Economic evaluation of tobacco control in Asia Tuvdendorj, Ariuntuya
DOI:
10.33612/diss.155457815
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Publication date: 2021
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Tuvdendorj, A. (2021). Economic evaluation of tobacco control in Asia: Dynamic population health impact assessment in Mongolia. University of Groningen. https://doi.org/10.33612/diss.155457815
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CHAPTER 8
Summary
Nederlandse samenvatting
Mongolian-language summary
Acknowledgements
About the author
SUMMARY
In the 1980’s and 90’s, the practice of cigarette smoking became more prevalent in Asian countries, approximately 40 years after its spread in Western countries. Particularly, in Asian countries that opened their market economy during the 1990’s, consumption of cigarettes per person significantly increased. Currently, Asia houses about half of the world’s smokers and is the largest tobacco consumer as well as producer. The tobacco smoking epidemic is still in its early stages and will remain a major public health threat for the coming decades.
Mongolia is a middle-income country located in Central Asia. Like many countries in Asia, the country has experienced rapid economic growth over the past decade, which has contributed to a demographic and epidemiological transition. Smoking prevalence has remained unchanged during the past decade. Among people aged 15 and over, 27% are current smokers. Almost half the men smoke compared with 5% of women, offering an important explanation for the large difference in life expectancy. Similar to many other countries in Asia, death due to noncommunicable diseases (NCDs) such as cardiovascular diseases and cancers is the most common cause of death in Mongolia, responsible for almost 80% of total mortality.
Numerous studies, primarily in Western countries, have shown that tobacco smoking is a major risk factor not only for lung cancer but also for different types of cancer, cardiovascular diseases and respiratory diseases. In addition to the harmful effects of smoking on morbidity and mortality, smoking also imposes substantial economic costs on individuals, society and the health system. Smoking-related health care accounts for between 6 and 15 percent of all annual health care costs. To accelerate implementation of tobacco control measures, the WHO encourages countries to realize at least one evidence-based measure included in the MPOWER package at the highest level of achievement in their context. The measures include: Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion, and sponsorship; and Raise taxes on tobacco. Choosing among available interventions is challenging. It requires robust and
Summary
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comparable estimates for all relevant interventions regarding their health benefits and net costs. Various modeling approaches have been used to assess the cost-effectiveness of tobacco control interventions, but most models were developed in Western settings. A limited number of cost-effective studies of tobacco control interventions in an Asian setting are available. This thesis addresses issues encountered when striving for an overall comparison of the cost-effectiveness of several tobacco control measures.
It is important to understand the magnitude of the burden caused by the tobacco smoking on population health. Particularly, in Mongolia, where large gender differences in smoking prevalence combine with a relatively young population. The country has a short smoking history compared to most Western countries. Therefore, country-specific information is required to explain the large variation in life expectancy observed in the population. The average life expectancy is 64 years for men compared to 76 years for women. Results from lung cancer incidence and mortality data were combined with country-specific current and former smoking prevalence and pooled relative risks of smoking from regional cohort studies in Asia to show that the burden of lung cancer caused by tobacco smoking varied between men and women. (Chapter 2) The population attributable fraction of lung cancer burden for current and former smokers combined was 58% for men and 9% for women. In 2016, smoking was responsible for about three thousand DALY lost for men and almost 140 DALY lost for women. The results of this study confirm that the health burden caused by tobacco smoking is much heavier for men than for women.
To ensure a sustainable health care system, efficient use of available resources is crucial. Public health spending on NCDs in Mongolia was similar to spending observed in high-income countries, with health care resources allocated to inpatient care consuming about 66% of healthcare spending compared with 3.5% for prevention policies. Chapter 3 examines the mean inpatient costs associated with three major NCDs (COPD, IHD and Stroke), linking anonymized inpatient records from the National Health Statistics with hospital-specific funding data over the period 2016 to 2018. Chapter 3 shows that mean annual inpatient costs for all three diagnoses were int$
677 for patients using official referral pathways and int$ 849 for unofficial referrals (int$ 721 on average). Next to referral pathway, key drivers of high inpatient costs were location, age, gender and comorbidity. The results from this chapter suggest that allocation of healthcare financing to inpatient care is partly inefficient and apparently room for improvements in service delivery exists.
Evidence-based decision making supports health care efficiency and priority-setting. To allow comparable estimates of alternative policy interventions, model-based economic evaluation studies provide insight into the long-term consequences of policy scenarios. However, different types of bias may occur when conducting such an economic evaluation study. Chapter 4 critically reviews existing decision analytic models used to estimate costs and the effects of population-level tobacco control interventions in an Asian setting. Existing dedicated checklists were used to assess quality of reporting, quality of input data and risk of bias. Previous studies demonstrated a high degree of heterogeneity in terms of model structural assumptions, the scope of the models applied, and the quality of the input data. Our results for the risk of bias score indicated that about 33% of the models had a high risk of bias and another 40% had a moderate risk of bias. The results from this chapter indicate a lack of high quality studies into the cost-effectiveness of tobacco control interventions in Asia. Possible reasons for this might be that relatively few local data sources have been employed and model structures were not always optimal. More locally relevant data is needed to support high-quality evidence regarding the cost-effectiveness of tobacco policies in Asia.
