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PubMed2003

Quality of care and the demand for health services in Bamako, Mali: the specific roles of structural, process, and outcome components.

The public finance and foreign exchange crisis of the 1980s aggravated the unfavourable economic trends in many developing countries and resulted in budget cuts in the health sector. Policymakers, following the suggestions of World Bank experts, introduced user fees. Economic analysis of the demand for health care in these countries focused on the impact of price and income on health service utilisation. But the lesson to date from experiences in cost recovery is that without visible and fairly immediate improvements in the quality of care, the implementation of user fees will cause service utilisation to drop. For this reason, the role of quality of health care has been recently a subject of investigation in a number of health care demand studies. In spite of using the data from both households and facilities, recent studies are quite limited because they measure quality only by structural attributes (availability of drugs, equipment, number and qualifications of staff, and so on). Structural attributes of quality are necessary but not sufficient conditions for demand. A unique feature of this study is that it also considers the processes followed by practitioners and the outcome of care, to determine simultaneously the respective influence of price and quality on decision making. A nested multinomial logit was used to examine the choice between six alternatives (self-treatment, modern treatment at home, public hospital, public dispensary, for-profit facility and non-profit facility). The estimations are based on data from a statistically representative sample of 1104 patients from 1191 households and the data from a stratified random sample of 42 out of 84 facilities identified. The results indicate that omitting the process quality variables from the demand model produces a bias not only in the estimated coefficient of the "price" variable but also in coefficients of some structural attributes of the quality. The simulations suggest that price has a minor effect on utilisation of health services, and that health authorities can simultaneously double user fees and increase utilisation by emphasising improvement of both the structural and process quality of care in public health facilities.

Decision Making↗
PubMed2003

Investments in social capital--implications of social interactions for the production of health.

This paper develops a theoretical model of the family as producer of health- and social capital. There are both direct and indirect returns on the production and accumulation of health- and social capital. Direct returns (the consumption motives) result since health and social capital both enhance individual welfare per se. Indirect returns (the investment motives) result since health capital increases the amount of productive time, and social capital improves the efficiency of the production technology used for producing health capital. The main prediction of the theoretical model is that the amount of social capital is positively related to the level of health; individuals with high levels of social capital are healthier than individuals with lower levels of social capital, ceteris paribus. An empirical model is estimated, using a set of individual panel data from three different time periods in Sweden. We find that social capital is positively related to the level of health capital, which supports the theoretical model. Further, we find that the level of social capital (1) declines with age, (2) is lower for those married or cohabiting, and (3) is lower for men than for women.

Age Factors↗
PubMed2003

Health insurance and child mortality in Costa Rica.

This study uses a natural experiment approach to evaluate the effect of health insurance on infant and child mortality. In the 1970s Costa Rica adopted national health insurance, which expanded children's insurance coverage from 42 percent in 1973 to 73 percent by 1984. Aggregate infant and child mortality rates dropped rapidly during this period, but this trend had begun prior to the insurance expansion, and may be related to other changes during this period. We use county-level vital statistics and census data to isolate the causal insurance effect on mortality using county fixed effects models. We find that insurance increases are strongly related to mortality decreases at the county level before controlling for other time-varying factors. However, after controlling for changes in other correlated maternal, household, and community characteristics, fixed effects models indicate that the insurance expansion could have explained only a small portion of the mortality change. These results question the proposition that health insurance can lead to large improvements in infant and child mortality, and that expanding insurance to the poor can substantially narrow socioeconomic differentials in mortality.

Cause of Death↗
PubMed2003

Revisiting the decision rule of cost-effectiveness analysis under certainty and uncertainty.

The classical decision rule of cost-effectiveness analysis uses a threshold cost-effectiveness ratio as a cut-off point for resources allocation. One assumption of this decision rule is complete divisibility of health care programs. In this article, we argue that health care programs cannot be completely divisible since individuals are not divisible. Consequently, instead of a linear programming approach, an integer programming approach to budget allocation is suggested. The integer programming framework can be extended to include uncertainty in the analysis. An objective function (expected aggregate effects) is maximised subject to the constraint that the probability of exceeding the budget is limited to an arbitrary level (e.g., 0.05). In case the budget is exceeded, the objective function is penalised in order to account for the opportunity costs of the additional resource requirements.

