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ObjectivesStudies have shown that demand-side interventions, such as conditional cash transfers and vouchers, can increase the proportion of women giving birth in a health facility in low-income and middle-income countries, but there is limited evidence of the effectiveness of supply-side interventions. We evaluated the impact of the Subsidy Reinvestment and Empowerment Programme Maternal and Child Health Project (SURE-P MCH) on rates of institutional delivery and antenatal care.Design, setting and participantsWe used a differences-in-differences study design that compared changes in rates of institutional delivery and antenatal care in areas that had received additional support through the SURE-P MCH programme relative to areas that did not. Data on outcomes were obtained from the 2013 Nigerian Demographic and Health Survey.ResultsWe found that the programme significantly increased the proportion of women giving birth in a health facility by approximately 7 percentage points (p=0.069) or approximately 10% relative to the baseline after 9 months of implementation. The programme, however, did not significantly increase the use of antenatal care.ConclusionThe findings of this study suggest there could be important improvements in institutional delivery rates through greater investment in supply-side interventions.

This paper develops theoretical criteria and econometric methods to rank policy interventions in terms of welfare when individuals are loss-averse. Our new criterion for "loss aversion-sensitive dominance" defines a weak partial ordering of the distributions of policy-induced gains and losses. It applies to the class of welfare functions which model individual preferences with non-decreasing and loss-averse attitudes towards changes in outcomes. We also develop new statistical methods to test loss aversion-sensitive dominance in practice, using nonparametric plug-in estimates; these allow inference to be conducted through a special resampling procedure. Since point-identification of the distribution of policy-induced gains and losses may require strong assumptions, we extend our comparison criteria, test statistics, and resampling procedures to the partially-identified case. We illustrate our methods with a simple empirical application to the welfare comparison of alternative income support programs in the US., 57 pages, 6 page appendix, 7 figures, 2 tables

In light of the shortage of healthcare professionals, many developing countries operate a defacto two-tiered system of healthcare provision, in which Community Health Workers (CHWs) supplement service provision by fully qualified physicians. CHWs are relatively inexpensive to train but can treat only a limited range of medical conditions. This paper explicitly models a two-tiered structure of healthcare provision and characterizes the optimal allocation of resources between training doctors and CHWs, and implications for population health outcomes. We analyze how medical migration alters resource allocation and population health outcomes, shifting resources towards training CHWs. In the model, migration stimulates health care provision at the lower end of the illness severity spectrum, improving health outcomes for those patients; sufferers of relatively severe medical conditions who can only be treated by doctors are made worse off. It is further shown that donor countries must be reimbursed by more than the training cost of emigrating physicians in order to restore aggregate population health to the pre-migration level, assuming that there are increasing marginal costs in involved in replacing migrating physicians.

The empirical analysis of inequality of opportunity centres on disparities between social types, defined by the exposure to circumstances beyond individual control. Despite this, its main theoretical foundation—the Roemer model—does not indicate how to carry out, in practice, the required partition of the population into such types. This paper operationalises this definition of social types using a latent classes approach. Our specification is embedded in a probabilistic extension of the canonical Roemer model, which assumes that the relevant population consists of a finite number of latent types, from which each individual can be treated as a random draw. This makes possible the use of the full set of circumstances in the data, allows for unobserved individual heterogeneity and does not require an ex-ante specification of the number of types by the researcher. Our approach is illustrated by an empirical application featuring a large UK cohort study that was used in earlier literature to examine inequalities of opportunity in a wide array of social outcomes.

Despite the growing prominence of theoretical analysis of inequality of opportunity over the past twenty years, empirical work towards the normative evaluation of real-world policies has been minimal. This paper seeks to address this issue. It proposes a normative framework to model the influence of educational policy on health outcomes, grounded in Roemer’s model of equality of opportunity. We apply this model to the National Child Development Study cohort, who, since their schooling lay within the transition period of the comprehensive education reform in England and Wales, attended different types of secondary school. We use this reform in two ways: first, to evaluate the health outcomes of different educational policies under different normative principles; second, to simulate counterfactual distributions of health outcomes by neutralising the different channels through which early life circumstances influence health. Evidence on the comparative performance of the two educational systems is mixed, suggesting that the opportunity-enhancing effects of the comprehensive reform were, at best, modest in terms of adult health. For some of the health outcomes considered, this leads to a convergence between the policy recommendations made by the two ethical principles of equality of opportunity and utilitarianism, while for others, the two principles diverge in their evaluation.