According to WHO research and the MPOWER measures, the share of global population covered by a sufficiently high tobacco tax was the lowest (14%) compared to package warning (52%), mass media (24%), monitoring (38%), smoke-free policy (22%), and advertising bans (18%). Strikingly, evidence from countries of all income levels shows that tobacco taxation is highly effective in reducing tobacco use. By applying a dynamic population model for health impact assessment (DYNAMO-HIA), Chapter 5 examines the long-term health benefit of different levels of cigarette price increases in Mongolia, using country-specific data on demography, disease prevalence,
Summary
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incidence and mortality, in combination with literature-based estimates for the risks of smoking and price elasticity of demand of cigarettes sourced from reviews of Asian studies. Findings show that a price increase of 75% (bringing the country up to the level suggested by the WHO) would reduce the prevalence of smoking by 1.2%, resulting in a gain of more than 137 thousand quality-adjusted life years due to the avoidance of smoking-related diseases in the population of three million individuals. These results support further tobacco control policies in the region and in Mongolia, since the effects of tobacco taxes on future smoking prevalence and associated disease burden was substantial.
Policy-makers are challenged to prioritize the key interventions based on their long-term health impacts as well as their cost-effectiveness. In resource limited settings, evidence to support decision-making has been limited. In Chapter 6, the dynamic population health modeling tool was used to examine the long-term impact of four population-based tobacco control interventions (tobacco taxation, cessation support, mass media and school programs) using the best available information from different sources. This demonstrates how existing modeling tools (DYNAMO-HIA, DISMOD and COST-IT) can be combined with local data in Mongolia. The study used smoking prevalence data from national STEPS surveys; disease-specific incidence, mortality, and prevalence data from national health records; intervention effect estimates based on meta-analysis of relevant literature; and costing data collected from our previous costing study (Chapter 4) in combination with intervention cost estimates based on the COST-IT tool, using local data. The results of this study show that all interventions were very cost-effective, while the school program was cost-saving.
In nutshell, effective anti-smoking policy can prevent a considerable proportion of lives lost due to potentially avoidable NCDs. Also, future healthcare costs may be saved. In absence of an effective tobacco prevention policy, the burden of disease associated with tobacco use continues to rise, and to impose extra costs on the healthcare system. More local epidemiological and costing studies are needed to support better informed decision-making on the costs-effectiveness of tobacco control interventions in Asia.
SAMENVATTING
Zeker de helft van de rokers leeft in Azie, en dit continent is de grootste consument en producent van tabak wereldwijd. De tabaksepidemie is er nog in een vroeg stadium, en zal een belangrijke bedreiging van de volksgezondheid blijven in de komende decennia.
Mongolië, gelegen in Centraal Azië en met een middeninkomen, heeft in de afgelopen periode een snelle economische groei en transitie doorgemaakt. Dit heeft bijgedragen aan een verschuiving in de ziektelast naar chronische aandoeningen. De sterfte aan chronische aandoeningen is tegenwoordig de belangrijkste doodsoorzaak en verantwoordelijk voor bijna 80% van de totale sterfte. Het percentage rokers lag redelijk stabiel op 27% bij mensen van 15 jaar en ouder over de afgelopen periode. Terwijl bijna de helft van de mannen rookt, is het percentage rokers bij vrouwen rond de 5%. Dit verschil in rookgedrag is een van de verklaringen voor een groot verschil in levensverwachting tussen mannen en vrouwen.
Dit proefschrift onderzoekt de uitdagingen die deze transities met zich meebrengen en meer in het bijzonder de gezondheids-economische aspecten van roken.
