21-40 of 310 Results

Article

Helmut Herwartz and Alexander Lange

Unlike traditional first order asymptotic approximations, the bootstrap is a simulation method to solve inferential issues in statistics and econometrics conditional on the available sample information (e.g. constructing confidence intervals, generating critical values for test statistics). Even though econometric theory yet provides sophisticated central limit theory covering various data characteristics, bootstrap approaches are of particular appeal if establishing asymptotic pivotalness of (econometric) diagnostics is infeasible or requires rather complex assessments of estimation uncertainty. Moreover, empirical macroeconomic analysis is typically constrained by short- to medium-sized time windows of sample information, and convergence of macroeconometric model estimates toward their asymptotic limits is often slow. Consistent bootstrap schemes have the potential to improve empirical significance levels in macroeconometric analysis and, moreover, could avoid explicit assessments of estimation uncertainty. In addition, as time-varying (co)variance structures and unmodeled serial correlation patterns are frequently diagnosed in macroeconometric analysis, more advanced bootstrap techniques (e.g., wild bootstrap, moving-block bootstrap) have been developed to account for nonpivotalness as a results of such data characteristics.

Article

Cristina Bellés-Obrero and Judit Vall Castelló

The impact of macroeconomic fluctuations on health and mortality rates has been a highly studied topic in the field of economics. Many studies, using fixed-effects models, find that mortality is procyclical in many countries, such as the United States, Germany, Spain, France, Pacific-Asian nations, Mexico, and Canada. On the other hand, a small number of studies find that mortality decreases during economic expansion. Differences in the social insurance systems and labor market institutions across countries may explain some of the disparities found in the literature. Studies examining the effects of more recent recessions are less conclusive, finding mortality to be less procyclical, or even countercyclical. This new finding could be explained by changes over time in the mechanisms behind the association between business cycle conditions and mortality. A related strand of the literature has focused on understanding the effect of economic fluctuations on infant health at birth and/or child mortality. While infant mortality is found to be procyclical in countries like the United States and Spain, the opposite is found in developing countries. Even though the association between business cycle conditions and mortality has been extensively documented, a much stronger effort is needed to understand the mechanisms behind the relationship between business cycle conditions and health. Many studies have examined the association between macroeconomic fluctuations and smoking, drinking, weight disorders, eating habits, and physical activity, although results are rather mixed. The only well-established finding is that mental health deteriorates during economic slowdowns. An important challenge is the fact that the comparison of the main results across studies proves to be complicated due to the variety of empirical methods and time spans used. Furthermore, estimates have been found to be sensitive to the use of different levels of geographic aggregation, model specifications, and proxies of macroeconomic fluctuations.

Article

Samuel Muehlemann and Stefan Wolter

The economic reasons why firms engage in apprenticeship training are twofold. First, apprenticeship training is a potentially cost-effective strategy for filling a firm’s future vacancies, particularly if skilled labor on the external labor market is scarce. Second, apprentices can be cost-effective substitutes for other types of labor in the current production process. As current and expected business and labor market conditions determine a firm’s expected work volume and thus its future demand for skilled labor, they are potentially important drivers of a firm’s training decisions. Empirical studies have found that the business cycle affects apprenticeship markets. However, while the economic magnitude of these effects is moderate on average, there is substantial heterogeneity across countries, even among those that at first sight seem very similar in terms of their apprenticeship systems. Moreover, identification of business cycle effects is a difficult task. First, statistics on apprenticeship markets are often less developed than labor market statistics, making empirical analyses of demand and supply impossible in many cases. In particular, data about unfilled apprenticeship vacancies and unsuccessful applicants are paramount for assessing potential market failures and analyzing the extent to which business cycle fluctuations may amplify imbalances in apprenticeship markets. Second, the intensity of business cycle effects on apprenticeship markets is not completely exogenous, as governments typically undertake a variety of measures, which differ across countries and may change over time, to reduce the adverse effects of economic downturns on apprenticeship markets. During the economic crisis related to the COVID-19 global pandemic, many countries took unprecedented actions to support their economies in general and reacted swiftly to introduce measures such as the provision of financial subsidies for training firms or the establishment of apprenticeship task forces. As statistics on apprenticeship markets improve over time, such heterogeneity in policy measures should be exploited to improve our understanding of the business cycle and its relationship with apprenticeships.

