Bruno Ventelou

Chercheur ,  CNRS

Économie publique
Ventelou
Statut
Directeur de recherche
Domaine(s) de recherche
Économie de la santé, Macroéconomie
Thèse
1995, Paris School of Economics, EHESS
Téléchargement
CV
Contact
bruno.ventelou[at]univ-amu.fr
+33(0)4 13 55 25 82
Adresse

AMU - AMSE
5-9 Boulevard Maurice Bourdet, CS 50498
​13205 Marseille Cedex 1

Résumé Since the COVID-19 pandemic, there is growing evidence that the social epidemiological context may play a crucial role in the adoption of health protective behaviours in response to emerging infectious diseases. Yet, our understanding of how and why these behaviours are influenced by the epidemiological forces remains relatively limited. This repeated, cross-sectional investigation examines the extent to which the association between the socio-epidemiological context and protective behaviour was mediated by a series of common social cognitive factors from leading models of health behaviour during the COVID-19 epidemic in France. Representative samples of the French population completed an online, self-report survey at seventeen intervals (March-November 2020), with approximately 2000 participants in each survey wave. Results indicate that both contextual and social cognitive variables largely drove the adoption of protective behaviours over time. However, social cognitive variables only partially mediated the effect of the epidemiological context on protective behaviour (physical distancing and hygiene measures), suggesting that unknown factors may be operating in addition to those commonly used in these models. These findings highlight the need for future research to consider the epidemiological context, and further possible mediating variables, when modelling determinants of social cognitions and preventive behaviour, and above all, to broaden its focus to include neglected underlying psychological mechanisms involved in the behavioural response to epidemics.
Mots clés Epidemic context, France, Protective behaviours, COVID-19, Social cognitive factors, Epidemiological context
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Résumé http://www.tei-c.org/ns/1.0">Recent advances in artificial intelligence (AI) have made it possible to detect neurodegenerative diseases (NDDs) earlier, potentially improving patient outcomes. However, AI-based detection tools remain underutilized. We studied individual valuation for early diagnosis tests for NDDs. We conducted a discrete choice experiment with a representative sample of the French adult population (N = 1017). Participants were asked to choose between early diagnosis tests that differed in terms of: (1) type of test (saliva vs. AI-based tests analysing electronic health records); (2) identity of the person communicating the test results; (3) sensitivity; (4) specificity; and (5) price. We calculated the weights in the decision for each attribute and examined how socio-demographic characteristics influenced them. Respondents revealed a reduced utility value when AI-based testing was involved (valuated at an average of €36.08, CI [€22.13; €50.89]) and when results were communicated by a private company (€95.15, CI [€82.01; €109.82]). We interpret these figures as the shadow price that the public attaches to medical data privacy. Beyond monetization, our representative sample of the French population appears reluctant to adopt AI-powered screening, particularly when performed on large sets of personal data. However, they would be more supportive when medical expertise is associated with the tests.
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Résumé Cet article explore les affordances perçues d’une solution d’intelligence artificielle (IA) dédiée au dépistage précoce des maladies neurodégénératives par les médecins généralistes. À travers une analyse basée sur 22 entretiens semi-directifs, il examine comment ces professionnels projettent les possibilités d’usage de l’IA en fonction de leur contexte d’exercice, de leurs facteurs individuels, et l’influence de ces projections sur l’acceptabilité. L’analyse révèle quatre types d’affordances perçues (habilitante, contraignante, facultative, transformative) engendrées par l’interaction entre contexte d’exercice, facteurs individuels et technologie. Ces types soulignent l’importance de considérer le contexte d’exercice dans la projection des usages et l’acceptabilité des solutions d’IA, aspect souvent occulté dans les modèles classiques de l’acceptabilité en management des systèmes d’information (SI).
Mots clés Acceptabilité, Étude qualitative, Perceptions d’usage, Médecins généralistes, Intelligence artificielle IA
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Résumé Des mutuelles de santé ont été mises en place dans de nombreux pays d’Afrique subsaharienne pour améliorer le recours aux soins et lutter contre les inégalités sociales de santé. C’est le cas au Sénégal, dans des zones rurales où les habitants ne disposaient d’aucune couverture santé. Plusieurs études questionnent leur rôle dans la perspective d’atteindre la couverture sanitaire universelle.
Mots clés Couverture santé, Assurance maladie, Accès aux soins, Senegal, Afrique subsaharienne
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Résumé Aims: This study analyses the acceptability of artificial intelligence (AI) to general practitioners, particularly in the early detection of neurodegenerative diseases. Methods: An exploratory qualitative method was adopted, with nine semi-directive interviews conducted with doctors, interns and an AI designer. Analysis of the data produced a coding grid structured around an original theoretical framework in information systems (IS) that combines the concepts of affordances and paradoxes, concepts that are commonly used in Management Sciences to understand technology adoption. Results: The results show that doctors have ambivalent perceptions of AI. Positive affordances include the reduction of errors, improved efficiency and support for complex diagnoses. AI is also seen as an opportunity to democratize medical knowledge, make practice more accessible, and improve productivity by allowing more patients to be treated in less time. However, the negative affordances raise several concerns, such as the biases that could affect the decision-making process, the loss of skills, increased dependence on technology, as well as the dehumanization of the doctor-patient relationship and the question of responsibility in the event of error. The study also identifies several paradoxes. For example, AI can both reduce and increase errors or improve skills while running the risk of degrading them because of technological dependence. These paradoxes are key to understanding the dynamics of AI acceptability. Conclusions: The research shows the importance of involving healthcare professionals in the development of AI solutions, improving their technical training and developing new affordances that can overcome paradoxes. By integrating affordances and paradoxes, it proposes an original theoretical framework for studying the integration of AI in general medicine. Future studies should extend the sample to obtain new insights.
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Résumé Introduction: Expanding health insurance is viewed as a core strategy for achieving universal health coverage. In Senegal, as in many other developing countries, this strategy has been implemented by creating community-based health insurance (CBHI) schemes with voluntary enrolment and a fixed premium paid by enrollees. Yet little is known about how the individuals’ experience of CBHI enrolment further influences their willingness to pay (WTP). In this paper, we test the existence of a reinforcement effect between effective enrolment in a CBHI and WTP for health insurance by analysing their mutual relationship. Methods: We rely on primary survey data collected in 2019–2020 in the rural area of Niakhar in Senegal. We use an econometric methodology involving: (1) Heckman-type selection models to estimate the determinants of CBHI membership conditioned on awareness of health insurance, addressing the issue of sample selection due to differential awareness and (2) a simultaneous equation model to jointly estimate the uptake and WTP for health insurance, addressing the issue of endogeneity due to reverse causality between both variables. We also focus on the roles that informational and geographical barriers, as well as individual risk preference and trust, play in both outcomes. Results: The final sample includes 1607 individuals. Results show that WTP further increases with the individuals’ direct experience in a CBHI scheme, despite an environment characterised by low enrolment rates. We also provide evidence for a U‐shaped relationship between risk tolerance and WTP for health insurance. Conclusion: We provide novel evidence on a reinforcement effect of enrolment in a CBHI on WTP for health insurance, with the presence of a substantial consumer surplus among enrolled individuals at the actual premium. Our findings suggest that policies aiming at improving health insurance awareness should foster the demand for health insurance in rural Senegal.
Mots clés Health insurance, Community-based health insurance, Uptake, Willingness to pay, Information, Rural health, Rural population, Senegal, Sub-Saharan Africa
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Résumé Within the International Health Regulations framework, the French High Council for Public Health was mandated in 2022 by health authorities to establish a list of priority infectious diseases for public health, surveillance and research in mainland and overseas France. Aim Our objective was to establish this list. Methods A multi-criteria decision analysis was used, as recommended by the European Centre for Disease Prevention and Control. A list of 95 entities (infectious diseases or groups of these, including the World Health Organization (WHO)-labelled ‘Disease X’) was established by 17 infectious disease experts. Ten criteria were defined to score entities: incidence rate, case fatality rate, potential for emergence and spread, impact on the individual, on society, on socially vulnerable groups, on the healthcare system, and need for new preventive tools, new curative therapies, and surveillance. Each criterion was assigned a relative weight by 77 multidisciplinary experts. For each entity, 98 physicians from various specialties rated each criterion against the entity, using a four-class Likert-type scale; the ratings were converted into numeric values with a nonlinear scale and respectively weighted to calculate the entity score. Results Fifteen entities were ranked as high-priorities, including Disease X and 14 known pathologies (e.g. haemorrhagic fevers, various respiratory viral infections, arboviral infections, multidrug-resistant bacterial infections, invasive meningococcal and pneumococcal diseases, prion diseases, rabies, and tuberculosis). Conclusion The priority entities agreed with those of the WHO in 2023; almost all were currently covered by the French surveillance and alert system. Repeating this analysis periodically would keep the list updated.
Mots clés Communicable Diseases, Decision Support Techniques, France, Health Priorities, Humans, PUBLIC HEALTH, Surveys and Questionnaires, Epidemiology, Multi-criteria decision analysis
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Résumé This study examines the acceptance of artificial intelligence (AI)-based diagnostic alternatives compared to traditional biological testing through a randomized scenario experiment in the domain of neurodegenerative diseases (NDs). A total of 3225 pairwise choices of ND risk-prediction tools were offered to participants, with 1482 choices comparing AI with the biological saliva test and 1743 comparing AI+ with the saliva test (with AI+ using digital consumer data, in addition to electronic medical data). Overall, only 36.68% of responses showed preferences for AI/AI+ alternatives. Stratified by AI sensitivity levels, acceptance rates for AI/AI+ were 35.04% at 60% sensitivity and 31.63% at 70% sensitivity, and increased markedly to 48.68% at 95% sensitivity (p
Mots clés Artificial intelligence, AI diagnostics, Neurodegenerative diseases, Machine learning
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Résumé We study the behavioral determinants of COVID-19 vaccination uptake. The vaccine-pass policy, implemented in several countries in 2021, conditioned the access to leisure and consumption places to being vaccinated against COVID-19 and created an unprecedented situation where individuals’ access to consumption goods and vaccine status were interrelated. We rely on a quasi-hyperbolic discounting model to study the plausible relationships between time preference and the decision to vaccinate in such context. We test the predictions of our model using data collected from a representative sample of the French population (N = 1034) in August and September 2021. Respondents were asked about their COVID-19 vaccination status (zero, one, or two doses), as well as their economic and social preferences. Preference elicitations were undertaken online through incentivized tasks, with parallel collection of self-stated preferences. Factors associated with COVID-19 vaccination were investigated using a logistic model. Both elicited and stated impatience were found to be positively associated with COVID-19 vaccination decisions. These results suggest that impatience is a key motivational lever for vaccine uptake in a context where the vaccination decision is multidimensional and impacts the consumption potential. Results also serve to highlight the potential effectiveness of public communications campaigns based on time preferences to increase vaccination coverage.
Mots clés Health behavior, COVID-19 Vaccination, Time inconsistency, Time preferences
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Résumé Background: Sexual and gender diverse people face intersecting factors affecting their well-being and livelihood. These include homophobic reactions, stigma or discrimination at the workplace and in healthcare facilities, economic vulnerability, lack of social support, and HIV. This study aimed to examine the association between such factors and symptoms of anxiety and depression among sexual and gender diverse people. Methods: This study is based on a sample of 108,389 gay, bisexual, queer and questioning men, and transfeminine people from 161 countries collected through a cross-sectional internet survey. We developed a multinomial logistic regression for each group to study the associations of the above factors at different severity scores for anxiety and depression symptoms. Results: Almost a third (30.3%) of the participants reported experiencing moderate to severe symptoms of anxiety and depression. Higher severity scores were found for transfeminine people (39%), and queer or questioning people (34.8%). Severe symptoms of anxiety and depression were strongly correlated with economic hardship for all groups. Compared to those who are HIV-negative, those living with HIV were more likely to report severe symptoms of anxiety and depression, and the highest score was among those who do not know their HIV status. Transfeminine people were the most exposed group, with more than 80% higher risk for those living with HIV suffering from anxiety and depression. Finally, homophobic reactions were strongly associated with anxiety and depression. The relative risk of severe anxiety and depression was 3.47 times higher for transfeminine people facing transphobic reactions than those with no symptoms. Moreover, anxiety and depression correlate with stigma or discrimination in the workplace and healthcare facilities. Conclusions: The strong association between the severity of anxiety and depression, and socioeconomic inequality and HIV status highlights the need for concrete actions to meet the United Nations' pledge to end inequalities faced by communities and people affected by HIV. Moreover, the association between stigma or discrimination and anxiety and depression among sexual and gender diverse people is alarming. There is a need for bold structural public health interventions, particularly for transfeminine, queer and questioning people who represent three communities under the radar of national HIV programmes.
