The economics of tobacco control in some African countries

Includes bibliographical referencesThis thesis examines some aspects of the economics of tobacco control in South Africa, Uganda and Zambia. The first part of the thesis examines whether tobacco expenditure displaces (or "crowds out") expenditure on other goods and services within Zambian households. In so doing, I make two contributions to the literature. Firstly, I use expenditure data from a low-income sub-Saharan African country where most households are poor. Secondly, I use the standard instrumental variable used in the literature, the adult sex ratio, to instrument for the tobacco smoking status of Zambian households. But unlike previous studies, I relax the strict exclusion restriction and allow for the adult sex ratio to be correlated with the error term. That is, I allow the instrumental variable to be imperfect. I consider the relaxation of the exclusion restriction to be reasonable given that the adult sex ratio is just as likely to influence tobacco expenditure as it is to influence expenditure on other goods and services. Even after relaxing the exclusion restriction, I, however, confirm many findings in the literature. For instance, I find that smoking households allocate less expenditure towards food, schooling, clothing, water, electricity, transportation, equipment maintenance and remittances. In addition, the crowding out patterns I uncover are in some ways related to the geographical location of households which in turn is related to socioeconomic status in Zambia. In sum, the results in this part of the thesis show that a broader accounting of tobacco's costs in Zambia should include other costs over and above mortality and morbidity considerations. We know from several studies that tax and price measures are the single most effective policy tool for reducing tobacco consumption. However, most of this evidence is based on studies conducted in developed countries with very few published studies on African countries. The second part of my thesis, therefore, contributes to the recent literature that uses expenditure data to estimate price and expenditure elasticities of demand for tobacco products in Low-and Middle-Income countries. I use expenditure data from Uganda and exploit the fact that prices of cigarettes vary across geographical space. I also adjust my demand elasticity estimates for measurement error and quality heterogeneity. I find price and expenditure elasticities that are in line with international evidence. For instance, I find that cigarette demand is expected to decline by between 3% and 4%, at the very least, for every 10% increase in cigarette prices. The authorities in Uganda ca n, therefore, reduce cigarette consumption by increasing excise taxes on cigarettes without reducing tax revenues. The third and final part of my thesis evaluates the impact on per capita cigarette consumption of South Africa's consistent excise tax increases that began in 1994. The tax rises have overtime translated into large increases in the inflation-adjusted price of cigarettes. For instance, the average real price per pack increased by 110% between 1994 and 2004. The main challenge in conducting pol icy evaluations is that of creating a credible counterfactual. That is, we want to know what would have happened to per capita cigarette consumption in South Africa if the excise tax increases had not occurred. This is particularly important in the case of South Africa because per capita cigarette consumption had already started declining by the time the tax rises started. I, therefore, use a transparent and data-driven technique, the Synthetic Control method, to create a credible counterfactual of South Africa's cigarette consumption after 1994. The counterfactual is constructed as a linear combination of the per capita cigarette consumption of countries that are similar to South Africa but did not engage in large-scale tobacco control efforts over the peri od 1994 to 2004. I find that per capita cigarette consumption would not have continued declining in the absence of the consistent tax rises that began in 1994. Specifically, I find that by 2004, per capita cigarette consumption was 36% lower than it would have been had the tax increases not occurred. This result is robust to several falsification (or placebo) exercises. Based on these results, I conclude that countries in Africa can achieve substantial reductions in cigarette consumption and prevent uptake from new smokers by consistently increasing excise taxes in the manner of South Africa

Ambiguity, ambiguity aversion and the coverage of uncertain risks : the case of the insurer

Ambiguity aversion is defined as an aversion to any mean-preserving spread in the probability space. Using the Smooth Ambiguity Model proposed by Klibanoff, Marinacci and Mukerji (2005), we show that ambiguity aversion results in a reduction in the proportion of insurance coverage offered by an insurer. This is because an ambiguity averse insurer calculates expected utilities by using a 'distorted' probability that raises the marginal disutility of wealth in the loss state. We also show that, in general, an ambiguity averse insurer will not offer more coverage to wealthier agents. Wealthier agents enjoy more coverage when the subjective average probability of loss is significantly high. Our results go a long way in reconciling theoretical models of insurance under ambiguity with the empirical finding that insurers are sensitive to ambiguity