Article

Alessandro Rebucci and Chang Ma

This paper reviews selected post–Global Financial Crisis theoretical and empirical contributions on capital controls and identifies three theoretical motives for the use of capital controls: pecuniary externalities in models of financial crises, aggregate demand externalities in New Keynesian models of the business cycle, and terms of trade manipulation in open-economy models with pricing power. Pecuniary and demand externalities offer the most compelling case for the adoption of capital controls, but macroprudential policy can also address the same distortions. So capital controls generally are not the only instrument that can do the job. If evaluated through the lenses of the new theories, the empirical evidence reviewed suggests that capital controls can have the intended effects, even though the extant literature is inconclusive as to whether the effects documented amount to a net gain or loss in welfare terms. Terms of trade manipulation also provides a clear-cut theoretical case for the use of capital controls, but this motive is less compelling because of the spillover and coordination issues inherent in the use of control on capital flows for this purpose. Perhaps not surprisingly, only a handful of countries have used capital controls in a countercyclical manner, while many adopted macroprudential policies. This suggests that capital control policy might entail additional costs other than increased financing costs, such as signaling the bad quality of future policies, leakages, and spillovers.

Article

The window of opportunity for containing risks of dangerous instability in the global climate system is closing rapidly. The response of the international community is embedded in the 2015 Paris Agreement, signed by 195 parties. Implementing the mitigation pledges parties submitted for the agreement is an important first step, although an additional mechanism to coordinate and scale up mitigation policy at the international level will likely be needed. Carbon taxation, or similar pricing, has a pivotal role, providing across-the-board incentives for reducing emissions and the critical price signal for redirecting investment, but pricing has proved difficult politically. Analytical literature on carbon taxation provides practical guidance on the role of taxation in implementing the Paris Agreement and enhancing its acceptability. Shifting taxes off labor and capital and onto carbon or fossil fuels can produce a “double dividend” by reducing environmental harm and lowering the burden broader taxes impose on the economy. Broader taxes both discourage work effort and investment and promote tax-sheltering behavior (e.g., activity in the informal sector). For various technical and practical reasons, however, it may not make sense to set the carbon tax rate above levels warranted on environmental grounds. The literature emphasizes the general importance of using carbon pricing revenues to benefit the economy, for example, lowering burdensome taxes or funding productive investments. These economic benefits are forgone if instead carbon pricing revenues are given to households in lump-sum dividends. Where higher energy prices are subject to public acceptability constraints, a package of regulations or their fiscal equivalents (known as “feebates”) have an important role in reinforcing carbon pricing. Carbon mitigation can also produce important domestic environmental co-benefits, such as reductions in local air pollution mortality. Unilateral action may be in many countries’ own interests before even counting the global climate benefits. Recent studies have quantified the carbon prices implicit in countries’ Paris mitigation pledges. These implicit prices differ widely across countries with the stringency of pledges and the responsiveness of emissions to pricing, underscoring the potential efficiency gains from some degree of price coordination at the international level. In fact, an international carbon price floor arrangement could be strikingly effective to the extent that it promotes more mitigation in key emerging market economies, such as China and India. The price floor need only cover a handful of large emitters, could be designed equitably with higher requirements for advanced countries, and could be designed flexibly to accommodate different policy approaches at the national level. Domestically, policymakers need to develop comprehensive mitigation strategies, ideally with carbon pricing as the key element. These strategies need to distribute burdens equitably, assist vulnerable groups, and include supporting measures for investment and pricing for broader sources of greenhouse gases.

