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Article

The Economics of Dementia  

Sheelah Connolly

In the coming years, it is predicted that there will be a significant increase in the number of people living with dementia and consequently, the demand for health and social care services. Given the budget constraints facing health systems, it is anticipated that economic analysis will play an increasingly important role in informing decisions regarding the provision of services for people with dementia. However, compared with other conditions and diseases, research in dementia has been relatively limited. While in the past this may have been related to an assumption that dementia was a natural part of aging, there are features of dementia that make applying research methods particularly challenging. A number of economic methods have been applied to dementia, including cost-of-illness analysis and economic evaluation; however, methodological issues in this area persist. These include reaching a consensus on how best to measure and value informal care, how to capture the many impacts and costs of the condition as the disease progresses, and how to measure health outcomes. Addressing these existing methodological issues will help realize the potential of economic analysis in answering difficult questions around care for people with dementia.

Article

The Economics of Gender and Educational Achievement: Stylized Facts and Causal Evidence  

Judith M. Delaney and Paul J. Devereux

There are two well-established gender gaps in education. First, females tend to have higher educational attainment and achievement than males, and this is particularly the case for children from less advantaged backgrounds. Second, there are large differences in the fields of specialization chosen by males and females in college and even prior to college, and females disproportionately enter less highly paid fields. Gender differences in noncognitive traits, behavior, and interests have been shown to relate to differences in educational outcomes; however, this evidence cannot generally be given a causal interpretation. In contrast, the literature has been creative in estimating causal impacts of a wide range of factors using experimental and quasiexperimental variation. While the approaches are compelling, the findings vary widely across studies and are often contradictory. This may partly reflect methodological differences across studies, but it also may result from substantial true heterogeneity across educational systems and time periods. Lower educational achievement of males has been linked to gender differences in attitudes, behaviors, and educational aspirations as well as the tendency of males to mature at older ages. Differential field choices by gender are related to differences in comparative advantage by gender and gender differences in preferences for types of study and work and for nonpecuniary aspects of jobs, such as their flexibility and gender mix. There are reasons to believe that policy should address the two gender gaps, and many possible policy approaches exist. However, their effectiveness is unclear, and there is scope for further work to determine which policies are likely to be effective and in which circumstances.

Article

The Economics of Health and Migration  

Osea Giuntella and Timothy J. Halliday

Migration and health are intimately connected. It is known that migrants tend to be healthier than non-migrants. However, the mechanisms for this association are elusive. On the one hand, the costs of migration are lower for healthier people, thereby making it easier for the healthy to migrate. Empirical evidence from a variety of contexts shows that the pre-migration health of migrants is better than it is for non-migrants, indicating that there is positive health-based selection in migration. On the other hand, locations can be viewed as a bundle of traits including but not limited to environmental conditions, healthcare quality, and violence. Each of these can impact health. Evidence shows that moving from locations with high mortality to low mortality can reduce mortality risks. Consistent with this, migration can increase mortality risk if it leads to greater exposure to risk factors for disease. The health benefits enjoyed by migrants can also be found in their children. However, these advantages erode with successive generations.

Article

Time Preferences for Health  

Marjon van der Pol and Alastair Irvine

The interest in eliciting time preferences for health has increased rapidly since the early 1990s. It has two main sources: a concern over the appropriate methods for taking timing into account in economics evaluations, and a desire to obtain a better understanding of individual health and healthcare behaviors. The literature on empirical time preferences for health has developed innovative elicitation methods in response to specific challenges that are due to the special nature of health. The health domain has also shown a willingness to explore a wider range of underlying models compared to the monetary domain. Consideration of time preferences for health raises a number of questions. Are time preferences for health similar to those for money? What are the additional challenges when measuring time preferences for health? How do individuals in time preference for health experiments make decisions? Is it possible or necessary to incentivize time preference for health experiments?

