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1.  An Alternative Framework for Analyzing Financial Protection in Health 
PLoS Medicine  2012;9(8):e1001294.
Jennifer Prah Ruger argues for a more multidemensional assessment of financial protection in health, which can better capture health expenditures and the full burden of health cost burdens.
PMCID: PMC3424259  PMID: 22927799
2.  Global Tobacco Control: An integrated approach to global health policy 
Following the development discussion in the last volume on the ‘politics of health’, Jennifer Prah Ruger argues that the Framework Convention on Tobacco Control (FCTC) represents a shift in global health policy that recognizes the importance of addressing health needs on multiple fronts and integrating public policies into a comprehensive set of health improvement strategies. She argues that the FCTC provides a model for multifaceted approaches to health improvement that require simultaneous progress on various dimensions.
PMCID: PMC4295830  PMID: 25598648
Framework Convention on Tobacco Control; global tobacco control; development policy; horizontal and vertical integration; integrated public policy
3.  Global health governance and the World Bank 
Lancet  2007;370(9597):1471-1474.
With the Paul Wolfowitz era behind it and new appointee Robert Zoellick at the helm, it is time for the World Bank to better define its role in an increasingly crowded and complex global health architecture, says Jennifer Prah Ruger, health economist and former World Bank speechwriter.
PMCID: PMC3988669  PMID: 17972367
4.  Normative Foundations of Global Health Law 
The Georgetown law journal  2008;96(2):423-443.
PMCID: PMC3988830  PMID: 24748684
5.  Reply 
PMCID: PMC4380324  PMID: 25838871
7.  Health and social justice 
Lancet  2004;364(9439):1075-1080.
PMCID: PMC4006198  PMID: 15380968
8.  Shared Health Governance 
Health and Social Justice (Ruger 2009a) developed the “health capability paradigm,” a conception of justice and health in domestic societies. This idea undergirds an alternative framework of social cooperation called “shared health governance” (SHG). SHG puts forth a set of moral responsibilities, motivational aspirations, and institutional arrangements, and apportions roles for implementation in striving for health justice. This article develops further the SHG framework and explains its importance and implications for governing health domestically.
PMCID: PMC3988676  PMID: 21745082
health governance; health ethics; social cooperation; self-interest; shared health governance
9.  Ethics of the social determinants of health 
Lancet  2004;364(9439):1092-1097.
PMCID: PMC3988689  PMID: 15380971
10.  Costs of Addressing Heroin Addiction in Malaysia and 32 Comparable Countries Worldwide 
Health Services Research  2011;47(2):865-887.
Develop and apply new costing methodologies to estimate costs of opioid dependence treatment in countries worldwide.
Data Sources/Study Setting
Micro-costing methodology developed and data collected during randomized controlled trial (RCT) involving 126 patients (July 2003–May 2005) in Malaysia. Gross-costing methodology developed to estimate costs of treatment replication in 32 countries with data collected from publicly available sources.
Study Design
Fixed, variable, and societal cost components of Malaysian RCT micro-costed and analytical framework created and employed for gross-costing in 32 countries selected by three criteria relative to Malaysia: major heroin problem, geographic proximity, and comparable gross domestic product (GDP) per capita.
Principal Findings
Medication, and urine and blood testing accounted for the greatest percentage of total costs for both naltrexone (29–53 percent) and buprenorphine (33–72 percent) interventions. In 13 countries, buprenorphine treatment could be provided for under $2,000 per patient. For all countries except United Kingdom and Singapore, incremental costs per person were below $1,000 when comparing buprenorphine to naltrexone. An estimated 100 percent of opiate users in Cambodia and Lao People's Democratic Republic could be treated for $8 and $30 million, respectively.
Buprenorphine treatment can be provided at low cost in countries across the world. This study's new costing methodologies provide tools for health systems worldwide to determine the feasibility and cost of similar interventions.
PMCID: PMC3419893  PMID: 22091732
Malaysia; micro-costing; gross-costing; heroin treatment; international comparison, health systems
11.  Economic evaluation of drug abuse treatment and HIV prevention programs in pregnant women: a systematic review 
Addictive behaviors  2011;37(1):1-10.