Budgets↗
PubMed2003

Child health on a dollar a day: some tentative cross-country comparisons.

Children living on a dollar a day-the international extreme poverty line-appear to have radically different chances of dying in childhood and being malnourished, depending on the country in which they live. In Kazakhstan, a child living on a dollar a day, has only a 10% risk of being underweight, while the risk facing a child living on a dollar a day in India is nearly 60%. The Kazakh child has a risk of less than 40 per 1000 of dying before his first birthday, while a child living on a dollar a day in Niger faces a risk of nearly 160 per 1000. Countries where mortality and malnutrition risks at a dollar a day are high are not typically those where there are large gaps in child survival and in malnutrition between the poor and better-off. The two concepts of inequality and health risks at the poverty line are not only conceptually distinct-they are empirically distinct too. The large differences between countries in the risks of mortality and malnutrition in childhood beg the obvious question-what accounts for these differences? Some regression results presented in the paper suggest that these differences may be due to differences across countries in levels of per capita expenditure on the health sector. Regressions find that higher levels of per capita public spending on the health sector are associated with significantly lower levels of mortality and malnutrition amongst children living on a dollar a day.

Body Weight↗
PubMed2004

Addressing government and market failures with payment incentives: Hospital reimbursement reform in Hainan, China.

This paper examines the role of provider payment policy as an instrument for addressing government and market failures and controlling costs in the health sector, particularly in developing countries. We empirically evaluate the impact of provider payment reform in Hainan province, China, on expenditures for different categories of services that had been subject to distorted prices under fee-for-service. Using a pre-post study design with a control group, we analyze two years of claims data to assess the impact of a January 1997 change to prospective payment for a sub-sample of the hospitals. This difference-in-difference empirical strategy allows us to isolate the supply-side payment reform effects from demand-side policy interventions. We find that prepayment is associated with a slower increase in spending on expensive drugs and high technology services, compared to fee-for-service. The fact that payment reform is associated with reduced growth in spending on the most expensive drugs is particularly encouraging, given that drugs account for a remarkably high percentage of both the level and growth of aggregate health expenditure in China. Payment reform can be an effective policy instrument for correcting market failures and adverse side effects of government health sector interventions (such as distorted prices to assure access to basic services), both of which can lead to excessive health care expenditure growth. Such health spending growth can have a particularly high opportunity cost for developing countries.

China↗
PubMed2003

Hidden health costs of pesticide use in Zimbabwe's smallholder cotton growers.

Balancing the numerous benefits that may accrue from pesticide use on cotton, farmers face health hazards. Pesticide-induced acute symptoms significantly increased the cost-of-illness in a survey of 280 smallholder cotton growers in two districts of Zimbabwe. Cotton growers lost a mean of 180 Zimbabwe dollars in Sanyati and 316 Zimbabwe dollars per year in Chipinge on pesticide-related direct and indirect acute health effects. These values are equivalent to 45% and 83% of annual household pesticide expenditures in the two districts. The time spent recuperating from illnesses attributed to pesticides averaged 2 days in Sanyati and 4 days in Chipinge during the 1998/1999 growing season. These pesticide health cost estimates represent lower bounds only; they omit chronic pesticide health effects as well as suffering and other non-monetary costs. Acute pesticide symptoms were determined in large part by pesticide use practices, notably the lack of protective clothing. Yet many smallholder farmers misunderstood pesticide health hazards, and so did little to protect themselves. Despite the use of simple color codes, 22% of smallholder cotton growers in Sanyati and 58% in Chipinge did not know how the four colored triangles communicated increasing degrees of pesticide toxicity. Better farmer education in exposure averting strategies is needed. Likewise, fuller accounting for hidden health costs in future would allow farmers to make more informed decisions about agricultural pest management.

Agricultural Workers' Diseases↗
PubMed2003

Optimizing a portfolio of health care programs in the presence of uncertainty and constrained resources.

Much research has been devoted to handling uncertainty in cost-effectiveness analysis. The current literature suggests summarizing uncertainty in cost-effectiveness analysis using acceptability curves or net health benefits. These approaches, however, focus only on uncertainty associated with costs and effects of the programs under consideration. In the real world, most decision-makers have to fund a portfolio of health care programs. Therefore, a more comprehensive approach would include in the analysis the uncertainty of costs and effects of all programs supported by the fixed budget. This paper extends the decision rule described by Birch and Gafni (J. Health Econ. 11(3) (1992) 279) within the context of a portfolio of programs when costs and effects are uncertain and resources constrained.