Using data from a major educational reform in England and Wales, we examine heterogeneity in the long-term impacts of the exposure to different secondary schooling systems, characterized by selective early-tracking system versus non-selective comprehensive schooling, on health outcomes and smoking. We adopt a local instrumental variables approach to estimate person-centered treatment (PeT) effects, thereby recovering the full distribution of individual-level causal effects. We find that the transition from a selective early-tracking system to a non-selective one produced, on a fraction of individuals, significantly increased depression and cigarette smoking. These effects were persistent over time. Cognitive abilities did not moderate the effects, but students with lower non-cognitive skills were most likely to be negatively affected by this exposure. Keywords: Educational reform, Health, Lifestyle, Heterogeneity, instrumental variable

The World Health Report 2000 proposed three fundamental goals for health systems encompassing population health, health care finance and health systems responsiveness. Each of the goals incorporates both an efficiency and equity dimension. While inequalities in population health and health care finance have motivated two important strands of research, inequalities in responsiveness have received less attention in health economics. This paper examines inequality and polarisation in responsiveness, bridging this gap in the literature and contributing towards an integrated analysis of health systems performance. It uses data from the World Health Survey to measure and compare inequalities in responsiveness across 25 European countries. In order to respect the inherently ordinal nature of the responsiveness data, median-based measures of inequality and polarisation are employed. The results suggest that, in the face of wide differences in the health systems analysed, there exists large variability in inequalit in responsiveness across countries.

This paper explores the role of quality of schooling as a source of\ud inequality of opportunity in health. Substantiating earlier literature that links differences in education to health disparities, the paper uses variation in quality of schooling to test for inequality of opportunity in health. Analysis of the 1958 NCDS cohort exploits the variation in type and quality of schools generated by the comprehensive schooling reforms in England and Wales. The analysis provides evidence of a statistically significant and economically sizable association between some dimensions of quality of education and a range of health and health-related outcomes. For some outcomes the association persists, over and above the effects of measured ability, social\ud development, academic qualifications and adult socioeconomic status and lifestyle.

This paper proposes an empirical implementation of the concept of inequality of opportunity in health and applies this to data from the UK National Child Development Study. Drawing on the distinction between circumstance and\ud effort variables in John Roemer’s work on equality of opportunity, circumstances are proxied by parental socioeconomic status and childhood health; effort is proxied by health-related lifestyles and educational attainment.\ud \ud Stochastic dominance tests are used to detect inequality of opportunity in the conditional distributions of self-assessed health in adulthood. Two alternative approaches are used to measure inequality of opportunity. Econometric models are estimated to illuminate and quantify the triangular relationship between circumstances, effort and health. The results indicate the existence of a considerable and persistent inequality of opportunity in health. Circumstances affect health in adulthood both directly and through effort factors such as educational attainment. This indicates that, while the influence of some unjust circumstances can only be tackled during childhood, the implementation of complementary educational policies may be of paramount importance.

We examine heterogeneity in the impacts of exposure to mixed-ability ‘comprehensive’ schools in adolescence on long-term health and smoking behaviour. We explore the roles that cognitive and non-cognitive skills may play in moderating these impacts. We use data from the 1958 National Child Development Study (NCDS) cohort, whose secondary schooling years lay within the transition years of a major reform that transformed secondary education in England and Wales from a selective system of schooling to mixed-ability comprehensive schools. We adopt a local instrumental variables approach to estimate person-centred treatment (PeT) effects of comprehensive over selective schooling system. Our results indicate that the newer comprehensive schooling system produced significant negative effects on long-term health and increased smoking behavior among a small fraction of individuals, for whom the effects were persistent over time. The ATE and TT were quantitatively similar and statistically insignificant indicating that cognitive abilities, the major driver for selection in to comprehensive schools, did not moderate the effects. The PeT effects indicate that individuals with lower non-cognitive skills were most likely to be negatively affected by exposure to mixed-ability schools. Our results also show that cigarette smoking could be a leading transmission channel of the long-term impact on health outcomes.

Members of the National Child Development Study cohort attended very different\ud types of secondary schools, as their schooling lay within the transition\ud period of the comprehensive education reform in England and Wales. This\ud provides a natural setting to explore the impact of educational attainment and\ud of school quality on health and health-related behavior later in life. We use a\ud combination of matching methods and parametric regressions to deal with selection effects and to evaluate differences in adult health outcomes and health-related behavior for cohort members exposed to the old selective and to the new comprehensive educational systems.

This paper proposes a behavioural model of inequality of opportunity in health that integrates John Roemer’s framework of inequality of opportunity with the Grossman model of health capital and demand for health.\ud The model generates a recursive system of equations for health and lifestyles, which is then jointly estimated by full information maximum likelihood with freely correlated error terms. The analysis innovates by accounting\ud for the presence of unobserved heterogeneity, therefore addressing the partial-circumstance problem, and by extending the examination of inequality of opportunity to health outcomes other than self-assessed\ud health, such as long-standing illness, disability and mental health. The results provide evidence for the existence of third factors that simultaneously influence health outcomes and lifestyle choices, supporting the empirical\ud relevance of the partial-circumstance problem. Accounting for these factors, the paper corroborates that the effect of parental and early circumstances on adult health disparities is paramount. However, the particular set of\ud circumstances that affect each of the analysed health outcomes differs substantially. The results also show that differences in educational opportunities, and in social development in childhood, are crucial determinants of lifestyles in adulthood, which, in turn, shape the observed health inequalities.