De aan roken toe te schrijven ziektelast van longkanker verschilt tussen mannen en vrouwen en was respectievelijk 58% en 9%. Hiervoor zijn nationale gegevens over longkanker en het voorkomen van roken gecombineerd met schattingen van het relatief risico van roken voor longkanker op basis van een review van Aziatische cohortstudies. Roken veroorzaakte een ziektelast aan longkanker van 3000 DALYs per jaar in mannen en 140 DALYs per jaar in vrouwen. Deze resultaten bevestigen dat de ziektelast van roken in Mongolië vooral groot is onder mannen. (hoofdstuk 2)
In veel landen met een laag- en gemiddeld inkomen groeien de zorgkosten snel als gevolg van de demografische en epidemiologische transitie. Een efficiënte verdeling van de beschikbare middelen is cruciaal voor een duurzaam zorgsysteem. In Mongolië werd ongeveer 66% van de zorguitgaven besteed aan ziekenhuiskosten, tegen 3.5% aan preventie. Dit proefschrift laat zien dat de gemiddelde ziekenhuiskosten voor 3 belangrijke
8
Nederlandse samenvatting
chronische aandoeningen (COPD, IHD en beroerte) 721 internationale dollar per patiënt per jaar waren, en 849 internationale dollar voor patiënten die afwijkende zorgpaden volgden en bijvoorbeeld rechtstreeks bij een ziekenhuis voor derdelijnszorg in opname kwamen. Ongeveer 25% van de patiënten volgde dergelijke inefficiënte zorgpaden, en hier is dus ruimte voor verbetering. (hoofdstuk 3)
Ter ondersteuning van tabaksontmoedigingsbeleid is meer inzicht in lange termijn kosten en baten gewenst. Simulatiemodellen zijn een hulpmiddel om de lange termijn effecten van beleidsscenarios in beeld te brengen. Een review in dit proefschrift heeft Aziatische evaluatiestudies geïnventariseerd en beoordeeld. De kwaliteit van veel studies laat nog te wensen over, met name wat betreft het gebruik van lokale bronnen voor invoergegevens en de keuze van de modelstructuur. Meer lokale data en beter gebruik van de beschikbare data is gewenst. (hoofdstuk 4)
De MPOWER maatregelen van de WHO zijn een samenhangend pakket maatregelen voor tabaksontmoediging. Wereldwijd is er nog veel te wensen, omdat de aandelen van de bevolking die bereikt worden met afdoende beleid variëren van 14% (accijnzen op tabak) tot 52% (waarschuwing op de verpakking). De resterende maatregelen zijn mediacampagnes (24%), monitoren van rookgedrag (38%), rookverboden (22%) en reclameverboden (18%). Accijnsverhoging blijkt een zeer effectieve maatregel, onafhankelijk van het inkomen in een land. In dit proefschrift worden de lange termijn opbrengsten van accijnsverhogingen in Mongolië in kaart gebracht, met een dynamisch volksgezondheidsmodel (DYNAMO-HIA). De resultaten laten zien dat een eenmalige prijsverhoging van 75% het accijnsniveau op de door de WHO geadviseerde hoogte brengt. Dit vermindert de prevalentie van roken met 1.2%, wat een gezondheidswinst van bijna 140 duizend QALYs oplevert op een populatie van 3 miljoen personen. Deze resultaten ondersteunen het tabaksontmoedigingsbeleid in Mongolië. (hoofdstuk 5)
Vervolgens zijn naast accijnsverhogingen nog 3 andere maatregelen doorgerekend met DYNAMO-HIA, waarbij ook de kosten van de maatregelen in kaart zijn gebracht. Voor accijnsverhogingen, ondersteuning van stoppen
met roken met nicotinevervangende middelen en advies, mediacampagnes en schoolprogramma’s is representatieve informatie verzameld over kosten, effecten, en bereik. International beschikbare modellen (DYNAMO-HIA, DISMOD en COST-IT) in combinatie met lokale data geven zo zicht op de lange termijn kosteneffectiviteit. Alle maatregelen waren zeer kosteneffectief volgens de WHO-criteria en het schoolprogramma bleek zelfs kostenbesparend te zijn. (hoofdstuk6)
Samenvattend kan effectief tabaksontmoedigingsbeleid vele ziektegevallen van chronische aandoeningen voorkomen en de daarmee gepaard gaande voortijdige sterfte en zorgkosten besparen. Zonder effectief preventiebeleid zal de ziektelast gerelateerd aan roken blijven stijgen. Juist lokale data geven goed zicht op de economische en gezondheidseffecten van tabaksontmoedigingsbeleid en kunnen betere preventie gericht ondersteunen.