Drug abuse and transmission of HIV during pregnancy are major public health problems that adversely affect pregnant women, their children and surrounding communities. Programs that address this vulnerable population have the ability to be cost effective due to resulting cost savings for mother, child and society. Economic evaluations of programs that address these issues are an important tool to better understand the costs of services and create sustainable healthcare systems. This study critically examined economic evaluations of drug abuse treatment and HIV prevention programs in pregnant women. A systematic review was conducted using the criteria recommended by the Panel on Cost-Effectiveness in Health and Medicine and the British Medical Journal (BMJ) checklist for economic evaluations. The search identified 6 economic studies assessing drug abuse treatment for pregnant women, and 12 economic studies assessing programs that focus on prevention of mother-to-child transmission (PMTCT) of HIV. Results show that many programs for drug abuse treatment and PMTCT among pregnant women are cost-effective or even cost-saving. This review identified several shortcomings in methodology and lack of standardization of current economic evaluations. Efforts to improve methodological challenges will help make future studies more comparable and have more influence on policy makers, clinicians and the public.
PMCID: PMC3216632  PMID: 21962429
systematic review; economic evaluation; drug abuse treatment; prevention of mother-to-child transmission (PMTCT); HIV prevention; pregnant women
12.  Health Capability: Conceptualization and Operationalization 
Current theoretical approaches to bioethics and public health ethics propose varied justifications as the basis for health care and public health, yet none captures a fundamental reality: people seek good health and the ability to pursue it. Existing models do not effectively address these twin goals.
The approach I espouse captures both of these orientations through a concept here called health capability. Conceptually, health capability illuminates the conditions that affect health and one’s ability to make health choices. By respecting the health consequences individuals face and their health agency, health capability offers promise for finding a balance between paternalism and autonomy.
I offer a conceptual model of health capability and present a health capability profile to identify and address health capability gaps.
PMCID: PMC2791246  PMID: 19965570
13.  Costs of HIV Prevention Among Out-of-Treatment Drug-Using Women: Results of a Randomized Controlled Trial 
Public Health Reports  2010;125(Suppl 1):83-94.
We developed a micro-costing methodology to estimate the real resource costs consumed by delivery of the National Institute on Drug Abuse (NIDA) Cooperative Agreement Standard Intervention (SI) for human immunodeficiency virus (HIV) prevention, plus two enhanced modules, in a three-arm randomized controlled trial (RCT) among drug-using women. To our knowledge, this is the first micro-costing study of the SI and enhanced modules and the first of its kind targeting drug-using women.
We conducted a micro-costing study alongside a three-arm RCT to estimate costs of (1) the modified NIDA SI; (2) the SI and a well woman exam (SI+WWE); and (3) the SI, WWE, and four educational sessions (SI+WWE+4ES) to prevent HIV and sexually transmitted diseases in at-risk, drug-using women in St. Louis, Missouri.
The cost of the SI that all 501 participants received was approximately $227 per person. The additional costs for the WWE and 4ES were approximately $145 and $942 per person, respectively. Total program costs for the SI (n=501) were $113,869; additional costs for the SI+WWE (n=342) were $49,403 and for the SI+WWE+4ES (n=170) were $160,189. The main cost component for the SI (64% of total costs) was testing costs, whereas building and facilities costs were the main cost component for the SI+WWE+4ES (75% of total costs).
This study provides accurate estimates of the real costs for standard and enhanced HIV interventions for policy makers seeking to implement targeted HIV-prevention programs with scarce resources.
PMCID: PMC2788412  PMID: 20408391
14.  Cost-Effectiveness of Motivational Interviewing for Smoking Cessation and Relapse Prevention among Low-Income Pregnant Women: A Randomized Controlled Trial 
Low-income women have high rates of smoking during pregnancy, but little is known about the costs, benefits, and cost-effectiveness of motivational interviewing (MI), focused on the medical and psychosocial needs of this population, as an intervention for smoking cessation and relapse prevention.
A sample of 302 low-income pregnant women was recruited from multiple obstetrical sites in the Boston metropolitan area into a randomized controlled trial of a motivational intervention for smoking cessation and relapse prevention versus usual care (UC). The findings of this clinical trial were used to estimate the costs, benefits, and cost-effectiveness of the intervention from a societal perspective, incorporating published quality-adjusted life-year (QALY) and life-year (LY) estimates. Outcomes included smoking cessation and relapse, maternal and infant outcomes, economic costs, LYs and QALYs saved, and incremental cost-effectiveness ratios.