The case for minimum unit prices on alcohol in South Africa

Background. Although only about a third of South African (SA) adults indicate that they consume alcohol, heavy drinking is common. As a result, society carries large alcohol-related mortality and economic burdens.Objectives. To investigate the feasibility of a minimum unit price (MUP) on alcohol, aimed at reducing the prevalence of heavy drinking.Methods. The study calculates unit values, defined as total monthly alcohol expenditure per household, divided by the household’s total monthly alcohol consumption, for four categories of drinking households (moderate, intermediate, occasional heavy and regular heavy), using wave 4 data (2015) from the National Income Dynamics Study. A cumulative distribution of the unit values is derived for each of the four categories of drinking households. A number of hypothetical MUPs are imposed, and the impact of these MUPs on the consumption of the different categories of drinking households is estimated, taking cognisance of the fact that these households respond differently to price changes. Moderately drinking households tend to be more price sensitive than regular heavy-drinking households.Results. Occasional and regular heavy-drinking households comprise a quarter of all households (and half of all drinking households) in SA, but consume 84% of all alcohol consumed in the country. There are large differences in the calculated average price of alcohol between different categories of drinking households, ranging from ZAR12.00 per standard drink among moderately drinking households to ZAR1.53 per standard drink among regular heavy-drinking households. An MUP of ZAR3.00 (alternatively ZAR10.00) per standard drink is estimated to reduce alcohol consumption by 11.9% (21.8%) among regular heavy-drinking households, by 3.1% (11.6%) among occasional heavy-drinking households, by 2.3% (15.9%) among intermediate-drinking households and by 0.3% (6.1%) among moderately drinking households.Conclusions. An MUP on alcohol is not a silver bullet, but could have a significant impact on reducing the consumption of alcohol among regular heavy-drinking households, and to a lesser extent among occasional heavy-drinking and intermediate-drinking households. The government should strongly consider implementing such a policy.

The effect of supply chain approaches on profitability in pharmaceutical supply chain of healthcare providers.

Thesis of Master of Business Administration in Management Strategy.Healthcare supply chain is plagued by misalignment, high costs for healthcare providers and heavy dependence on third parties, distributors and manufacturers. In contrast to traditional supply chain models, Vendor Managed Inventory (VMI) can be used to gain a competitive advantage through effective supply chain. A VMI approach can improve supply chain performance by decreasing inventory-related costs and increasing customer service. This study aimed at understanding the effects of traditional and VMI strategies on profitability in private health care facilities. Using a mixed methods approach, the study compared financial statements of two healthcare facilities who used only traditional supply chain and of two additional facilities both for when they used traditional supply chain methods and when they used a VMI model. The analysis reviewed changes in gross profit margin and cashflow margin from 2016 to 2017. In-depth interviews were conducted to provide insights of the health care providers who work in VMI facilities a total of 8 staff members were interviewed. Data collected from financial statements and in-depth interviews was analysed using SPSS and Excel. Facilities that used VMI saw a combined growth in revenue from drug sales of 37% in contrast to 12.3 for those that used traditional models. A strong positive linear relationship was found to exist between VMI adoption and Gross profit margin with correlation values at 0.978 and 0.88 for VMI facilities. While no significant correlation was found between cash flow margins and VMI adoption, 87.5% of staff members interviewed said they would recommend VMI suppliers to their peers. Findings showed that both the facilities that implemented VMI in 2017 experienced significant revenue growth as compared to the hospitals that maintained a traditional model. In addition to this VMI hospitals had higher growth profit margins in 2017 than the traditional supply chain ones. However, the cases have been conducted over a short period of time, which may affect the generalization of the findings. Wider empirical evidence from more facilities over a longer period of time will be beneficial

PENGARUH SISTEM PENGENDALIAN INTERN, PRINSIP PENGELOLAAN KEUANGAN DAERAH, DAN PENERAPAN STANDAR AKUNTANSI PEMERINTAHAN, TERHADAP KUALITAS LAPORAN KEUANGAN DAERAH PADA ORGANISASI PERANGKAT DAERAH KABUPATEN JEPARA

