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In their quest for universal health coverage (UHC), many developing countries explore alternative financing strategies to address the potential budgetary impact of health coverage expansion (for example, deferred debt versus current finance through taxation or premiums). Given the limited fiscal space, these policies may have different implications for fiscal sustainability and may worsen intergenerational inequality.
We assessed the impact of UHC on fiscal sustainability and intergenerational inequality using an overlapping generations model within a general equilibrium framework, which we calibrate using data from the Palestinian Expenditures and Consumption Survey (PECS-2011) and the Social Accounting Matrix (SAM-2011). Fiscal sustainability is assessed using a prudent debt–GDP level of 39%. Intergenerational inequality induced by different policies is assessed by comparing the relative incremental burden (RIB) borne by each generation following the policy adjustment.
In the absence of any policy adjustment, an ad hoc expansion of health coverage would increase the debt–GDP level to 15% above the prudent level. This indicates that the UHC fiscal stance may be financially unsustainable in the long run, therefore calling for a policy adjustment. Among the policies we examined, UHC finance through the increase of premiums (whether current or deferred) seems to be unsustainable and may further widen intergenerational inequality (RIB∈[3,6]). By contrast, current finance through indirect taxes helps to restore a prudent debt–GDP level and seems to be associated with a lower level of intergenerational inequality than deferred-debt finance through direct taxation (RIB of 1·25 and 5, respectively).
Among the policy options assessed, the current indirect taxation emerged as the best policy option in terms of its impact on both fiscal sustainability and intergenerational inequalities. However, from a policy perspective, the capacity of governments to raise additional revenues might be constrained in the short-term. Under such circumstances, deferred-debt finance may be preferred—a situation in which policy makers may have to trade fiscal sustainability against intergenerational inequality.
The A*MIDEX project (number ANR-11-IDEX-0001-02) funded by the French Government programme Investissements d'avenir, managed by the French National Research Agency (ANR).
SA prepared the data, conceived the framework for the study and carried out data analysis. MA-Z developed the framework for the study, carried out data analysis and wrote the Interpretation section. BV developed the framework for the study. All authors have seen and approved the final version of the Abstract for publication.
This paper analyses the relationships between HIV/AIDS and education taking into account the appropriative nature of child income. Using a theoretical model, we show that considering remittances from one’s child as an insurance asset can reverse the usual negative relationship between disease prevalence and educational investment. This prediction confirms the results of an empirical study conducted on data compiled from the Demographic and Health Survey (DHS) database for 12 sub-Sahara African countries for children aged between 7 and 22-years-old. Using regional HIV prevalence as a measure of health risk, we find that the ‘sign of the slope’ between health risk and the enrolment of children is not constant. Splitting the data based on expected remittance patterns (for example rural versus urban), we obtain that the effect is most likely driven by household characteristics related to child income appropriation.
In this paper, we report the results of risk attitudes elicitation of a French general practitioners national representative sample (N=1568).
Real reductions in decedents’ per-capita Medicare fee-forservice
(FFS) spending accounted for most of Medicare’s
cost growth mitigation between 2009 and 2014.1 Decedents’
spending reductions immediately followed the Great Recession
of 2007–2009, which accounted for 14% of the decline
in overall Medicare spending growth between 2009 and
2012.2 Since Medicare patients living in lower income areas
spend more at the end of life (EOL),3 we sought to explore
whether local economic distress levels were associated with
This paper investigates the predictive power of several risk attitude measures on a series of medical practices. We elicit risk preferences on a sample of 1500 French general practitioners (GPs) using two different classes of tools: scales, which measure GPs’ own perception of their willingness to take risks between 0 and 10; and lotteries, which require GPs to choose between a safe and a risky option in a series of hypothetical situations. In addition to a daily life risk scale that measures a general risk attitude, risk taking is measured in different domains for each tool: financial matters, GPs’ own health, and patients’ health. We take advantage of the rare opportunity to combine these multiple risk attitude measures with a series of self-reported or administratively recorded medical practices. We successively test the predictive power of our seven risk attitude measures on eleven medical practices affecting the GPs’ own health or their patients’ health. We find that domain-specific measures are far better predictors than the general risk attitude measure. Neither of the two classes of tools (scales or lotteries) seems to perform indisputably better than the other, except when we concentrate on the only non-declarative practice (prescription of biological tests), for which the classic money-lottery test works well. From a public health perspective, appropriate measures of willingness to take risks may be used to make a quick, but efficient, profiling of GPs and target them with personalized communications, or interventions, aimed at improving practices.
Dans plusieurs pays en développement et en particulier au Moyen-Orient et en Afrique du Nord, l’informalité est regardée comme une fatalité et laisse une proportion importante de la population non couverte par le système de sécurité sociale. Une enquête d’évaluation contingente a été menée en Tunisie en 2013, se proposant d’estimer les consentements à payer (CAP) pour deux régimes hypothétiques d’assurance volontaire : un régime d’assurance maladie géré par la ‘Caisse Nationale d’Assurance Maladie’ et un régime vieillesse géré par la ‘Caisse Nationale de Sécurité Sociale’.
