challenges in Africa and the way forward

MoNitoriNG aNd EValUatioN oF HEaltH sECtor rEForMs iN tHE wHo aFriCaN rEGioN