Article

Diane McIntyre, Amarech G. Obse, Edwine W. Barasa, and John E. Ataguba

Within the context of the Sustainable Development Goals, it is important to critically review research on healthcare financing in sub-Saharan Africa (SSA) from the perspective of the universal health coverage (UHC) goals of financial protection and access to quality health services for all. There is a concerning reliance on direct out-of-pocket payments in many SSA countries, accounting for an average of 36% of current health expenditure compared to only 22% in the rest of the world. Contributions to health insurance schemes, whether voluntary or mandatory, contribute a small share of current health expenditure. While domestic mandatory prepayment mechanisms (tax and mandatory insurance) is the next largest category of healthcare financing in SSA (35%), a relatively large share of funding in SSA (14% compared to <1% in the rest of the world) is attributable to, sometimes unstable, external funding sources. There is a growing recognition of the need to reduce out-of-pocket payments and increase domestic mandatory prepayment financing to move towards UHC. Many SSA countries have declared a preference for achieving this through contributory health insurance schemes, particularly for formal sector workers, with service entitlements tied to contributions. Policy debates about whether a contributory approach is the most efficient, equitable and sustainable means of financing progress to UHC are emotive and infused with “conventional wisdom.” A range of research questions must be addressed to provide a more comprehensive empirical evidence base for these debates and to support progress to UHC.

Article

Since the 1980s policymakers have identified a wide range of policy interventions to improve hospital performance. Some of these have been initiated at the level of government, whereas others have taken the form of decisions made by individual hospitals but have been guided by regulatory or financial incentives. Studies investigating the impact that some of the most important of these interventions have had on hospital performance can be grouped into four different research streams. Among the research streams, the strongest evidence exists for the effects of privatization. Studies on this topic use longitudinal designs with control groups and have found robust increases in efficiency and financial performance. Evidence on the entry of hospitals into health systems and the effects of this on efficiency is similarly strong. Although the other three streams of research also contain well-conducted studies with valuable findings, they are predominantly cross-sectional in design and therefore cannot establish causation. While the effects of introducing DRG-based hospital payments and of specialization are largely unclear, vertical and horizontal cooperation probably have a positive effect on efficiency and financial performance. Lastly, the drivers of improved efficiency or financial performance are very different depending on the reform or intervention being investigated; however, reductions in the number of staff and improved bargaining power in purchasing stand out as being of particular importance. Several promising avenues for future investigation are identified. One of these is situated within a new area of research examining the link between changes in the prices of treatments and hospitals’ responses. As there is evidence of unintended effects, future studies should attempt to distinguish between changes in hospitals’ responses at the intensive margin (e.g., upcoding) versus the extensive margin (e.g., increase in admissions). When looking at the effects of entering into a health system and of privatizations, there is still considerable need for research. With privatizations, in particular, the underlying processes are not yet fully understood, and the potential trade-offs between increases in performance and changes in the quality of care have not been sufficiently examined. Lastly, there is substantial need for further papers in the areas of multi-institutional arrangements and cooperation, as well as specialization. In both research streams, natural experiments carried out using program evaluation design are lacking. One of the main challenges here, however, is that cooperation and specialization cannot be directly observed but rather must be constructed based on survey or administrative data.

