Philosophiae Doctor - PhD / This thesis purposes to examine the impact of financial development on health outcomes, health care expenditure and financial protection in health in 46 selected sub-Saharan African (SSA) countries from 1995 to 2014. It also estimates the impact of health care expenditure on health outcomes. The thesis is premised on the hypothesis that health care expenditure is a critical transmission mechanism through which financial development leads to better health outcomes. The health care expenditure channel is conspicuously absent in the literature on financial development and health outcomes; hence the need for this study to fill the gap in the literature. The thesis explores the effects of both depth and access dimensions of financial development on health outcomes, expenditure and financial protection. Throughout the study, financial access is measured by the number of automated teller machines (ATMs) and commercial bank branches per 100 000 people, while financial depth is measured by the proportion of broad money and bank credit to the private sector, to Gross Domestic Product (GDP). The study uses fixed and random effects and the Two-Stage Least Squares estimation approaches. The Generalised Method of Moments (GMM) is also used to estimate the impact of health care expenditure and health outcomes given the absence of valid instrumental variables. The results of the regression analyses show that financial development leads to increased health care expenditure and health outcomes. The analysis also shows that health care expenditure leads to better health outcomes. Additionally, the study indicates that financial development leads to financial protection in health care by reducing out-of-pocket health care expenditure. Well-developed financial systems provide financial protection from the risk of catastrophic health care expenditure and impoverishment resulting from illness. The study shows that health care systems financed through prepaid mechanisms reduce neonatal, infant and under-five mortality rates and increase life expectancy, while those relying on out-of-pocket expenditure have adverse effects on health outcomes.

This thesis examines the convergence in health care spending in euro area member countries during the period 1995-2010 and the influence of joining euro zone on convergence of health care expenditure. Panel data set covering 17 cross-sectional units (current eurozone member countries) over 15-years time period is examined using the classical approach to convergence. The analyses presented in this thesis provide evidence of sigma-convergence of HCE as a share of GDP. Conditions for sigma-convergence of HCE per capita are not satisfied. As for beta-convergence, the analysis of HCE as a share of GDP confirm the absolute convergence, conditional convergence did not occur. As for HCE per capita, absolute and conditional convergence hypotheses were affirmed. In both cases of absolute convergence, joining the euro area significantly supported convergence of HCE.

This dissertation consists of six essays in health economics.The first essay, “Economic evaluations in health care: Basic principles and special topics”, serves as an introduction to economic evaluations in health care, including estimations of costs, health effects, and the discount rate. Special topics of interest for the rest of the studies are also discussed, e.g. the role of modelling in cost-effectiveness analysis, and methods for dealing with incomplete observations in clinical trial data. The main theme of the second essay, “Consumption and production by age in Sweden: Basic facts and health economic implications”, is a fairly detailed compilation of consumption and production figures by age in Sweden. The purpose of this is to use the difference between consumption and production in each age group as a measure of the average costs of added years of life in the general population. In economic evaluations of health care interventions, only future costs for related ill­nesses have typically been included in the analysis. However, the health economist David Meltzer has argued that future costs for un­related illnesses and general consumption should also be in­cluded in eco­nomic evaluations. Otherwise, the analysis will not be consistent with expected utility maximiza­tion. The third essay is entitled “The possibility of predicting health care costs in the future from predicted changes in age structure and age specific mortality: The case of Sweden”. Changes in the age structure, especially the growing number of elderly people, have raised concerns about increasing costs for health and elderly care in the future. However, the number of elderly per se is not the main problem, since the growing number of elderly people is a result of better health and hence lower morta­lity. The main purpose of the study is to investigate if future health care costs can be predicted based on forecasts of future changes in age structure and mortality rates. It is shown here that at least in Sweden and in the U.S., there is a linear relationship between age-specific mortality and age-specific health care costs. When these relationships are applied retrospectively to old data, however, the predictions are underestimates of the actual costs. These results are in line with earlier studies, which show that the future age structure is not likely to have a great impact on the future health care costs. The fourth essay is called “Cost effectiveness of bisoprolol in the treatment of chronic congestive heart failure in Sweden: Analysis using data from the Cardiac Insufficiency Bisoprolol Study II” (with Niklas Zethraeus and Bengt Jönsson). Treatment of heart failure with beta blockers was introduced in Sweden already in the 1970s, but it was not until the 1990s that large-scale clinical trials established the efficacy of beta blockers in reducing heart failure mortality. The study consists of an economic evaluation of the beta blocker bisoprolol added to standard treatment of chronic heart failure, compared with placebo added to the same standard treatment. The study raises a number of methodological issues. At the forefront are the inclusion of costs of added years of life, and the question of how to model health effects that extend beyond the clinical trial on which the economic evaluation is based. The results indi­cate that treatment with bisoprolol is cost-effective. A drawback of the analysis in the fourth study was that the expected survival after the end of follow-up was modelled deterministically. This makes it impossible to assess the uncertainty of the cost-effectiveness estimate in a realistic way. The fifth essay is entitled “Assessing uncertainty in cost-effectiveness analysis by combining resampling of clinical trial data with stochastic modelling: The economic evaluation of bisoprolol for heart failure revisited”. Here, the drawback with the fourth study that was mentioned above is addressed by using resamp­ling of the clinical trial data in combination with stochastic modelling of the expected survival after the end of follow-up in the clinical trial. The methodology is inspired by the bootstrap method, which is a simulation technique whereby various statistics, like the mean and variance, can be estimated through repeated resampling from the original sample. The difference from the traditional boot­strap method is that resampling of observations from the clinical trial data is combined with stochastic modelling of the expected remaining lifetime of the patients who were alive at the end of the clinical trial. Cost-effectiveness acceptability curves for treatment of heart failure with bisoprolol were obtained as a result of the analysis. The sixth essay, “Survival analysis techniques for estimating the costs attributable to head and neck cancer in Sweden”, concerns the estimation of average treatment cost attri­butable to a disease when the data contain censored, i.e. incomplete, observations. For various reasons, censored observations are common in medical and epidemiological studies. As a result, the length of the survival time or the size of the costs for those who are alive at the end of follow-up are not exactly known. This is of course problematic if we want to estimate the average survival time or the average cost for all patients, both survivors and non-survivors included. In this study, the Kaplan-Meier sample-average estimator is used for overcoming the problem with censored observations. It is a method that has been proposed specifically for handling censored cost data. / Diss. Stockholm: Handelshögsk., 2002

