nep-hea New Economics Papers
on Health Economics
Issue of 2009‒04‒25
eighteen papers chosen by
Yong Yin
SUNY at Buffalo, USA

  1. Long-Term Absenteeism and Moral Hazard : Evidence from a Natural Experiment By Nicolas R. Ziebarth
  2. Are Maternal and Child Care Programs Reaching the Poorest Regions in the Philippines? By Lavado, Rouselle F.; Lagrada, Leizel P.
  3. Elasticity of cigarette demand in Argentina: An empirical analysis using vector error-correction model. By Eugenio Martínez; Raúl Mejía; Eliseo Pérez Stable
  4. Malaria: Disease Impacts and Long-Run Income Differences By Douglas Gollin; Christian Zimmermann
  5. Does Conditionality Matter for Adults' Health? Evidence from a Randomized Experiment By Ciro Avitabile
  6. Putting teenagers on the pill: the consequences of subsidized contraception By Grönqvist, Hans
  7. Infant Mortality in Rural Bangladesh: State Dependence vs. Unobserved Heterogeneity By Saha, U.R.; Soest, A.H.O. van
  8. The Impact of a Large Parental Leave Benefit Reform on the Timing of Birth around the Day of Implementation By Marcus Tamm
  9. Essential Drugs in Government Healthcare: Emerging Model of Procurement and Supply By Lalitha N
  10. Why Does the Utilization of Pharmaceuticals Vary So Much Across Europe? Evidence from Micro Data on Older Europeans By Lambrelli, D; O’Donnell, O
  11. Does the Profitability of an Outpatient Surgery Influence where it is Performed? A Look at Ambulatory Surgery Centers and Hospitals By Plotzke, Michael; Courtemanche, Charles
  12. Health Effects of Occupational Change By Olga Lazareva
  13. The Intra-household Economics of Polygyny: Fertility and Child Mortality in Rural Mali By Kazianga, Harounan; Klonner, Stefan
  14. Equity of health care financing in Iran By Hajizadeh, Mohammad; Connelly, Luke B
  15. Child Health and the Income Gradient: Evidence from Australia By Khanam, Rasheda; Nghiem, Hong Son; Connelly, Luke B.
  16. Waiting-time targets in healthcare markets: How long are we waiting? By Dixon, Huw David; Siciliani, Luigi
  17. The Long Term Consequences of Famine on Survivors: Evidence from a Unique Natural Experiment using China's Great Famine By Xin Meng; Nancy Qian
  18. Adolescent Cognitive and Non-cognitive Correlates of Adult Health By Robert Kaestner

  1. By: Nicolas R. Ziebarth
    Abstract: Sick leave payments represent a significant portion of public health expenditures and labor costs. Reductions in replacement levels are a commonly used instrument to tackle moral hazard and to increase the efficiency of the health insurance market. In Germany’s Statutory Health Insurance (SHI) system, the replacement level for periods of sickness of up to six weeks was reduced from 100 percent to 80 percent of an employee’s gross wage at the end of 1996. At the same time, the replacement level for individuals absent for a long-term period, i.e., from the seventh week onwards, was reduced from 80 to 70 percent. We show theoretically that the net reform effects on long-term absenteeism can be disentangled into a direct and an indirect effect. Using SOEP data, a natural control group, and two different treatment groups, we estimate the net and the direct effect on the incidence and duration of long-term absenteeism by difference-in-differences. Our findings suggest that, on population average, the reforms have not affected long-term absenteeism significantly, which is in accordance with our theoretical predictions, assuming that employees on long-term sick leave are seriously sick. However, we find some heterogeneity in the effects and a small but significant decrease in the duration of long-term absenteeism for the poor and middle-aged full-time employed persons. All in all, moral hazard and presenteeism seem to be less of an issue in the right tail of the sickness spell distribution. Finally, our calculations suggest that from 1997 to 2006, around five billion euros were redistributed from persons on long-term sick leave to the SHI insurance pool.