Mots clés PHQ-4, Stigma and discrimination, Homophobia, HIV, Anxiety, Depression, Queer, Transgender, Bisexual, Gay, LGBT
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Résumé This paper studies the behavioral and socio-demographic determinants of reported compliance with prophylactic measures against COVID-19: barrier gestures, lockdown restrictions and mask wearing. The study contrasts two types of measures for behavioral determinants: experimentally elicited preferences (risk tolerance, time preferences, social value orientation and cooperativeness) and stated preferences (risk tolerance, time preferences, and the GSS trust question). Data were collected from a representative sample of the metropolitan French adult population (N=1154) surveyed during the first lockdown in May 2020, and the experimental tasks were carried out on-line. The in-sample and out-of-sample predictive power of several regression models - which vary in the set of variables that they include - are studied and compared. Overall, we find that stated preferences are better predictors of compliance with these prophylactic measures than preferences elicited through incentivized experiments: self-reported level of risk, patience and trust are predicting compliance, while elicited measures of risk-aversion, patience, cooperation and prosociality did not.
Mots clés COVID-19, Individual preferences, Social preferences, Elicited preferences, Stated preferences
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Résumé Background Efficiency analyses have been widely used in the literature to rank countries regarding their health system performances. However, little place has been given to the environmental aspect: two countries with the same characteristics could experience completely different healthcare system outcomes just because they do not face the same environmental quality situation, which is a major determinant of the health of inhabitants. Methods Using a stochastic frontier model, this paper analyses the effect of environmental quality on health system outcomes in OECD countries, measured by life expectancy at birth. Results We show that the healthcare system performance ranking of OECD countries changes significantly, depending on whether the environmental index is taken into account. Conclusions These findings, once again, underline the critical importance of the environment when addressing population health issues. In general, our results can be aligned with the messages of the One Health approach literature.
Mots clés Health, Healthcare system efficiency, Health production function, Environment, Stochastic frontier analysis, Panel data
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Résumé With the low adherence to voluntary mutual health insurance, Senegal’s policymakers have sought to understand the feasibility of compulsory health insurance membership. This study aims to measure the acceptability of mandatory membership in community-based mutual health insurance (CBHI) and to understand its possible administrative modalities. The study consists of a national survey among a representative population sample selected by marginal quotas. The survey was conducted in 2022 over the phone, with a random composition method involving 914 people. The questionnaire measured the socio-economic characteristics of households, their level of acceptability concerning voluntary and compulsory membership, and their level of confidence in CBHIs and the health system. Respondents preferred voluntary (86%) over mandatory (70%) membership of a CBHI. The gap between voluntary and compulsory membership scores was smaller among women (p = 0.040), people under 35 (p = 0.033), and people with no health coverage (p = 0.011). Voluntary or compulsory membership was correlated (p = 0.000) to trust in current CBHIs and health systems. Lack of trust in the CBHI management has been more disadvantageous for acceptance of the mandatory than the voluntary membership. No particular preference emerged as the preferred administrative channel (e.g. death certificate, identity card, etc.) to enforce the mandatory option. The results confirmed the well-known challenges of building universal health coverage based on CBHIs—a poorly appreciated model whose low performance reduces the acceptability of populations to adhere to it, whether voluntary or mandatory. Suppose Senegal persists in its health insurance approach. In that case, it will be essential to strengthen the performance and funding of CBHIs, and to gain population trust to enable a mandatory or more systemic membership.
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Résumé Efficiency within the health system is well recognised as key for achieving Universal Health Coverage (UHC). However, achieving equity and efficiency simultaneously is often seen as a conflicting effort. Using 12 years of data (2003–2014) from the selection of a number of low- and lower middle-income countries (Afghanistan, Bangladesh, Burkina Faso, Ghana, Indonesia, Mongolia, Mozambique, Tajikistan, Togo, Uzbekistan and Yemen Republic), we compute an index of Universal health coverage (UHC), measure the health system’s performance (HSp) and, finally, investigate the cross-dynamics of the resulting HSp and the UHC previously obtained. We find that, with the few exceptions over the statistical sample, the causality between performances of the national health system and the universal health coverage is typically bidirectional. From an empirical standpoint, our findings challenge the idea from economic orthodoxy that efficiency must precede equity in healthcare services. Rather, our findings support the view of simultaneous efforts to improve expansion of the coverage and efficiency of the health system, directing attention towards the importance of organisation of the health system in the country context.
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Résumé Background Given the importance of the continuous follow-up of chronic patients, we evaluated the performance of French private practice general practitioners (GPs) practicing in multi-professional group practices (MGP) regarding chronic care management during the first Covid-19 lockdown in Spring 2020 compared to GPs not in MGP. We consider two outcomes: continuity of care provision for chronic patients and proactivity in contacting these patients. Methods The cross-sectional web questionnaire of 1191 GPs took place in April 2020. We exploit self-reported data on: 1) the frequency of consultations for chronic patients during lockdown compared to their “typical” week before the pandemic, along with 2) GPs’ proactive behaviour when contacting their chronic patients. We use probit and bivariate probit models (adjusted for endogeneity of choice of engagement in MGP) to test whether GPs in MGP had significantly different responses to the Covid-19 crisis compared to those practicing outside MGP. Results Out of 1191 participants (response rate: 43.1%), around 40% of GPs were female and 34% were younger than 50 years old. Regression results indicate that GPs in MGP were less likely to experience a drop in consultations related to complications of chronic diseases (− 45.3%). They were also more proactive (+ 13.4%) in contacting their chronic patients compared to their peers practicing outside MGP. Conclusion We demonstrate that the MGP organisational formula was beneficial to the follow-up of patients with chronic conditions during the lockdown; therefore, it appears beneficial to expand integrated practices, since they perform better when facing a major shock. Further research is needed to confirm the efficiency of these integrated practices outside the particular pandemic setup.
Mots clés Long-term care, Provider-sponsored organizations, France, General practitioners, COVID-19
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Résumé Background: Epistemic injustices are increasingly decried in global health. This study aims to investigate whether the source of knowledge influences the perception of that knowledge and the willingness to use it in francophone African health policy-making context. Methods: The study followed a randomized experimental design in which participants were randomly assigned to one of seven policy briefs that were designed with the same scientific content but with different organizations presented as authors. Each organization was representative of financial, scientific or moral authority. For each type of authority, two organizations were proposed: one North American or European, and the other African. Results: The initial models showed that there was no significant association between the type of authority or the location of the authoring organization and the two outcomes (perceived quality and reported instrumental use). Stratified analyses highlighted that policy briefs signed by the African donor organization (financial authority) were perceived to be of higher quality than policy briefs signed by the North American/European donor organization. For both perceived quality and reported instrumental use, these analyses found that policy briefs signed by the African university (scientific authority) were associated with lower scores than policy briefs signed by the North American/European university. Conclusions: The results confirm the significant influence of sources on perceived global health knowledge and the intersectionality of sources of influence. This analysis allows us to learn more about organizations in global health leadership, and to reflect on the implications for knowledge translation practices.
Mots clés Power, Structural drivers, Policy briefs, Global health, COVID-19, Santé mondiale, Notes de politiques, Déterminants structurels, Pouvoir
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Résumé The public acceptability of a policy is an important issue in democracies, in particular for anti-COVID-19 policies, which require the adherence of the population to be applicable and efficient. Discrete choice experiment (DCE) can help elicit preference ranking among various policies for the whole population and subgroups. Using a representative sample of the French population, we apply DCE methods to assess the acceptability of various anti-COVID-19 measures, separately and as a package. Owing to the methods, we determine the extent to which acceptability depends on personal characteristics: political orientation, health vulnerability, or age. The young population differs in terms of policy preferences and their claim for monetary compensation, suggesting a tailored policy for them. The paper provides key methodological tools based on microeconomic evaluation of individuals’ preferences for improving the design of public health policies.
Mots clés Policy design, Discrete choice experiment, Individual preferences, Acceptability
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Résumé This study aims to evaluate people’s willingness to provide their geospatial global positioning system (GPS) data from their smartphones during the COVID-19 pandemic. Based on the self-determination theory, the addition of monetary incentives to encourage data provision may have an adverse effect on spontaneous donation. Therefore, we tested if a crowding-out effect exists between financial and altruistic motivations. Participants were randomized to different frames of motivational messages regarding the provision of their GPS data based on (1) self-interest, (2) pro-social benefit, and (3) monetary compensation. We also sought to examine the use of a negative versus positive valence in the framing of the different armed messages. 1055 participants were recruited from 41 countries with a mean age of 34 years on Amazon Mechanical Turk (MTurk), an online crowdsourcing platform. Participants living in India or in Brazil were more willing to provide their GPS data compared to those living in the United States. No significant differences were seen between positive and negative valence framing messages. Monetary incentives of $5 significantly increased participants’ willingness to provide GPS data. Half of the participants in the self-interest and pro-social arms agreed to provide their GPS data and almost two-thirds of participants were willing to provide their data in exchange for $5. If participants refused the first framing proposal, they were followed up with a “Vickrey auction” (a sealed-bid second-priced auction, SPSBA). An average of $17 bid was accepted in the self-interest condition to provide their GPS data, and the average “bid” of $21 was for the pro-social benefit experimental condition. These results revealed that a crowding-out effect between intrinsic and extrinsic motivations did not take place in our sample of internet users. Framing and incentivization can be used in combination to influence the acquisition of private GPS smartphone data. Financial incentives can increase data provision to a greater degree with no losses on these intrinsic motivations, to fight the COVID-19 pandemic.
Mots clés Economics, Science, Technology and society, Sociology
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Résumé Dans le cadre du premier appel à projet « Flash-COVID-19 » de l’Agence nationale de la recherche, nous avons mobilisé des méthodes récentes de l’économie comportementale afin de mieux comprendre les décisions des individus face à la crise sanitaire due à la pandémie de COVID-19 ( coronavirus disease 2019 ) et d’identifier les paramètres pouvant influencer le respect des mesures sanitaires. Cet article introduit brièvement l’économie comportementale, présente un compte rendu des attendus du projet CONFINOBS (Observance et observation des mesures barrières et du confinement : une approche d’économie comportementale) et de ses méthodes, puis il propose une synthèse des résultats obtenus.
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Résumé Contexte : Les injustices épistémiques sont de plus en plus décriées dans le domaine de la santé mondiale. Cette étude vise à déterminer si la source des connaissances influence la perception de ces connaissances et la volonté de les utiliser. Méthodes : L’étude suit un devis expérimental randomisé dans lequel les participant·es ont été assigné·es au hasard à l'une des sept notes de politique conçues avec le même contenu scientifique, mais avec différentes organisations présentées comme autrices. Chaque organisation était représentative d'une autorité financière, scientifique ou morale. Pour chaque type d'autorité, deux organisations étaient proposées : l'une nord-américaine ou européenne, l'autre africaine. Résultats : Les résultats montrent que le type d’autorité et la localisation des organisations autrices ne sont pas significativement associés à la qualité perçue et à l’utilisation instrumentale déclarée. Toutefois, des interactions entre le type d’autorité et la localisation étaient significatives. Ainsi, les analyses stratifiées ont mis en évidence que pour la qualité perçue, les notes de politique signées par l'organisme bailleur (autorité financière) africain obtenaient de meilleurs scores que les notes de politique signées par l’organisme bailleur nord-américain/européen. Tant pour la qualité perçue que pour l'utilisation instrumentale déclarée, ces analyses stratifiées ont révélé que les notes de politique signées par l'université africaine (autorité scientifique) étaient associées à des scores plus faibles que les notes de politique signées par l'université nord-américaine/européenne. Interprétation : Les résultats confirment l'influence significative des sources sur la perception des connaissances en santé mondiale et rappellent l’intersectionnalité de l’influence des sources d’autorité. Cette analyse nous permet à la fois d'en apprendre davantage sur les organisations qui dominent la scène de la gouvernance mondiale en santé et de réfléchir aux implications pour les pratiques d'application des connaissances.
Mots clés COVID-19, Pouvoir, Notes de politique, Déterminants structurels, Santé mondiale
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Résumé We test the effectiveness of a social comparison nudge to enhance lockdown compliance during the Covid-19 pandemic, using a representative sampleof metropolitan French adultpopulation(N=1154). Respondents were randomly assigned to a favourable/unfavourable informational feedback (daily road traffic mobility patterns, in Normandy -a region of France) on peer lockdown compliance.Our dependent variable was the intention to comply with a possible future lockdown. We controlled for risk, time, and social preferences and tested the effectiveness of the nudge. We found no evidence of theeffectiveness of thesocial comparison nudge among the wholepopulation, butthe nudgewas effective when its recipient and the reference population shared the same geographical location(Normandy). Exploratory results on this subsample (N=52) suggest that this effectiveness could be driven by non-cooperative individuals.
Mots clés Risk preferences, Social preferences, Social Comparison Nudge, Time preferences, Lockdown compliance, COVID-19
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Résumé This study examines the impact of personalized gender-based communication to encourage the screening of depression and seeking out mental health care consultation. An internet search engine advertisement was deployed on Bing, Microsoft during the COVID-19 pandemic lockdowns in the Provence–Alpes–Côte d'Azur (PACA) region in France during the month of May 2020, the height of the France lockdowns. A two-armed study was conducted with Arm A containing a non-personalized (control) advertisement and Arm B containing a personalized gender-based advertisement. 53,185 advertisements were shown between the two arms. Results show that receiving a personalized gender-based message increases the probability of clicking on the advertisement. However, upon clicking the advertisement, there was no significant difference in the completion of the depression questionnaire between the two groups. These results suggest that although personalized gender messaging is effective at drawing in a greater click rate, it did not increase, nor decreased, the conversion rate to monitor depression by self-assessment.
