Background: Presenteeism is an economic concept that is difficult to identify, measure, and value. Rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) are three chronic auto-immune conditions that increase levels of presenteeism. Workplace interventions (WPIs) help individuals to manage their health condition at work. Existing methods used to quantify the impact of presenteeism are unable to adequately inform the employer of the productive benefits of WPIs. The overall aim of this thesis was to appraise current methods used to quantify presenteeism and to develop methods to value the impact of presenteeism suitable for use in economic evaluations (EE) of WPIs. Methods: Two systematic reviews were conducted: 1) to assess the extent to which self-report measure of presenteeism were underpinned by economic theory; and 2) to explore if, and how, productivity was quantified and included in EE of WPIs for musculoskeletal conditions (MSDs). Thematic analysis methods were used to analyse qualitative data collected from working individuals with RA, AS or PsA (n=22) that explored the extent to which measures of health status (EQ5D; SF6D) and capability (ICECAP-A) capture the impact on ability to work caused by RA, AS or PsA. Econometric methods were used to specify prediction models that included measures of health status, capability and presenteeism, using a sample of 542 working people with RA and AS. Results The first systematic review identified 24 self-report measures of presenteeism; all, except one measure were not underpinned by economic theory. The second systematic review identified 20 EE of WPIs for MSDs. Absenteeism was included in all studies (n=20); however, presenteeism was included in only four. The qualitative data confirmed measures of health status and capability had the ability to capture those aspects of RA, AS and PsA that impact an individual’s ability to work. The best performing prediction model used an OLS specification including SF6D, age and gender to predict presenteeism measured by the WPAI. Conclusion: The results suggest that HRQoL measures, specifically the SF6D, can be used to capture and predict levels of presenteeism caused by RA, AS and PsA.

This dissertation proposal examines empirically the determinants of Olympic performance and the transition and persistence of Major League Soccer (MLS). The first chapter estimates the relationship between the performance by a country at the Olympics, measured by number of medals obtained, and a country's health indicators. We want to examine the relationship that improved sanitation access has on Olympic performance. The data sources are from the Olympic Committee, World Development Indicators and various sources. A panel tobit estimation will be used to examine this relationship. The second chapter deals with the determinants of Major League Soccer teams' performance. We want to examine and estimate variables that improve the performance of MLS teams. The data sources are taken from Major League Soccer teams main pages, Bureau of Economic Analyis, Bureau of Labor Statistics and the United States Census Bureau. We will use a Generalized Method of Moments (GMM) estimation and instrumental variable (IV) estimation which assists us in controlling for observed endogeneity. The third chapter examines the competitive transition and persistence associated with Major League Soccer. A proportional hazard model and a multinomial logit model is used in this estimation to examine the ability of teams to remain competitive, where we explore the factors that assists teams in remaining in specific states of competitiveness.

This thesis identifies and analyzes current problems in the healthcare market in China. Although many health indicators of China such as life expectancy and child mortality rates have improved significantly and suggest that the healthcare reform in China is successful, there have been many more reports of patient's violent attack towards the doctor, the sudden death of doctors, and decreasing doctor supplies that suggest otherwise. I observed that the relationship between doctors and patients are intense, doctors experience enormous working pressure, and many doctors are leaving the market. It makes me wonder how did government fail to improve its healthcare quality while health indicators suggest huge improvements. This thesis mainly focuses on how institutions contribute to the market inefficiencies. I hope this thesis will provide some insights for future reform policies.

Chapter 1. In the 1970s, competition policy in the United States banking sector changed from exempting competition to liberalization and deregulation. Competition not only plays an important role in allocational efficiency but it is also essential for long-term economic growth. This chapter develops a model of banking contributions to evaluate to what extent banks affect the level of competition in the banking sector, and tests the model's predictions using a novel detailed dataset which includes all contributions made by banks from 1993 to 2010 in the United States. Controlling for banks' characteristics, the results are consistent with the model's predictions and show show that a higher level of contributions increases the Lerner index (as a measure of competition) or in the other words, decreases the level of competition. Chapter 2. This chapter provides the first empirical evidence that market structure affects the electoral power of firms as special interest groups. Firms not only affect the election outcomes by making contributions to their preferred candidates, they also enforce social norms among their members by encouraging them to vote for the candidate with the most closely-aligned interests. This chapter uses a linear probability model to analyze 574 open-seat races for the House of Representatives in the United States between 1990 and 2014. The results show that, even when controlling for the total value of contributions made to a candidate, political donations made by firms with high market power have a positive effect on the candidates' probability of winning. The findings are consistent with the idea from collective action theory that concentrated industries are more likely to behave as an organized interest group to advance their interests. Chapter 3. Ethnic heterogeneity is an important factor in the formation of human sexual network and the prevalence of STDs. Racial and ethnic ties create closed social networks with rigid in-group boundaries and hampers the intra-group dissemination of information. Slow information flow among groups facilitates the spread of STDs by encouraging individuals to ethnically diversify their sexual partners in order to lower the chance of getting caught cheating. Analyzing a cross-province sample of 39,830 sexually active adults driven from the 2013-2014 Canadian Community Health Survey, we find that individuals who live in a highly ethnically diversified neighbourhood are more susceptible to STDs compared to ones who live in a ethnically homogenous neighbourhood. Evidence from several robustness checks suggests that the relationship is causal.