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ТОВЧ ХУРААНГУЙ Азийн улс орнуудад тамхины хэрэглээ 1980–аад оноос эхлэн эрчимтэй нэмэгдсэн байдаг. Эдийн засаг хурдацтай хөгжихийн хэрээр хүн амын амьдралын хэв маяг өөрчлөгдөж, олон зан үйл шинээр гарсаны нэг нь (янжуур) тамхины хэрэглээ юм. Ази тив нь тамхи татдаг хүний тоогоороо дэлхийд нэгдүгээрт эрэмблэгддэг төдийгүй хамгийн олон хэрэглэгч, үйлдвэрлэгчтэй. Монгол улсын хувьд нийгэм, эдийн засгийн хөгжил, шилжилтээс хамааралтай эерэг, сөрөг олон өөрчлөлт гарсан. Тухайлбал, сүүлийн 20 жилийн хугацаанд хүн амын тоо 2.4 саяас 3.3 сая буюу жилд дунджаар 1.7 хувиар өсчээ. Энэ хугацаанд хүн амын дундаж наслалт 70-д хүрч 7.6 жилээр уртассан боловч хүн амзүйн энэхүү өсөлт хүйсийн хувьд ялгаатай байгаагийн нэг нотолгоо нь эрэгтэйчүүд эмэгтэйчүүдээс ойролцоогоор 9 жилээр богино насалж байгаагаас харж болно. Хүн амын дундаж наслалтанд гарсан ялгаатай байдлыг нэмэгдүүлж буй гол шалтгаан нь урьдчилан сэргийлэх боломжтой хорт хавдар, зүрх судасны өвчлөл, цус харвалт зэрэг халдварт бус өвчний (ХБӨ) дарамт юм. ХБӨ-ний эрсдэлт хүчин зүйлсийн үндэсний 2013 оны судалгаагаар хүн амын 27 хувь тамхи татдаг бөгөөд ялангуяа эрэгтэйчүүдийн тал хувь нь, эмэгтэйчүүдийн 5 хувь нь татаж байна. ХХI зууны чимээгүй тахал болох тамхины хэрэглээг бууруулахтай холбоотой олон бодлогын баримт бичгүүд гарсан боловч тамхи таталтын хэмжээ дорвитой буурахгүй хэвээр байгаа нь анхаарал татсан асуудал болж байна. Дэлхийн эрүүл мэндийн байгууллагаас тамхины хэрэглээг бууруулах зорилгоор “Тамхины хяналтын суурь конфенц”-ийг баталж, улс орон бүр өөрийн нөхцөлд тохирсон багц хөтөлбөрөө сонгож, зардал-үр ашгийн хэмжээгээр нь эрэмбэлэн, боломжит түвшинд хэрэгжүүлэхийг санал болгосон. Энэхүү багцад, тамхины хэрэглээг тогтмол хянах хөтөлбөр, тамхинаас гаргах эмийн эмчилгээний хөтөлбөр, тамхины хор хөнөөлийг таниулах хөтөлбөр, реклам сурталчилгааг дэмжихийг хориглосон хөтөлбөр, олон нийтийг Mongolian-language summaryмэдээллээр хангах хөтөлбөр болон тамхины татварын хөтөлбөрийг тус тус багтаасан. Эдгээр хөтөлбөрүүдээс улс орнууд өөрийн онцлогт тохирсон оновчтой багцыг сонгохын тул хөтөлбөр тус бүрийн урт хугацаанд гарах үр дүн, зардлыг судалсны үндсэн дээр шийдвэр гаргах шаардлагатай. Хөтөлбөрийн үнэлгээг загварт суурилсан эрүүл мэндийн эдийн засгийн үнэлгээний (ЭМЭЗҮ) аргаар гүйцэтгэдэг. Загварт суурилсан ЭМЭЗҮ-нд хүн ам зүйн үзүүлэлтүүд, хүн амын нийт нас баралт, өвчлөлийн тархалт, өвчний шинэ тохиолдол, тухайн оношоор бүртгэгдсэн нас баралт, тамхи таталтын хэмжээ, түүнд хамаатуулах эрсдэл, эмчилгээ болон хөтөлбөрийг хэрэгжүүлэхэд гарах зардал гэх мэт олон төрлийн тоо мэдээлэл ашиглан судалдаг. Одоогоор тамхины хөтөлбөрүүдийн ЭМЭЗҮ-г хийх судалгааны загварууд нь өндөр хөгжилтэй улс орнуудын онцлогт тохируулан хийгдсэн байдаг. Иймээс тамхины хэрэглээг бууруулахын тулд Монгол улсын тамхины хэрэглээнээс үүдэлтэй эрүүл мэндэд учирч буй дарамтыг тооцох, боломжит хөтөлбөрүүдийн зардал-үр дүнг тооцох, тамхины хяналтын суурь конвенцид орсон хөтөлбөрүүдийн ЭМЭЗҮ хийсэн загваруудын чанарыг Азийн улс орнуудын жишээн дээр системтэй тоймлон судлах, улмаар нотолгоонд суурилсан бодлого шийдвэр гаргахад дэмжлэг үзүүлэх зорилгоор дараах судалгаануудыг хийлээ. Тамхинаас шалтгаалсан эрүүл мэндэд үзүүлж буй дарамтыг Монгол улсад бүртгэгдсэн уушгины хорт хавдарын өвчлөлийн статистик мэдээллийг ашиглан тооцсон. Манай улсад 2006-2018 онд бүртгэгдсэн уушгины хорт хавдрын нас баралт, шинээр оношлогдсон хавдрын тоо мэдээллийг, тамхины тархалт, тамхины харьцангуй эрсдэлийн мэдээлэлтэй холбон судалсан бидний эхний судалгааны үр дүнгээс харахад уушгины хавдараас үүдэлтэй хөдөлмөрийн чадвар алдагдсан нийт 63 мянга жил гарсаны 38 хувь нь тамхинаас шалтгаалсан болох нь батлагдсан. Энэхүү судалгаагаар тамхины шалтгаант уушгины хавдар эрэгтэйчүүдэд хамгийн өндөр буюу 58%,