Article

Across the United States, charter schools—publicly funded and regulated, but privately run schools—appear to perform, on average, at about the same level as their district counterparts. The broadest studies of charter school effectiveness use observational methods, which may not fully account for selection of students into charter schools. However, this finding is confirmed by lottery-based evidence from a few broad samples that again presents a varied picture of charter impact and little average difference across sectors. Underlying the similarity in performance across sectors is one of the most consistent findings from both observational and lottery-based evidence of charter schools’ impact on student achievement: Charters located in urban areas boost student test scores, particularly for Black, Latinx, and students from lower-income households. The test score gains appear to be largest in urban charters that employ “No Excuses” practices. Attending some urban charter schools also increases college enrollment and voting and reduces risky behavior. However, evidence on such long-term outcomes is limited to a few samples, and evidence on college graduation and adult earnings is even rarer, making it difficult to draw conclusions beyond test scores about the overall effectiveness of the charter sector. Research on the mechanisms underlying charter successes, when they occur, is growing. No Excuses charter schools—which employ high expectations, strict disciplinary codes, and intense academic focus—generate consistent test score gains, but their controversial disciplinary practices are not necessarily a condition for academic success. Charter school teachers tend to be less qualified and more likely to leave the profession than traditional public school teachers, though the impact of these challenges for the labor market is understudied. Similarly, the influence of charter authorizers and related accountability structures is limited and would benefit from examination using more rigorous methodologies. The competitive impact of charter schools on traditional public schools typically suggests a small, beneficial influence on neighboring schools’ student achievement, though there is variation across contexts. Additionally, while some local analyses suggest charters reduce funding in nearby districts, at least in the short term, a larger scale study finds charter entry generates more revenue per pupil for district schools. There is competing evidence on charters’ contribution to school racial segregation, and little evidence on the impact of newer, intentionally diverse school models. In all, more research, in more contexts, is needed to further understand where, for whom, and why charters are most effective.

Article

Governments around the world are increasingly investing resources for young children, and universal provision of early childhood education and care (ECEC) has become widespread. Children’s development is affected by the investments they receive both within and outside the household. A simple theoretical framework predicts that the provision of public childcare will improve children’s development if it offers more stimulation than the care it replaces. Generally, carefully designed studies show that the provision of early childcare is beneficial, especially for children from disadvantaged backgrounds. This is in line with expectations that the alternative care experienced by children from less affluent, less educated, and immigrant backgrounds is likely to be of lower quality. Interestingly, however, studies show that the children who would benefit the most are least likely to receive care, providing a challenge for policy makers. Some programs, such as the $5-per-day childcare in Quebec, have negative effects and therefore may be of poor quality. However, comparing results across programs that vary in several dimensions makes it difficult to separate out the ingredients that are most important for success. Studies that focus on identifying the factors in ECEC that lead to the greatest benefit indicate that some standard measures such as staff qualifications are weakly linked to children’s outcomes, whereas larger staff–child ratios and researcher-measured process quality are beneficial. Spending more time in high-quality childcare from around age 3 has proved to be beneficial, whereas the effect of an increase in childcare for younger children is particularly sensitive to each program’s features and context.

Article

Lawrence J. Lau

Chinese real gross domestic product (GDP) grew from US$369 billion in 1978 to US$12.7 trillion in 2017 (in 2017 prices and exchange rate), at almost 10% per annum, making the country the second largest economy in the world, just behind the United States. During the same period, Chinese real GDP per capita grew from US$383 to US$9,137 (2017 prices), at 8.1% per annum. Chinese economic reform, which began in 1978, consists of two elements—introduction of free markets for goods and services, coupled with conditional producer autonomy, and opening to international trade and direct investment with the rest of the world. In its transition from a centrally planned to a market economy, China employed a “dual-track” approach—with the pre-existing mandatory central plan continuing in force and the establishment of free markets in parallel. In its opening to the world, China set a competitive exchange rate for its currency, made it current account convertible in 1994, and acceded to the World Trade Organisation (WTO) in 2001. In 2005, China became the second largest trading nation in the world, after the United States. Other Chinese policies complementary to its economic reform include the pre-existing low non-agricultural wage and the limit of one-child per couple, introduced in 1979 and phased out in 2016. The high rate of growth of Chinese real output since 1978 can be largely explained by the high rates of growth of inputs, but there were also other factors at work. Chinese economic growth since 1978 may be attributed as follows: (a) the elimination of the initial economic inefficiency (12.7%), (b) the growth of tangible capital (55.7%) and labor (9.7%) inputs, (c) technical progress (or growth of total factor productivity (TFP)) (8%), and (d) economies of scale (14%). The Chinese economy also shares many commonalities with other East Asian economies in terms of their development experiences: the lack of natural endowments, the initial conditions (the low real GDP per capita and the existence of surplus agricultural labor), the cultural characteristics (thrift, industry, and high value for education), the economic policies (competitive exchange rate, export promotion, investment in basic infrastructure, and maintenance of macroeconomic stability), and the consistency, predictability, and stability resulting from continuous one-party rule.