Três modelos teóricos de negociação entre seguradores e provedores privados são desenvolvidos e seus resultados simulados e analisados. Os modelos procuram captar o que seria o encontro entre um segurador e um provedor vinculados entre si por um contrato de parceria e sentados à mesa para negociarem os preços do seguro-saúde e do bem/serviço médico. Na estrutura dos modelos está presente o problema de agente-principal característico da relação entre os dois atores, dadas as assimetrias informacionais inerentes ao campo da saúde. Tanto o segurador quanto o provedor estão restritos por considerações junto a seus consumidores. O processo de negociação em si baseia-se no modelo de Stackelberg para oligopólios, o que produz dois cenários: num primeiro cenário o líder da negociação é o provedor e num segundo cenário o líder da negociação é o segurador. / Three theoretical models about negotiation between private insurers and providers are developed and their results are simulated and analyzed. The models try to catch what would be a meeting between an insurer and a provider tied each other by an association contract bargaining the health insurance price and the medical good/service price. The main problem is the agent-principal relationship in an environment with asymmetric information. Both agents are restricted by consumer behavior. The basis for the bargain process is the Stackelberg model for oligopolies, which gives two scenes: one with insurer leadership and other with provider leadership.

Na literatura de federalismo fiscal, além da discussão relativa ao efeito flypaper, surge para despesas condicionais evidência de que o gasto na área escolhida pode aumentar menos do que a quantidade da transferência destinada àquela área, sendo o restante dos recursos destinados a outros bens e serviços públicos - o efeito fungibilidade. Pretende-se avaliar o impacto das transferências do Sistema Único de Saúde testando além do efeito flypaper, o efeito fungibilidade para despesas municipais de saúde (totais, com pessoal, com medicamentos, com serviços de terceiros e com investimentos). Utilizaram-se modelos clássicos de dados em painel e regressões quantílicas com efeitos fixos. Obteve-se evidência de que, para o total, ocorre o efeito fungibilidade para transferências do Piso de Atenção Básica fixo, uma vez que para cada R$ 1 de transferências para saúde cerca de R$ 0,20 é aplicado em outras áreas. Além disso, tal efeito parece ser menor em municípios que apresentam gastos mais elevados em saúde. Ademais, o efeito flypaper parece estar mais associado a despesas com pessoal. / In the fiscal federalism literature, beyond the discussion on the flypaper effect arises evidence for conditional grants that spending in the chosen area may increase by less than the amount of the transfer meant to that area, with the remaining funds being used for other goods and public services - the fungibility effect. This work aims to assess the impact of transfers from Unified Health System besides the flypaper effect, testing also the fungibility effect for different kinds of municipal health expenditures (total expenditures, expenditures with employees, expenditures with drugs, expenditures with outsourced services and investment expenditures). Classical models of panel data and quantile regressions with fixed effects were used. There is evidence that, for total expenditures, fungibility effect occurs for Fixed Basic Atention National Policy grants, since for every R$ 1 of health transfers to approximately R$ 0,20 is applied in other areas. Moreover, this effect appears to be lower in cities that have higher health care expenditures. Furthermore, the flypaper effect seems to be more associated with expenditures with expenditures.

