Community-Based Health Insurance and Out-of-Pocket Healthcare Spending in Africa: Evidence from Rwanda

In the absence of third party and prepayment systems such as health insurance and tax-based healthcare financing, households in many low-income countries are exposed to the financial risks of paying large medical bills from out-of-pocket. In recent years, community based health insurance schemes have become popular alternatives to fill such void in the healthcare financing systems. This paper investigates the impact of these schemes on out-of-pocket spending based on three rounds of nationally representative data from Rwanda. We estimate an Extended Two-Part Model to address endogeniety in insurance enrollment and censoring in healthcare expenditure data. We find that community based health insurance program has non-linear and mixed impacts on out-of-pocket expenditure. While the program significantly increases the probability of overall spending, it decreases the amount of per capita spending on healthcare. The program also significantly reduces spending on drug but increases outpatient spending with no detectable impact on inpatient services. Furthermore, we find notable heterogeneity in treatment effects in which households in the top income distribution realize the highest reduction in out-of-pocket spending

Essays on Formal and Informal Long-Term Health Insurance Markets

This dissertation consists of two essays examining formal and informal long term health insurance markets. The first essay analyzes heterogeneity of Long-Term Care Insurance policyholders in their lapse decision, and how their ex-ante and ex-post subjective beliefs about the probability of needing Long-Term Care affect their lapse decisions. In this essay, I develop a model of lapse decision in a two-period insurance framework with a Bayesian learning process and implement several empirical specifications of the model using longitudinal data from the Health and Retirement Study. The results show that policyholders\u27 ex- ante point predictions of their probabilities and their uncertainties about them have a persistent but declining impact on lapse decisions. Those who believe that their risk is higher are indeed more likely to remain insured. However, as their uncertainties surrounding their ex-ante point predictions increase, their chances of lapsing increase regardless of their initial perception biases. These results are heterogeneous across cohorts and policyholders and, in particular, show that those in the older group near the average age of Nursing Home entry have a precise prediction of their risk levels compared to the younger cohort. Policy simulations show that a more informed initial purchase decision reduces the chance of lapsing down the road. The second essay examines the extent to which informal risk sharing arrangement provides insurance against health shocks. I develop a comprehensive model of informal risk sharing contract with two-sided limited commitment which extends the standard model to a regime with the following features. Information regarding the nature of realized health shocks is imperfect and individuals\u27 health capital stock serves as a storage technology and is a factor of production. The theoretical results show that, in such a regime, Pareto optimal allocations are history dependent even if participation constraints do not bind. I perform numerical analysis to show that risk sharing against health shock is less likely to be sustainable among non-altruistic individuals with different levels of biological survival rates and health capital productivity. The results also show that optimal allocations vary depending on the set of information available to individuals. Using panel data of households from villages in rural Ethiopia, I test the main predictions of the theoretical model. While there is negative history dependence in transfers among non-altruistic partners, history dependence is positive when risk sharing is along bloodline and kinship. However, neither short-term nor long-term health shocks are insured through informal risk sharing arrangements among non-altruistic individuals

Women Self-Selection out of the Credit Market in Africa

Women are disproportionately disadvantaged in access to finance in Africa. While supply-side detriments, such as high interest rates and collateral requirements, are well documented in the literature, little is understood about how demand-side factors contribute to the observed gender gap in access to finance. This paper provides the first empirical evidence on how women managers’ perception about their creditworthiness contributes to the large gender gap in Africa, particularly in the Northern region. One of the innovations of the paper is introducing a theoretical model using the credit market framework with imperfect and asymmetric information to explain what may drive loan applicants to self-select. We use firm-level data for 47 African countries from the World Bank Enterprise Survey. We find that women entrepreneurs in Africa, in general, and in North Africa, in particular, are more likely to self-select themselves out of the credit market due to low perceived creditworthiness compared to their men counterparts. The results also suggest that the observed self-selection behavior is not a response mechanism to current discriminatory lending practices by the banks. The results are robust to different empirical specifications. The findings will inform policies towards greater financial inclusion of women in the region

Women Self-Selection out of the Credit Market in Africa

Women are disproportionately disadvantaged in access to finance in Africa. While supply-side detriments, such as high interest rates and collateral requirements, are well documented in the literature, little is understood about how demand-side factors contribute to the observed gender gap in access to finance. This paper provides the first empirical evidence on how women managers’ perception about their creditworthiness contributes to the large gender gap in Africa, particularly in the Northern region. One of the innovations of the paper is introducing a theoretical model using the credit market framework with imperfect and asymmetric information to explain what may drive loan applicants to self-select. We use firm-level data for 47 African countries from the World Bank Enterprise Survey. We find that women entrepreneurs in Africa, in general, and in North Africa, in particular, are more likely to self-select themselves out of the credit market due to low perceived creditworthiness compared to their men counterparts. The results also suggest that the observed self-selection behavior is not a response mechanism to current discriminatory lending practices by the banks. The results are robust to different empirical specifications. The findings will inform policies towards greater financial inclusion of women in the region

Foresight Africa: Top Priorities for the Continent 2020-2030

The new year 2020 marks the beginning of a promising decade for Africa. Through at least the first half of the decade, economic growth across Africa will continue to outperform that of other regions, with the continent continuing to be home to seven of the world's 10 fastest-growing economies. Collective action among African and global policymakers to improve the livelihoods of all under the blueprint of the Sustainable Development Goals and the African Union's Agenda 2063 is representative of the shared energy and excitement around Africa's potential. With business environments improving, regional integration centered around the African Continental Free Trade Agreement progressing, and the transformational technologies of Fourth Industrial Revolution spreading, never before has the region been better primed for trade, investment, and mutually beneficial partnerships. The recent, unprecedented interest of an increasingly diversified group of external partners for engagement with Africa highlights this potential. Despite the continent's promise, though, obstacles to success linger, as job creation still has not caught up with the growing youth labor force, gaps in good and inclusive governance remain, and climate change as well as state fragility threaten to reverse the hard-fought-for gains of recent decades.This special edition of Foresight Africa highlights the triumphs of past years as well as strategies from our experts to tackle forthcoming, but surmountable, obstacles to a prosperous continent by 2030

Uneven Impacts of Climate Change on Productivity

This study documents the impacts of climate change on firm-level productivity by matching a globally comparable and standardized survey of nonagricultural firms covering 154 countries with climate data. The findings show that the overall effects of rising temperatures on productivity are negative but nonlinear and uneven across climate zones. Firms in hotter zones experience steeper losses with increases in temperature. A 1 degree Celsius increase from the typical wet-bulb temperature levels in the hottest climate zone (25.7 degrees Celsius and above) results in a productivity decline of about 20.8 percent compared to firms in the coldest climate zone. The effects vary not only based on the temperature zones within which firms are located, but also on other factors such as firm size, industry classification, income group, and region. Large firms, firms in manufacturing, and those in low-income countries and hotter climate zones tend to experience the biggest productivity losses. The uneven impacts, with firms in already hotter regions and low-income countries experiencing steeper losses in productivity, suggest that climate change is reinforcing global income inequality. If the trends in global warming are not reversed over the coming decades, there is a heightened risk of widening inequality across countries. The implications are especially dire for the poorest countries in the hottest regions