Article

The house price boom that has been present in most Chinese cities since the early 2000s has triggered substantial interest in the role that China’s housing policy plays in its housing market and macroeconomy, with an extensive literature employing both empirical and theoretical perspectives developed over the past decade. This research finds that the privatization of China’s housing market, which encouraged households living in state-owned housing to purchase their homes at prices far below their market value, contributed to a rapid increase in homeownership beginning in the mid-1990s. Housing market privatization also has led to a significant increase in both housing and nonhousing consumption, but these benefits are unevenly distributed across households. With the policy goal of making homeownership affordable for the average household, the Housing Provident Fund contributes positively to homeownership rates. By contrast, the effectiveness of housing policies to make housing affordable for low-income households has been weaker in recent years. Moreover, a large body of empirical research shows that the unintended consequences of housing market privatization have been a persistent increase in housing prices since the early 2000s, which has been accompanied by soaring land prices, high vacancy rates, and high price-to-income and price-to-rent ratios. The literature has differing views regarding the sustainability of China’s housing boom. On a theoretical front, economists find that rising housing demand, due to both consumption and investment purposes, is important to understanding China’s prolonged housing boom, and that land-use policy, which influences the supply side of the housing market, lies at the center of China’s housing boom. However, regulatory policies, such as housing purchase restrictions and property taxes, have had mixed effects on the housing market in different cities. In addition to China’s housing policy and its direct effects on the nation’s housing market, research finds that China’s housing policy impacts its macroeconomy via the transmission of house price dynamics into the household and corporate sectors. High housing prices have a heterogenous impact on the consumption and savings of different types of households but tend to discourage household labor supply. Meanwhile, rising house prices encourage housing investment by non–real-estate firms, which crowds out nonhousing investment, lowers the availability of noncollateralized business loans, and reduces productive efficiency via the misallocation of capital and managerial talent.

Article

In many countries of the world, consumers choose their health insurance coverage from a large menu of often complex options supplied by private insurance companies. Economic benefits of the wide choice of health insurance options depend on the extent to which the consumers are active, well informed, and sophisticated decision makers capable of choosing plans that are well-suited to their individual circumstances. There are many possible ways how consumers’ actual decision making in the health insurance domain can depart from the standard model of health insurance demand of a rational risk-averse consumer. For example, consumers can have inaccurate subjective beliefs about characteristics of alternative plans in their choice set or about the distribution of health expenditure risk because of cognitive or informational constraints; or they can prefer to rely on heuristics when the plan choice problem features a large number of options with complex cost-sharing design. The second decade of the 21st century has seen a burgeoning number of studies assessing the quality of consumer choices of health insurance, both in the lab and in the field, and financial and welfare consequences of poor choices in this context. These studies demonstrate that consumers often find it difficult to make efficient choices of private health insurance due to reasons such as inertia, misinformation, and the lack of basic insurance literacy. These findings challenge the conventional rationality assumptions of the standard economic model of insurance choice and call for policies that can enhance the quality of consumer choices in the health insurance domain.

