Disentangling extrinsic and intrinsic motivations: the case of French GPs dealing with prevention

The economic literature attaches great importance to the analysis of "professional motivations", in particular examining the possible crowding-out effects between extrinsic and intrinsic motivations. This article applies these questions to the healthcare professions with a view to providing a fair scaling of the implementation of pay-for-performance policies by public decision-makers. We assemble a panel of 528 independent general practitioners in the "Provence-Alpes-Côte d’Azur" region in France and provide an inter-personal statistical decomposition between extrinsic and intrinsic motivations with regard to preventive actions. The proportion of intrinsic motivations is relatively greater among physicians paid with fixed fees. The significant effect of age describes a U shape which can be interpreted as being the result of a "life cycle of medical motivations". Finally, econometric estimations demonstrate a correlation between a small proportion of intrinsic motivation and a feeling of injustice with regard to the reforms. The cross-sectional nature of the data does not allow us to draw any conclusions concerning the direction of the causality. But the above correlation would seem to support the theory that the implementation of a policy based on monetary incentives towards performance is perceived as being offensive and may be accompanied by a reduction in intrinsic motivations in medical practice.General practitioners, Motivations, Prevention, Payment for performance, Intrinsic and extrinsic incentives, France

Confluence via strong normalisation in an algebraic \lambda-calculus with rewriting

The linear-algebraic lambda-calculus and the algebraic lambda-calculus are untyped lambda-calculi extended with arbitrary linear combinations of terms. The former presents the axioms of linear algebra in the form of a rewrite system, while the latter uses equalities. When given by rewrites, algebraic lambda-calculi are not confluent unless further restrictions are added. We provide a type system for the linear-algebraic lambda-calculus enforcing strong normalisation, which gives back confluence. The type system allows an abstract interpretation in System F.Comment: In Proceedings LSFA 2011, arXiv:1203.542

Semantics of a Typed Algebraic Lambda-Calculus

Algebraic lambda-calculi have been studied in various ways, but their semantics remain mostly untouched. In this paper we propose a semantic analysis of a general simply-typed lambda-calculus endowed with a structure of vector space. We sketch the relation with two established vectorial lambda-calculi. Then we study the problems arising from the addition of a fixed point combinator and how to modify the equational theory to solve them. We sketch an algebraic vectorial PCF and its possible denotational interpretations

Canada-Africa Relations in Changing Core-Periphery Dynamics: A Chance to "Come Back" Differently

The Department of Foreign Affairs Canada sees the dynamism at play across the African continent as calling out for Canadian engagement. Africa in the twenty-first century is no longer the continent emerging from colonial rule; it seeks new forms of relationships with international partners. The African Development Bank, for instance, has identified five priorities for inclusive growth on the continent. The challenges are huge, as is the potential for transformative change. But the conditions for international collaboration in achieving these goals have changed; African leaders are seeking new forms of associations and teamwork. Canada has an opportunity to "come back" differently if it can look beyond its narrow mining interests and become an active partner working with public authorities in need of new and bold international partnerships. Unfortunately, Trudeau's "Canada is back" campaign does not look set to change the status quo. And, in a world where the political economic power is moving east, African countries do not have much reason to listen to Canada

The Macroeconomic Consequences of Renouncing to Universal Access to Antiretroviral Treatment for HIV in Africa: A Micro-Simulation Model

AIM: Previous economic literature on the cost-effectiveness of antiretroviral treatment (ART) programs has been mainly focused on the microeconomic consequences of alternative use of resources devoted to the fight against the HIV pandemic. We rather aim at forecasting the consequences of alternative scenarios for the macroeconomic performance of countries. METHODS: We used a micro-simulation model based on individuals aged 15-49 selected from nationally representative surveys (DHS for Cameroon, Tanzania and Swaziland) to compare alternative scenarios : 1-freezing of ART programs to current levels of access, 2- universal access (scaling up to 100% coverage by 2015, with two variants defining ART eligibility according to previous or current WHO guidelines). We introduced an "artificial" ageing process by programming methods. Individuals could evolve through different health states: HIV negative, HIV positive (with different stages of the syndrome). Scenarios of ART procurement determine this dynamics. The macroeconomic impact is obtained using sample weights that take into account the resulting age-structure of the population in each scenario and modeling of the consequences on total growth of the economy. RESULTS: Increased levels of ART coverage result in decreasing HIV incidence and related mortality. Universal access to ART has a positive impact on workers' productivity; the evaluations performed for Swaziland and Cameroon show that universal access would imply net cost-savings at the scale of the society, when the full macroeconomic consequences are introduced in the calculations. In Tanzania, ART access programs imply a net cost for the economy, but 70% of costs are covered by GDP gains at the 2034 horizon, even in the extended coverage option promoted by WHO guidelines initiating ART at levels of 350 cc/mm(3) CD4 cell counts. CONCLUSION: Universal Access ART scaling-up strategies, which are more costly in the short term, remain the best economic choice in the long term. Renouncing or significantly delaying the achievement of this goal, due to "legitimate" short term budgetary constraints would be a misguided choice