Penelitian ini bertujuan untuk mengetahui pengaruh sistem pengendalian intern, prinsip pengelolaan keuangan daerah, dan penerapan standar akuntansi pemerintahan terhadap kualitas laporan keuangan daerah. Metode analisis data yang digunakan adalah uji validitas, uji reabilitas, uji asumsi klasik yang terdiri dari uji normalitas, uji multikolinearitas, uji heteroskedastisitas, dan uji hipotesisnya menggunakan analisis regresi linear berganda, uji koefisien determinasi, uji statistik F, dan uji statistik t. Metode analisis yang digunakan dalam penelitian ini adalah analisis regresi linear berganda dengan menggunakan program SPSS 23. Hasil penelitian menunjukkan bahwa sistem pengendalian intern dan prinsip pengelolaan keuangan daerah secara parsial berpengaruh signifikan terhadap kualitas laporan keuangan daerah pada OPD Kabupaten Jepara, sedangkan penerapan standar akuntansi pemerintahan secara parsial tidak berpengaruh signifikan terhadap kualitas laporan keuangan daerah pada OPD Kabuapten Jepara, dan secara simultan sistem pengendalian intern, prinsip pengelolaan keuangan daerah, dan penerapan standar akuntansi pemerintahan berpengaruh terhadap kualitas laporan keuangan daerah pada OPD Kabupaten Jepara. Koefisien determinasi dari sistem pengendalian intern, prinsip pengelolaan keuangan daerah, dan penerapan standar akuntansi memberikan sebesar 56,4% kepada variabel kualitas laporan keuangan daerah, 43,6% dipengaruhi oleh variabel lain

PENGARUH SISTEM PENGENDALIAN INTERN, PRINSIP PENGELOLAAN KEUANGAN DAERAH, PENERAPAN STANDAR AKUNTANSI PEMERINTAHAN, DAN SISTEM AKUNTANSI KEUANGAN DAERAH TERHADAP KUALITAS LAPORAN KEUANGAN DAERAH PADA ORGANISASI PERANGKAT DAERAH KABUPATEN JEPARA

Penelitian ini bertujuan untuk mengetahui pengaruh sistem pengendalian intern, prinsip pengelolaan keuangan daerah, penerapan standar akuntansi pemerintahan, dan sistem akuntansi keuangan daerah terhadap kualitas laporan keuangan daerah. Teknik pengumpulan data yang digunakan adalah dengan menggunakan instrumen kuesioner. Penelitian ini menggunakan data primer. Penelitian ini dilakukan pada OPD Kabupaten Jepara. Teknik pengambilan sampel yang digunakan adalah purposive sampling, sampel yang digunakan berjumlah 71 responden. Metode analisis data yang digunakan adalah uji validitas, uji reabilitas, uji asumsi klasik yang terdiri dari uji normalitas, uji multikolinearitas, uji heteroskedastisitas, dan uji hipotesisnya menggunakan analisis regresi linear berganda, uji koefisien determinasi, uji statistik F, dan uji statistik t. Metode analisis yang digunakan dalam penelitian ini adalah analisis regresi linear berganda dengan menggunakan program SPSS 23. Hasil penelitian menunjukkan bahwa sistem pengendalian intern dan prinsip pengelolaan keuangan daerah secara parsial berpengaruh signifikan terhadap kualitas laporan keuangan daerah pada organisasi perangkat daerah Kabupaten Jepara, sedangkan penerapan standar akuntansi pemerintahan dan sistem akuntansi keuangan daerah secara parsial tidak berpengaruh signifikan terhadap kualitas laporan keuangan daerah pada OPD Kabuapten Jepara, dan secara simultan sistem pengendalian intern, prinsip pengelolaan keuangan daerah, penerapan standar akuntansi pemerintahan dan sistem akuntansi keuangan daerah secara berpengaruh terhadap kualitas laporan keuangan daerah pada OPD Kabupaten Jepara. Koefisien determinasi dari sistem pengendalian intern, prinsip pengelolaan keuangan daerah, penerapan standar akuntansi pemerintahan dan sistem akuntansi keuangan daerah memberikan sebesar 55,8% kepada variabel kualitas laporan keuangan daerah, 44,2% dipengaruhi oleh variabel lain