Article

In the wake of the 2008 financial collapse, clearinghouses have emerged as critical players in the implementation of the post-crisis regulatory reform agenda. Recognizing serious shortcomings in the design of the over-the-counter derivatives market for swaps, regulators are now relying on clearinghouses to cure these deficiencies by taking on a central role in mitigating the risks of these instruments. Rather than leave trading firms to manage the risks of transacting in swaps privately, as was largely the case prior to 2008, post-crisis regulation requires that clearinghouses assume responsibility for ensuring that trades are properly settled, reported to authorities, and supported by strong cushions of protective collateral. With clearinghouses effectively guaranteeing that the terms of a trade will be honored—even if one of the trading parties cannot perform—the market can operate with reduced levels of counterparty risk, opacity, and the threat of systemic collapse brought on by recklessness and over-complexity. But despite their obvious benefit for regulators, clearinghouses also pose risks of their own. First, given their deepening significance for market stability, ensuring that clearinghouses themselves operate safely represents a matter of the highest policy priority. Yet overseeing clearinghouses is far from easy and understanding what works best to undergird their safe operation can be a contentious and uncertain matter. U.S. and EU authorities, for example, have diverged in important ways on what rules should apply to the workings of international clearinghouses. Secondly, clearinghouse oversight is critical because these institutions now warehouse enormous levels of counterparty risk. By promising counterparties across the market that their trades will settle as agreed, even if one or the other firm goes bust, clearinghouses assume almost inconceivably large and complicated risks within their institutions. For swaps in particular—whose obligations can last for months, or even years—the scale of these risks can be far more extensive than that entailed in a one-off sale or a stock or bond. In this way, commentators note that by becoming the go-to bulwark against risk-taking and its spread in the financial system, clearinghouses have themselves become the too-big-to-fail institution par excellence.

Article

Xiaoyu Li and Sathya Gopalakrishnan

The convergence of geophysical and economic forces that continuously influence environmental quality in the coastal zone presents a grand challenge for resource and environmental economists. To inform climate adaptation policy and identify pathways to sustainability, economists must draw from different lines of inquiry, including nonmarket valuation, quasi-experimental analyses, common-pool resource theory, and spatial-dynamic modeling of coupled coastal-economic systems. Theoretical and empirical contributions in valuing coastal amenities and risks help examine the economic impact of climate change on coastal communities and provide a key input to inform policy analysis. Co-evolution of community demographics, adaptation decisions, and the physical coastline can result in unintended consequences, like climate-induced migration, that impacts community composition after natural disasters. Positive and normative models of coupled coastline systems conceptualize the feedbacks between physical coastline dynamics and local community decisions as a dynamic geoeconomic resource management problem. There is a pressing need for interdisciplinary research across natural and social sciences to better understand climate adaptation and coastal resilience.

Article

Claude Diebolt and Michael Haupert

Cliometrics is the application of economic theory and quantitative methods to the study of economic history. The methodology rose to favor in economics departments in the 1960s. It grew to dominate the discipline over the next two decades, culminating in the awarding of the 1993 Nobel Prize in Economics to two of its pioneers, Robert Fogel and Douglass North. Cliometrics has always had its share of critics, and some have blamed it for the diminished role that economic history has had in economics programs in the 21st century.

Article

Katarina Juselius

The cointegrated VAR approach combines differences of variables with cointegration among them and by doing so allows the user to study both long-run and short-run effects in the same model. The CVAR describes an economic system where variables have been pushed away from long-run equilibria by exogenous shocks (the pushing forces) and where short-run adjustments forces pull them back toward long-run equilibria (the pulling forces). In this model framework, basic assumptions underlying a theory model can be translated into testable hypotheses on the order of integration and cointegration of key variables and their relationships. The set of hypotheses describes the empirical regularities we would expect to see in the data if the long-run properties of a theory model are empirically relevant.

Article

Giovanni Federico

The literature on market integration explores the development of the commodity market with data on prices, which is a useful complement to analysis of trade and the only feasible approach when data on trade are not available. Data on prices and quantity can help in understanding when markets developed, why, and the degree to which their development increased welfare and economic growth. Integration progressed slowly throughout the early modern period, with significant acceleration in the first half of the 19th century. Causes of integration include development of transportation infrastructure, changes in barriers to trade, and short-term shocks, such as wars. Literature on the effects of market integration is limited and strategies for estimating the effects of market integration are must be developed.