    Keywords: long-term absenteeism, sick pay, moral hazard, natural experiment, SOEP
    JEL: I18 J22
    Date: 2009
  2. By: Lavado, Rouselle F.; Lagrada, Leizel P.
    Abstract: While the national average for maternal and child health services utilization shows improvement, the Philippines is yet to achieve the MDG targets for maternal and child health. This study shows inequality in maternal and child health services utilization across economic classes and across regions. Moreover, based on regional Gini coefficient, there are various patterns of utilization and concentration of services across living standards. Interventions to increase the uptake of maternal and child health services based on these patterns are recommended.
    Keywords: utilization, inequality, maternal and child care, access
    Date: 2008
  3. By: Eugenio Martínez (Instituto de Estaudios Laborales (IELDE), Universidad Nacional de Salta); Raúl Mejía (Centro de Estudios de Estado y Sociedad and Programa de Medicina Interna General, Universidad de Buenos Aires, Buenos Aires, Argentina); Eliseo Pérez Stable (Division of General Internal Medicine, Department of Medicine, Medical Effectiveness Research Center for Diverse Populations, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA.)
    Abstract: Is objective this paper estimate empirically the short and long-term effects on cigarette demand in Argentina based on changes in cigarette price and income. We analyzed data from the Ministry of Economy and Production of Argentina. Analysis was based on monthly time-series data between 1994 and 2004. The econometrics specification is a linear double-logarithmic form using cigarettes consumption per person older than 14 y. as dependent variable and real income per person older than 14 y. and the real average price of cigarettes sales as independent variables. Empirical analyses were done in three steps: 1) To verify the order of integration of the variables using the augmented Dickey-Fuller test; 2) To test for co-integration using the Johansen-Juselius maximum likelihood approach to capture the long-term effects; and 3) To utilize the Vector error-correction model to capture the short-run dynamics of the variables.Results: The empirical results showed that in the long-term period the demand for cigarettes in Argentina is affected by changes in real income and real average price of cigarettes. The value of income elasticity is equal to 0.54 while the value of own-price elasticity is equal to –0.34. The results using vector error-correction model estimation suggest that the short-term cigarette demand in Argentina is independent of price (not statistically significant). The value of the short-term income elasticity is equal to 0.49. A simulation exercise show that increasing the prices in a 120% we can obtain a maximum of revenues from cigarette tax and obtain also a big impact in the fall of the total consumption of cigarettes in the country.
    Keywords: Price elasticity, cigarette demand, Tobacco control
    JEL: D12 I18
    Date: 2008–12
  4. By: Douglas Gollin (Williams College); Christian Zimmermann (University of Connecticut)
    Abstract: The World Health Organization (WHO) reports that malaria, a parasitic disease transmitted by mosquitoes, causes over 300 million episodes of “acute illness” and more than one million deaths annually. Most of the deaths occur in poor countries of the tropics, and especially sub-Saharan Africa. Most of the countries with high rates of malaria prevalence are also poor, and some researchers have suggested a direct link from malaria to poverty. This paper explores the potential impact of malaria on national income levels, using a dynamic general equilibrium framework with epidemiological features. We find that if there is no feasible prevention or control, malaria can have a significant impact on income levels. However, if people have any effective way of avoiding infection, the disease impacts on income levels are likely to be small. This is true even where preventive measures are costly.
    Date: 2008–10
  5. By: Ciro Avitabile (University College London, University of Naples Federico II and CSEF)
    Abstract: We present evidence on how the requirement to attend health and nutrition sessions affects the health behaviour of adults living in households targeted by a nutritional programme in rural Mexico. The evaluation sample of the Programa de Apoyo Alimentario (PAL) is unique in having four different treatment types, which are randomly assigned to four different groups of localities, with one group designated to receive transfers but without any requirement to attend health and nutrition courses. We find that attendance at educational sessions does not affect drinking and smoking behaviour, but significantly reduces the probability of having a large waist circumference among women. We provide evidence that attending health and nutrition related courses determines a large drop in the probability that adult women have excessive calorie intake. The results suggest that lack of information can explain, at least in part, the impressive rise in female obesity in developing countries.