Mots clés Bing, COVID-19, Depression, Personalized communication
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Résumé Limited access to information is one of the main health insurance market imperfections in developing countries. Differential access to information may determine individuals' awareness of health insurance schemes, thereby influencing their probability of enrollment. Relying on primary data collected in 2019-2020 in rural Senegal, we estimate the uptake of community-based health insurance using a Heckman-type model to correct for awarenessbased sample selection bias. Besides showing that health insurance awareness is a precondition for effective enrollment in community-based health insurance schemes, we also bring new evidence on the roles which geographic factors and individual risk preference play in health insurance uptake by rural dwellers. We show that geographic distance prevents individuals from accessing information on health insurance schemes, and discourage those who are informed from enrolling, because of the additional distance they must travel to benefit from covered healthcare services. Results also show that individual risk preference influences health insurance uptake, but only when information barriers are taken into account. Overall, our results could help decisionmakers better shape the universal health coverage roadmap, as policies to improve health insurance awareness differ substantially from policies to improve the features of health insurance schemes.
Mots clés Sub-Saharan Africa, Senegal, Selection bias, Risk preference, Health insurance, Geographic distance, Awareness
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Résumé Self-assessed health (SAH) is a widely used tool to estimate population health. However, the debate continues as to what exactly this ubiquitous measure of social science research means for policy conclusions. This study is aimed at understanding the tenability of the construct of SAH by simultaneously modelling SAH and clinical morbidity. Using data from 17 waves (2001–2017) of the Russian Longitudinal Monitoring Survey, which captures repeated response for SAH and frequently updates information on clinical morbidity, we operationalise a recursive semi-ordered probit model. Our approach allows for the estimation of the distributional effect of clinical morbidity on perceived health. This study establishes the superiority of inferences from the recursive model. We illustrated the model use for examining the endogeneity problem of perceived health for SAH, contributing to population health research and public policy development, in particular, towards the organisation of health systems.
Mots clés Russia, Semi-ordered, Recursive, Perceived health, Endogeneity, Clinical morbidity
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Résumé Exploring rich panel data from the Niakhar Health and Demographic Surveillance System, this study investigates the effects of migration on child mortality among families left behind in rural areas. Migration, particularly short-term, is positively associated with the survival probability of under-5 children in the household. We also find that the short-term moves of working-age women impact child mortality more than those of working-age men. Moreover, we detect crossover effects between households in the same compound, consistent with the idea that African rural families share part of their migration-generated gains with an extended community of neighbours. Lastly, we investigate the effect of maternal short-term migration on the survival of under-5 children. The aggregate effect is still positive but much weaker. Specifically, maternal migration during pregnancy seems to enhance children’s survival immediately after birth, but the probability of survival tends to decrease after age 1 when the mother is absent.
Mots clés Child mortality, Long-term migration, Short-term migration, Senegal, Niakhar
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Résumé We study physicians’ incentives to use personalised medicine techniques, replicating the physician’s trade-offs under the option of personalised medicine information. In a laboratory experiment conducted in two French Universities, prospective physicians played a real-effort game. We vary both the information structure (free access versus paid access to personalised medicine information) and the payment scheme (pay-for-performance (P4P), capitation (CAP) and fee-for-service (FFS)), implementing a within-subject design. Our results are threefold: (i) Compared to FFS and CAP, the P4P scheme strongly and positively impacts the decision to adopt personalised medicine. (ii) Although expected to dominate the other schemes, P4P is not always efficient in transforming free access to personalised medicine into higher quality of care. (iii) When it has to be paid for and after controlling for self-selection, personalised medicine is positively associated with quality, suggesting that subjects tend to make better use of information that comes at a cost. We find this effect to be stronger for males than for females prospective physicians. Quantification of our results however suggests that this positive impact is not strong enough to justify generalising the payment for personalised medicine access. Finally, we develop a theoretical model that includes in its set-up a commitment device component, which is the mechanism that we inferred from the data of the experiment. Our model replicates the principal results of the experiment, reinforcing the interpretation that the higher quality provided by subjects who bought personalised medicine can be interpreted as a commitment device effect.
Mots clés Prospective physicians, Laboratory Experiment, Personalised medicine, Capitation, Fee-forservice, Pay-for-performance
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Résumé Cette étude a pour objectif d’évaluer différents modes de financement de la couverture santé universelle au Sénégal. La méthode utilisée, la micro-simulation, permet d’examiner l’impact de différents scenarii sur les consommations des ménages ainsi que sur les dépenses publiques. Les résultats montrent que la généralisation d’une assurance-maladie à l’ensemble de la population, associée à une réduction des coûts directs des soins, augmenterait les consommations de soins des Sénégalais, améliorant donc leur accès aux services de santé. Néanmoins, une telle généralisation serait coûteuse pour les finances publiques. Pour limiter les coûts supportés par le gouvernement, l’augmentation du taux d’imposition sur la consommation et de la prime de contribution à l’assurance-maladie serait utile et permettrait de ramener les finances publiques à l’équilibre.
Mots clés Sahel, Coûts directs des soins, Finances publiques, Micro-simulation, Couverture sante universelle
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Résumé Online surveys of health professionals have become increasingly popular during the COVID-19 crisis because of their ease, speed of implementation, and low cost. This article leverages an online survey of general practitioners’ (GPs’) attitudes toward the soon-to-be-available COVID-19 vaccines, implemented in October–November 2020 (before the COVID-19 vaccines were authorized in France), to study the evolution of the distribution of their demographic and professional characteristics and opinions about these vaccines, as the survey fieldwork progressed, as reminders were sent out to encourage them to participate. Focusing on the analysis of the potential determinants of COVID-19 vaccine acceptance, we also tested if factors related to survey participation biased the association estimates. Our results show that online surveys of health professionals may be subject to significant selection bias that can have a significant impact on estimates of the prevalence of some of these professionals’ behavioral, opinion, or attitude variables. Our results also highlight the effectiveness of reminder strategies in reaching hard-to-reach professionals and reducing these biases. Finally, they indicate that weighting for nonparticipation remains indispensable and that methods exist for testing (and correcting) selection biases.
Mots clés Heckman method, Weighting, COVID-19, Practices, Attitudes, Selection bias, Online surveys, Health care professionals
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Résumé Il est courant d’entendre s’exprimer un sentiment de rejet face à l’intervention des économistes dans le système de santé. D’aucuns diront notamment que le secteur de la santé est un « secteur à part », qui n’est pas susceptible de régulation économique. Pendant la crise de la COVID-19, cette idée s’est traduite par l’opposition stérile entre la lutte contre l’épidémie et la défense de l’activité économique, présentées comme deux objectifs nécessairement rivaux. Le premier serait l’apanage des seuls médecins, désireux de réduire la mortalité par COVID-19, tout en préservant les capacités hospitalières, et de facto ardents défenseurs du confinement. Le second apparaitrait comme l’étendard des économistes qui ne verraient dans la sauvegarde du PIB que l’unique objectif d’une société développée et épanouie… Pourtant la crise de la COVID-19 a souligné, parfois avec cruauté, certaines insuffisances du système de santé français. Elle a jeté la lumière sur l’absence de stratégie globale de gestion du risque sanitaire et la difficulté de prendre des décisions adaptées à un niveau infranational. Elle a enfin exacerbé la rigidité d’un système de soins centralisé, spécialiste de la prise en charge de malades chroniques à l’hôpital public. Mais elle a aussi été porteur d’espoir en révélant une véritable capacité d’adaptation des professionnels de santé à l’hôpital et en ville et des industriels pharmaceutiques, accélérant les processus d’innovation thérapeutique et technologique, de coordination des acteurs et de production de vaccins à une échelle internationale. Pour faire face à cette crise, dans les premiers mois de la crise sanitaire, une logique médicale à court terme s’est imposée, reléguant au second plan toute autre forme de critère de jugement. L’objectif unique affiché est d’une déconcertante simplicité : réduire la mortalité par COVID-19, « quoi qu’il en coûte ». L’objectif de santé n’aurait donc plus de limite, exonérant ainsi l’individu ou la société de tout arbitrage personnel ou collectif, au motif, tantôt d’une supposée gratuité, tantôt de l’absolue priorité. La pertinence même de l’apport des sciences humaines et sociales, en particulier de l’économie, serait alors réduite à peau de chagrin… Au moment où se polarisent ces convictions et se figent ces croyances, il semble, aujourd’hui plus que jamais, nécessaire qu’un ouvrage en économie de la santé puisse éclairer les débats qui traversent le système de santé afin de promouvoir le recours plus systématique à l’évaluation médico-économique comme outil de régulation « fine » des dépenses de santé. De nombreux défis sont à relever parmi lesquels : le financement et la régulation des dépenses de santé, l’accès aux soins primaires sur tout le territoire, le manque de coordination entre médecine de ville et hôpital, d’une part, et entre soins et médico-social, d’autre part ; le déficit de prévention et l’invisibilité de la santé publique ; les inégalités sociales de santé et d’accès aux soins ou encore la surconsommation de tabac et d’alcool. Ces défis interrogent chacun des acteurs du système de santé (patients, offreurs de soins, industriels…). A l’occasion de ses 30 ans, le Collège des Économistes de la santé, la société savante française d’économie de la santé, propose un ouvrage collectif réunissant 30 contributeurs et ambitionne d’analyser et de disséquer les principaux défis auxquels le système de santé fait face à travers 15 chapitres. De façon dépassionnée, et sur la base d’une littérature académique nationale et internationale particulièrement étoffée, il tente également de proposer des pistes de recommandations pour améliorer le système.
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Résumé Background Asthma affects over 330 million people worldwide. Timing of an asthma event is extremely important and lack of identification of asthma increases the risk of death. A major challenge for health systems is the length of time between symptom onset and care seeking, which could result in delayed treatment initiation and worsening of symptoms. Objective This study evaluates the utility of the internet search query data for the identification of the onset of asthma symptoms. Methods Pearson correlation coefficients between the time series of hospital admissions and Google searches were computed at lag times from 4 weeks before hospital admission to 4 weeks after hospital admission. An autoregressive integrated moving average (ARIMAX) model with an autoregressive process at lags of 1 and 2 and Google searches at weeks –1 and –2 as exogenous variables were conducted to validate our correlation results. Results Google search volume for asthma had the highest correlation at 2 weeks before hospital admission. The ARIMAX model using an autoregressive process showed that the relative searches from Google about asthma were significant at lags 1 (P
Mots clés Health information seeking, Symptoms, Asthma, Google queries, Digital epidemiology
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Résumé Au cours des mois de novembre et décembre 2020, les participants au quatrième Panel d’observation des pratiques et des conditions d’exercice en médecine générale ont à nouveau été interrogés sur leurs perceptions et leurs opinions quant aux futurs vaccins contre la Covid-19. Huit médecins généralistes sur 10 considèrent que la vaccination est le meilleur moyen pour éviter la survenue de nouvelles vagues épidémiques de Covid-19. 8 médecins sur 10 estiment également qu’ils ont un rôle à jouer dans la vaccination de la population contre la Covid-19 et plus de la moitié sont favorables à une obligation de vaccination pour les professionnels de santé. Globalement, les trois quarts des médecins accepteraient a priori de se faire vacciner contre la Covid-19 et de le recommander à leurs patients. L’opinion individuelle sur la vaccination contre la Covid-19 a par ailleurs changé chez certains médecins : entre l’enquête du 6 octobre au 15 novembre 2020 et celle du 24 novembre au 27 décembre 2020, 1 médecin sur 10 est passé de l’hésitation ou de la réticence face au vaccin à l’acceptation – modérée ou forte – tandis qu’1 médecin sur 10 a fait le chemin inverse.
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Résumé Cette étude vise à évaluer la faisabilité et l'impact macro-économique de l'extension de la couverture sanitaire à l'ensemble de la population en vue de l'atteinte de la couverture universelle (CSU) au Mali et au Tchad. Nous utilisons une approche méthodologique par micro-simulation pour examiner l'impact d'un scénario de CSU sur les dépenses de santé des ménages ainsi que les recettes et les dépenses publiques. Etant donné les diffèrent taux actuels de couverture de la population, les résultats montrent que l'atteinte de l'objectif coûterait aux gouvernements du Mali et du Tchad 17 182 et 44 415 millions de FCFA, respectivement. L'atteinte de la CSU pourrait augmenter l'accès aux soins des ménages, mais aussi le fardeau budgétaire du gouvernement ; il faudrait donc disposer de bonnes stratégies de financement public. L'étude évalue donc en parallèle les bénéfices à attendre d'une hausse de la prime d'assurance maladie.
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Résumé Currently, countries across the world are applying policies designed to combat the COVID-19 pandemic, such as lockdowns, international travel restrictions, subsectoral closures, and adjustments in public transportation. Although these restrictions can be effective in controlling the epidemiological dynamics, they also need to be assessed in terms of their acceptability by populations. The preferences of populations should matter, particularly after months of efforts, and the new requirements of lockdowns in several European countries despite these efforts.