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Mongolian-language summary харин эмэгтэйчүүдэд 9% байгаа нь тамхинаас шалтгаалсан өвчний дарамт нь эрэгтэйчүүдэд илүү өндөр байгааг мөн баталсан. Эрүүл мэндийн салбарын санхүүгийн нөөцийг үр ашигтай зарцуулах, тасралтгүй нэмэгдэж буй зардлыг хянах нь бүх нийтийн хамрагдалтыг нэмэгдүүлэх чухал хөшүүрэг юм. Монголчуудын дунд зонхилон тохиолддог уушгины архаг бөглөрөлт, харвалт болон зүрхний ишеми оношоор улсын эмнэлгүүдэд 2016-2018 онуудад хэвтэж эмчлүүлсэн нийт 117 мянган хүний, 137 мянган стационарийн бүртгэлийн мэдээлэлд хийсэн бидний судалгаагаар нэг иргэнд жилд улсын төсвөөс дунджаар 677 ам.доллар зарцуулсан гэсэн үр дүн гарсан. Уг зардлыг шатлал алгасаагүй болон шатлал алгасан хэвтүүлэн эмчлэх үйлчилгээ авсан байдлаар харьцуулахад, 721 ам.доллараас 849 ам.доллар болж нэмэгдсэн. Мөн дундаж зардал нь тухайн хүний хавсарсан онош, байршил, нас, хүйс зэрэг олон хүчин зүйлээс хамаараад статистикийн ач холбогдол бүхий ялгаатай гарсан. Энэхүү судалгааны үр дүнгээс тусламж, үйлчилгээний зохион байгуулалтыг сайжруулах, шатлал алгасан хэвтэх байдлыг бууруулах замаар эрүүл мэндийн салбарын зардлын үр ашгийг нэмэгдүүлэх, нөөцийг оновчтой хуваарилах боломжтой болохыг нотолсон. Тамхины хөтөлбөрүүдийн урт хугацаанд гарах үр нөлөөг харьцуулан судлахад загварт суурилсан ЭМЭЗҮ чухал үүрэгтэй. Энэ төрлийн үнэлгээг хийх явцад загварын бүтэц, мэдээллийн төрөл болон загварын баталгаатай байдалтай холбоотой олон төрлийн алдаа гарч болно. Тамхины хяналтын шийдвэр гаргалтанд ашиглагдаж буй ЭМЭЗҮ-ний талаарх хэвлэлийн тойм судалгаагаар Азийн улс орнуудад нийт 9 төрлийн загвар ашиглан судалгааг хийсэн байдаг. Эдгээр загварууд нь дэвшүүлсэн таамаглал, ашигласан мэдээллийн төрөл, үр дүнг тооцсон хугацаа, хүрээнээс хамаарч харилцан адилгүй ялгаатай байсан. Эдгээр судалгаанд ашигласан загвар тус бүрийн чанарыг 56 асуумж бүхий стандарт шалгуур үзүүлэлтээр үнэлэхэд 33 хувь нь өндөр алдаатай, 40 хувьд нь дунд зэргийн алдаатай гэсэн үр дүн гарсан. Цаашид чанартай загварт суурилсан ЭМЭЗҮ хийхийн тулд тухайн улсад тамхинаас хамааралтай оношийн бүлгийн өртгийнсудалгаа, тархвар зүйн судалгаа, хөтөлбөрийн үр дүнгийн судалгаа, тамхины үнийн мэдрэмжийн судалгаа зэрэг суурь судалгаануудыг хөгжүүлэх шаардагатай байгааг тогтоосон. Тамхины хэрэглээг бууруулахад тамхины татварын бодлого хамгийн өндөр үр дүнтэй хөтөлбөр гэдгийг бусад улс орнуудын хийсэн судалгаанууд тогтоосон байдаг. Иймээс тамхинд ногдож буй онцгой албан татварын хэмжээ нь тамхины жижиглэнгийн үнийн 70 хувиас дээш байх шалгуурыг улс орнуудад тавьдаг. Манай улсын хувьд энэ нь 2018 онд 38 хувьтай буюу “хангалтгүй” гэж үнэлэгдсэн байдаг. Нэг хайрцаг янжуур тамхинд ногдож буй онцгой албан татварын жилийн өсөлт нь 77 төгрөг буюу $0.03 байгаа нь дээрх шалгуурт хүрэхэд хүндрэл учруулж байна. Тамхины татварын хэмжээг нэг удаад 75 хувиар нэмэгдүүлэх гэсэн таамаглал дэвшүүлэн, загварт суурилсан ЭМЭЗҮ-ний аргаар судлахад тамхины тархалт нийт хүн амын дунд 1.2 пункт хэмжээгээр буурсан буюу үүнээс