    Keywords: Adult Health, Conditional Cash Transfers, Information, PAL
    JEL: I12 O12
    Date: 2009–04–08
  6. By: Grönqvist, Hans (SOFI, Stockholm University)
    Abstract: This paper investigates the consequences of a series of Swedish policy changes beginning in 1989 where different regions started subsidizing the birth control pill. The reforms were significant and applied to all types of oral contraceptives. My identification strategy takes advantage of the fact that the reforms were implemented successively over time and targeted specific cohorts of young women, in particular teenagers. This generates plausibly exogenous variation in access to the subsidy. The paper first demonstrates that access significantly increased pill use. Using regional, temporal, and cohort variation in access, I then go on to examine the impact on abortions. The estimates show that the subsidy significantly decreased the abortion rate by about 8 percent. Furthermore, long-term access decreased the likelihood of teenage childbearing by about 20 percent. However, there is no significant effect on labor supply, marriage, educational attainment or welfare take-up.
    Keywords: Natural experiment; abortions; teenage childbearing; labor supply
    JEL: J13
    Date: 2009–04–07
  7. By: Saha, U.R.; Soest, A.H.O. van (Tilburg University, Center for Economic Research)
    Abstract: Using longitudinal data of the Health and Demographic Surveillance System (HDSS) in Matlab, Bangladesh, covering the time period 1982 – 2005, and exploiting dynamic panel data models, we analyze siblings’ death at infancy, controlling for unobserved heterogeneity and a causal effect of death of one child on survival chances of the next child. Matlab is a rural area split into two: a “treatment†area where along with standard government services extensive maternal and child health interventions are available, and a “comparison†area where only the standard government services are available. The observed infant mortality rates are 50 per 1,000 live births in the treatment area and 67.4/1,000 in the comparison area. We use separate models for the two areas and analyze the differences in infant mortality between the two areas using several decompositions. Our model predicts that in the comparison area, the likelihood of infant death is about 30% larger if the previous sibling died at infancy than if it did not, and the estimates suggest that, in the absence of this “scarring†effect, the infant mortality rate among the second and higher order births would fall by 6.2%. There is no evidence of such a scarring effect in the treatment area, perhaps because learning effects play a larger role with the available extensive health interventions. We find that distance to the nearest health clinic can explain a substantial part of the gap in infant mortality between the two areas.
    Keywords: childhood mortality;millennium goals;death clustering;dynamic panel data models
    JEL: I12 J13 C33
    Date: 2009
  8. By: Marcus Tamm
    Abstract: The introduction of the German parental leave benefit (Elterngeld) applied to all children born on January 1st, 2007 or later. The new Elterngeld considerably changed the amount of transfers to families during the first two years postpartum. We show that the incentives created by using a cut-off date led more than 1000 parents to postpone the delivery of their children from December 2006 to January 2007. Besides analyzing the timing of delivery the paper focuses on potential adverse health outcomes of children affected by the shift in date of birth.
    Keywords: Cut-off date effect, fertility, policy evaluation
    JEL: H31 J13
    Date: 2009–03
  9. By: Lalitha N
    Abstract: This paper details the procedures adopted by the Tamil Nadu Medical Services Corporation in procuring and supplying essential drugs to the government health care which is a positive measure in ensuring `health for all’. [GIDR WP No. 161].
    Keywords: financial resources, prices, market, Procurement, medicines, population, utility, utilies, health, Supplyhealth care, India, drugs, Tamil Nadu, medical services, WHO, essential drugs, public health services
    Date: 2009
  10. By: Lambrelli, D; O’Donnell, O
    Abstract: We analyze the relative importance of population versus institutional factors in explaining cross-country variation in the utilization of pharmaceuticals among older Europeans. Use of medication is examined among all individuals aged 50+ in eleven European countries and, to better control for need, among those diagnosed with medical conditions for which there exist effective drug therapies. Organizational factors include the density of pharmacies and of physicians, retail prices, reimbursement rates, restrictions on retailing of pharmaceuticals and incentives designed to influence prescribing behaviour. Differences in population health and demographics account for almost 75% of the cross-country variation in the propensity to use pharmaceuticals among all older Europeans but this fraction falls to only 12% among those with a diagnosed condition, while, for this group, differences in the organization of the pharmaceutical and health sectors explain 32-54% of the cross-European variation in utilization of medicines. Organizational differences are more important in explaining variation in receipt of medication for serious conditions, such as asthma, arthritis, diabetes, heart attack and stroke, for which 60-80% of the crosscountry variation can be explained by population and organizational factors, and less important for asymptomatic conditions, such as high cholesterol and hypertension, for which less than 35% of the variation is explained.
