Indiana University-Purdue University Indianapolis (IUPUI) / My dissertation is a collection of three essays on the design of public health insurance in the United States. Each essay examines the responsiveness of health behavior and healthcare utilization to insurance-related incentives and draws implications for health policy in addressing the needs of disadvantaged populations. The first two essays evaluate the impact of Medicaid expansions under the Affordable Care Act (ACA) on health and healthcare utilization. The Medicaid expansions that included full coverage of preconception care, led to a decline in childbirths, particularly those that are unintended. In addition, these fertility reductions are attributable to higher utilization of Medicaidfinanced prescription contraceptives. The second essay documents patterns of aggregate prescription drug utilization in response to the Medicaid expansions. Within the first 15 months following the policy change, Medicaid prescriptions increased, with relatively larger increases for chronic drugs such as diabetes and cardio-vascular medications, suggesting improvements in access to medical care. There is no evidence of reductions in uninsured or privately-insured prescriptions, suggesting that Medicaid did not simply substitute for other forms of payment, and that net utilization increased. The effects on utilization are relatively higher in areas with larger minority and disadvantaged populations, suggesting reduction in disparities in access to care. Finally, the third essay considers the effect of Medicaid coverage loss on hospitalizations and uncompensated care use among non-elderly adults. The results show that coverage loss led to higher uninsured hospitalizations, suggesting higher uncompensated care use. Most of the increase in uninsured hospitalizations are driven by visits originating in the ED - a pattern consistent with losing access to regular place of care. These results indicate that policies that reduce Medicaid funding could be particularly harmful for patients with chronic conditions.

Includes abstract. Includes bibliographical references.

Includes bibliographical references (leaves 114-123). / Malaria is a major public health problem in Zambia accounting for more than 3 million clinical cases and about 33,000 deaths annually. Artemether-Iumefantrine, (a relatively expensive drug) is being used for first line treatment of uncomplicated malaria. However, diagnostic capacity in Zambia is low, which has both economical, and health implications for the health system. The current alternatives for diagnosis of malaria are clinical, microscopy and rapid diagnostic tests (RDTs). This study consists of an economic evaluation of the alternative malaria diagnosis methods in outpatient facilities in Zambia. The study is expected to contribute to effective decision-making in Zambia, especially when considering scaling up malaria diagnosis in health facilities.

This study aims to critically evaluate the ISPA [indirectly supervised pharmacists assistants] and nurse-based pharmaceutical care models against the standard of care that involves a pharmacist dispensing ART, on the basis of cost, and patient preference.

Includes bibliographical references (leaves 96-109). / The purpose of this study has been to determine the costs of an expanded free ART programme in Uganda and its implications for financial sustainability. The annual and lifetime incremental costs of ART from one treatment centre in Uganda were analysed. The key results from this centre were used to estimate the incremental costs associated with the scaling up of ART services in Uganda from the provider's perspective. A key concern was that the financial costs involved might not be financially sustainable by the country.

Bibliography: leaves 52-55.

Includes bibliographical references (leaves 103-107). / This study is from the perspective of rural South Africa using the case of Zithulele Hospital as an area of interest. The research is qualitative in nature and will make use of both focus group discussions and key informant inter-views, in order to assess the access to child health care provided at Zithulele Hospital. The focus will be on the acceptability of access to child health care and more specifically, the acceptability of treatment for diarrhoeal disease.

Although Zimbabwe has invested in nationwide scale-up of prevention of mother to child transmission (PMTCT) services, high HIV-specific under-five mortality rates continue to be observed. This study aimed to document the potential reasons for low PMTCT uptake by examining factors constraining access to PMTCT services.

Background: Although physician and hospital services are universally accessible without user charges through the stipulations of the Canada Health Act (CHA), formal home care is not included in the CHA and may be subject to user charges, which vary across provinces. The user charges may result in differential substitutability with informal care across provinces according to an individual’s income. Objectives: The objective of this research is to understand if income is related to the probability of receipt of caregiving, formal or informal, in the community (excluding institutional care). It will also be investigated if and in what measure income-related horizontal inequity exists for the receipt of formal and informal care and if this relationship varies across provinces. Methods: This secondary analysis first specified a logic regression model for predicting the use of informal care and home care. After standardizing for need, a concentration index was computed to measure horizontal inequity, which was then decomposed to understand the contributing factors to the unequal distribution in the receipt of formal home care and informal care. Results: After controlling for need, pro-poor income-related horizontal inequity exists for the receipt of formal home care and informal care. Conclusions: Income-tested provincial user charges for home care may contribute to a greater utilization of home care among the poor, but it should be further investigated if there is an unequal distribution of informal caregiver burden that results from the substitution with informal care due to these user charges. / Thesis / Master of Public Health (MPH)

Background: High quality evidence on the cost-effectiveness of planned birth in alternative settings (at home, in a midwifery unit or an obstetric unit) has been lacking, and is a priority area for maternity policy. Aim: To provide evidence about the efficiency of the configuration of maternity care in England and to estimate the cost-effectiveness of alternative settings for intrapartum care for ‘low risk’ women, thereby providing guidance for commissioners, clinicians and for pregnant women and their families. Methods: A literature review of existing evidence was followed by four stand-alone empirical studies using different methods to determine the efficiency and cost-effectiveness of alternative settings for intrapartum care. Data from the Birthplace in England Programme of Research were analysed to explore whether there are differences in the efficiency of maternity units when they are stratified according to the type and scale of unit. Incremental cost-effectiveness ratios were used to estimate the short-term cost-effectiveness of different planned settings for birth for ‘low risk’ women and to develop a template for the design of decision-analytic models to estimate life-long cost-effectiveness for the mother and baby dyad. Findings: The larger obstetric units (OUs) tended to be more efficient than the smaller OUs. Less than half of free-standing midwifery units (FMUs) were operating at full efficiency. The cost of intrapartum and after birth care, and associated related complications, was less for births planned at home, in a free standing midwifery unit (FMU), or in an alongside midwifery unit (AMU) compared with planned births in an obstetric unit (OU). Planned birth in a FMU or in an AMU compared with an OU will generate incremental cost savings but with uncertainty surrounding the outcomes for the baby. Planned birth in all non-OU settings generated incremental cost savings and improved outcomes for mothers. For ‘low risk’ women having a second or subsequent birth, planned birth at home was found to be the most cost-effective option.