Budgets↗
PubMed2004

Wage inequality, the health system, and infant mortality in wealthy industrialized countries, 1970-1996.

This pooled, cross-sectional, time-series study assesses the impact of health system variables on the relationship between wage inequality and infant mortality in 19 OECD countries over the period 1970-1996. Data are derived from the OECD, World Value Surveys, Luxembourg Income Study, and political economy databases. Analyses include Pearson correlation and fixed-effects multivariate regression. In year-specific and time-series analyses, the Theil measure of wage inequality (based on industrial sector wages) is positively and statistically significantly associated with infant mortality rates--even while controlling for GDP per capita. Health system variables--in particular the method of healthcare financing and the supply of physicians--significantly attenuated the effect of wage inequality on infant mortality. In fixed effects multivariate regression models controlling for GDP per capita and wage inequality, variables generally associated with better health include income per capita, the method of healthcare financing, and physicians per 1000 population. Alcohol consumption, the proportion of the population in unions, and government expenditures on health were associated with poorer health outcomes. Ambiguous effects were seen for the consumer price index, unemployment rates, the openness of the economy, and voting rates. This study provides international evidence for the impact of wage inequalities on infant mortality. Results suggest that improving aspects of the healthcare system may be one way to partially compensate for the negative effects of social inequalities on population health.

Community Participation↗
PubMed2004

Insurance and the utilization of medical services.

Most data sets indicate a positive correlation between having health insurance and utilizing health care services. Yet the direction of causality is not at all clear. If we observe a positive correlation between the utilization of health care services and insurance status, we do not know if this is because people who anticipate poor health buy more insurance (or take jobs with generous medical coverage), or because insurance lowers the cost of health care, increasing the quantity demanded. While a few attempts have been made to implement an instrumental variables (IV) strategy to deal with endogeneity, the instruments chosen have not been entirely convincing. In this paper we revisit the IV estimation of the reduced form relationships between insurance and health care utilization taking advantage of what we argue is a good instrument-the individual's self-employment status. Our main finding is that a positive and statistically significant effect of insurance continues to obtain even after instrumenting. Indeed, instrumental variables estimates of the impact of insurance on utilization of a variety of health care services are larger than their non-instrumented counterparts. The validity of this exercise depends on the extent to which self-employment status is a suitable instrument. To argue this case, we analyze panel data on transitions from wage-earning into self-employment and show that individuals who select into self-employment do not differ systematically from those who remain wage-earners with respect to either the utilization of health care or health status. While this finding does not prove that self-employment status is an appropriate instrument, it is encouraging that there appear to be no underlying differences that might lead to self-employment per se affecting health services utilization.

Adult↗
PubMed2004

Effects of early health-insurance programs on European mortality and fertility trends.

In this study, we examined the mortality and fertility effects of the early health-insurance programs sponsored by several European governments in the course of the demographic transition. Three sets of effects were hypothesized, and tested with data for five countries, covering the 1875-1913 period. First, although initially small, the growing health-insurance coverage of national populations accelerated longer-term downtrends in mortality. It not only expanded access to health care, but also helped in disseminating health information and awareness. Second, widening coverage also had an opposite effect on fertility; by lowering the costs of bearing and rearing children, it acted to slow the ongoing downtrend in marital fertility. Third, there was a diverse set of interactions between the mortality and fertility effects. Improved prospects for the survival of infants and children weakened parents' motivation to produce "extra" offspring to offset losses to mortality and to insure against future losses. Child survival was further enhanced by longer intervals between births and fewer children per family. However, the reduced cost of children tended to dilute these antenatal effects. Our regression results supported the expected pattern of partial effects, but simulations were needed to gauge the total impacts of health-insurance. Two sets of simulations were conducted: first, historical simulations, which closely tracked the actual experience of each sample country; second, counterfactuals, in which health-insurance coverage was set at zero for the entire time period. Comparisons of the historical and counterfactual simulations clearly indicated that health-insurance accelerated the downtrend in mortality, but slightly retarded the secular decline in marital fertility. These effects varied in magnitude, but not in direction, among the sample countries.