Mots clés COVID-19
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Résumé Disparities in physicians' geographical distribution lead to highly unequal access to healthcare, which may impact quality of care in both high and low-income countries. This paper uses a 2013-2014 nationally representative survey of French general practitioners (GPs) matched with corresponding administrative data to analyze the effects of practicing in an area with weaker medical density. To avoid the endogeneity issue on physicians' choice of the location, we enriched our variable of interest, practicing in a relatively underserved area, with considering changes in medical density between 2007 and 2013, thus isolating GPs who only recently experienced a density decline (identifying assumption). We find that GPs practicing in underserved areas do shorter consultations and tend to substitute time-consuming procedures with alternatives requiring fewer human resources, especially for pain management. Results are robust to considering only GPs newly exposed to low medical density. Findings suggest a significant impact of supply-side shortages on the mix of healthcare services used to treat patients, and point to a plausible increased use of painkillers, opioids in particular.
Mots clés France, Opioids, Health workforce, Medically underserved area, General practitioners, Prescriptions
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Résumé Fêtes de réveillon en petit comité ou annulées, familles dispersées et isolées, autoconfinement, confinements locaux, partiels ou généralisés, couvre-feu, restrictions de déplacement, fermeture des frontières, incertitudes quant à la réouverture de certains secteurs : la France, comme de nombreux autres pays du monde, a fait face à une série de restrictions pour tenter d'endiguer l'épidémie. Si chaque type de mesures/restrictions a sa propre efficacité dans le contrôle de la dynamique épidémiologique, ces dernières doivent également être évaluées en fonction de leur acceptabilité par la population. À l'heure où les décideurs se posent la question de ré-évaluer les mesures restrictives pour éviter un rebond de l'épidémie, les préférences des populations devraient compter dans la décision publique.
Mots clés Confinement, Epidémie de Covid-19, Mesure restrictive
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Résumé Background: Ageing populations and rising prevalence of non-communicable diseases (NCDs) increasingly contribute to the growing cost burden facing European healthcare systems. Few studies have attempted to quantify the future magnitude of this burden at the European level, and none of them consider the impact of potential changes in risk factor trajectories on future health expenditures. Methods: The new microsimulation model forecasts the impact of behavioural and metabolic risk factors on NCDs, longevity and direct healthcare costs, and shows how changes in epidemiological trends can modify those impacts. Economic burden of NCDs is modelled under three scenarios based on assumed future risk factors trends: business as usual (BAU); best case and worst case predictions (BCP and WCP). Findings: The direct costs of NCDs in the EU 27 countries and the UK (in constant 2014 prices) will grow under all scenarios. Between 2014 and 2050, the overall healthcare spending is expected to increase by 0.8% annually under BAU. In the all the countries, 605 billion Euros can be saved by 2050 if BCP is realized compared to the BAU, while excess spending under the WCP is forecast to be around 350 billion. Interpretation: Although the savings realised under the BCP can be substantial, population ageing is a stronger driver of rising total healthcare expenditures in Europe compared to scenario-based changes in risk factor prevalence.
Mots clés Obesity, Cardiovascular disease risk, Cancer risk factors, Noncommunicable diseases, European union, Medical risk factors, Europe, Health economics
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Résumé This paper analyses the evolution of COVID-19 in Cameroon over the period March 6-April 2020 using SIR models. Specifically, we 1) evaluate the basic reproduction number of the virus, 2) determine the peak of the infection and the spread-out period of the disease, and 3) simulate the interventions of public health authorities. Data used in this study is obtained from the Cameroonian Public Health Ministry. The results suggest that over the identified period, the reproduction number of COVID-19 in Cameroon is about 1.5, and the peak of the infection should have occurred at the end of May 2020 with about 7.7% of the population infected. Furthermore, the implementation of efficient public health policies could help flatten the epidemic curve.
Mots clés Infectious disease control, Hygiene, Viral evolution, Respiratory infections, Infectious disease epidemiology, Cameroon, Public and occupational health, COVID 19
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Résumé In their quest for universal health coverage (UHC), many developing countries use alternative financing strategies including general revenues to expand health coverage to the whole population. Unless a policy adjustment is undertaken, future generations may foot the bill of the UHC. This raises the important policy questions of who bears the burden of UHC and whether the UHC-fiscal stance is sustainable in the long term. These two questions are addressed using an overlapping generations model within a general equilibrium (OLG-CGE) framework applied to Palestine. We assess and compare alternative ways of financing the UHC-ridden deficit (viz. deferred-debt, current and phased-manner finance) and their implications on fiscal sustainability and intergenerational inequalities. The policy instruments examined include direct labour-income tax and indirect consumption taxes as well as health insurance contributions. Results show that in the absence of any policy adjustment, the implementation of UHC would explode the fiscal deficit and debt-GDP ratio. This indicates that the UHC-fiscal stance is rather unsustainable in the long term, thus, calling for a policy adjustment to service the UHC debt. Among the policies we examined, a current rather than deferred-debt finance through consumption taxation emerged to be preferred over other policies in terms of its implications for both fiscal sustainability and intergenerational inequality.
Mots clés Fiscal sustainability, Computable general equilibrium, Overlapping generations, Universal health coverage, Intergenerational inequality
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Résumé In this article, we studied geographic variation in the use of personalized genetic testing for advanced non-small cell lung cancer (NSCLC) and we evaluated the relationship between genetic testing rates and local socioeconomic and ecological variables. We used data on all advanced NSCLC patients who had a genetic test between April 2012 and April 2013 in France in the frame of the IFCT Biomarqueurs-France study (n = 15814). We computed four established measures of geographic variation of the sex-adjusted rates of genetic testing utilization at the "départment" (the French territory is divided into 94 administrative units called 'départements') level. We also performed a spatial regression model to determine the relationship between département-level sex-adjusted rates of genetic testing utilization and economic and ecological variables. Our results are the following: (i) Overall, 46.87% lung cancer admission patients obtained genetic testing for NSCLC; département-level utilization rates varied over 3.2-fold. Measures of geographic variation indicated a relatively high degree of geographic variation. (ii) there was a statistically significant relationship between genetic testing rates and per capita supply of general practitioners, radiotherapists and surgeons (negative correlation for the latter); lower genetic testing rates were also associated with higher local poverty rates. French policymakers should pursue effort toward deprived areas to obtain equal access to personalized medicine for advanced NSCLC patients.
Mots clés Personalized medicine, Biogeography, Physicians, Human genetics, France, Lung and intrathoracic tumors, Non-small cell lung cancer, Genetic testing
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Résumé No abstract available
Mots clés Sex based disparities, Primary care, Premiums, Physicians, Physician pay, Health policy, Health disparities, Gender pay gap
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Résumé Background: The future burden of non-communicable diseases (NCDs) depends on numerous factors such as population ageing, evolution of societal trends, behavioural and physiological risk factors of individuals (e.g. smoking, alcohol use, obesity, physical inactivity, and hypertension). This study aims to assess the burden of NCDs in Europe by 2050 under alternative scenarios. Methods: This study combines qualitative and quantitative forecasting techniques to examine how population health in Europe may evolve from 2015 to 2050, taking into account future societal trends. Four scenarios were developed (one business-as-usual scenario, two response scenarios and one pessimistic scenario) and assessed against 'best' and 'worst'-case scenarios. This study provides quantitative estimates of both diseases and mortality outcomes, using a microsimulation model incorporating international survey data. Findings: Each scenario is associated with a different risk factor prevalence rate across Europe during the period 2015-2050. The prevalence and incidence of NCDs consistently increase during the analysed time period, mainly driven by population ageing. In more optimistic scenarios, diseases will appear in later ages, while in the pessimistic scenarios, NCDs will impair working-age people. Life expectancy is expected to grow in all scenarios, but with differences by up to 4 years across scenarios and population groups. Premature mortality from NCDs will be reduced in more optimistic scenarios but stagnate in the worst-case scenario. Interpretation: Population ageing will have a greater impact on the spread of NCDs by 2050 compared to risk factors. Nevertheless, risk factors, which are influenced by living environments, are an important factor for determining future life expectancy in Europe.
Mots clés Behavioral and social aspects of health, Social systems, Public and occupational health, Death rates, Health care policy, Epidemiology, Life expectancy, Europe
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Résumé Cette étude a pour objectif d’évaluer différents modes de financement de la couverture santé universelle au Sénégal. La méthode utilisée, la micro-simulation, permet d’examiner l’impact de différents scenarii sur les consommations des ménages ainsi que sur les dépenses publiques. Les résultats montrent que la généralisation d’une assurance-maladie à l’ensemble de la population, associée à une réduction des coûts directs des soins, augmenterait les consommations de soins des Sénégalais, améliorant donc leur accès aux services de santé. Néanmoins, une telle généralisation serait coûteuse pour les finances publiques. Pour limiter les coûts supportés par le gouvernement, l’augmentation du taux d’imposition sur la consommation et de la prime de contribution à l’assurance-maladie serait utile et permettrait de ramener les finances publiques à l’équilibre.
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Résumé Background: In France, Health Regional Agencies (HRA) have to elaborate a Public Health Plan for the 5 coming years. For estimating future population health needs and associated costs to adapt the health services on the regional territory, the HRA in southeastern France requested a prospective analysis, based on demographic and epidemiologic scenarios about major chronic diseases, to evaluate future trends. Methods: Six chronic diseases were selected: diabetes (1 or 2), cardiovascular diseases, respiratory diseases, cancers, neurological diseases and dementia. We used medico-administrative data from the National health insurance fund, and adapted algorithms to identify people with these diseases. We calculated prevalence rates according to gender and age and used two alternative scenarios (a constant one, and a trend-based one) to estimate the number of people with chronic diseases in 2023 and 2028, starting in 2016. We also estimated future healthcare costs according a constant and a trend-based scenario. Results: The algorithms detect reasonable rates of disease compared to official rates available for 2016. Due to demographic (ageing) and/or epidemiologic trends, the number of people with chronic diseases will highly increase during the next ten years in the South of France region. For instance, between 2016 and 2028, there will be from 15% to 20% more people with diabetes. Associated costs will also be higher (+33% between 2016 and 2028), especially those granted to nursing care (+40%). Conclusions: Burden of diseases and health expenditures are going to increase in the future. Projections are needed to help policymakers anticipating the required health services adaptation. Medico-administrative database are an invaluable source of data to do so. The next step of this project will consist in estimating those trends for smaller geographical areas.
Mots clés Type 2, Cancer, Aging, Cardiovascular diseases, Diabetes mellitus, Nervous system disorders, Chronic disease, Dementia, Cost of illness, Demography, Geographic area, Health care costs, Population health, Fiberoptic examinations anoscopy high resolution, Gender, Public health medicine, Nursing care, Respiration disorders, Health insurance, Health services, Health expenditures
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Résumé This paper aims at quantifying the effect of healthcare programs on economic outcomes in the context of developing countries experiencing epidemiological transitions. It is widely accepted in the literature that treatment programs result in production gains among ill-health workers. However, these programs have the additional effect of modifying both the size and the composition of the working population by increasing the proportion of chronically-ill individuals. First, we define the theoretical conditions under which this macro-epidemiological phenomenon outweighs the positive effect of an increase in production. Second, we decompose the economic consequences of access to antiretroviral treatments against HIV in three sub-Saharan African countries. Forecasts of an individual’s health status, depending on whether he or she has access to medication, are generated using a microsimulation model. We use the model to generate a counterfactual (as if the adverse epidemiological effect did not exist), which allows decomposing the total impact of the HIV-medicines program into two different effects: positive and negative. We find that the positive effect of treatment procurement outweighs the negative epidemiological effect. Of course, this approach is only an indicator of economic performance and should in no way constitute a decision-making criterion about the ethical necessity of access to health care.
Mots clés Microsimulation, Demographic changes, Treatment programs, Macroeconomic indicators, HIV/AIDS, VIH-SIDA, Changements démographiques, Programmes de traitement, Indicateurs macroéconomiques, Microsimulation
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Résumé Selon les projections récentes, les effectifs de médecins libéraux diminueront de 30 % d’ici à 2027 et la densité standardisée diminuerait jusqu’en 2023, créant des poches de sous-densité relativement nombreuses sur le territoire français métropolitain. L’article s’intéresse aux ajustements que les médecins généralistes de ville mettent en œuvre lorsque, sur leur territoire, ils sont d’ores et déjà confrontés à cette raréfaction. Les données utilisées sont celles du troisième panel des médecins généralistes enrichies d’indicateurs fournis par la CNAMTS. Nous nous sommes appuyés sur l’indicateur d’accessibilité potentielle localisé, développé par l’IRDES et la DREES, pour définir les zones les moins dotées en généralistes. En comparant les comportements des généralistes exerçant dans les zones les moins dotées à leurs homologues des zones mieux dotées, il est apparu d’abord que le planning d’activité du médecin tend à s’intensifier plutôt qu’à s’allonger. Nos données semblent en effet montrer que les rythmes de consultation dans les zones les moins dotées sont plus élevés, alors que le temps de travail global des généralistes s’avère quant à lui peu réactif à la densité en médecins alentour. On note aussi quelques différences statistiquement significatives sur les pratiques médicales : usage accru de certains médicaments, moins de renvoi vers des soins paramédicaux, suivis gynécologique probablement un peu moins réguliers, etc. Cependant, il semble que les différences ne sont pas statistiquement significatives pour les indicateurs de qualité des pratiques rattachés au dispositif de rémunération sur objectifs de santé publique (ROSP).