The cost-effectiveness of MI for relapse prevention compared to UC was estimated to be $851/LY saved and $628/QALY saved. Including savings in maternal medical costs in sensitivity analyses resulted in cost savings for MI for relapse prevention compared to UC. For smoking cessation, MI cost more but did not provide additional benefit compared to UC. In one-way sensitivity analyses, the incremental cost-effectiveness of MI versus UC would have been $117,100/LY saved and $86,300/QALY saved if 8% of smokers had quit. In two-way sensitivity analyses, MI was still relatively cost-effective for relapse prevention ($17,300/QALY saved) even if it cost as much as $2000/participant and was less effective. For smoking cessation, however, a higher level of effectiveness (9/110) and higher cost ($400/participant) resulted in higher incremental cost-effectiveness ratios ($112,000/QALY).
Among low-income pregnant women, MI helps prevent relapse at relatively low cost, and may be cost-saving when net medical cost savings are considered. For smoking cessation, MI cost more but provided no additional benefit compared to UC, but might offer benefits at costs comparable to other clinical preventive interventions if 8–10% of smokers are induced to quit.
PMCID: PMC2775431  PMID: 17854434
cost-effectiveness; low-income; pregnant women; relapse prevention; smoking cessation
15.  Economic Evaluations of Smoking Cessation and Relapse Prevention Programs for Pregnant Women: A Systematic Review 
Smoking cessation and relapse prevention during and after pregnancy reduces the risk of adverse maternal and infant health outcomes, but the economic evaluations of such programs have not been systematically reviewed. This study aims to critically assess economic evaluations of smoking cessation and relapse prevention programs for pregnant women.
All relevant English-language articles were identified using PubMed (January 1966–2003), the British National Health Service Economic Evaluation Database, and reference lists of key articles. Economic evaluations of smoking cessation and relapse prevention among pregnant women were reviewed. Fifty-one articles were retrieved, and eight articles were included and evaluated. A single reviewer extracted methodological details, study designs, and outcomes into summary tables. All studies were reviewed, and study quality was judged using the criteria recommended by the Panel on Cost-Effectiveness in Health and Medicine and the British Medical Journal (BMJ) checklist for economic evaluations.
The search retrieved 51 studies. No incremental cost-effectiveness studies or cost-utility studies were found. A narrative synthesis was conducted on the eight studies that met the inclusion criteria. Roughly one-third employed cost–benefit analyses (CBA). Those conducting CBA have found favorable benefit–cost ratios of up to 3:1; for every dollar invested $3 are saved in downstream health-related costs.
CBA suggests favorable cost–benefit ratios for smoking cessation among pregnant women, although currently available economic evaluations of smoking cessation and relapse prevention programs for pregnant women provide limited evidence on cost-effectiveness to determine optimal resource allocation strategies. Although none of these studies had been performed in accordance with Panel recommendations or BMJ guidelines, they are, however, embryonic elements of a more systematic framework. Existing analyses suggest that the return on investment will far outweigh the costs for this critical population. There is significant potential to improve the quality of economic evaluations of such programs; therefore, additional analyses are needed. The article concludes with ideas on how to design and conduct an economic evaluation of such programs in accordance with accepted quality standards.
PMCID: PMC2732023  PMID: 17854435
economic evaluations; pregnant women; relapse prevention; smoking cessation; systematic review
16.  Responses to donor proliferation in Ghana’s health sector: a qualitative case study 
To investigate how donors and government agencies responded to a proliferation of donors providing aid to Ghana’s health sector between 1995 and 2012.
We interviewed 39 key informants from donor agencies, central government and nongovernmental organizations in Accra. These respondents were purposively selected to provide local and international views from the three types of institutions. Data collected from the respondents were compared with relevant documentary materials – e.g. reports and media articles – collected during interviews and through online research.
Ghana’s response to donor proliferation included creation of a sector-wide approach, a shift to sector budget support, the institutionalization of a Health Sector Working Group and anticipation of donor withdrawal following the country’s change from low-income to lower-middle income status. Key themes included the importance of leadership and political support, the internalization of norms for harmonization, alignment and ownership, tension between the different methods used to improve aid effectiveness, and a shift to a unidirectional accountability paradigm for health-sector performance.
In 1995–2012, the country’s central government and donors responded to donor proliferation in health-sector aid by promoting harmonization and alignment. This response was motivated by Ghana’s need for foreign aid, constraints on the capacity of governmental human resources and inefficiencies created by donor proliferation. Although this decreased the government’s transaction costs, it also increased the donors’ coordination costs and reduced the government’s negotiation options. Harmonization and alignment measures may have prompted donors to return to stand-alone projects to increase accountability and identification with beneficial impacts of projects.