Article

Models of comparative advantage in international trade explain specialization using differences in autarky relative prices. This literature has traditionally focused on the Heckscher–Ohlin and Ricardian models. The former emphasizes differences in factor abundance across countries and in factor intensity across goods; the latter focuses on relative productivity differences across countries and goods. However, unrealistic assumptions and stark assumptions have hindered empirical assessment of these models. Contemporary models now allow researchers to overcome these hurdles. New models of Ricardian comparative advantage incorporate realistic geography and multiple countries. Similar advances have freed the Heckscher–Ohlin model from some of its theoretical straightjackets. In addition, researchers have started to provide microfoundations for the Ricardian model and to formalize how institutions and factor market distortions might generate patterns of comparative advantage. Trade economists have also started to think about magnitudes in a different way; that is, through general equilibrium counterfactual experiments.

Article

Peter Sivey and Yijuan Chen

Quality competition between alternative providers is an increasingly important topic in the health economics literature. This literature includes theoretical and empirical studies that have been developed in parallel to 21st-century policies to increase competition between doctors or hospitals. Theoretical studies have clarified how competitive markets can give healthcare providers the incentive to improve quality. Broadly speaking, if providers have an incentive to attract more patients and patients value quality, providers will raise quality until the costs of raising quality are equal to the additional revenue from patients attracted by the rise in quality. The theoretical literature has also investigated how institutional and policy parameters determine quality levels in equilibrium. Important parameters in models of quality competition include the degree of horizontal differentiation, the level of information about provider quality, the costs of switching between providers, and the time-horizon of quality investment decisions. Empirical studies have focused on the prerequisites of quality competition (e.g., do patients choose higher quality providers?) and the impact of pro-competition policies on quality levels. The most influential studies have used modern econometric approaches, including difference-in differences and instrumental variables, to identify plausibly causal effects. The evidence suggests that in most contexts, quality is a determinant of patient choice of provider, especially after greater patient choice is made available or information is published about provider quality. The evidence that increases in competition improve quality in healthcare is less clear cut. Perhaps reflecting the economic theory of quality competition, showing that different parameter combinations or assumptions can produce different outcomes, empirical results are also mixed. While a series of high-quality studies in the United Kingdom appear to show strong improvements in quality in more competitive areas following pro-competition reforms introducing more choice and competition, other studies showed that these quality improvements do not extend to all types of healthcare or alternative measures of quality. The most promising areas for future research include investigating the “black box” of quality improvement under competition, and behavioral studies investigating financial and nonfinancial motivations for quality improvements in competitive markets.

Article

In order to secure effective service access, coverage, and impact, it is increasingly recognized that the introduction of novel health technologies such as diagnostics, drugs, and vaccines may require additional investment to address the constraints under which many health systems operate. Health-system constraints include a shortage of health workers, ineffective supply chains, or inadequate information systems, or organizational constraints such as weak incentives and poor service integration. Decision makers may be faced with the question of whether to invest in a new technology, including the specific health system strengthening needed to ensure effective implementation; or they may be seeking to optimize resource allocation across a range of interventions including investment in broad health system functions or platforms. Investment in measures to address health-system constraints therefore increasingly need to undergo economic evaluation, but this poses several methodological challenges for health economists, particularly in the context of low- and middle-income countries. Designing the appropriate analysis to inform investment decisions concerning new technologies incorporating health systems investment can be broken down into several steps. First, the analysis needs to comprehensively outline the interface between the new intervention and the system through which it is to be delivered, in order to identify the relevant constraints and the measures needed to relax them. Second, the analysis needs to be rooted in a theoretical approach to appropriately characterize constraints and consider joint investment in the health system and technology. Third, the analysis needs to consider how the overarching priority- setting process influences the scope and output of the analysis informing the way in which complex evidence is used to support the decision, including how to represent and manage system wide trade-offs. Finally, there are several ways in which decision analytical models can be structured, and parameterized, in a context of data scarcity around constraints. This article draws together current approaches to health system thinking with the emerging literature on analytical approaches to integrating health-system constraints into economic evaluation to guide economists through these four issues. It aims to contribute to a more health-system-informed approach to both appraising the cost-effectiveness of new technologies and setting priorities across a range of program activities.