үүдэлтэй тамхинаас шалтгаалсан өвчлөл, нас баралтаас сэргийлэх замаар нийт 137 мянган хөдөлмөрийн чадвар алдалтыг тооцсон жилийг сэргийлж чадна гэсэн үр дүнд хүрсэн. Иймд тамхины татварын хэмжээг нэмэгдүүлэх замаар хүн амын эрүүл мэндийг сайжруулж ХБӨ-өөс сэргийлэх боломжтой болохыг нотолсон. Оновчтой хөтөлбөр сонгох шийдвэр гаргалт нь хувилбар тус бүрийн урт хугацаанд гарах зардар-үр дүнгийн хэмжээнээс хамаарна. Бид судалгааны дараах 2 төрлийн хэрэглэгдэхүүн ашиглан зардал-үр дүнгийн шинжилгээг хийсэн. Үүнд, нэгдүгээрт, эрүүл мэндийн нөлөөллийн үнэлгээг хүн амын динамик өсөлттэй уялдуулан тооцох хэрэглэгдэхүүн, хоёрдугаарт, хөтөлбөрийн зардал тооцох хэрэглэгдэхүүн. Үнэлгээнд тамхины татварын хөтөлбөр, мэдээлэл сургалт сурталчилгааны хөтөлбөр, тамхинаас гаргах эмийн эмчилгээний хөтөлбөр болон сургуулийн насны хүүхдүүдэд чиглэн хөтөлбөр тус тус хамруулсан. Судалгаанд хамрагдсан бүх хөтөлбөрүүдийн зардал-үр дүнгийн хувьд “маш үр ашигтай” буюу хөдөлмөрийн чадвар алдсан нэг жилийг хамгаалахад гаргах зардал нь нэг хүнд ноогдох дотоодын нийт бүтээгдэхүүний хэмжээнээс
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Mongolian-language summary бага байсан. Мөн сургуулийн насны хүүхдүүдэд чиглэн урьдчилан сэргийлэх хөтөлбөр нь бусад хөтөлбөрүүдтэй харьцуулахад урт хугацаанд гарах зардлыг хэмнэх боломжтой болох нь нотлогдсон. Дээрх судалгаануудын үр дүнгээс харахад нотолгоонд суурилсан тамхины оновчтой хөтөлбөр сонгон хэрэгжүүлснээр хүн амын дундах тамхины хэрэглээг бууруулах, тамхинаас шалтгаалсан эрүүл мэндэд учирч буй ХБӨ-ийн дарамтыг бууруулах, дундаж наслалтын зөрүүг багасгах, хөдөлмөрийн чадвар алдагдалтай жилүүдийн тоог бууруулах, улмаар эрүүл мэндийн салбарын санхүүжилтийн нөөцийг үр ашгийг нэмэгдүүлэх олон давуу талтай болохыг тогтоосон.ACKNOWLEGDMENT
Reflecting on the four years I’ve lived in Groningen, I feel that many days were full of excitement, fulfilling experiences, delightful memories, as well as steady activity and hard work. My routine often involved academic tasks, yet sometimes, it was quite challenging to stay on track. I never could have finished my thesis without the support from many incredible people accompanying me. You all deserve my most sincere gratitude.
Foremost, my sincere appreciation goes to my supervisors: prof. Erik Buskens and prof. Talitha Feenstra. I appreciate both of you wholeheartedly for your immense academic support and continual encouragement through my ups and downs during these years.
To my first supervisor, Erik: I want to thank you for offering me a PhD position and helping me throughout the stages of my PhD project. Your extensive knowledge and critical thinking have very much inspired me.
To my daily supervisor, Talitha: you made the biggest contribution to the completion of this thesis. Your professional guidance and supervision helped me tremendously in accomplishing my PhD project. I feel so fortunate to have you as my daily supervisor.
I express my sincere gratitute to prof. Tjalling Halbertsma, for giving me opportunity to study on PhD in Groningen. Thank you very much for always supporting me and other fellow PhDs from Mongolia.
I would also like to acknowledge prof. Henriette Boshuizen, prof. Marika Boezen, and prof. Chimedsuren Ochir for agreeing to be members of the thesis assessment committee and thank them for the time and effort they have put into critically reviewing and approving this thesis.
