ESSAYS IN ECONOMICS OF HEALTH - A DEVELOPING COUNTRY PERSPECTIVE

The concept of health insurance (HI) is relatively new in the developing world. Meanwhile among countries experimenting HI, there is a dearth of empirical studies regarding the impact of the HI scheme on healthcare expenditure, particularly in Sub Saharan African (SSA). This study provides an insight into how Ghana is using her health insurance scheme; the country's major social protection programme, to impact out-of-pocket (OOP) healthcare expenditure and facility utilisation. The policy impact is estimated by using difference-in-difference (DID) estimation strategy. The analysis also takes into account self selection into the HI programme by using propensity score matching to create a comparable control group. The use of DID estimation means that the impact estimated here relates to the effect of the HI only on those covered by the scheme (average treatment effect on the treated). Generally the results in the full set model show that the HI scheme is serving as a cushion against the burden of OOP healthcare expenditure in Ghana. Meanwhile, the outcome by gender indicates that the magnitude of the benefits derived from the scheme is only marginally higher in the female sample. Finally, the insured are found to be more likely to seek healthcare from appropriate heath facilities than their uninsured counterparts. Given that the HI scheme is criticised for its piece-meal implementation, to achieve improvements in the health of all, the findings in this chapter is an indication for policy makers to introduce some form of incentives to encourage those in the informal sector to enrol. Keywords: health insurance, healthcare expenditure, utilisation, Ghana JEL: I13Aside from being ranked among the most unequal countries in the world, there is evidence of health disparities and comparatively poor health indicators in Nigeria. Commonly-cited evidence suggest inequality in socio-economic status (SES) harms health but this hypothesis remains inconclusive. Meanwhile, most studies in the developing world have focused on ma- ternal and child health creating a research gap in other aspects of health. In addition, many exiting studies have relied on methods that fail to account for unobserved heterogeneity be- tween individuals. Using data from Nigeria, this paper estimates the effect of SES inequality on inequality in health status and health expenditure using concentration indices and fixed effect (FE) models. The relationship between SES and health inequality shrinks in models that account for other covariates. In the FE models, the SES remains statistically significant in explaining inequality in health status and this finding holds for two indicators of SES: consumption and wealth. However, the relationship between SES and inequality in health expenditure disappears in the FE model for all three SES indicators (consumption, income and wealth). Meanwhile, a decomposition analysis shows that reducing health inequalities is not a simple case of redistributive policies but age, marital status, household size and residing in rural areas also have appreciable contributions to health inequalities. Keywords: socio-economic status, concentration index, health inequality JEL: I14 D6

Temporal trends in between and within‐country inequalities in caesarean delivery in low‐ and middle‐income countries: a Bayesian analysis

Objective: To provide updated information about between-country variations, temporal trends and changes in inequalities within countries in caesarean delivery (CD) rates. Design: Cross-sectional study of Demographic and Health Survey (DHS) during 1990–2018. Setting: 74 low- and middle-income countries (LMICs). Population: Women 15–49 years of age who had live births in the last 3 years. Methods: Bayesian linear regression analysis was performed and absolute differences were calculated. Main outcome measure: Population-level CD by countries and sociodemographic characteristics of mothers over time. Results: CD rates, based on the latest DHS rounds, varied substantially between the study countries, from 1.5% (95% CI 1.1–1.9%) in Madagascar to 58.9% (95% CI 56.0–61.6%) in the Dominican Republic. Of 62 LMICs with at least two surveys, 57 countries showed a rise in CD during 1990–2018, with the greatest increase in Sierra Leone (19.3%). Large variations in CD rates were observed across mother's wealth, residence, education and age, with a higher rate of CD by the richest and urban mothers. These inequalities have widened in many countries. Stratified analyses suggest greater provisioning of CD by the richest mothers in private facilities and poorest mothers in public facilities