Essais en économie des politiques de santé

Cette thèse contribue à l’analyse des relations entre santé, revenu et politiques de santé. Il m’a semblé nécessaire de mener cette recherche pour chaque direction de la relation. Ainsi, le 1er article étudie la solvabilité financière de différentes politiques de lutte contre le SIDA grâce à un modèle de microsimulation. La santé y est vue comme un facteur de production ; son amélioration génère des gains de productivité. Cette analyse montre que les programmes de traitement peuvent générer un surplus économique et ce net des coûts engendrés. Le 4ème article étudie la relation entre santé infantile et milieu social d’origine à partir d’une enquête internationale. Les analyses montrent que si un gradient socio-économique de santé s’impose à tous à travers le globe (les enfants issus de milieux pauvres sont en moins bonne santé), ce gradient varie selon le niveau de revenu et d’offre de soin du pays considéré. Les deux autres articles s’intéressent aux problèmes de mesures liés à la mise sous traitement des agents malades : le poids de ces derniers dans la population augmente. Au niveau macroéconomique, le PIB par habitant pourrait diminuer si les traitements ne permettent pas de maintenir un niveau de productivité suffisant. Les analyses dans le cadre du VIH montrent que cet effet pervers ne supplante pas les effets positifs. Cette problématique est élargie à la mesure du bien être dans le 3ème article de la thèse. En ne s’attachant qu’aux populations vivantes, les indicateurs traditionnels ne tiennent pas compte du fait que certains agents auraient pu être maintenus en vie (avec un bien être moindre). Les comparaisons inter-pays pourraient ainsi être faussées.This dissertation aims at improving our understanding of the links between health and wealth, and between health programs and macroeconomic outcomes. Because the former might be bi-directional, it seemed sensible to tackle this issue for each direction of the causality. In the 1st paper, I examine using microsimulation the financial solvability of alternative policies against HIV. Health improvements at the individual level generate productivity gains which translate into an economic surplus that outweighs programs’ costs. In the 4th paper, I examine the relationship between child health and social background using an international survey. Analysis reveals a substantial gradient in health: across the globe, poorer children have worse health. Yet, the effect of wealth is moderated by country-level income and health-supply variables. The two other papers focus on rather methodological issues raised by the fact that curative programs save lives but increase the prevalence of the disease. One study highlights that average income could fall if treatments cannot guarantee a sufficient level of productivity among sick workers. Despite this adverse effect, the microsimulation model demonstrates that treatment policies can raise per capita income in the context of HIV. The 3rd paper of the thesis extends this message to welfare measurement. By restricting attention to the living population, standard indicators of welfare ignore the fact that individuals who would otherwise be dead can be kept alive through treatment, but with a lower than average welfare. Cross-country comparisons based on indicators that are made invariant to the population size may therefore be biased

Epidemiological transition and the wealth of nations: the case of HIV/AIDS in a microsimulation model

International audienceThis paper aims at quantifying the effect of healthcare programs on economic outcomes in the context of developing countries experiencing epidemiological transitions. It is widely accepted in the literature that treatment programs result in production gains among ill-health workers. However, these programs have the additional effect of modifying both the size and the composition of the working population by increasing the proportion of chronically-ill individuals. First, we define the theoretical conditions under which this macro-epidemiological phenomenon outweighs the positive effect of an increase in production. Second, we decompose the economic consequences of access to antiretroviral treatments against HIV in three sub-Saharan African countries. Forecasts of an individual’s health status, depending on whether he or she has access to medication, are generated using a microsimulation model. We use the model to generate a counterfactual (as if the adverse epidemiological effect did not exist), which allows decomposing the total impact of the HIV-medicines program into two different effects: positive and negative. We find that the positive effect of treatment procurement outweighs the negative epidemiological effect. Of course, this approach is only an indicator of economic performance and should in no way constitute a decision-making criterion about the ethical necessity of access to health care.Cet article vise à décomposer l’effet de programmes curatifs sur la performance macroéconomique de pays en développement en phase de transition épidémiologique. Il est largement admis dans la littérature que les programmes d’accès aux soins génèrent des gains de productivité chez les travailleurs en mauvaise santé. Cependant, ces programmes modifient par nature la taille et la composition de la population active en augmentant la proportion d’individus souffrant de maladies chroniques, atténuant ainsi l’effet sur la productivité moyenne. Après avoir défini les conditions théoriques nécessaires à ce que cet effet de structure supplante l’effet productif de l’accès aux soins, nous transposons cette investigation au cas des programmes de traitements antirétroviraux dans trois pays d’Afrique subsaharienne touchés par le VIH/SIDA. Un modèle de microsimulation est utilisé pour générer ex-ante les trajectoires de santé et de production d’individus représentatifs, selon qu’ils aient ou non accès aux antirétroviraux. Nous utilisons le modèle pour générer un « contrefactuel » (en l’absence de l’effet de composition) et constatons que l’effet productif l’emporte sur l’effet épidémiologique négatif. Bien entendu, cette approche n’est qu’un indicateur des performances économiques et, en tout état de cause, ne doit pas constituer un critère de décision sur la nécessité éthique de l’accès aux soins