The central goal of my dissertation is to answer important questions about market design in health care when consumers have inertia, using modern industrial organization tools. The presence of consumer inertia in several markets has been well established in the literature, although we still know very little about how inertia affects the way markets work. In my dissertation, I shed light on these issues in the context of different institutional settings of health care sectors in different countries. Health care markets are extremely relevant because of their huge impacts on the quality of life and on mortality of individuals. In times when the expenditure on health care is increasingly high in modern economies, a better understanding of how these markets work is needed in order to decrease costs and improve their performance. The first chapter disentangles the effects of reductions in switching costs and in the length of contracts (lock-in) on consumer welfare, using quasi-experimental variation in the length of contracts in the Uruguayan health care system. In the second chapter, I study the effect of supply-side firm responses in terms of pricing and offering of new products, on consumer welfare in Medicare Part D in the U.S. Finally, the third chapter studies the effects of increased competition induced by reductions of consumer inertia, on quality and returns to skills for physicians, using uniquely detailed data from the Uruguayan health care sector. The use of tools from the field of industrial organization allows me to combine a solid theoretical background with clearly identified reduced-form and structural models, to analyze the welfare implications of equilibrium behavior in these markets, and to evaluate policy interventions and regulations aimed at improving welfare.

Discrete choice experiments (DCEs) are a stated preference valuation method. As a ubiquitous component of healthcare delivery, risk is increasingly used as an attribute in DCEs. Risk is a complex concept that is open to misinterpretation; potentially undermining the robustness of DCEs as a valuation method. This thesis employed quantitative, qualitative and eye-tracking methods to understand if and how risk communication formats affected individuals’ choices when completing a DCE and the valuations derived. This thesis used a case study focussing on the elicitation of women’s preferences for a national breast screening programme. Breast screening was chosen because of its relevance to primary care and potential contribution to the ongoing debate about the benefits and harms of mammograms. A DCE containing three attributes (probability of detecting a cancer; risk of unnecessary follow-up; and cost of screening) was designed. Women were randomised to one of two risk communication formats: i) percentages only; or ii) icon arrays and percentages (identified from a structured review of risk communication literature in health).Traditional quantitative analysis of the discrete choices made by 1,000 women recruited via an internet panel revealed the risk communication format made no difference in terms of either preferences or the consistency of choices. However, latent class analysis indicated that women’s preferences for breast screening were highly heterogeneous; with some women acquiring large non-health benefits from screening, regardless of the risks, and others expressing complete intolerance for unnecessary follow-ups, regardless of the benefits. The think-aloud method, identified as a potential method from a systematic review of qualitative research alongside DCEs, was used to reveal more about DCE respondents’ decision-making. Nineteen face-to-face cognitive interviews identified that respondents felt more engaged with the task when risk was presented with an additional icon array. Eye-tracking methods were used to understand respondents’ choice making behaviour and attention to attributes. The method was successfully used alongside a DCE and provided valid data. The results of the eye-tracking study found attributes were visually attended to by respondents most of the time. For researchers seeking to use DCEs for eliciting individuals’ preferences for benefit-risk trade-offs, respondents were more receptive to risk communicated via an icon array suggesting this format is preferable. Policy-makers should acknowledge preference heterogeneity, and its drivers, in their appraisal of the benefits of breast screening programmes. Future research is required to test alternative risk communication formats and explore the robustness of eye-tracking and qualitative research methods alongside DCEs.

This work includes a series of studies that examines the health and economic impacts of screening mammography from international and Canadian perspectives. This work is a compendium of several researched chapters that include an introduction, four body chapters, and a discussion. The body chapters include a systematic review of the health economic literature on screening mammography, a review of quantitative models used to examine the consequences of breast cancer screening, and cost-effectiveness analyses of screening mammography programs in Canada for the general female population and for subgroups of the population at high-risk for breast cancer. There are three analytic chapters that will be submitted as manuscripts for peer-reviewed publication. The main results of this research show that current screening mammography practices in Canada may extend life at an acceptable cost to the health care system. Due to the outlined methodological limitations of this research the results should be interpreted with caution.

Evaluating Drugs for Rare Diseases (DRDs) for the purpose of reimbursement and beyond represents a tremendous challenge for most health care priorities. A consensus is set about the irrelevance of cost e ectiveness analysis to evaluate such drugs. The appeal for multi criteria decision aid models seems reasonable as the evaluation of DRDs is indeed multifaceted. However, the application of MCDA for the purpose of evaluating DRDs is yet primitive and simplistic. The present work tries to tackle the issue of evaluating DRDs from a decision maker angle by adopting an innovative robust ordinal regression MCDA method, UTADIS-GMS, that helps the decision maker discern between the DRDs based on their multi criteria value.