    Keywords: Pharmaceuticals, heath care, elderly, Europe
    JEL: I11 I18
    Date: 2009–04
  11. By: Plotzke, Michael (Abt Associates Inc.); Courtemanche, Charles (University of North Carolina at Greensboro, Department of Economics)
    Abstract: Ambulatory Surgery Centers (ASCs) are small (typically physician owned) healthcare facilities that specialize in performing outpatient surgeries and therefore compete against hospitals for patients. Physicians who own ASCs could potentially treat their most profitable patients at their ASCs and less profitable patients at hospitals, reducing hospitals' profit. This paper asks if the profitability of an outpatient surgery impacts where a physician performs the surgery. Using data from the National Survey of Ambulatory Surgery, we find that higher profit surgeries do have a higher probability of receiving treatment at an ASC compared to a hospital. After controlling for the type of surgery performed, we find that a 10% increase in a surgery's profitability is associated with a 1 to 2 percentage point increase in the probability the surgery is performed at an ASC.
    Keywords: Ambulatory Surgery Center; Physician Ownership; Outpatient Surgery; Profit
    JEL: I11
    Date: 2009–03–06
  12. By: Olga Lazareva (Stockholm School of Economics and Center for Economic and Financial Research (CEFIR), Moscow)
    Abstract: Rapidly changing technologies and the growing openness of economies to international trade sometimes make entire occupations in the countries affected redundant. People employed in these occupations have to switch to other occupations that they do not necessarily like. Such “forced” occupational change causes stress, which can be harmful to their health. The effect of people losing their profession on their health has not been previously studied. This paper is intended to fill the gap. I study the effect of occupational change on health and health-related behavior using data from Russia’s economic transition, which was characterized by massive occupational mobility. The results show that “forced” occupational change has a significant negative effect on individual health; it also increases smoking and alcohol consumption. These results survive a number of robustness checks.
    Keywords: occupational change, health, smoking, alcohol
    JEL: J62 J24 I10
    Date: 2009–04
  13. By: Kazianga, Harounan; Klonner, Stefan
    Abstract: Building on anthropological evidence, we develop a model of intra-household decision making on fertility and child survival within the framework of the collective household model. We carry out a test of the implications of this framework with data from Demographic and Health Surveys in rural Mali, where polygyny rates among married women are close to 50 per cent. The econometric tests reject the implications of efficient intra-household allocations for junior wives in bigynous households and fail to reject for senior wives in bigynous households as well as for wives in monogamous households. These findings are consistent with existing narrative evidence according to which co-wife rivalry is responsible for resource-consuming struggle and junior wives are the adults with the weakest bargaining position in the household.
    Keywords: intrahousehold models; polygyny; child mortality; fertility; Mali
    JEL: J13 D13 I12 O15
    Date: 2009–04–21
  14. By: Hajizadeh, Mohammad; Connelly, Luke B
    Abstract: This study presents the rst analyses of the equity of health care financing in Iran. Kakwani Progressivity Indices (KPIs) and concentration indices (CIs) are estimated using ten national household expenditure surveys, which were conducted in Iran from 1995/96 to 2004/05. The indices are used to analyze the progressivity of two sources of health care financing: health insurance premium payments and consumer co-payments (and the sum of these), for Iran as a whole, and for rural and urban areas of Iran, separately. The results suggest that health insurance premium payments became more progressive over the study period; however the KPIs for consumer co-payments suggest that these are still mildly regressive or slightly progressive, depending upon whether household income or expenditure data are used to generate the indices. Interestingly, the Urban Inpatient Insurance Scheme (UIIS), which was introduced by the Iranian government in 2000 to extend insurance to uninsured urban dwellers, appears to have had a regressive impact on health care nancing, which is contrary to expectations. This result sounds a cautionary note about the potential for public programs to crowd out private sector, charitable activity, which was prevalent in Iran prior to the introduction of the UIIS.
