Assessing the Economic Impact of HIV/AIDS on Nigerian Households: A Propensity Score Matching Approach

We assess the impact of HIV/AIDS on individuals’ health care utilization and spending in the Oyo and Plateau states of Nigeria and income foregone from work time lost. Data was from a 2004 survey of nearly 1,500 households, including 482 individuals living with HIV/AIDS. Estimating the effect of HIV is complicated by the fact that our sample of HIV positive individuals is non-random; there are selection effects, both in acquiring HIV, and in being in our sample our HIV positive people, which was based on contacts through non-governmental organizations. To overcome this selection effect, we compare HIV positive people with a control group with similar observed characteristics, using propensity score matching. The matched control group has very different health and economic outcomes than a random sample of the population indicating that our HIV sample would not have had "average" outcomes even if they had not acquired HIV. HIV is associated with significantly increased morbidity, health care utilization, public health facility use, lost work time and increased time devoted to care-giving relative to outcomes in the control group. Direct health care costs and indirect income loss per HIV positive individual were 16,569 Naira, about 32% of annual income per capita in affected households. About 40% of these costs are income losses associated with sickness and care-giving. 15% of the cost of HIV is accounted for by public subsidies on health. The largest single economic cost, representing 45% of the total economic burden of HIV, are out of pocket expenses, mainly for health care.HIV, Nigeria, Economic Impacts, Households, Direct Costs, Propensity Score

Economic security arrangements in the context of population ageing in India

The rapid ageing of India's population, in conjunction with migration out of rural areas and the continued concentration of the working population in the informal sector, has highlighted the need for better economic security arrangements for the elderly. Traditional family ties that have been key to ensuring a modicum of such security are beginning to fray, and increased longevity is making care of the elderly more expensive. As a result, the elderly are at increased risk of being poor or falling into poverty. In parallel with its efforts to address this issue, the Government of India and some of the Indian states have initiated an array of programmes for providing some level of access to health care or health insurance to the great majority of Indians who lack sufficient access. Formal-sector workers have greater social security than those in the informal sector, but they only represent a small share of the workforce. Women are particularly vulnerable to economic insecurity. India's experience offers some lessons for other countries. Although there is space for private initiatives in the social security arena, it is clear that most such efforts will need to be tax-financed. The role that private providers can play is substantial, even when most funding comes from public sources, but such activity will face greater challenges as more individuals seek benefits. India has also shown that implementation can often be carried out well by states using central government funds, with a set of advantages and disadvantages that such decentralization brings. Finally, India's experience with implementation can offer guidance on issues such as targeting, the use of information technology in social security systems, and human resource management.old age risk, old age benefit, medical care, social security administration, demographic aspect, India

Decentralization and public sector delivery of health and education services: The Indian experience

The paper has two main objectives. The first is to trace the progress in the process of decentralisation in the provision of public services in India. The second is to test the hypothesis that decentralisation in the system of public service delivery in primary health care and education led to improved outcomes for the rural Indian population. Before 1992, with few exceptions, there was little movement towards decentralisation. Rural local bodies functioned primarily as program executing agents for government line departments, with little control over finances, administration, or the pattern of expenditure. The only decentralisation that existed was in the importance of state governments vis-à-vis the centre. After the 1992 Constitutional Amendments, significant progress has taken place in the form of the passing of conformity legislation by state governments, the setting up of State Finance Commissions to examine the distribution of resources from states to local bodies, and accelerated moves towards transfer of planning and expenditure responsibilities to village bodies. The paper used data from the 1994 NCAER survey to test the hypothesis that increased decentralisation/democratisation positively influences enrolment rates and child mortality once the influence of socioeconomic circumstances, civil society organisations, the problem of capture of local bodies by elite groups, and so on are controlled for. Our main empirical findings are that indicators of democratisation and public participation, such as frequency of elections, presence of non-governmental organisations, parent-teacher associations and indicator variables for decentralised states generally have the expected positive effects, although these are not always statistically indistinguishable from zero.Die vorliegende Arbeit analysiert zwei Aspekte der dezentralisierten Bereitstellung öffentlicher Güter in Indien. Der erste Teil veranschaulicht den Prozeß der Dezentralisierung, während im zweiten Teil die Hypothese getestet wird, daß eine dezentralisierte Bereitstellung von medizinischer Grundversorgung und Schulen zu einer Verbesserung der Rahmenbedingungen der indischen Landbevölkerung geführt hat. Im Zuge der Verwaltungsreform 1992 wurden den ländlichen Organen zunehmend Aufgaben übertragen. Durch die entsprechende Verfassungsänderung wurde ein fiskalischer Föderalismus eingeführt, der den Gemeinden und Kreisen auch nötige finanzielle Unabhängigkeit verschaffte. Der empirischen Analyse liegen die Daten der NCAER - Erhebung aus dem Jahre 1994 zugrunde. Die Hypothese des positiven Einflusses der Dezentralisierung auf Sterblichkeitsrate und Schülerzahlen wird um die sozioökonomischen Rahmenbedingungen ergänzend überprüft. Die Ergebnisse deuten auf einen positiven Einfluß der verwandten Variablen hin, wobei dieser Einfluß z.T. jedoch gering ausfällt