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Résumé OBJECTIVES: This study assesses the change in premature mortality and in morbidity under the scenario of meeting the World Health Organization (WHO) global targets for non-communicable disease (NCD) risk factors (RFs) by 2025 in France. It also estimates medical expenditure savings because of the reduction of NCD burden. STUDY DESIGN: A microsimulation model is used to predict the future health and economic outcomes in France. METHODS: A 'RF targets' scenario, assuming the achievement of the six targets on RFs by 2025, is compared to a counterfactual scenario with respect to disability-adjusted life years and healthcare costs differences. RESULTS: The achievement of the RFs targets by 2025 would save about 25,300 (and 75,500) life years in good health in the population aged 25-64 (respectively 65+) years on average every year and would help to reduce healthcare costs by about €660 million on average per year, which represents 0.35% of the current annual healthcare spending in France. Such a reduction in RFs (net of the natural decreasing trend in mortality) would contribute to achieving about half of the 2030 NCD premature mortality target in France. CONCLUSIONS: The achievement of the RF targets would lead France to save life years and life years in good health in both working-age and retired people and would modestly reduce healthcare expenditures. To achieve RFs targets and to curb the growing burden of NCDs, France has to strengthen existing and implement new policy interventions.
Mots clés Projection, Obesity, Non-communicable diseases, Smoking, Alcohol, Healthcare expenditure
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Résumé Background: 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. Methods: 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. Findings: 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). Interpretation: 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. Funding: 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). Contributors: 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.
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Résumé In this paper, we report the results of risk attitudes elicitation of a French general practitioners national representative sample (N=1568).
Mots clés Risk attitudes, GP&#039, s behavior, Patient-regarding preferences, Representative sample, Medical decision making
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Résumé 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.
Mots clés Lottery choice, Medical practices, Risk attitude, Scale, Domain specificity JEL Classification C93, D81, I10
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Résumé Antimicrobial resistance challenge requests to be able to measure patient medication-adherence in outpatient setting, where more than 90% of antibiotics are prescribed. We take advantage of an original dataset where adherence to treatment has been measured through two alternative measurements: pills count and the Morisky scale. Considering the first measure as benchmark, we test the validity of each of the Morisky items and their composition in a synthetic scale. We show that the short-form version of the medication-adherence scale with three items has the best predictive properties in the domain of antibiotic treatments. Given its concision, this tool could even be used by clinicians to quickly assess patients’ adherence and modify it in the course, when needed.
Mots clés Datasets, Medication adherence, Outpatients, Microbial, Drug resistance, Benchmarking, Patient compliance, Antibiotics
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Résumé Introduction Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers). Methods and analysis This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs’ qualitative decisional need assessment (semistructured interviews and focus group with stakeholders). Ethics and dissemination This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs’ decisional needs (practical contribution). We will adapt the IP-SDM model, normally dealing with a single decision, for PCCNs who experience cascade of decisions involving different stakeholders (theoretical contribution). Knowledge users will facilitate dissemination of the results in the Canadian primary care network. PROSPERO registration number CRD42015020558.
Mots clés Shared decision making, Primary care, Patients with complex care needs, Interprofessional care
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Résumé BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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
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Résumé 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.
Mots clés Economie quantitative
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Résumé 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.
Mots clés Infectious diseases, Health outcomes, Value, Specialist care, Referrals
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Résumé 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.
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Mots clés Biens et services de santé, Rareté
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Résumé In many developing countries and in the particular context of Middle East and North Africa (MENA) region, the challenge of informality is regarded as a fatality. This leads a large fraction of the population being deprived of any social security system. Following an original approach, a cross-sectional contingent valuation study was conducted in Tunisia, between August and September 2013, dealing with willingness to take-up two mandatory health and pension insurance schemes currently run by two national funds: ‘Caisse Nationale d’Assurance Maladie’ (CNAM) and ‘Caisse Nationale de Sécurité Sociale’ (CNSS), respectively. The sample size covers 456 respondents, all non-covered by any social security scheme (health or pension scheme) and recruited in all parts of the country (North, Central and South). The Willingness-to-pay (WTPs) of respondents are elicited in two sampling points: the informal markets (known as Souks) characterized by the high presence of informal workers and the public squares (known as Al-mydan) where peaceful demonstrations of unemployed people were commonplace following the so-called ‘Arab Spring’ that began in Tunisia at the end of 2010. Results support the hypotheses that the proposition of a voluntary affiliation to mandatory insurance schemes, referred to as social insurance schemes, can be accepted by the majority of non-covered and that the WTPs stated are substantial. Willingness-to-join the proposed schemes by informal workers and unemployed varies regarding the three health insurance plans described (the scheme run by the CNAM includes three plans) and risks covered (with an added pension scheme or not). The WTPs declared, for each insurance scheme, show preferences (utility) of Tunisian households to both mandatory health and pension insurance schemes. Accordingly, this suggests important implications for the Tunisian health insurance policy (with universal health coverage goal in mind) and the pension system. The message of this paper is to outline that informality is not an irrevocable choice and that control of social evasion in Tunisia is possible. Another strength of the paper is that it gives some data and information on a population generally difficult to reach, the demonstrators, although informal-workers (non-demonstrators) appear strongly interested by the insurance program.
Mots clés Willingness-to-pay, Contingent Valuation Method, Social insurance, Health Risk, Old-Age Risk, Informal Workers, Consentement à payer, Évaluation contingence, Assurance sociale, Risque maladie, Risque vieillesse, Informalité
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Résumé AbstractBackgroundThe literature offers competing estimates of disease costs, with each study having its own data and methods. In 2007, the Dutch Center for Public Health Forecasting of the National Institute for Public Health and the Environment provided guidelines that can be used to set up cost-of-illness (COI) studies, emphasising that most COI analyses have trouble accounting for comorbidity in their cost estimations. When a patient has more than one chronic condition, the conditions may interact such that the patient’s healthcare costs are greater than the sum of the costs for the individual diseases. The main objective of this work was to estimate the costs of 10 non-communicable diseases when their co-occurrence is acknowledged and properly assessed.MethodsThe French Echantillon Généraliste de Bénéficiaires (EGB) database was used to assign all healthcare expenses for a representative sample of the population covered by the National Health Insurance. COIs were estimated in a bottom-up approach, through regressions on individuals’ healthcare expenditure. Two-way interactions between the 10 chronic disease variables were included in the expenditure model to account for possible effect modification in the presence of comorbidity(ies).ResultsThe costs of the 10 selected chronic diseases were substantially higher for individuals with comorbidity, demonstrating the pattern of super-additive costs in cases of diseases interaction. For instance, the cost associated with diabetes for people without comorbidity was estimated at 1776 €, whereas this was 2634 € for people with heart disease as a comorbidity. Overall, we detected 41 cases of super-additivity over 45 possible comorbidities. When simulating a preventive action on diabetes, our results showed that significant monetary savings could be achieved not only for diabetes itself, but also for the chronic diseases frequently associated with diabetes.ConclusionsWhen comorbidity exists and where super-additivity is involved, a given preventive policy leads to greater monetary savings than the costs associated with the single diagnosis, meaning that the returns from the action are generally underestimated.
Mots clés Prevention policies, Chronic diseases, Comorbidity, Cost of illness
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Mots clés Economie quantitative
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Résumé Background: Recently, French policymakers have tried to improve care at the end-of-life, by improving access to community-based palliative care, particularly for patients with cancer and neurological diseases. If effective, these efforts should reduce the proportion of such patients who die in the hospital. In light of these policies, we sought to determine the effectiveness of these efforts on reducing inpatient deaths by conducting a retrospective, observational analysis of patients aged 65 and older who were admitted to hospitals in France between 2010 and 2013 for 1 of 3 non-surgical conditions. Methods: We calculated department-specific age- and sex-adjusted inpatient death rates for 3 types of non-surgical admissions and modeled expected number of inpatient deaths had their rates for patients with cancer or neurological disease tracked those of patients with non-cancer non-neurological diseases. Results: We found that patients admitted with a cancer diagnosis experienced 20,394 (13.0%) fewer inpatient deaths that expected had non-surgical cancer diagnosis admission rates tracked those of non-surgical non-cancer and non-neurological admission rates; patients admitted with a primary neurological disease diagnosis experienced 513 (4.5%) fewer inpatient deaths than expected. During the study period, observed-to-expected inpatient deaths fell more dramatically and consistently for patients admitted with cancer diagnoses than for those admitted with neurological diseases. Observed-to-expected ratios fell least in departments that were on the periphery of the French mainland. Conclusions: Our findings suggest that, in France, efforts to reduce inpatient death rates among patients with cancer or neurological disease diagnoses appear to be effective. However, their effectiveness varies geographically, suggesting that targeted efforts to improve lower performing departments may generate substantial performance improvements.
Mots clés Economie quantitative
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Résumé Evidence suggests that the effect of health expenditure on health outcomes is highly context-specific and may be driven by other factors. We construct a panel dataset of 18 countries from the Middle East and North Africa region for the period 1995–2012. Panel data models are used to estimate the macro-level determinants of health outcomes. The core finding of the paper is that increasing health expenditure leads to health outcomes improvements only to the extent that the quality of institutions within a country is sufficiently high. The sensitivity of the results is assessed using various measures of health outcomes as well as institutional variables. Overall, it appears that increasing health care expenditure in the MENA region is a necessary but not sufficient condition for health outcomes improvements.
Mots clés Economie quantitative
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Résumé Abstract Objectives The French pay-for-performance (P4P) contract CAPI implemented by the national health insurance included a target-goal which aims at reducing benzodiazepines prescriptions. In this investigation, we would like to assess whether: (1) the general practitioners (GPs) having signed P4P contract obtain better results regarding the target-goal than non-signatories; (2) (part of) this progression is due to the CAPI contract itself (tentative measurement of a “causal effect”); (3) (part of) the money spent on this P4P incentive can be self-financed with the amount of pharmaceuticals saved. Methods We matched cross-sectional and longitudinal data including 4622 French GPs from June 2011 to December 2012. A treatment effect model using instrumental variables was performed to take into account potential self-selection issue in signing. After having identified the NET impact of the P4P, we calculate the cost of an avoided benzodiazepines treatment. Results In our study, GPs who have signed the CAPI contract (36 % of the sample) are more numerous in achieving benzodiazepines target goal than non-signatories: 90.7 vs. 85.5 %. After controlling for the self-selection bias, the propensity of GPs to achieve the benzodiazepines target is only 0.31 % higher for signatories than for their non-signing counterparts—estimate for June 2012, which yields a statistically significant gap. Our economic analysis demonstrates that the CAPI contract does not allow savings, but presents in 2012 a NET cost of 93.6€ per avoided benzodiazepines treatment (291€ in 2011). Conclusions The P4P contract has a positive but modest impact on the achievement of GPs regarding benzodiazepines indicator.
Mots clés Pay-for-performance, General practitioners, CAPI, Benzodiazepines, Behaviors
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Résumé Background: Admissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume. Methods: We calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries. Results: The highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients’ use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined. Conclusions: Because admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them.
Mots clés Ambulatory care sensitive conditions, International, Potential cost savings, International comparisons JEL Classification I11, I18, H51, Preventable admissions
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Résumé In almost all African countries, informal payments are frequently made when accessing health care. Some literature suggests that the informal payment system could lead to quasi-redistribution among patients, with physicians playing a ‘Robin Hood’ role, subsidizing the poor at the expense of the rich. We empirically tested this assumption with data from the rounds 3 and 5 of the Afrobarometer surveys conducted in 18 and 33 African countries respectively, from 2005 to 2006 for round 3 and from 2011 to 2013 for round 5. In these surveys, nationally representative samples of people aged 18 years or more were randomly selected in each country, with sizes varying between 1048 and 2400 for round 3 and between 1190 and 2407 for round 5. We used the ‘normalized’ concentration index, the poor/rich gap and the odds ratio to assess the level of inequality in the payment of bribes to access care at the local public health facility and implemented two decomposition techniques to identify the contributors to the observed inequalities. We obtained that: i) the socioeconomic gradient in informal payments is in favor of the rich in almost all countries, indicating a rather regressive system; ii) this is mainly due to the socioeconomic disadvantage itself, to poor/rich differences in supply side factors like lack of medicines, absence of doctors and long waiting times, as well as regional disparities. Although essentially empirical, the paper highlights the need for African health systems to undergo substantial country-specific reforms in order to better protect the worse-off from financial risk when they seek care.
Mots clés Supply side factors, Socioeconomic inequalities, Informal payments, Decomposition technique, Dec, Concentration index, Africa
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Résumé Since 1945, the provision of health care in France has been grounded in a social conception promoting universalism and equality. The French health-care system is based on compulsory social insurance funded by social contributions, co-administered by workers' and employers' organisations under State control and driven by highly redistributive financial transfers. This system is described frequently as the French model. In this paper, the first in The Lancet's Series on France, we challenge conventional wisdom about health care in France. First, we focus on policy and institutional transformations that have affected deeply the governance of health care over past decades. We argue that the health system rests on a diversity of institutions, policy mechanisms, and health actors, while its governance has been marked by the reinforcement of national regulation under the aegis of the State. Second, we suggest the redistributive mechanisms of the health insurance system are impeded by social inequalities in health, which remain major hindrances to achieving objectives of justice and solidarity associated with the conception of health care in France.
