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Background: The adoption of the Sustainable Development Goals in 2015 has renewed interest in maternal mortality reduction. Indonesia"'s maternal mortality ratio is among the highest in Southeast Asia. While skilled birth attendance (SBA) reduces the risk of maternal death, few studies have been done on SBA utilization in Indonesia using nationally representative data. This study estimated the own-price, cross-price, and income elasticities of demand for SBA in Indonesia. The effects of community and health system factors on SBA were also explored. Methods: Data from the 2004 wave of the Indonesia Family Life Survey, were used as the primary source of information. These data were supplemented with information from reports produced by the Indonesian Ministries of Health and Finance and the World Bank. The polytomous outcome variable was choice of attendance at last birth. Three estimation strategies were used to estimate the elasticities"u2014multinomial logit, multinomial probit, and an instrumental variable multinomial probit model. Statistical significance was determined at the 5% level. Results: The own-price elasticities of the facility-based delivery alternatives were between -1 and 0, indicating that demand is own-price inelastic for those alternatives. Two cross-price elasticities"u2014price of skilled home deliveries on demand for unskilled home deliveries and price of public facility deliveries on demand for skilled home deliveries"u2014indicated that women chose lower priced alternatives as the price of an alternative is increased. Increased income reduced demand for unskilled home deliveries and increased the demand for skilled home and private facility deliveries. Community and health system-level factors had small but significant effects on delivery attendance. Increases in the percentage of women in the community with SBA were associated with higher likelihood of using skilled delivery alternatives over unskilled home deliveries. Health worker density increased likelihood of choosing public facility deliveries over unskilled home deliveries. Finally, government health expenditure was positively associated with choosing skilled home and public facility deliveries over unskilled home deliveries, but was negatively associated with choosing private facility over unskilled home deliveries. Discussion: The elasticities revealed that women substituted for lower-priced alternatives as the price of an alternative increased and that they increased utilization of skilled delivery alternatives as household income increased. These findings can be interpreted as evidence that price is still a barrier to accessing SBA in Indonesia. The findings from the community and health system-level variables suggest extra-individual characteristics also affect individual decision-making on choice of delivery attendance. / 1 / Rieza Hawarina Soelaeman

This dissertation consists of three chapters on health economics, two of which focus on contraception and the third on vaccination. Chapter one examines the impact of state-level contraception insurance coverage mandates on women's fertility outcomes. It utilizes variation in mandated insurance coverage for contraception across states and over time to determine the causal impact of insurance coverage of contraception on fertility outcomes, specifically abortion rates and birth rates. State-level results indicate that a mandate decreases abortion rates by 6% in the year of introduction and decreases birth rates by 3% two years following introduction, with the magnitude of both effects remaining steady over the long run. Chapter two utilizes longitudinal data on varicella (chicken pox) immunizations in order to estimate the causal effects of state-level school-entry and daycare-entry immunization mandates within the United States. We find significant causal effects of mandates upon vaccination rates among preschool children aged 19-35 months; these effects appear in the year of mandate adoption, peak two years after adoption, and show a minimal difference from the aggregate trend about six years after adoption. For a mandate enacted in 2000, the model and estimates imply that roughly 20% of the short-run increase in state-level immunization rates was caused by the mandate introduction. We find no evidence of differential effects for different socioeconomic groups. Combined with the previous cost-benefit analyses of the varicella vaccine, the estimates suggest that state-level mandates have been effective from an economic standpoint. Chapter three utilizes variations in access to emergency contraception (EC) across states to determine the impact of over the counter access on abortion rates, birth rates, and risky sexual behavior. Using state-level data, a flexible time specification finds that giving individuals over the counter access to EC reduces births and increases risky behavior, which is captured by STD rates. These effects are larger for adults compared with teenagers, however, there are not significant differential effects by race. Finally, the effects are increasing over time following the legislation. / text

Several reviews have shown that health problems are the single most common adverse event experienced by households in many low- and middle-income countries. There is a great deal of research documenting household health expenditure and its impact on poverty. However, evidence on the costs incurred by households outside of the health care system is at best scattered. The objective of this present study is to document the household response to illness in China using two large-scale panel household surveys and following a 'health shocks' approach. Health shocks are used to address endogeneity concerns associated with the use of alternative traditional health measures. In this manuscript, the impact of health shocks on household socio-economic status and welfare is analysed using a framework encompassing household income, medical expenditure, consumption patterns, coping strategies, and labour force supply. We find that health shocks lead to a significant increase in medical expenditure (significant for all types of shocks), and in the case of a health shock experienced by a household head, to a decrease in income ranging around five per cent of the total household income. This decrease in income is partly explained by a statistically significant reduction in labour force supply (work hours and labour force participation) from individuals who experienced a shock (larger for women and elderly). In addition, for rural-to-urban migrant workers, health shocks are associated with a higher probability of returning. However, spouses also increase their labour force supply in response, which helps avoiding large shortfalls in income. Significant coping strategies include increase in debts and remittances; and in some cases, sale of assets. On consumption, households are mostly able to maintain consumption levels following the occurrence of a health shock (with the exception of food consumption). Nonetheless, we find a significant large negative trailing impact on consumption in subsequent years. This is in line with the literature arguing that households are risk adverse and deploy ineffective coping strategies to avoid immediate shortfalls in consumption, which generate delayed costs in the long run. The results of the analyses carried out in this thesis highlight some of the potential channels of impoverishment due to health shocks, which might be of interest for policy makers, especially in China where a large-scale health system reform is currently taking place.

