Heterogeneous Impact of the "Seguro Popular" Program on the Utilization of Obstetrical Services in Mexico, 2001-2006: A Multinomial Probit Model with a Discrete Endogenous Variable

Objective: We evaluated the impact of Seguro Popular (SP), a program introduced in 2001 in Mexico primarily to finance health care for the poor. We studied the effect of SP on pregnant women's access to obstetrical services. Data: We analyzed the cross-sectional 2006 National Health and Nutrition Survey (ENSANUT), focusing on the responses of 3,890 women who delivered babies during 2001-2006 and whose households lacked employer-based health care coverage. Methods: We formulated a multinomial probit model that distinguished between three mutually exclusive sites for delivering a baby: a health unit accredited by SP; a clinic run by the Department of Health (Secretaria de Salud, or SSA); and private obstetrical care. Our model accounted for the endogeneity of the household's binary decision to enroll in the SP program. Results: Women in households that participated in the SP program had a much stronger preference for having a baby in a SP-sponsored unit rather than paying out of pocket for a private delivery. At the same time, participation in SP was associated with a stronger preference for delivering in the private sector rather than at a state-run SSA clinic. On balance, the Seguro Popular program reduced pregnant women's attendance at an SSA clinic much more than it reduced the probability of delivering a baby in the private sector. The impacts of the SP program at the individual and population levels varied with the woman's education and health, as well as the assets and location (rural versus urban) of the household. Conclusions: The SP program had a robust, significantly positive impact on access to obstetrical services. Our finding that women enrolled in SP switched from non-SP state-run facilities, rather than from out-of-pocket private services, is important for public policy and requires further exploration.

Impact of "Seguro Popular" on Prenatal Visits in Mexico, 2002-2005: Latent Class Model of Count Data with a Discrete Endogenous Variable

We employ a latent class model to assess the impact of Mexico's Seguro Popular ("SP") program on the number of prenatal visits in a cross-sectional sample of 4,381 women who gave birth during 2002-2005. We specify an ordered probit model to permit a pregnant woman's probability of membership in one of three latent classes to depend on observed covariates. In the ordered probit model, enrollment in SP is explicitly treated as an endogenous variable. We model the number of prenatal visits, conditional upon membership in a particular latent class, as a Poisson regression. We employ the EM algorithm to reduce the computational burden of model estimation. At any iteration of the algorithm, the parameters of the model of latent class membership can be estimated separately from the parameters of the model of prenatal care utilization. We find that enrollment in SP was associated with a mean increase in 1.65 prenatal visits during pregnancy. Approximately 59 percent of this treatment effect is the result of increased prenatal care among women in the first latent class, that is, women who had with little or no access to care. The remaining 41 percent of the treatment effect is the result of a shift in membership from the second to the third latent class, which we interpret as increased recognition of complications of pregnancy prior to labor and delivery. Our model has a better fit and predicts a larger impact of SP than alternative models that relax the assumption of endogeneity, do not impose ordering on the latent classes, or incorporate only two latent classes. Our findings are consistent with prior work on the favorable impact of SP on maternal health (Sosa-Rubí, Galárraga, Harris 2009).

The relationship of age and place of delivery with postpartum contraception prior to discharge in Mexico: A retrospective cohort study

AbstractObjectivesTo test the association of age (adolescents vs. older women) and place of delivery with receipt of immediate postpartum contraception in Mexico.Study designRetrospective cohort study, Mexico, nationally representative sample of women 12–39years old at last delivery. We used multivariable logistic regression to test the association of self-reported receipt of postpartum contraception prior to discharge with age and place of delivery (public, employment based, private, or out of facility). We included individual and household-level confounders and calculated relative and absolute multivariable estimates of association.ResultsOur analytic sample included 7022 women (population, N=9,881,470). Twenty percent of the population was 12–19years old at last birth, 55% aged 20–29 and 25% 30–39years old. Overall, 43% of women reported no postpartum contraceptive method. Age was not significantly associated with receipt of a method, controlling for covariates. Women delivering in public facilities had lower odds of receipt of a method (Odds Ratio=0.52; 95% Confidence Interval (CI)=0.40–0.68) compared with employment-based insurance facilities. We estimated 76% (95% CI=74–78%) of adolescents (12–19years) who deliver in employment-based insurance facilities leave with a method compared with 59% (95% CI=56–62%) who deliver in public facilities.ConclusionBoth adolescents and women ages 20–39 receive postpartum contraception, but nearly half of all women receive no method. Place of delivery is correlated with receipt of postpartum contraception, with lower rates in the public sector. Lessons learned from Mexico are relevant to other countries seeking to improve adolescent health through reducing unintended pregnancy.ImplicationsAdolescents receive postpartum contraception as often as older women in Mexico, but half of all women receive no method

The labour supply of nurses in the UK: evidence from the British Household Panel Survey

We investigate the impact of the onset of prenatal care and the quality of health services on the health of the newborn. Our specification is nonlinear and simultaneous and uses latent factors to allow for unobserved influences on onset and quality of prenatal care to affect infant’s health. We apply maximum simulated likelihood (MLS) techniques to estimate the parameters of our models. The quality of prenatal health care shows a large and positive effect on the health of the newborn. On the contrary, we find a small and non significant effect of the timely use of prenatal care on the weight of the infant.

Influence of supply-side factors on voluntary medical male circumcision costs in Kenya, Rwanda, South Africa, and Zambia.

BACKGROUND:In this study, we described facility-level voluntary medical male circumcision (VMMC) unit cost, examined unit cost variation across facilities, and investigated key facility characteristics associated with unit cost variation. METHODS:We used data from 107 facilities in Kenya, Rwanda, South Africa, and Zambia covering 2011 or 2012. We used micro-costing to estimate economic costs from the service provider's perspective. Average annual costs per client were estimated in 2013 United States dollars (US$). Econometric analysis was used to explore the relationship between VMMC total and unit cost and facility characteristics. RESULTS:Average VMMC unit cost ranged from US$66 (SD US$79) in Kenya to US$160 (SD US$144) in South Africa. Total cost function estimates were consistent with economies of scale and scope. We found a negative association between the number of VMMC clients and VMMC unit cost with a 3% decrease in unit cost for every 10% increase in number of clients and we found a negative association between the provision of other HIV services and VMMC unit cost. Also, VMMC unit cost was lower in primary health care facilities than in hospitals, and lower in facilities implementing task shifting. CONCLUSIONS:Substantial efficiency gains could be made in VMMC service delivery in all countries. Options to increase efficiency of VMMC programs in the short term include focusing service provision in high yield sites when demand is high, focusing on task shifting, and taking advantage of efficiencies created by integrating HIV services. In the longer term, reductions in VMMC unit cost are likely by increasing the volume of clients at facilities by implementing effective demand generation activities