Birth Rate↗
PubMed1997

Mapping visual analogue scale health state valuations onto standard gamble and time trade-off values.

Despite becoming increasingly common in evaluations of health care, different methods of quantitatively measuring health status appear to produce different valuations for identical descriptions of health. This paper reports on a study that elicited health state valuations from the general public using three different methods: the visual analogue scale (VAS), the standard gamble (SG) and the time trade-off (TTO). Two variants of the SG and TTO were tested: Props (using specially designed boards and cards); and No Props (using a self-completion booklet). This paper focuses on empirical relationships between health state valuations from the VAS and the (four) other methods. The relationships were estimated using Tobit regression of individual-level data. In contrast to a priori expectations, the mapping functions estimated suggest that differences are more pronounced across variant than across method. Furthermore, relationships with VAS scores are found to depend on the severity of the state: TTO Props valuations are higher than VAS responses for mild states and lower for more severe states; SG Props valuations are broadly similar to VAS scores over a wide range; and No Props responses are consistently higher than VAS valuations, particularly for more severe states. Explanations are proposed for these findings.

Economics, Medical↗
PubMed1997

Constant and decreasing timing aversion for saving lives.

The traditional model of time preferences employed by economists is characterised by constant timing aversion. The available evidence suggests that this is not an appropriate assumption. This paper examines evidence for constant and decreasing timing aversion with respect to saving lives. Three discounting models are considered: the constant discounting model; the proportional discounting model; and the hyperbolic discounting model. Data collected from the general public are used to test the constant timing aversion model. Overall, the findings suggest that there is substantial evidence for decreasing timing aversion and against the constant timing aversion hypothesis.

Attitude to Health↗
PubMed1998

The tradeoff between price and quality of services in the Philippines.

This paper examines the tradeoff that consumers make between price and quality in the demand for health care. The analysis is based on data collected from both households and health care facilities in Cebu, Philippines. The availability of both types of data makes this one of only a handful of demand for health care studies that includes detailed information on both individual characteristics and facility attributes of all relevant alternatives. The developing country setting provides substantial variation in the type of facility chosen, ranging from home delivery aided only by friends and relatives at one extreme to modern private hospitals at the other end of the spectrum. The alternatives vary greatly in quality and price, making this an ideal context for examining the role of these variables in facility choice. The nested logit model specifications that are estimated contain price, travel time, and different combinations of quality measures, including the availability of medical supplies, practitioner training, service availability, facility size and crowdedness, and their interaction with individual characteristics. In addition, the sensitivity of the results to different choice-set definitions is analyzed. In particular, models that use conventional choice-set definitions that are based only on nominal status are compared with models that attempt to classify facilities into relatively homogeneous groups based on price and quality. The estimation results, which correct for the two-stage design of the household survey, indicate that facility crowding and practitioner training are significant determinants of consumer choice. The results also indicate that individual characteristics such as education of the woman interact in important ways with quality in influencing choice. For example, the availability of drugs is a significant determinant of facility choice for women with high levels of education, but not for others. In addition, the results support the hypothesis that price is a significant determinant for poor households, but not for other households. The model is used to conduct policy simulations designed to be informative to public officials interested in the effect of cost recovery schemes on utilization patterns. The simulations indicate that, when public facilities simultaneously increase user fees and the aspects of quality over which policy makers can exercise control in the short-run, the mean probability of using public facilities increases for both poor and non-poor households.

Adolescent↗
PubMed1998

Cost-effectiveness analysis and capital costs.

Traditionally, economic evaluations in terms of cost-effectiveness analysis are based, explicitly or implicitly, on the assumption of constant returns to scale. This assumption has been criticized in the literature and the role of cost-effectiveness as a tool for decision making has been questioned. In this paper we analyze the case of increasing returns to scale due to fixed capital costs. Cost-effectiveness analysis is regarded as a tool for estimating a cost function. To this cost function two types of decision rules can be applied, the budget approach and the constant price approach. It is shown that in the presence of fixed capital costs the application of these two decision rules to a specific patient group will give different results. The budget approach may lead to suboptimizations, while using the price as a decision rule will give optimal solutions. With fixed capital costs and when an investment can be used for treating several patient groups, these groups are no longer independent. Therefore the cost-effectiveness analysis has to be performed simultaneously for all patient groups that are potential users of the investment.