Zambia Signal Functions study 2016 dataset

This dataset contains information related to health facilities’ infrastructure, staffing, equipment, supplies, and capacity to perform various clinical functions related to reproductive and maternal health service provision. The study was conducted in Central Province, Zambia and its primary aim was to assess facilities’ capacity to provide termination of pregnancy services

Treading the thin line: pharmacy workers’ perspectives on medication abortion provision in Lusaka, Zambia

Context: Despite liberal abortion laws, safe abortion access in Zambia is impeded by limited legal awareness, lack of services, and restrictive clinical policies. As in many countries with restricted abortion access, women frequently seek abortions informally from pharmacies. Methods: We conducted 16 in-depth interviews in 2019 to understand the experiences and motivations of pharmacy workers who sell medication abortion (MA) drugs in Lusaka. Results: We found that pharmacy staff reluctantly assume a gatekeeper role for MA due to competing pressures from clients and from regulatory constraints. Pharmacy staff often decide to provide MA, motivated by their duty of care and desire to help clients, as well as financial interests. However, pharmacy workers’ motivation to protect themselves from legal and business risk perpetuates inequalities in abortion access, as pharmacy workers improvise additional eligibility criteria based on personal risk and values such as age, partner approval, reason for abortion and level of desperation. Conclusion: These findings highlight how pharmacy staff informally determine women’s abortion access when laws and policies prevent comprehensive access to safe abortion. Reform of clinical guidelines, public education, strengthened public sector availability, task-sharing, and improved access to prescription services are needed to ensure women can legally access safe abortion

A new approach to assess the capability of health facilities to provide clinical care for sexual violence against women: a pilot study.

Several tools have been developed to collect information on health facility preparedness to provide sexual violence response services; however, little guidance exists on how this information can be used to better understand which functions a facility can perform. Our study therefore aims to propose a set of signal functions that provide a framework for monitoring the availability of clinical sexual violence services. To illustrate the potential insights that can be gained from using our proposed signal functions, we used the framework to analyse data from a health facility census conducted in Central Province, Zambia. We collected the geographic coordinates of health facilities and police stations to assess women's proximity to multi-sectoral sexual violence response services. We defined three key domains of clinical sexual violence response services, based on the timing of the visit to the health facility in relation to the most recent sexual assault: (1) core services, (2) immediate care, and (3) delayed and follow-up care. Combining information from all three domains, we estimate that just 3% of facilities were able to provide a comprehensive response to sexual violence, and only 16% could provide time-sensitive immediate care services such as HIV post-exposure prophylaxis and emergency contraception. Services were concentrated in hospitals, with few health centres and no health posts fulfilling the signal functions for any of the three domains. Only 23% of women lived within 15 km of comprehensive clinical sexual violence health services, and 38% lived within 15 km of immediate care. These findings point to a need to develop clear strategies for decentralizing sexual violence services to maximize coverage and ensure equity in access. Overall, our findings suggest that our proposed signal functions could be a simple and valuable approach for assessing the availability of clinical sexual violence response services, identifying areas for improvement and tracking improvements over time

A case-study of OVC Case Management through the Zambia Family (ZAMFAM) project

Zambia’s HIV prevalence is estimated at 11% among adults aged 15–49 years and 1% among children younger than 15 years. An estimated 10% of Zambia’s population is at high risk of being orphaned or vulnerable due to the HIV epidemic. The Zambia Family (ZAMFAM) project aims to improve the care and resilience of vulnerable populations while supporting HIV epidemic control. ZAMFAM used a case management approach that tracks beneficiaries from identification to graduation. The Population Council conducted a qualitative case study to understand actors and perceptions, and document best practices. Program beneficiaries viewed the ZAMFAM program as having made a positive contribution to the lives of orphans and vulnerable children. Testimonials from beneficiaries reflect high knowledge of HIV prevention, care, and management and identify educational support as a benefit of the program. Home visitations were also hailed by beneficiaries and key stakeholders. As noted in this report, the perspectives of beneficiaries and stakeholders were sought in addition to a detailed review of key program documentation to identify best practices and lessons for future programming