L’échantillon se compose de 456 individus non couverts par un régime de sécurité sociale (maladie ou vieillesse), interrogés dans les régions Nord, Centre et Sud du pays. Les personnes interrogées ont été recrutées sur les marchés (souks) – caractérisés par la forte présence d’acteurs du secteur informel – et les places publiques (Al-mydan) – où s’organisaient régulièrement des rassemblements pacifiques de chômeurs pour revendiquer des droits sociaux peu après ce qui a été appelé ‘le printemps Arabe’ qui a débuté en Tunisie fin 2010.
L’intention d’adhésion déclarée par les travailleurs informels et les sans-emploi varie selon le type de filière de soins proposée et selon les risques couverts (avec ou sans assurance-vieillesse). Les résultats confirment les hypothèses selon lesquelles une affiliation volontaire à deux régimes d’assurance serait majoritairement acceptée par les non couverts et les CAPs déclarés pour cette affiliation seraient substantiels. Ils apportent donc des éléments de discussion en termes de politiques tunisiennes de santé (objectif de couverture santé universelle) et d’assurance-vieillesse.
Finalement, nos résultats montrent d’une part que l’informalité n’est pas un choix des individus et que le contrôle de l’évasion sociale en Tunisie est possible. D’autre part, la comparaison manifestants/non manifestants montre qu’il est possible de généraliser une offre d’assurance sociale au-delà du cercle restreint des « activistes ».
This study evaluated the impact of infectious disease (ID) specialist referrals on outcomes in a tertiary hospital in France. This study tackled methodological constraints (selection bias, endogeneity) using instrumental variables (IV) methods in order to obtain a quasi-experimental design. In addition, we investigated whether certain characteristics of patients have a bearing on the impact of the intervention. We used the payments database and ID department files to obtain data for adults admitted with an ID diagnosis in the North Hospital, Marseille from 2012 to 2014. Comparable cohorts were obtained using coarsened exact matching and analysed using IV models. Mortality, readmissions, cost (payer perspective) and length of stay (LoS) were analysed. We recorded 15,393 (85.97%) stays, of which 2,159 (14.03%) benefited from IDP consultations. The intervention was seen to significantly lower the risk of inpatient mortality (marginal effect (M.E) = –19.06%) and cost of stay (average treatment effect (ATE) = – €5,573.39). The intervention group was seen to have a longer LoS (ATE = +4.95 days). The intervention conferred a higher reduction in mortality and cost for stays that experienced ICU care (mortality: odds ratio (OR) =0.09, M.E cost = –8,328.84 €) or had a higher severity of illness (mortality: OR=0.35, M.E cost = –1,331.92 €) and for patients aged between 50 and 65 years (mortality: OR=0.28, M.E cost = -874.78 €). This study shows that ID referrals are associated with lower risk of inpatient mortality and cost of stay, especially when targeted to certain subgroups.
This paper analyses how French general practitioners? (GPs) labour supply would respond to changes in their fee per consultation, seeking to determine whether there is a backward-bending curve.?Because French GPs? fees only evolve very slowly and are generally fixed by the National Health Insurance Fund, fee variability is not sufficient to observe changes in labour supply.?Therefore, we designed a contingent valuation survey randomly presenting GPs with three hypothetical fee increases.?Empirical evidence from 1,400 GPs supports the hypothesis of a negative slope in their labour supply curve.?This suggests that increasing fees is not an effective policy to increase the supply of medical services. JEL Codes: C21, I12, J22, J4.
From November 2014 to November 2015, an experiment in French community pharmacies replaced traditional pre-packed boxes by per-unit dispensing of pills in the exact numbers prescribed, for 14 antibiotics.
A cluster randomised control trial was carried out in 100 pharmacies. 75 pharmacies counted out the medication by units (experimental group), the other 25 providing the treatment in the existing pharmaceutical company boxes (control group). Data on patients under the two arms were compared to assess the environmental, economic and health effects of this change in drug dispensing. In particular, adherence was measured indirectly by comparing the number of pills left at the end of the prescribed treatment.
Out of the 1185 patients included during 3 sessions of 4 consecutive weeks each, 907 patients experimented the personalized delivery and 278 were assigned to the control group, consistent with a 1/3 randomization-rate at the pharmacy level. 80% of eligible patients approved of the per-unit dispensing of their treatment. The initial packaging of the drugs did not match with the prescription in 60% of cases and per-unit dispensing reduced by 10% the number of pills supplied. 13.1% of patients declared that they threw away pills residuals instead of recycling—no differences between groups. Finally, per-unit dispensing appeared to improve adherence to antibiotic treatment (marginal effect 0.21, IC 95, 0.14–0.28).
Supplying antibiotics per unit is not only beneficial in terms of a reduced number of pills to reimburse or for the environment (less pills wasted and non-recycled), but also has a positive and unexpected impact on adherence to treatment, and thus on both individual and public health.