Mots clés Health Policies, Social Inequalities in Health, Health Finance, PUBLIC HEALTH, Health Care, Health economics, France, Health Reforms, Social security
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Résumé With aging populations, European countries face difficult challenges. In 2002, France implemented a public allowance program (APA) offering financial support to the disabled elderly for their long-term care (LTC) needs. Although currently granted to 1.2 million people, it is suspected that some of those eligible do not claim it—presenting a non-take-up behavior. The granting of APA is a decentralized process, with 94 County Councils (CC) managing it, with wide room for local interpretation. This spatial heterogeneity in the implementation of the program creates the conditions for a “quasi-natural experiment”, and provides the opportunity to study the demand for APA in relation to variations in CCs’ “generosity” in terms of both eligibility and subsidy rate for LTC. We use a national health survey and administrative data in a multilevel model controlling for geographical, cultural and political differences between counties. The results show that claiming for APA is associated with the “generosity” of CCs: the population tends to apply less for the allowance if the subsidy rate is in average lower. This pecuniary trade-off, revealed by our study, can have strong implications for the well-being of the elderly and their relatives.
Mots clés Social benefit, Non-take-up, Multilevel model, Long-term care
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Résumé A growing number of developing countries are currently promoting health system reforms with the aim of attaining ‘ universal health coverage’ (UHC). In Tunisia, several reforms have been undertaken over the last two decades to attain UHC with the goals of ensuring financial protection in health and enhancing access to healthcare. The first of these goals has recently been addressed in a companion paper by Abu-Zaineh et al. (Int J Health Care Financ Econ 13(1):73–93, 2013). The present paper seeks to assess whether these reforms have in fact enhanced access to healthcare. The average treatment effects of two insurance schemes, formal-mandatory (MHI) and state-subsidized (MAS) insurance, on the utilization of outpatient and inpatient healthcare are estimated using propensity score matching. Results support the hypothesis that both schemes (MHI and MAS) increase the utilization of healthcare. However, significant variations in the average effect of these schemes are observed across services and areas. For all the matching methods used and compared with those the excluded from cover, the increase in outpatient and inpatient services for the MHI enrollees was at least 19 and 26 %, respectively, in urban areas, while for MAS beneficiaries this increase was even more pronounced (28 and 75 % in the urban areas compared with 27 and 46 % in the rural areas for outpatient and inpatient services, respectively). One important conclusion that emerges is that the current health insurance schemes, despite improving accessibility to healthcare services, are nevertheless incapable of achieving effective coverage of the whole population for all services. Attaining the latter goal requires a strategy that targets the “trees” not the “forest”. Copyright Springer Science+Business Media New York 2015
Mots clés Universal health coverage, State-subsidized insurance, Propensity score mat, Healthcare utilization
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Résumé Populations' structures and sizes can be a result of healthcare policy decisions. We use a two‐period theoretical framework and a dynamic microsimulation model to examine the consequences of this assertion on the appraisal of alternative health policy options. Results show that standard welfare‐in‐health measures are sensitive to changes in populations' sizes, in that taking into account the (virtual) existence of the dead can alter the ranking of policy options. Disregarding differences in the survivals induced by alternative policies can bias programmes' ranking in favour of less live‐saving policies. The paper alerts on the risk of policy misranking by the use of ex‐post cross‐sectional analyses, neglecting deaths occurring in the past as well as counterfactual deaths in alternative policy scenarios. Copyright © 2013 John Wiley & Sons, Ltd.
Mots clés Utilitarianism, Social choice, Population issues, Mortality, Moral philosophy, Microsimulation, HIV/AIDS, Health programmes, Health outcomes, Developing countries
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Résumé Objectives We tested the following hypotheses: (i) risk-averse general practitioners (GPs) are more likely to be vaccinated against influenza; (ii) and risk-averse GPs recommend influenza vaccination more often to their patients. In risk-averse GPs, the perceived benefits of the vaccine and/or the perceived risks of the infectious disease might indeed outweigh the perceived risks of the vaccine. Patients/Methods In 2010–2012, we conducted a cross-sectional survey of a nationwide French representative sample of 1136 GPs. Multivariate analyses adjusted for four stratification variables (age, gender, urban/suburban/rural practice location and annual patient consultations) and for GPs’ characteristics (group/solo practice, and occasional practice of alternative medicine, e.g., homeopathy) looked for associations between their risk attitudes and self-reported vaccination behavior. Individual risk attitudes were expressed as a continuous variable, from 0 (risk-tolerant) to 10 (risk-averse). Results Overall, 69% of GPs reported that they were very favorable toward vaccination in general. Self-reported vaccination coverage was 78% for 2009/2010 seasonal influenza and 62% for A/H1N1 pandemic influenza. Most GPs (72%) reported recommending the pandemic influenza vaccination to at-risk young adults in 2009, but few than half (42%) to young adults not at risk. In multivariate analyses, risk-averse GPs were more often vaccinated against seasonal (marginal effect = 1.3%, P = 0.02) and pandemic influenza (marginal effect = 1.5%, P = 0.02). Risk-averse GPs recommended the pandemic influenza vaccination more often than their more risk-tolerant colleagues to patients without risk factors (marginal effect = 1.7%, P = 0.01), but not to their at-risk patients and were more favorable toward vaccination in general (marginal effect = 1.5%, P = 0.04). Conclusion Individual risk attitudes may influence GPs’ practices regarding influenza vaccination, both for themselves and their patients. Our results suggest that risk-averse GPs may perceive the risks of influenza to outweigh the potential risks related to the vaccine.
Mots clés Immunization, Pandemic influenza, Primary care, Risk aversion, Seasonal influenza, Vaccine
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Résumé Geographic variation in use of elective surgeries has been widely studied in the US, where over-utilization is incentivized. We wanted to explore recent trends in the geographic variation of common surgical procedures in France – where a global budget, centralized planning process, and compulsory insurance scheme are in place – and to compare measures of variation there to those in the US and Britain. For 2008–2010, we calculated French age- and sex-adjusted per capita utilization rates and four measures of geographic variation for hip fracture admission (which is standard treatment and shows minimal geographic variation across countries) and 14 elective surgical procedures. We found substantial geographic variation in age-sex adjusted per capita admission rates for elective procedures: radical prostatectomy, spine surgery, and CABG showed the greatest variation, while hip fracture, colectomy, and cholecystectomy showed the least. Among older patients, most French admission rates were lower than those seen in the US. In general, measures of geographic variation were lower in France than those reported in the US or Britain. French policymakers could use analyses of geographic variation in service utilization to inform policy, to identify areas for intervention, or to measure the effectiveness of efforts designed to reduce variation in care.
Mots clés Surgical procedures, Policy development, Geographic variation
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Résumé INTRODUCTION: We sought to determine whether there was evidence of supplier-induced demand in mainland France, where health care is mainly financed by a public and compulsory health insurance and provided by both for-profit and not-for-profit hospitals. METHODS: Using a dataset of all admissions to French hospitals for 2009 and 2010, we calculated department-level age-adjusted and sex-adjusted per capita admission rates for hip replacement, knee replacement, and hip fracture for 2 age groups (45-64 and 65-99 y old), for-profit and not-for-profit hospitals. We used spatial regression analysis to examine the relationship between ecological variables, procedure rates, and supply of surgeons or sector-specific surgical beds. RESULTS: The large majority of hip and knee replacement surgeries were performed in for-profit hospitals, whereas the large majority of hip fracture admissions were in not-for-profit hospitals; nonetheless, we found approximately 2-fold variation in per capita rates of hip and knee replacement surgery in both age groups and settings. Spatial regression results showed that among younger patients, higher incomes were associated with lower admission rates; among older patients, higher levels of reliance on social benefits were associated with lower rates of elective surgery in for-profit hospitals. Although overall surgical bed supply was not associated with admission rates, for-profit-specific and not-for-profit-specific bed supply were associated with higher rates of elective procedures within a respective hospital type. DISCUSSION: We found evidence of supplier-induced demand within the French for-profit and not-for-profit hospital systems; however, these systems appear to complement one another so that there is no overall national supplier-induced effect.
Mots clés Male, Aged, Aged, 80 and over, Arthroplasty, Replacement, Hip, Hip/statistics &amp, numerical data, Knee, Knee/statistics &amp, numerical data, Patient Admission/statistics &amp, numerical data, Patient Admission, Middle Aged, Bias Epidemiology, Knee Injuries/therapy, Knee Injuries, Humans, Voluntary/utilization, Voluntary, Proprietary/statistics &amp, numerical data, Proprietary, Hospitals, Hip Fractures/therapy, Hip Fractures, Health Services Needs and Demand/statistics &amp, numerical data, Health Services Needs and Demand, France, Female
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Résumé Anecdotal evidence on hidden inequity in health care in North African countries abounds. Yet firm empirical evidence has been harder to come by. This article fills the gap. It presents the first analysis of equity in the healthcare system using the particular case of Tunisia. Analyses are based on an unusually rich source of data taken from the Tunisian HealthCare Utilization and Morbidity Survey. Payments for health care are derived from the total amount of healthcare spending which was incurred by households over the last year. Utilization of health care is measured by the number of physical units of two types of services: outpatient and inpatient. The measurement of need for health care is apprehended through a rich set of ill-health indicators and demographics. Findings are presented and compared at both the aggregate level, using the general summary index approach, and the disaggregate level, using the distribution-free stochastic dominance approach. The overall picture is that direct out-of-pocket payments, which constitute a sizeable share in the current financing mix, emerge to be a progressive means of financing health care overall. Interestingly, however, when statistical testing is applied at the disaggregate level progressivity is retained over the top half of the distribution. Further analyses of the distributions of need for—and utilization of—two types of health care—outpatient and inpatient—reveal that the observed progressivity is rather an outcome of the heavy use, but not need, for health care at the higher income levels. Several policy relevant factors are discussed, and some recommendations are advanced for future reforms of the health care in Tunisia.
Mots clés Tunisia, Progressivity, Horizontal equity, Healthcare finance, Healthcare delivery
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Résumé Les conditions d’exercice de la médecine générale connaissent des évolutions importantes. Le paiement à la performance, généralisé depuis 2012, et la coopération avec les infirmiers, pratique encore à un stade essentiellement expérimental, sont deux dispositifs emblématiques. La quasi-totalité des médecins interrogés à la fin 2012 dans le cadre du panel de médecins généralistes de ville déclarent avoir adhéré à la Rémunération sur objectifs de santé publique mise en place par l’Assurance maladie en janvier 2012, et 80 % d’entre eux pensent pouvoir en remplir la majorité des objectifs. En revanche, ils sous-estiment nettement la rémunération qu’ils pourraient percevoir grâce à ce dispositif. Un tiers d’entre eux se déclarent favorables à des coopérations avec un infirmier sur une ou plusieurs tâches. Cependant, ce résultat est très sensible au mode de financement d’un tel dispositif : la coopération est nettement plus acceptée (dans les deux tiers des cas) dans un scénario où l’auxiliaire médical serait entièrement rémunéré par un forfait extérieur. Les tâches qui relèvent des compétences réglementaires du médecin telles que les prescriptions seraient moins volontiers déléguées à un infirmier, contrairement aux actes d’éducation thérapeutique ou de surveillance de la tension artérielle
Mots clés Cooperation, Paiement à la performance, Médecins généralistes
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Résumé We analyze the impact of healthcare financing on economic growth, focusing on the issue of the joint public-private financing of healthcare (co-payment). We use an overlapping-generations model with endogenous growth based on health human capital accumulation, where families pay for childhood preventive care and the government can either fully finance or co-finance adulthood curative care. From a growth maximizing perspective, distortionary taxes give an advantage to co-financing. Nevertheless, we prove that, if agents are assumed to be heterogeneous in preferences, full financing can become the best option.
Mots clés Human capital, Health, Growth, Economic development
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Résumé In this investigation, we wanted: (i) to describe the attitudes and declared practices of a representative sample of French general practitioners (GPs) regarding rapid antigen diagnostic tests (RADTs) for acute pharyngitis and (ii) to identify the GPs’ characteristics associated with the use of an RADT in the last paediatric patient with pharyngitis. We performed a cross-sectional survey conducted in 2012 among a representative sample of 1,126 self-employed GPs in France. 60.1 % of GPs declared that they used an RADT in their last patient aged between 3 and 16 years presenting with acute pharyngitis; 29.6 % of these tests were positive. Among the GPs who did not use an RADT, 50.2 % prescribed an antibiotic, compared to 30.5 % of prescriptions among GPs who performed an RADT, whatever its result. In a multivariate analysis, GPs’ age between 45 and 54 years and having attended Continuing Medical Education (CME) sessions on infectious diseases in the past year were significantly associated with an increased use of an RADT in the last patient with pharyngitis, whereas a low volume of activity, occasionally practising alternative medicine, receiving pharmaceutical representatives at the practice and declaring a consultation duration \textless15 min were factors associated with a decreased use of RADTs. The use of RADTs by GPs must be promoted; our findings could help define interventions to improve practice.