Both economists and policy makers are interested in understanding the welfare effect of economic policies, especially in small open economies such as Turkey and Iran. This knowledge is crucial for priority setting in any informed policy discussion. This dissertation aims to study the impoverishing effect of high levels of out-of-pocket (OOP) payments in the health sector, referred to as catastrophic health expenditure (CHE), and investigates the impact of exchange rate pass-through (ERPT) on both the microeconomic and macroeconomic indicators of a country. For millions of people worldwide, health payments present a huge financial risk. A high rate of OOP health care payments can lead to CHE, which can force households to cut down their consumption, minimize access to their needs, or face poverty. This makes the design of financial risk protection necessary for governments in order to secure people against the financial hardship at the time of incurring CHE. This thesis comprises three essays. The first investigates financial risk protection indicators related to OOP health care payments through CHE mean positive overshoot and incidence and depth of impoverishment. This research observes that in the absence of universal health care insurance in Iran, together with a high share of OOP spending for health care (more than 52%), the Iranian households facing CHE will eventually face poverty. In the second essay, using a difference-in-differences propensity score matching approach, I seek to analyze the degree to which Iranian universal health care insurance protects households from high rates of OOP health expenditure. In this study, I evaluate the effect of the universal health insurance program on Iranian CHE. The results show that the program was successful in decreasing the rate of OOP health expenditures and CHE in Iran during the sample period. The third essay estimates the ERPT using product-level daily data on wholesale prices of imported agricultural products, where the identification is possible by using daily data on the domestic inflation rate. The results of standard empirical analyses are in line with existing studies that employ lower frequencies of data by showing evidence for incomplete daily ERPT of about 5 percent.

This paper uses the panel data of 11 OECD countries over a period from 1971 to 2006. Unlike the traditional cointegration model which omitted the impact of structural breaks in the analysis, this paper applies panel cointegration with structural break test proposed by Westerlund (2006), panel unit root test, and panel dynamic OLS test. The empirical results indicate that health care expenditure and economic growth (GDP per capita) are non-stationary in the series; and between the two variables, a long-term cointegration relationship exists. Moreover, a positive correlation between HCE and economic growth is found in the panel dynamic OLS model. The researcher concludes that investing in health capital improves human capital and that boosts economic growth in the sample countries, and vice versa. More importantly, allowing structural breaks in the cointegration analysis obtains reliability in the estimation and proves more detailed and specific information on the consequence of the momentous events on the two variables; and thus enables policy makers and health economists to propose more effective strategies.

<p>This thesis consists of a summary and four papers. The first two concerns health care and sickness absence, and the last two pharmaceutical costs and prices.</p><p>Paper [I] presents an economic federation model which resembles the situation in, for example, Sweden. In the model the state governments provide health care, the fed-eral government provides a sickness benefit and both levels tax labor income. The re-sults show that the states can have either an incentive to under- or over-provide health care. The federal government can, by introducing an intergovernmental transfer, in-duce the state governments to provide the socially optimal amount of health care.</p><p>In Paper [II] the effect of aggregated public health care expenditure on absence from work due to sickness or disability was estimated. The analysis was based on data from a panel of the Swedish municipalities for the period 1993-2004. Public health care expenditure was found to have no statistically significant effect on absence and the standard errors were small enough to rule out all but a minimal effect. The result held when separate estimations were conducted for women and men, and for absence due to sickness and disability.</p><p>The purpose of Paper [III] was to study the effects of the introduction of fixed pharmaceutical budgets for two health centers in Västerbotten, Sweden. Estimation results using propensity score matching methods show that there are no systematic differences for either price or quantity per prescription between health centers using fixed and open-ended budgets. The analysis was based on individual prescription data from the two health centers and a control group both before and after the introduction of fixed budgets.</p><p>In Paper [IV] the introduction of the Swedish substitution reform in October 2002 was used as a natural experiment to examine the effects of increased consumer infor-mation on pharmaceutical prices. Using monthly data on individual pharmaceutical prices, the average reduction of prices due to the reform was estimated to four percent for both brand name and generic pharmaceuticals during the first four years after the reform. The results also show that the price adjustment was not instant.</p>