I also would like to thank prof. Fanny Janssen, prof. Marc Willems, prof. Maarten Postma, and prof. Ardine de Wit for attending my defense as my opponents.
I sincerely thank the co-authors of my manuscripts: prof. Truusk de Bock, dr.Bayarsaikhan Dorjsuren, prof. Stefan Lhachimi, dr. Grigory Sidorenkov, dr. Badamsuren Tseveen, Du Yihui, Steef Konings, Otgonjargal Dechinkhorloo, and Kh.Narantuya for their excellent collaborations, critical comments and
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Acknowledgments
contributions.
To prof. Jacky Mathonnat and prof. Martine Audibert from the University of Clermont Auvergne: I wouldn’t have been able to start my academic career without your support. You came to Mongolia and selected me to be your student in health economics at CERDI in France. I feel privileged to have had you both as my mentors.
I would also like to express my thanks to my teachers, mentors, and colleagues from the School of Public Health, Mongolian National University of Mongolia (MNUMS) for their support and guidance. Special thanks to prof. Davaalkham Dambadarjaa, Director of School of Public Health;
prof. Munkh-Erdene Luvsan, Head of the Department of Health Policy; and the teachers and colleagues from the Department of Health Policy, MNUMS. I look forward to working with you again in the future.
To Ahmad and Steef: thanks for being my paranymphs. Ahmad, I enjoyed sharing the office with you. Our breaks were always a welcome respite during busy days. Steef, you helped me so much with handling difficult R scripts and dealing with dirichlet distribution. Good luck to both of you with everything.
Many thanks to all my colleagues from the Department of Epidemiology: Erwin Kort, Aukje van der Zee, Kuil Lisette and Geuze Roelian. Thank you for all the different kinds of support you provided, from arranging financial support to organizing conference and meeting schedules.
My gratitude to the HTA unit, chaired by prof. Paul Krabbe and to the senior staff, Karin, Thea, Henk, Maarten, Ant, and others, for having me as a part of your unit.
Big thanks to my colleagues and friends: Ahmad, Yihui, Omar, Bale, Nigus, Kedede, Tian, Jing, Xin, Elnaz, Sara, Pato and others. You all brightened my PhD journey through scientific meetings and emotional support. Thanks to you, my days have been much more cheerful, full of laughter and conversation. I wish you all great success in the future.
I would also like to extend my thanks to my colleagues and friends from Health economics modeling-observational data group: Kaying, Steef, Sajad, Xinyu, and Koen, for their scientific meetings and spontaneous conversation
on many occasions.
My big and warmest thanks go to my fellow Mongolian PhD students, friends and their family. I admire and will always be grateful to my dear friends V. Byambsuren, L.Simeon, B.Enkh-Orchlon and his family, N.Otgongerel and little E.Anir, B.Oyuntugs, L.Khosbayar and his wife B. Saranchimeg, their sons Tergel and Tenuun, D.Turtushikh and his wife Z.Dulguun, their boy Irmuun, and N.Altanzul and her daughter O.Namuunzul. I am truly lucky to be surrounded by such compassionate friends and take pride in our friendship. I cherish every moment we have had and look forward to those we will enjoy together in the future.
For the friends I met in Groningen, Z.Tsogzolmaa, D.Uuriintuya, and J.Ulziidelger: thank you girls, for always cooking such delicious food, your thoughtfulness, and supporting me through everything. I wish you all the best.
To my dearest friend Marie-Charlotte and her husband Guillaume, their lovely children, their parents Jean-Luc Buisson, Francine Buisson and Mamie Lilyane Buisson: thank you for your support, kindness and hospitality. Our glorious friendship will continue to flourish for years to come.
My dear friend Julin-Lee, you are such a kind and open-minded person. I will always remember our meeting in Australia. Thank you for always being my closest friend.
My deepest gratitude goes to my family:
To my dear parents, N.Tuvdendorj (Ноосгойн Түвдэндорж) and N.Enkhtuya (Надмидын Энхтуяа): no words would be enough to show my love and appreciation. None of my achievements would have been possible without your support and encouragement. Thank you so much for your endless love and unconditional support. I wish you both long, healthy and happy lives.
To my dear parents-in-law, A.Byartsogt (Аюурын Баярцогт) and B.Sarantuya (Бодьсадын Сарантуяа): I am so grateful to have you in my life. My deepest gratitude for helping me to take care of our sons for the last two years while I was in the Netherlands. Your love and support in these years have
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Acknowledgments
been irreplaceable; I cannot thank you enough for this.