Mots clés Economie quantitative
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Résumé En France, la couverture vaccinale est insuffisante. Les médecins généralistes étant des acteurs essentiels de la politique vaccinale, il est utile de connaître leurs opinions et pratiques à ce sujet. Nous avons interrogé 1431 médecins généralistes français et 98% se déclaraient favorables à la vaccination dans leur pratique quotidienne. Leurs couvertures vaccinales étaient de 73% pour l’hépatite B, 64% pour la coqueluche et 77% pour la grippe saisonnière. Les médecins se trouvaient très efficaces pour obtenir l’adhésion pour le vaccin ROR (Rougeole-Oreillons-Rubéole) chez les enfants de moins de deux ans et la grippe saisonnière chez les adultes de moins de 65 ans à risque, mais beaucoup moins pour l’hépatite B chez les adolescents. La mise en place d’un registre national informatisé des vaccinations et de messages de promotion vaccinale différenciés par vaccin semblent les deux voies prioritaires pour améliorer la couverture vaccinale.
Mots clés Promotion de la santé, Prevention, Pratiques, Comportement de santé, Maladies transmissibles
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Résumé The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material. The healthy ageing assumptions may lead to substantial changes in paths of aggregate health care expenditure, notably catastrophic expenditure of people at the end of the life. But clear assessments of involved amounts are not available when we specifically consider ambulatory care (as drug expenditure) generally offered to chronically-ill people. We estimate the effects of epidemiological and life expectancy changes on French health expenditure until 2029 by applying a Markovian micro-simulation model from a nationally representative database. The originality of these simulations holds in using an aggregate indicator of morbidity–mortality, capturing vital risk and making it possible to adapt the quantification of life expectancies by taking into account the presence of severe chronic pathologies. We forecast future national drugs expenditure, under different epidemiological scenarios of chronic morbidity: trend scenario, healthy ageing scenario and medical progress scenario. For the population aged 25+, results predict an increase in reimbursable drug expenditure of between 1.1% and 1.8% (annual growth rate), attributable solely to the ageing population and changes in health status.
Mots clés Health expenditures, Computer simulation, Ageing, Forecasting
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Résumé Despite the remarkable progress in expanding the coverage of social protection mechanisms in health, the Tunisian healthcare system is still largely funded through direct out-of-pocket payments. This paper seeks to assess financial protection in health in the particular policy and epidemiological transition of Tunisia using nationally representative survey data on healthcare expenditure, utilization and morbidity. The extent to which the healthcare system protects people against the financial repercussions of ill-health is assessed using the catastrophic and impoverishing payment approaches. The characteristics associated with the likelihood of vulnerability to catastrophic health expenditure (CHE) are examined using multivariate logistic regression technique. Results revealed that non-negligible proportions of the Tunisian population (ranging from 4.5 % at the conservative 40 % threshold of discretionary nonfood expenditure to 12 % at the 10 % threshold of total expenditure) incurred CHE. In terms of impoverishment, results showed that health expenditure can be held responsible for about 18 % of the rise in the poverty gap. These results appeared to be relatively higher when compared with those obtained for other countries with similar level of development. Nonetheless, although households belonging to richer quintiles reported more illness episodes and received more treatment than the poor households, the latter households were more likely to incur CHE at any threshold. Amongst the correlates of CHE, health insurance coverage was significantly related to CHE regardless of the threshold used. Some implications and policy recommendations, which might also be useful for other similar countries, are advanced to enhance the financial protection capacity of the Tunisian healthcare system.
Mots clés Health Sciences, Medicine, Statistics for Life Sciences, Statistics for Business/Economics/Mathematical Finance/Insurance, PUBLIC HEALTH, Public Finance &amp, Economics, Health Informatics, Economic Policy
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Résumé Our objectives for this investigation were: (i) to design quality measures of outpatient antibiotic use that could be calculated at the individual general practitioner (GP) level using reimbursement data only; and (ii) to analyse the variability in antibiotic prescriptions between GPs regarding these measures in south-eastern France. Based on the literature and international therapeutic guidelines, we designed a set of quality measures in an exploratory attempt to assess the quality of antibiotic prescriptions. We performed a cross-sectional study of antibiotic prescriptions in adults in south-eastern France in 2009, using data from the outpatient reimbursement database of the French National Health Insurance (NHI). We carried out a cluster analysis to group GPs according to their antibiotic prescribing behaviour. Six quality measures were calculated at the GP level, with wide variations in practice regarding all these measures. A six-cluster solution was identified, with one cluster grouping 56 % of the sample and made up of GPs having the most homogeneous pattern of prescription for all six quality measures, probably reflecting better antibiotic prescribing. Total pharmaceutical expenses (per patient), penicillin combinations use, quinolone use and seasonal variation of quinolone use were all positively associated with a more heterogeneous and possibly less appropriate use of antibiotics in a multivariate analysis. These quality measures could be useful to assess GPs' antibiotic prescribing behaviour in countries where no information system provides easy access to data linking drug use to a clinical condition.
Mots clés Female, Adolescent, Adult, Aged, 80 and over, Anti-Bacterial Agents/therapeutic use, Cross-Sectional Studies, Drug Prescriptions/standards/statistics &amp, numerical data, France, Young Adult, Incentive/statistics &amp, numerical data, Reimbursement, Primary Health Care/methods, Middle Aged, Male, Humans, Guideline Adherence/statistics &amp, numerical data
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Résumé Objectif – Garantir un accès aux soins bucco-dentaires équitable et de qualité aux personnes âgées reste un défi. Ce travail a pour objectif de comparer le recours au chirurgien-dentiste des personnes âgées institutionnalisées à celui des personnes âgées vivant à domicile. Méthode – Les données analysées, restreintes aux sujets de plus de 60 ans, sont issues de l’enquête Handicap-Santé menée en France en ménages ordinaires (HSM) et en institutions (HSI). La technique d’appariement par score de propension a été utilisée afin de permettre la comparaison des deux populations en minimisant les biais. Les variables d’appariement étaient l’âge, le sexe, le degré de dépendance, la catégorie socioprofessionnelle et la fréquence des contacts avec la famille. Résultats – Un sous-échantillon de 3 358 sujets âgés (1 679 paires) a été constitué. La probabilité de recours au chirurgien-dentiste est diminuée d’un quart lorsque les personnes sont institutionnalisées (OR=0,7 ;p \textless0,001) par rapport aux personnes vivant à domicile. Pour les personnes institutionnalisées, le recours au chirurgien-dentiste apparaît cependant plus fréquent dans les établissements privés à but non lucratif que dans les structures publiques ou privées à but lucratif. Conclusion – Toutes choses égales par ailleurs, la vie en institution peut être considérée comme une barrière pour le recours au chirurgien-dentiste.
Mots clés Economie quantitative
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Résumé OBJECTIVES: We tested the following hypotheses: (1) risk-averse general practitioners (GPs) might use more Rapid Antigen Diagnostic Tests (RADTs) in tonsillitis in children, probably to decrease their diagnostic uncertainty regarding the aetiology of the disease (viral vs due to group A Streptococcus); and (2) GPs not using RADT might prescribe more antibiotics when they are risk averse. DESIGN, SETTING AND PARTICIPANTS: We conducted a cross-sectional survey of a nationwide French representative sample of 1093 GPs in 2012. OUTCOME MEASURES: Multivariate analyses adjusted on the four stratification variables (age, gender, location and volume of activity, ie, the number of annual consultations) were performed to identify the risk domains associated with indicators of good or poor practice. RESULTS: 69.4% of GPs were aware of national guidelines regarding tonsillitis and declared that they had taken these guidelines into account for their last paediatric tonsillitis case. 59.1% declared they used RADT in their last patient aged between 3 and 16 years presenting with tonsillitis; 29.7% of these tests were positive. Among the GPs who used RADT, 30.7% prescribed an antibiotic; 98.3% did either prescribe an antibiotic because of a positive RADT result, or did not prescribe an antibiotic in view of a negative result. Among the GPs who did not use RADT, 50.7% prescribed an antibiotic. In multivariate analyses, risk-averse GPs declared being more aware of and compliant with guidelines (OR=1.56, p\textless0.01), and used RADTs more often for their last patient (OR=1.30, p\textless0.05). Among GPs not using RADT in their last patient, risk-averse GPs prescribed more antibiotics compared with risk-tolerant doctors (OR=1.18, p\textless0.05). CONCLUSIONS: Individual risk attitudes influenced GPs' practices in tonsillitis, particularly the use of RADTs and antibiotic prescriptions.
Mots clés Economie quantitative
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Résumé Quality indicators assessing the use of antibiotics among general practitioners (GPs) would be useful to target antibiotic stewardship interventions. We adapted to an individual GP level a set of 12 drug-specific quality indicators of outpatient antibiotic use in Europe developed by the European surveillance of antimicrobial consumption project. We performed a cross-sectional study analysing reimbursement data on outpatient antibiotic prescriptions in adults in south-eastern France in 2009. Substantial heterogeneity in antibiotic prescribing among French GPs was observed, and opportunity to improve antibiotic prescribing can be identified.
Mots clés Incentive/statistics &amp, numerical data, Quality Indicators, Health Care, Adolescent, Adult, Aged, 80 and over, Anti-Bacterial Agents/therapeutic use, Cross-Sectional Studies, Young Adult, Drug Prescriptions/statistics &amp, numerical data, Reimbursement, Physician&#039, s Practice Patterns/standards, Outpatients, Middle Aged, Male, Humans, General practitioners, France, Female, Drug Utilization/standards
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Résumé The study examines the triangular relationship between adult mortality, per capita income and foreign aid. Data are taken from the 'Institute for Health Metrics and Evaluation'. We have included 37 low-income (LIC), 39 lower middle-income (LMIC), and 20 upper middle income (UMIC) for the period 1990-2008. The study starts from the idea that the statistical relationship between series of foreign aid and population health may be bidirectional, adding a new stage of complexity for testing the impact of a third variable : GDP, which could also predetermine the levels of aid granted. The Granger causality test is the most effective and practical way to determine the direction of the causalities. Although less effective for particular groups of countries (UMIC), foreign aid generally has a negative impact on mortality, as reported by tests taking into account directional causalities (70 % of valid coefficients are negative). This result moderates the pessimistic view of international development aid, at least in the domain of assistance for health.
Mots clés Tests de causalité ? laGranger, Santé globale, Panel, Mortalité adulte, Health aid, Health, Granger-Causality, Aide ? la santé
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Résumé This paper examines the efficient allocation of international health aid. We built a simple macroeconomic model which considers an endogenous allocation of aid mixed between the public and the private channels. We derive a non-cooperative interaction-game involving the private sector, the donor and the recipient government. We compare the equilibrium of the game to the optimal level of health aid allocation, showing a gap between both. The empirical analysis is based on the Institute for Health Metrics and Evaluation (IHME) and World Health Organization (WHO) data sets using dynamic panel data model with fixed effects (system-GMM). Our results show that health aid actually reduces adult mortality in developing countries. Furthermore, we show that the actual allocation of aid-mix between government and private channels is not health efficient and there is room for reallocation.
Mots clés Régulation, PUBLIC HEALTH, Policy coordination, Panel data, International organizations, Foreign aid
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Résumé The purpose of this investigation was to adapt to an individual physician level and to the paediatric context a set of drug-specific indicators of outpatient antibiotic use developed by the European Surveillance of Antimicrobial Consumption (ESAC) project, and to describe the differences in antibiotic prescriptions between general practitioners (GPs) and paediatricians. We conducted a retrospective cross-sectional study analysing antibiotic prescriptions in 2009 for children below 16 years of age in south-eastern France, using the National Health Insurance (NHI) outpatient reimbursement database. A generalised linear model adjusted on physicians' characteristics and patient population characteristics was used to compare indicators between GPs and paediatricians. We included 4,921 self-employed GPs and 301 paediatricians. Penicillins accounted for 47% and 45% of all antibiotics prescribed by GPs and paediatricians, respectively, followed by cephalosporins (33% and 39%) and macrolides (14% and 9%). In both specialties, there were around 70% more antibiotic prescriptions during the winter quarters compared to the summer quarters. The 13 indicators we calculated showed wide variations in antibiotic prescriptions among GPs, among paediatricians, and between GPs and paediatricians. In an adjusted econometric model, GPs were found to issue 54% more antibiotic prescriptions than paediatricians, whereas paediatricians used a significantly higher proportion of co-amoxiclav (18% vs. 12%) and cephalosporins (39% vs. 33%) and a significantly lower proportion of macrolides (9% vs. 14%) compared to GPs. A set of 13 indicators may be calculated using reimbursement data to describe outpatient antibiotic use at the physician level. We observed very different prescribing profiles between GPs and paediatricians.