This thesis consists of a summary and four papers. The first two concerns health care and sickness absence, and the last two pharmaceutical costs and prices. Paper [I] presents an economic federation model which resembles the situation in, for example, Sweden. In the model the state governments provide health care, the fed-eral government provides a sickness benefit and both levels tax labor income. The re-sults show that the states can have either an incentive to under- or over-provide health care. The federal government can, by introducing an intergovernmental transfer, in-duce the state governments to provide the socially optimal amount of health care. In Paper [II] the effect of aggregated public health care expenditure on absence from work due to sickness or disability was estimated. The analysis was based on data from a panel of the Swedish municipalities for the period 1993-2004. Public health care expenditure was found to have no statistically significant effect on absence and the standard errors were small enough to rule out all but a minimal effect. The result held when separate estimations were conducted for women and men, and for absence due to sickness and disability. The purpose of Paper [III] was to study the effects of the introduction of fixed pharmaceutical budgets for two health centers in Västerbotten, Sweden. Estimation results using propensity score matching methods show that there are no systematic differences for either price or quantity per prescription between health centers using fixed and open-ended budgets. The analysis was based on individual prescription data from the two health centers and a control group both before and after the introduction of fixed budgets. In Paper [IV] the introduction of the Swedish substitution reform in October 2002 was used as a natural experiment to examine the effects of increased consumer infor-mation on pharmaceutical prices. Using monthly data on individual pharmaceutical prices, the average reduction of prices due to the reform was estimated to four percent for both brand name and generic pharmaceuticals during the first four years after the reform. The results also show that the price adjustment was not instant.

The diploma thesis contains a comprehensive view of the health system in the Federal Republic of Germany in 1995-2015. The main aim of this work is to establish recommendations for improvement of the Czech health system based on the evaluation of the findings on the German health system. The partial aims of the diploma thesis are the characteristics of the health system and the analysis of income and expenditure in health care in Germany. The thesis is divided into six chapters. The first chapter is focused on the information obtained from professional literature. In particular, it describes the different concepts related to healthcare and its financing. The second chapter focuses on the economic concept and the issue of the health system. The third part contains a description of the country's health system. Here are also some selected data about Germany, organization or authority at federal, state and local levels. The fourth chapter deals with the insurance market in Germany. The fifth part summarizes the fundamental reforms of the health system of the Federal Republic. The last chapter is an analysis of income and expenditure of the health system. This section analyzes the data available from statistics from the German Statistical Office or from multinational organizations such as WHO, OECD or the World Bank.

No description available.

Fondée sur deux analyses empiriques et sur un travail de modélisation théorique, cette thèse traite de la problématique du vieillissement de la population, en France, en termes de dépenses de biens et services de santé, et en termes de prise en charge des personnes âgées dépendantes. Dans un premier chapitre, une méthode de microsimulation dynamique est mise au point afin d'évaluer l'évolution des dépenses de médicaments remboursables (en médecine de ville) sous l'effet du vieillissement de la population et de l'évolution de l'état de santé chronique des personnes âgées. Un deuxième chapitre s'intéresse aux tenants d'une possible réforme de l'Allocation Personnalisée d'Autonomie (APA), qui viserait à récupérer sur la succession une partie des fonds versés aux personnes dépendantes. Nous développons un modèle théorique de transfert intergénérationnel en individualisant les décisions des deux membres d'une famille, un parent dépendant et un enfant aidant informel potentiel. Enfin, dans une dernière partie, nous évaluons empiriquement les facteurs modifiant la demande d'aide à domicile des bénéficiaires de l'APA, en nous concentrant, afin d'anticiper sur de possibles réformes de l'aide publique, sur l'évaluation des effets-prix dans la demande d'aide formelle. / This thesis addresses, using an elaborated theoretical model and two empirical applications, issues related to population ageing and health care expenditures as per the French context. In the first chapter, a method of dynamic microsimulation is developed to assess the evolution of outpatient reimbursable drugs expenditures as a result of the ageing population and the evolution of health status of chronically ill elderly people. The second chapter focuses on the ins and outs of a possible reform of the Personal Allowance for Autonomy (APA), which would seek to recover a portion of the funds paid to disabled elderly on the inheritance of their heirs. A theoretical model of intergenerational transfers is developed to study the individual decisions of a two-member family - a disabled parent and a child who can play the role of informal care giver. The final section presents an empirical evaluation of the factors affecting the demand of APA's recipients for home care. This work examines the price effects in the demand for formal care in order to anticipate possible reforms of public allowance.