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Bibliography : leaves 69-73. / This study analyses the user fee policy for health care in Kenya that was introduced to try and recoup some of the costs incurred in providing care as well as rationalise the use of resources. The study aims to generate policy-related findings that are crucial to MOH policy makers in their attempt to provide quality and affordable care. In particular, factors associated with proper function or malfunction of the user fee policy are discussed. The study focussed on four hospitals located in Central province of Kenya. This province was purposefully chosen for its convenience and its high potential for cost recovery. Equity in health care consumption, efficiency, sustainability and perceived quality of care are reviewed. Both primary and secondary data were used. Quantitative and qualitative data were solicited by way of administering questionnaires. Respondents were divided into two categories: providers (staff) and consumers (patients) of health care. The latter were subdivided into inpatients and outpatients. Each of these categories had a specific questionnaire. Further, an attempt is made to estimate net revenue generated in the year 1997/98 by the facilities under study. Costs associated with fee collection were estimated on monthly basis and then projected for the whole year. There are important findings from the study; though patients are charged higher fees at hospitals than at primary levels in order to bolster the referral system, many patients are bypassing the nearby primary care facilities. This study recommends that bypassing patients should be charged higher fees than referred ones.

Includes bibliographical references. / Some people have argued that there is no reason to expect economic efficiency in a government enterprise because the funds allocated to various ends have to be exhausted to meet targets. In a social and welfarist sense, this argument seems valid if in essence, such earmarked targets, to improve societal welfare, are met. However, in the face of rising hospital costs and insufficient government funds, the issue of effectively allocating government funds to alternative uses becomes paramount. The setting for this research paper is Nigeria. This research work aims at investigating how well financial resources are used in government hospitals in Nigeria. It not only explores the resources employed in hospitals, but also how well these hospitals use minimum resources to achieve maximum outpatient and inpatient output. Hospital cost and expenditure data are collected from 40 government cottage and general hospitals in South East Nigeria (Anambra and Enugu states specifically). The data is collected by means of open-ended questionnaires, which are filled in by relevant administrators in the hospitals visited and also by ministry of health personnel at the state levels. The main research question asked is whether hospitals in this part of the country (and indeed Nigeria as a whole) are allocatively inefficient. A second question as to whether hospitals in Anambra State are more efficient than Enugu State is also posed. The major component of the research involves using the cost and expenditure data to build cost functions for the entire hospitals studied. The main thrust of analysis is the stochastic frontier process, which also incorporates an efficiency effects model. The choice of this model, above all else, is because it provides numerical efficiency estimates and thus provides quantifiable proof of how well poorly Nigerian hospitals fare. It is found in the analysis of the data collected that the hospitals studied are generally inefficient, as 70 percent of them operate at costs above the average permissible cost frontier.

This thesis consists of three major essays that respectively investigate three factors that might influence child well-being: family income, family structure, and time spent in child care. Using the Canadian National Longitudinal Survey of Children and Youth (NLSCY), the first essay finds that income-based gaps in child health are statistically significant, quantitatively meaningful, and more pronounced as children age. Contrary to previous U.S. evidence, the observed income gradient in child health cannot be attributed to the protective effects of income on the incidence and severity of children’s health problems at birth and chronic conditions. This contrast may reflect the effects of universal health insurance in Canada. An instrumental variable estimator predicts a stronger causal effect of income on child health than does OLS. Also using the NLSCY, the second essay indicates that children persistently living in single-parent families have poorer health and educational outcomes compared to children persistently living in intact families. In addition, children whose parents separate during a given period exhibit worse health and educational outcomes compared to children whose parents remain together. Using a sibling fixed-effect approach substantially reduces the associations between children’s outcomes and parental separation predicted by OLS, but several gaps, especially in mental health, remain statistically significant and quantitatively meaningful. Using time-use data taken from the General Social Survey (GSS), the third essay finds that parental time spent in child care continuously and dramatically increased in Canada between 1986 and 2010. The increase in average time spent in child care applied to all gender and education groups but was associated with a growing dispersion in child care time. While more highly educated parents are more likely to spend time in child care, the education-based gaps in child care time are found to decline. / Thesis / Doctor of Philosophy (PhD)

The Affordable Care Act (ACA) was designed to reduce the number of citizens who do not have health insurance, and reduce the prices of health insurance premiums. Using multiple regression analysis, the effects of the components of the ACA, along with baseline characteristics of the states, are examined in relation to ACA premium prices and the rate of uninsured. We find that premium prices are higher in states with more uninsured, and states with more obesity have more uninsured. This is most likely related to pre-ACA practice of excluding people with pre-existing conditions from health insurance coverage, yet still caring for those uninsured individuals in emergency departments and hospitals, while passing on the costs of their care to those with insurance. When examining the specific components of the ACA, we find that premium prices are lower in states that implemented state run Internet exchanges, and that less people are uninsured in states that implemented state sponsored Internet exchanges. The other elements of the ACA, namely the number of available insurance plans, and the number of ACO’s, had no effect on either the premium prices or the number of uninsured. Given the possible influence of the political opposition to the ACA on the general population’s cooperation with the ACA, the political dominance of the states was also examined, but found to have no effect on either premium price or the number of uninsured. In conclusion, we find that states with higher rates of uninsured have higher premium rates, and states with higher rates of obesity have more uninsured. After one year of the ACA, we can measure the effect of Internet exchanges on reducing premium prices and the expansion of Medicaid on reducing the uninsured.

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