PMCID: PMC4271686  PMID: 25558103
We investigate whether better population health may impact economic performance through improvements in technical efficiency in agricultural production. Using district-level data from India, we employ a random-coefficients approach to estimate a Cobb-Douglas production function, computing overall and input-specific technical efficiencies for each district. We then model health (district infant mortality rate) as a determinant of (in)efficiency in a second stage, controlling for a range of other socioeconomic variables. In the preferred specifications, we find that decreases in the infant mortality rate are associated with substantively and statistically significant increases in overall technical efficiency, and that a good portion of this association is likely due to improvements in the efficiency of labor use.
PMCID: PMC4238038  PMID: 25419029
Agricultural Production; Economic Development; Health; India; Labor; Random Coefficients; Technical Efficiency
Harvard law review  2008;121:43-56.
PMCID: PMC4186715  PMID: 25298547
21.  Catastrophic health expenditure 
Lancet  2003;362(9388):996-997.
PMCID: PMC4114756  PMID: 14511936
22.  Micro-costing studies in the health and medical literature: protocol for a systematic review 
Systematic Reviews  2014;3:47.
Micro-costing is a cost estimation method that allows for precise assessment of the economic costs of health interventions. It has been demonstrated to be particularly useful for estimating the costs of new interventions, for interventions with large variability across providers, and for estimating the true costs to the health system and to society. However, existing guidelines for economic evaluations do not provide sufficient detail of the methods and techniques to use when conducting micro-costing analyses. Therefore, the purpose of this study is to review the current literature on micro-costing studies of health and medical interventions, strategies, and programs to assess the variation in micro-costing methodology and the quality of existing studies. This will inform current practice in conducting and reporting micro-costing studies and lead to greater standardization in methodology in the future.
We will perform a systematic review of the current literature on micro-costing studies of health and medical interventions, strategies, and programs. Using rigorously designed search strategies, we will search Ovid MEDLINE, EconLit, BIOSIS Previews, Embase, Scopus, and the National Health Service Economic Evaluation Database (NHS EED) to identify relevant English-language articles. These searches will be supplemented by a review of the references of relevant articles identified. Two members of the review team will independently extract detailed information on the design and characteristics of each included article using a standardized data collection form. A third reviewer will be consulted to resolve discrepancies. We will use checklists that have been developed for critical appraisal of health economics studies to evaluate the quality and potential risk of bias of included studies.
This systematic review will provide useful information to help standardize the methods and techniques for conducting and reporting micro-costing studies in research, which can improve the quality and transparency of future studies and enhance comparability and interpretation of findings. In the long run, these efforts will facilitate clinical and health policy decision-making about resource allocation.
Trial registration
Systematic review registration: PROSPERO CRD42014007453.
PMCID: PMC4036677  PMID: 24887208
Systematic review; Micro-costing; Health; Economic evaluation; Cost analysis
23.  Health and development 
Lancet  2003;362(9385):678.
PMCID: PMC4006200  PMID: 12957088
24.  Global Health Governance at a Crossroads 
This review takes stock of the global health governance (GHG) literature. We address the transition from international health governance (IHG) to global health governance, identify major actors, and explain some challenges and successes in GHG. We analyze the framing of health as national security, human security, human rights, and global public good, and the implications of these various frames. We also establish and examine from the literature GHG’s major themes and issues, which include: 1) persistent GHG problems; 2) different approaches to tackling health challenges (vertical, horizontal, and diagonal); 3) health’s multisectoral connections; 4) neoliberalism and the global economy; 5) the framing of health (e.g. as a security issue, as a foreign policy issue, as a human rights issue, and as a global public good); 6) global health inequalities; 7) local and country ownership and capacity; 8) international law in GHG; and 9) research gaps in GHG. We find that decades-old challenges in GHG persist and GHG needs a new way forward. A framework called shared health governance offers promise.
PMCID: PMC3983705  PMID: 24729828
25.  The Global Role of the World Health Organization 
The 21st century global health landscape requires effective global action in the face of globalization of trade, travel, information, human rights, ideas, and disease. The new global health era is more plural, comprising a number of key actors, and requiring more coordination of effort, priorities and investments. The World Health Organization (WHO) plays an essential role in the global governance of health and disease; due to its core global functions of establishing, monitoring and enforcing international norms and standards, and coordinating multiple actors toward common goals. Global health governance requires WHO leadership and effective implementation of WHO’s core global functions to ensure better effectiveness of all health actors, but achieving this global mission could be hampered by narrowing activities and budget reallocations from core global functions.
PMCID: PMC3981564  PMID: 24729827

Results 1-25 (37)