Does the AIDS Epidemic Really Threaten Economic Growth?

This study examines the claim that the AIDS epidemic will slow the pace of economic growth. We do this by examining the association, across fifty-one developing and industrial countries for which we were able to assemble data, between changes in the prevalence of AIDS and the rate of growth of GDP per capita. Our analysis uses well-established empirical growth models to control for a variety of factors possibly correlated with AIDS prevalence that migt also influence growth. We also account for possible simultaneity in the relationship between AIDS and economic growth. Our main finding is that the AIDS epidemic has had an insignificant effect on the growth rate of per capita income, with no evidence of reverse causality. We also find evidence that the insignificant effect of AIDS on income per capita is qualitatively similar to an insignificantly effect on wages of the Black Death in England and France during the Middle Ages and an insignificant effect on output per capita of influenza in India during 1918-19

The AIDS Epidemic and Economic Policy Analysis

Economists have a vital role to play in helping public health officials and policymakers understand the AIDS epidemic and design efficient policies to limit its impact. AIDS is first and foremost a public health problem, but it is a problem with deep economic roots and potentially devastating economic consequences. The main purpose of this article is to document this assertion

Decentralization and public sector delivery of health and education services : The Indian experience

The paper has two main objectives. The first is to trace the progress in the process of decentralisation in the provision of public services in India. The second is to test the hypothesis that decentralisation in the system of public service delivery in primary health care and education led to improved outcomes for the rural Indian population. Before 1992, with few exceptions, there was little movement towards decentralisation. Rural local bodies functioned primarily as program executing agents for government line departments, with little control over finances, administration, or the pattern of expenditure. The only decentralisation that existed was in the importance of state governments vis-à-vis the centre. After the 1992 Constitutional Amendments, significant progress has taken place in the form of the passing of conformity legislation by state governments, the setting up of State Finance Commissions to examine the distribution of resources from states to local bodies, and accelerated moves towards transfer of planning and expenditure responsibilities to village bodies. The paper used data from the 1994 NCAER survey to test the hypothesis that increased decentralisation/democratisation positively influences enrolment rates and child mortality once the influence of socioeconomic circumstances, civil society organisations, the problem of capture of local bodies by elite groups, and so on are controlled for. Our main empirical findings are that indicators of democratisation and public participation, such as frequency of elections, presence of non-governmental organisations, parent-teacher associations and indicator variables for decentralised states generally have the expected positive effects, although these are not always statistically indistinguishable from zero

The Contribution of Population Health and Demographic Change to Economic Growth in China and India

We find that a cross-country model of economic growth successfully tracks the growth takeoffs in China and India. The major drivers of the predicted takeoffs are improved health, increased openness to trade, and a rising labor force-to-population ratio due to fertility decline. We also explore the effect of the reallocation of labor from low-productivity agriculture to the higher productivity industry and service sectors. Including the money value of longevity improvements in a measure of full income reduces the gap between the magnitude of China's takeoff relative to India's due to the relative stagnation in life expectancy in China since 1980.aging, health, retirement

Needle Sharing and HIV Transmission: A Model with Markets and Purposive Behavior

Without well designed empirical studies, mathematical models are an important way to use data on needle infection for inferences about human infection. We develop a model with explicit behavioral foundations to explore an array of policy interventions related to HIV transmission among IDU. In our model, needle exchanges affect the spread of HIV in three ways: more HIV-negative IDUs use new needles instead of old ones; needles are retired after fewer uses; and the proportion of HIV-positive IDUs among users of both old and new needles rises owing to sorting effects. The first and second effects reduce the long-run incidence of HIV, while the third effect works in the opposite direction. We compare the results of our model with those of Kaplan and O'Keefe (1993) that is the foundation of many later models of HIV transmission among IDU.