Mots clés Cross-Sectional Studies, General practitioners, Specialization, Adolescent, Anti-Bacterial Agents/therapeutic use, Child, Preschool, Female, Drug Prescriptions/statistics &amp, numerical data, Retrospective Studies, Male, Newborn, Infant, Humans, France
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Résumé no abstract
Mots clés Economie quantitative
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Résumé Women represent a growing proportion of the physician workforce, worldwide. Therefore, for the purposes of workforce planning, it is increasingly important to understand differences in how male and female physicians work and might respond to financial incentives. A recent survey allowed us to determine whether sex-based differences in either physician income or responses to a hypothetical increase in reimbursement exist among French General Practitioners (GPs). Our analysis of 828 male and 244 female GPs' responses showed that females earned 35% less per year from medical practice than their male counterparts. After adjusting for the fact that female GPs had practiced medicine fewer years, worked 11% fewer hours per year, and spent more time with each consultation, female GPs earned 11,194euro, or 20.6%, less per year (95% CI: 7085euro-15,302euro less per year). Male GPs were more likely than female GPs to indicate that they would work fewer hours if consultation fees were to be increased. Our findings suggest that, as the feminization of medicine increases, the need to address gender-based income disparities increases and the tools that French policymakers use to regulate the physician supply might need to change.
Mots clés Sex-based disparities, Productivity, Physician income, Incentives
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Mots clés Médecine de ville, Prevention
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Résumé BACKGROUND: Macroeconomic policy requirements may limit the capacity of national and international policy-makers to allocate sufficient resources for scaling-up access to HIV care and treatment in developing countries. METHOD: An endogenous growth model, which takes into account the evolution of society's human capital, was used to assess the macroeconomic impact of policies aimed at scaling-up access to HIV/AIDS treatment in six African countries (Angola, Benin, Cameroon, Central African Republic, Ivory Coast and Zimbabwe). RESULTS: The model results showed that scaling-up access to treatment in the affected population would limit gross domestic product losses due to AIDS although differently from country to country. In our simulated scenarios of access to antiretroviral therapy, only 10.3% of the AIDS shock is counterbalanced in Zimbabwe, against 85.2% in Angola and even 100.0% in Benin (a total recovery). For four out of the six countries (Angola, Benin, Cameroon, Ivory Coast), the macro-economic gains of scaling-up would become potentially superior to its associated costs in 2010. CONCLUSION: Despite the variability of HIV prevalence rates between countries, macro-economic estimates strongly suggest that a massive investment in scaling-up access to HIV treatment may efficiently counteract the detrimental long-term impact of the HIV pandemic on economic growth, to the extent that the AIDS shock has not already driven the economy beyond an irreversible 'no-development epidemiological trap'.
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Résumé La réforme de l'assurance maladie comporte trois volets. Le premier prévoit la création d'une Haute autorité de santé, (responsable de l'évaluation médicale, de la définition des " bonnes pratiques " médicales et des actes ayant vocation à être pris en charge par la Sécurité sociale) et une Union nationale des caisses d'assurance maladie (UNCAM) regroupant les caisses de salariés et de non salariés. L'État reste le décideur principal. Toutefois, la réforme confère plus de responsabilité à l'UNCAM qui pourra définir plus librement le champ des dépenses remboursables et les taux de remboursement, l'État ne pouvant intervenir dans ces domaines qu'au seul motif de la santé publique. Les assureurs complémentaires (mutuelles, institutions de prévoyance et assureurs privés) restent cantonnés dans leur rôle de payeurs subordonnés aux décisions de l'État et des caisses, même s'ils sont maintenant associés aux débats (...).
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Résumé Sur la question de la dépense de santé, les principaux partis politiques semblent en accord : on ne change rien, ou pas grand chose ; les difficultés vécues par le gouvernement Juppé en 1995 expliquent en partie cet " affichage " quasi général de la classe politique. Au-delà du consensus et des déclarations de principe (qualité des soins, grand respect des professions de santé, meilleure coordination entre ville et hôpital, prévention), c'est dans la nuance et par des mesures techniques que se distinguent les programmes. Il faut néanmoins y être attentif, car lorsqu'une mesure technique, comme le paiement à la pathologie, est susceptible de modifier le mode de fonctionnement d'un secteur représentant près de 5 % du PIB et des emplois français -- i.e. le secteur hospitalier français, un éclairage et une évaluation sont, au minimum, nécessaires. Au total, le secteur de la santé représente près de 10 % du PIB et constitue un des trois postes de dépenses les plus importants des ménages (...).
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Résumé L'article propose une revue des débats économiques que suscite la pandémie de SIDA en Afrique, notamment les débats portant sur l'accès restreint aux thérapeutiques brevetées et sur le droit international en matière de propriété intellectuelle (OMC, accords TRIPs). Après une rapide description de la maladie, de son épidémiologie, et des traitements existants, il énonce les différentes formes d'impact de la maladie sur l'économie et examine les études macroéconomiques disponibles pour les pays africains. La méconnaissance des aspects différés du choc, sur l'accumulation de capital et sur l'éducation, peut avoir conduit les études à sous-estimer l'effet de la maladie sur les mécanismes de développement de ces pays très pauvres. Ce constat, la gravité de la maladie, ainsi que l'observation des formes concrètes de l'échange international, plaident pour une intervention publique mondiale à deux niveaux : d'une part une réévaluation critique de la législation sur la protection des droits de propriété intellectuelle, mise en place sous l'égide de l'Organisation mondiale du commerce ; d'autre part la constitution d'un " fonds global " de connaissances et de moyens financiers, dans lequel les pays pauvres pourraient trouver les traductions concrètes des solidarités et d'une véritable gouvernance mondiales.
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Résumé Cet article propose une approche théorique de l'incidence des politiques de santé (contingentement, ticket modérateur, contrôle qualitatif) ; la voie envisagée est une analyse micro-macroéconomique. Le comportement de l'offre médicale est construit sur un choix d'allocation du temps de travail entre deux activités : l'une utile et l'autre inutile. Ce fondement microéconomique des arbitrages médicaux est ensuite intégré dans un modèle de croissance avec accumulation de capital ; les conclusions concernent alors les évolutions des dépenses de santé, du bien-être et de l'accumulation de patrimoine au regard de différents plans de politique de santé.
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Résumé Dans une première section, on testera, à l'aide d'un modèle macroéconomique conjoncturel, l'effet d'un programme " d'économies de dépenses de santé " (celui envisagé par la CNAM en 1999) et quelques variantes jugées pertinentes (ré-injection ou non des économies réalisées). Dans une seconde section, nous proposerons une réflexion à moyen terme -- à l'horizon 2004 -- sur trois scénarios alternatifs de croissance des dépenses de santé. Nous verrons que si les évolutions récentes de la dépense maladie se reproduisent sur les prochaines années, elles seront relativement bien financées par les recettes de cotisations aujourd'hui engendrées par la croissance économique de la France.
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Résumé Background. Earlier detection of neurodegenerative diseases may help patients plan for their future, achieve a better quality of life, access clinical trials and possible future disease modifying treatments. Due to recent advances in artificial intelligence (AI), a significant help can come from the computational approaches targeting diagnosis and monitoring. Yet, detection tools are still underused. We aim to investigate the factors influencing individual valuation of AI-based prediction tools. Methods. We study individual valuation for early diagnosis tests for neurodegenerative diseases when Artificial Intelligence Diagnosis is an option. We conducted a Discrete Choice Experiment on a representative sample of the French adult public (N=1017), where we presented participants with a hypothetical risk of developing in the future a neurodegenerative disease. We ask them to repeatedly choose between two possible early diagnosis tests that differ in terms of (1) type of test (biological tests vs AI tests analyzing electronic health records); (2) identity of whom communicates tests’ results; (3) sensitivity; (4) specificity; and (5) price. We study the weight in the decision for each attribute and how socio-demographic characteristics influence them. Results. Our results are twofold: respondents indeed reveal a reduced utility value when AI testing is at stake (that is evaluated to 36.08 euros in average, IC = [22.13; 50.89]) and when results are communicated by a private company (95.15 €, IC = [82.01; 109.82]). Conclusion. We interpret these figures as the shadow price that the public attaches to medical data privacy. The general public is still reluctant to adopt AI screening on their health data, particularly when these screening tests are carried out on large sets of personal data.
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Résumé Objectives: To analyse how general practitioners (GPs) respond to insucient GP supply in their practice area in terms of quantity and quality of care, and how this response can be mediated by enrolment in integrated primary care teams (multi-professional group practices (MGP)). Methods: We used three representative cross-sectional surveys (2019-2020) of 1,209 French GPs. Using structural equations, we assumed that low GP density inuences GPs' work-related stress (mediator 1) as well as their use of e-health tools (mediator 2) and ultimately quantity and quality of care. Quantity (respectively quality) of care were approximated by demand absorption capacities (respectively frequencies of vaccine recommendations). We estimated an additional specication where enrolment in an MGP was a mediator between GP density and the two mediators dened above. Results: GP density was signicantly and positively associated with work-related stress, which was consecutively associated with deteriorated demand absorption capacity. Higher use of e-health tools was associated with greater involvement in vaccine recommendations. Lastly, GPs in MGP tend to use more e-health tools than those practicing outside MGP, with a favourable eect on quality of care. Discussion: This study demonstrates that a lower level of work-related stress is the key mediator in handling patients' requests. Correcting for the self-selection into MGP, we amend some unstable results contained in the literature: there is no signicant mediation eect of enrolment in integrated primary care teams on the quantity of care, but rather an eect on the quality of care. Although probably disappointing for the quantity of care provided, our results pinpoint a novel added value of enrolment in an integrated practice as a response to decreasing GP density.
Mots clés General practitioners, Medically underserved area, Integrated care, France
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Résumé Background: Given the importance of continuous follow-up of chronic patients, we evaluated performance of French private practice general practitioners (GPs) practicing in multi-professional group practices (MGP), compared to their peers practicing outside MGP, regarding chronic care management during rst Covid-19 lockdown in spring 2020. Methods: The cross-sectional web questionnaire of 1,191 GPs took place in April 2020. We exploit self-reported data on: 1) frequency of consultations for chronic patients during lockdown compared to their typical week before the pandemic, along with 2) GPs proactive behaviour when contacting their chronic patients. We use probit and seemingly unrelated probit models (adjusted for endogeneity of choice of engagement in MGP) to test whether GPs in MGP had signicantly dierent responses to the Covid-19 crisis. Results: We nd that GPs in MGP were less likely to experience a drop in consultations related to complications of chronic diseases. They were also more proactive to contact their chronic patients. Conclusions: Quick policy response is needed to alleviate diculties encountered by GP practicing outside MGPs. Results advocate for further development of integrated care in the long run.
Mots clés General practitioners, France, Provider-sponsored organizations, Long-term care
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Résumé This study analyses the relationship between a household member’s migration and child mortality within the family left behind in rural areas. Exploring the richness of the Niakhar Health and Demographic Surveillance System panel, we use high-frequency migration data to investigate the effects of migration on child mortality at the household level over 16 years. Migrations, particularly short-term migrations, are positively associated with the survival probability of under-five children in the household. Also, we find that working age women's short-term migrations impact child mortality more than working age men's short-term migrations. This observation supports hypotheses in the economic literature on the predominant role of women in rural households in obtaining welfare improvements. Moreover, we detect crossover effects between households of the same compound –in line with the idea that African rural families share part of their migration-generated gains with an extended community of neighbors. Lastly, we investigate the effect of a mother's short-term migration on the survival of her under-5 children. The aggregate effect of a mother’s migration on child survival is still positive, but much weaker. Specifically, mother migration during pregnancy seems to enhance the wellbeing of the child, considered immediately after birth. However, when the child is older (more than one year), the absence of the mother tends to decrease the probability of survival.
Mots clés Niakhar, Senegal, Short- and long-term migrations, Child mortality
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Résumé We study physicians’ incentives to use personalized medicine techniques, replicating the physician’s trade-offs under the option of personalized medicine information. In a laboratory experiment where prospective physicians play a dual-agent real-effort game, we vary both the information structure (free access versus paid access to personalized medicine information) and the payment scheme (pay-for-performance (P4P), capitation (CAP) and fee-for-service (FFS)) by applying a within-subject design. Our results are threefold. i) Compared to FFS and CAP, the P4P payment scheme strongly impacts the decision to adopt personalized medicine. ii) Although expected to dominate the other schemes, P4P is not always efficient in transforming free access to personalized medicine into higher quality patient care. iii) When it has to be paid for, personalized medicine is positively associated with quality, suggesting that subjects tend to make better use of information that comes at a cost. We conclude that this last result can be considered a “commitment device”. However, quantification of our results suggests that the positive impact of the commitment device observed is not strong enough to justify generalizing paid access to personalized medicine.
Mots clés Personalized medicine, Fee-for-service, Capitation, Pay-for-performance, Physician altruism, Laboratory Experiment
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Résumé This paper analyzes the relationships between HIV/AIDS and education taking into account the appropriative nature of child income. We first build a simple theoretical model linking parental health risk, educational choice and appropriation of future children's income. We show that considering (remittances from) child's income as an insurance asset can reverse the usual negative relationship between disease prevalence and educational investment. This prediction is tested on data compiled from the Demographic and Health Survey (DHS) database for 17 Sub-Sahara African (SSA) countries between the years 2003 to 2010 for children aged between 6 and 22-years-old. To account for the hierarchical nature of the data we employ a multilevel analysis. We find that, in general, the impact of community HIV prevalence on school enrollment is insignificant. Once the data is split to account for differences in appropriation, the effect of community prevalence becomes positive and sometimes significant for highly appropriable groups (rural, girls) and remains either negative for the rest.
Mots clés Health Risk, Education, Insurance mechanism, Remittance
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