Budgets↗
PubMed1999

Do measures of self-reported morbidity bias the estimation of the determinants of health care utilisation?

Most national surveys of health care utilisation capture only self-reported measures of morbidity. If self-reported morbidity is measured with error, then the results of applied work may be misleading. In this paper we propose a model of the relationship between morbidity and health service utilisation which allows for reporting errors and simultaneity. Errors in self-reported morbidity are expressed as a function of person-specific reporting thresholds and recent contact with health services, arising because of better self-evaluation of current health status or a desire to justify consumption of a publicly-provided good. We demonstrate the bias in ignoring the potential problems of reporting errors and simultaneity for a variety of special cases, but in the general case the biases are of ambiguous sign. The empirical nature of these biases is investigated using limiting long-standing illness (LLI) and recent contact with a General Practitioner (GP) in two waves of The UK Health and Lifestyle Survey. Biomedical measures of functioning are used as objective indicators of health status. We find evidence of substantial and significant differences between individuals in reporting thresholds and some evidence that the reporting of LLI may depend on recent visits to a GP. Adjustments for these biases significantly increase the estimated effect of morbidity on utilisation.

Adult↗
PubMed2000

Cost analysis as a vitamin A program design and evaluation tool: a case study of the Philippines.

Vitamin A deficiency (VAD) is a serious and widespread public health problem in the Philippines. Initiated in 1993, the Philippines National Vitamin A Supplementation Program (NVASP) is one of the oldest, most mature and comprehensive of its kind. This paper presents a cost-effectiveness and efficiency analysis of the NVASP and of a hypothetical program of vitamin A fortification of wheat flour that was conducted to inform policymakers as to how to modify the program. Employing a proxy effectiveness indicator of VAD--the intake of < 70% of the recommended daily allowance of vitamin A--in a series of simulations using individual child consumption data, the analysis finds that fortification is more efficient in reducing inadequate vitamin A intake (IVAI) compared to the NVASP. Due to the nature of food consumption patterns, however, fortification alone, is not enough. At what is regarded as the maximum politically acceptable fortification level, there will still be 2.2 million (29%) Filipino children aged 12-59 months who will have IVAI. An investigation of the cost and efficiency of geographically targeted supplementation programs reveals that maintaining a universal supplementation program in urban areas and, in rural areas, introducing a targeted program to only the poorest municipalities (where the prevalence of VAD is the highest) will provide a more acceptable public health policy response than fortification alone. Such a policy will reduce incremental direct Government expenditures on vitamin A programs by nearly 20% and will reduce the number of children with IVAI to 900,000 (12%) Filipino children. The paper describes the fortification and supplementation programs, and how their costs were estimated. Lessons for program designers and policymakers in other countries in which vitamin A deficiency constitutes a public health problem are also discussed.

Child, Preschool↗
PubMedDate not supplied

[What is the cost of inappropriate admission of pneumonia patients?].

BACKGROUND: The number of patients admitted with community-acquired pneumonia (CAP) varies greatly from one hospital to another. Prognostic models for CAP can help physicians decide which cases to treat on an outpatient basis. Our aims were: a) to validate a model for predicting low-risk CAP, and b) to estimate savings that would have resulted if the low-risk patients identified by the model had been treated at home rather than in hospital. PATIENTS AND METHODS: All CAP cases diagnosed by the emergency room physicians of a hospital in northwestern Spain (Ferrol) were enrolled prospectively over a period of 19 months. The prediction rule of Fine et al was used to classify all patients. Mortality in each category was compared with the mortality predicted by Fine's system. Patients in the lowest risk categories (I and II) were considered to have been inappropriately admitted unless they were hypoxemic or had significant comorbidity. Costs were figured based on data provided by our accounting department. RESULTS: Of 192 CAP patients enrolled, 131 were admitted and 61 were treated as outpatients. Ten patients died, none of whom was in classes I or II. The costs of the apparently unnecessary hospital stays of the 34 patients in these classes was 6,979,756 pesetas. The estimated savings that would have derived from treating these patients out-of-hospital was 6,133,292 pesetas (36,862 euros; 322,804 pesetas/month). CONCLUSIONS: a) The predictive model used has been found useful for identifying patients at very low risk of dying from CAP; b) Using this model can improve CAP admission criteria, and c) Application of the model can lead to savings.

Community-Acquired Infections↗