    Keywords: Equity; Health care nancing; Kakwani progressivity index; Iran.
    JEL: D31 D63 P43 I18
    Date: 2009–03
  15. By: Khanam, Rasheda; Nghiem, Hong Son; Connelly, Luke B.
    Abstract: The positive relationship between household income and child health is well documented in the child health literature but the precise mechanisms via which income generates better health and whether the income gradient is increasing in child age are not well understood. This paper presents new Australian evidence on the child health-income gradient. We use data from the Longitudinal Survey of Australian (LSAC), which involved two waves of data collection for children born between March 2003 and February 2004 (B-Cohort), and between March 1999 and February 2000 (K-Cohort). This data set allows us to test the robustness of some of the findings of the influential studies of Case et al. (2002) and J.Currie and Stabile (2003), and a recent study by A.Currie et al. (2007) , using a sample of Australian children. The richness of the LSAC data set also allows us to conduct further exploration of the determinants of child health. Our results reveal an increasing income gradient by child age using similar covariates to Case et al. (2002). However, the income gradient disappears if we include a rich set of controls. Our results indicate that parental health and, in particular, the mother's health plays a significant role, reducing the income coefficient to zero. Thus, our results for Australian children are similar to those produced by Propper et al. (2007) on their British child cohort. We also find some evidence that higher incomes have a protective effect when health shocks do arise: for several chronic conditions, children from higher-income households are less likely to be reported as being in poor health than children from lower-income households who have the same chronic conditions. The latter result is similar to some recent findings by Condliffe and Link (2008) on a sample of US children.
    Keywords: Child health; Income gradient; Parental health; Nutrition; Panel data; Australia
    JEL: J13 I12 I1
    Date: 2008–11
  16. By: Dixon, Huw David; Siciliani, Luigi
    Abstract: Waiting-time targets are frequently used by policy makers in the healthcare sector to monitor provider's performance. Such targets are based on the distribution of the patients on the list. We compare and link such distribution with the distribution of waiting time of the patients treated, as opposed to on the list, which is arguably a better measure of welfare or total disutility from waiting (although it can only be calculated retrospectively). We show that the latter can be estimated from the former, and viceversa. We also show that, depending the hazard function, one distribution may be more or less favourable than the other. However, empirically we find that the proportion of patients waiting on the list more than x months is a downward estimate of the proportion of patients treated waiting more than x months, therefore biasing downwards the total disutility from waiting.
    Keywords: duration; targets; Waiting times
    JEL: I11 I18
    Date: 2009–04
  17. By: Xin Meng; Nancy Qian
    Abstract: This paper estimates the long run impact of famine on survivors in the context of China's Great Famine. To address problems of measurement error of famine exposure and potential endogeneity of famine intensity, we exploit a novel source of variation in regional intensity of famine derived from the unique institutional determinants of the Great Famine. To address attenuation bias caused by selection for survival, we estimate the impact on the upper quantiles of the distribution of outcomes. Our results indicate that in-utero and early childhood exposure to famine had large negative effects on adult height, weight, weight-for-height, educational attainment and labor supply.
    JEL: I1 J01 J1 O1
    Date: 2009–04
  18. By: Robert Kaestner
    Abstract: While it is widely acknowledged that the family and childhood environments affect adult well being, why they matter is still an area of significant debate. Previous research concerned with this issue has focused on the influence of family income, family structure, and cognitive ability. Much of this research has focused on economic and social outcomes. Notably, the influence of childhood environments on adult health has not received as much attention as other outcomes, and when health has been the focus, interest has been mainly on childhood health. Here, I present a descriptive analysis of the associations between cognitive and non-cognitive traits measured at the end of childhood (age 14) and mental and physical health at age 41. Results suggest that, on average, adolescent cognitive ability and self esteem have a significant association with health at age 41. Other non-cognitive factors such as locus of control and adolescent substance use do not have significant associations with adult health. Net of adolescent influences, completed education has a significant association with adult health.
    JEL: I12
    Date: 2009–04

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