To my siblings and their families. To my sister T.Ankhzaya and her husband D. Adiyatumur, my brother T. Amarbold and his wife Kh.Unurmunkh, my sister T. Adiltsetseg and her husband R.Erdene-Bayar, my youngest brother T.Ajrakhgui and his wife A.Delgermaa, my sister-in-law B.Battsetseg and her husband J.Munkhsaikhan, their kids, my sister-in-law M.Nomio, and my nephews and nieces: I am so grateful to you all taking care of our parents when I was not in Mongolia. The peace of mind that this brought allowed me to focus in the work of completing my PhD.
To my lovely sons B. Saruul and B.Sanchir: you are the source of my joy. Mom loves you both so much. My heart is always filled with love seeing you both healthy and happy. I wish you could have been with me in Groningen for the entire four years and I can’t wait to see both again very soon.
To my beloved husband, B.Batzorig, for his enduring love, his understanding, encouragement, and for accepting the whole responsibilities to our family and allowing me to pursue my PhD during these years. All my achievements are possible because of your tremendous support. You deserve everything and more.
Ariuntuya Tuvdendorj
Groningen, Netherlands December , 2020
ABOUT THE AUTHOR
Ariuntuya Tuvdendorj was born on 16 September 1984 in Ulaangom city in Mongolia. She graduated from secondary school in Ulaangom. She moved to Ulaanbaatar and graduated as a Health Economist at the School of Public Health (SPH), at Mongolian National University of Medical Sciences (MNUMS) in 2006.
Her first job was at State Clinic Hospital #1. In 2007, she got a scholarship from Universite d’Auvergne in France to study for a Master’s in Health Economics at Centre d’Etudes et de Recherches sur le Développement International (CERDI). Her master’s thesis focused on “The distribution of health care resources in Mongolia” under the supervision of prof. Jacky Mathonnat and prof. Martine Audibert.
Soon after graduating, she returned to Mongolia and joined the first team on the National Health Accounts in Mongolia, working as an officer at the Government Implementing Agency, Department of Health in Mongolia. She decided to pursue her career as a lecturer at the Department of Health Policy, at SPH, MNUMS in 2012.
She started her PhD trajectory in 2016 at the Unit of Patient-Centered Health Technology Assessment (HTA), Department of Epidemiology, University Medical Center Groningen (UMCG), University of Groningen in the Netherlands under the supervision of Prof. Erik Buskens and Prof.Talitha Feenstra. Ariuntuya received scholarships from Mongolian State Training Fund and the UMCG. Her PhD project focused on the model-based economic evaluation of tobacco control interventions in Asia, and in Mongolia in particular.
Currently, she will be continuing her career as a lecturer in the same department at MNUSM in Mongolia. Her research interests are in the areas of data-driven prevention policies, public health modeling, model-based economic evaluations, health financing policy, healthcare and services delivery.
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About the author
PRESENTATIONS IN THE SCIENTIFIC CONFERENCE
2020 European Conference on Health Economics conference, University of Oslo,
Denmark. Virtual Conference: Risk of bias in model-based economic evaluations of tobacco control interventions in Asia
2019 Australian Health Economics Society Conference and Doctoral
Workshop-Australian Health Economics. University of Melbourne, Australia. Oral presentation: Reducing burden of diseases through tobacco taxes intervention in Mongolia
2019 13th World Congress-International Health Economics Association (IHEA)
in Basel, Switzerland. Oral presentation: Sin-tax, their health consequences in Mongolia.
2018 Lowlands Health Economics Conference, in Hoenderloo, The Netherlands.
Oral presentation: Oral presentation: Smoking-attributable burden of lung cancer in Mongolia.
GRANT
2019 AHES Student grant, Australian Health Economics Society Conference. in
Melbourne, Australia
ACTIVITY
2019 World Congress - International Health Economics Association, in
Basel, Switzerland. Organized joint-session. Sin-tax, their health and fiscal consequences. Application in OECD and Asian countries.
PUBLICATIONS
Tuvdendorj A., Feenstra T., Tseveen B. and Buskens E., 2020.
Smoking-attributable burden of lung cancer in Mongolia a data synthesis study on differences between men and women. PloS one, 15(2), p.e0229090.
Tuvdendorj A, Du Y, Sidorenkov G, Buskens E, de Bock GH, Feenstra T. Informing
policy makers on the efficiency of population level tobacco control interventions in Asia: A systematic review of model-based economic evaluations. Journal of Global Health 2020;10:020437
ReseaRchinstitute SHARE
This thesis is published within the Research Institute SHARE (Science in Healthy Ageing and healthcaRE) of the University Medical Center Groningen / University of Groningen.
Further information regarding the institute and its research can be obtained from our internet site: http://www.share.umcg.nl/
More recent theses can be found in the list below. (supervisors are between brackets)
2020 Wijnen A
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For earlier theses visit our website