The effect of community health worker-led education on women's health and treatment-seeking: A cluster randomised trial and nested process evaluation in Gujarat, India.

BACKGROUND: A community-based health insurance scheme operated by the Self-Employed Women's Association in Gujarat, India reported that the leading reasons for inpatient hospitalisation claims by its members were diarrhoea, fever and hysterectomy - the latter at the average age of 37. This claims pattern raised concern regarding potentially unnecessary hospitalisation amongst low-income women. METHODS: A cluster randomised trial and mixed methods process evaluation were designed to evaluate whether and how a community health worker-led education intervention amongst insured and uninsured adult women could reduce insurance claims, as well as hospitalisation and morbidity, related to diarrhoea, fever and hysterectomy. The 18-month intervention consisted of health workers providing preventive care information to women in a group setting in 14 randomly selected clusters, while health workers continued with regular activities in 14 comparison clusters. Claims data were collected from an administrative database, and four household surveys were conducted amongst a cohort of 1934 randomly selected adult women. RESULTS: 30% of insured women and 18% of uninsured women reported attending sessions. There was no evidence of an intervention effect on the primary outcome, insurance claims (risk ratio (RR) = 1.03; 95% confidence interval (CI) 0.81, 1.30) or secondary outcomes amongst insured and uninsured women, hospitalisation (RR = 1.05; 95% CI 0.58, 1.90) and morbidity (RR = 1.09; 95% CI 0.87, 1.38) related to the three conditions. The process evaluation suggested that participants retained knowledge from the sessions, but barriers to behaviour change were not overcome. CONCLUSIONS: We detected no evidence of an effect of this health worker-led intervention to decrease claims, hospitalisation and morbidity related to diarrhoea, fever and hysterectomy. Strategies that capitalise on health workers' role in the community and knowledge, as well as those that address the social determinants of diarrhoea, fever and the frequency of hysterectomy - such as water and sanitation infrastructure and access to primary gynaecological care - emerged as areas to strengthen future interventions

Incidence and determinants of hysterectomy in a low-income setting in Gujarat, India.

Hysterectomy is a leading reason for use of health insurance amongst low-income women in India, but there are limited population-level data available to inform policy. This paper reports on the findings of a mixed-methods study to estimate incidence and identify predictors of hysterectomy in a low-income setting in Gujarat, India. The estimated incidence of hysterectomy, 20.7/1000 woman- years (95% CI: 14.0, 30.8), was considerably higher than reported from other countries, at a relatively low mean age of 36 years. There was strong evidence that among women of reproductive age, those with lower income and at least two children underwent hysterectomy at higher rates. Nearly two-thirds of women undergoing hysterectomy utilized private hospitals, while the remainder used government or other non-profit facilities. Qualitative research suggested that weak sexual and reproductive health services, a widespread perception that the post-reproductive uterus is dispensable and lack of knowledge of side effects have resulted in the normalization of hysterectomy. Hysterectomy appears to be promoted as a first or second-line treatment for menstrual and gynaecological disorders that are actually amenable to less invasive procedures. Most women sought at least two medical opinions prior to hysterectomy, but both public and private providers lacked equipment, skills and motivation to offer alternatives. Profit and training benefits also appeared to play a role in some providers' behaviour. Although women with insecure employment underwent the procedure knowing the financial and physical implications of undergoing a major surgery, the future health and work security afforded by hysterectomy appeared to them to outweigh risks. Findings suggest that sterilization may be associated with an increased risk of hysterectomy, potentially through biological or attitudinal links. Health policy interventions require improved access to sexual and reproductive health services and health education, along with surveillance and medical audits to promote high-quality choices for women through the life cycle