Article

Unintended Fertility: Trends, Causes, Consequences  

Christine Piette Durrance and Melanie Guldi

Unintended fertility occurs when an individual, who did not intend to, becomes pregnant or gives birth. Most measures of unintended fertility account for whether the pregnancy (birth) was wanted and whether it occurred at a desired time. Economic models of fertility provide a framework for understanding an individual’s desire to have children (or not), the number of children to have alongside the quality of each child, and the timing of childbirth. To study fertility intendedness, researchers often classify pregnancies or births as unintended using self-reported retrospective (or prospective) survey responses. However, since survey information on the intendedness of pregnancies and births is not always available, the research on unintended fertility using survey data is necessarily limited to the population surveyed. Consequently, to broaden the population studied, researchers also often rely on reported births, abortions, and miscarriages (fetal deaths) to estimate intendedness. However, other factors (such as laws restricting access or financial hurdles to overcome) may restrict access to the methods used to control reproduction, and these restrictions in turn may influence realized (observed) pregnancies, births, and abortions. Furthermore, abortion and miscarriages are not consistently reported and, when reported, they exhibit more measurement error than births. Despite these research challenges, the available data have allowed researchers to glean information on trends in unintendedness and to study the relationship between fertility-related policies and unintendedness. Over the last 2 decades, unintended fertility has declined in many countries and fewer births are happening “too soon.” There are multiple factors underlying these changes, but changes in access to and quality of reproductive technologies, changes in macroeconomic conditions, and socioeconomic characteristics of fertility-aged individuals appear to be crucial drivers of these changes.

Article

Valuation of Health Risks  

Henrik Andersson, Arne Risa Hole, and Mikael Svensson

Many public policies and individual actions have consequences for population health. To understand whether a (costly) policy undertaken to improve population health is a wise use of resources, analysts can use economic evaluation methods to assess the costs and benefits. To do this, it is necessary to evaluate the costs and benefits using the same metric, and for convenience, a monetary measure is commonly used. It is well established that money measures of a reduction in health risks can be theoretically derived using the willingness-to-pay concept. However, because a market price for health risks is not available, analysts have to rely on analytical techniques to estimate the willingness to pay using revealed- or stated-preference methods. Revealed-preference methods infer willingness to pay based on individuals’ actual behavior in markets related to health risks, and they include such approaches as hedonic pricing techniques. Stated-preference methods use a hypothetical market scenario in which respondents make trade-offs between wealth and health risks. Using, for example, a random utility framework, it is possible to directly estimate individuals’ willingness to pay by analyzing the trade-offs they make in the hypothetical scenario. Stated-preference methods are commonly applied using contingent valuation or discrete choice experiment techniques. Despite criticism and the shortcomings of both the revealed- and stated-preference methods, substantial progress has been made since the 1990s in using both approaches to estimate the willingness to pay for health-risk reductions.

Article

Value-Added Estimates of Teacher Effectiveness: Measurement, Uses, and Limitations  

Jessalynn James and Susanna Loeb

Since the turn of the 21st century, an abundant body of research has demonstrated that teachers meaningfully contribute to their students’ learning but that teachers vary widely in their effectiveness. Measures of teachers’ “value added” to student achievement have become common, and sometimes controversial, tools for researchers and policymakers hoping to identify and differentiate teachers’ individual contributions to student learning. Value-added measures aim to identify how much more a given teacher’s students learn than what would be expected based on how much other, similar students learn with other teachers. The question of how to measure value added without substantial measurement error and without incorrectly capturing other factors outside of teachers’ control is complex and sometime illusory, and the advantages and drawbacks to any particular method of estimating teachers’ value added depend on the specific context and purpose for their use. Traditionally, researchers have calculated value-added scores only for the subset of teachers with students in tested grades and subjects—a relatively small proportion of the teaching force, in a narrow set of the many domains on which teachers may influence their students. More recently, researchers have created value-added estimates for a range of other student outcomes, including measures of students’ engagement and social-emotional learning such as attendance and behavioral incidences, which may be available for more teachers. Overall, teacher value-added measures can be useful tools for understanding and improving teaching and learning, but they have substantial limitations for many uses and contexts.

Article

Variations in the Adoption of Healthcare Innovation: A Literature Review  

Marisa Miraldo, Katharina Hauck, Antoine Vernet, and Ana Wheelock

Major medical innovations have greatly increased the efficacy of treatments, improved patient outcomes, and often reduced the cost of medical care. However, innovations do not diffuse uniformly across and within health systems. Due to the high complexity of medical treatment decisions, variations in clinical practice are inherent to healthcare delivery, regardless of technological advances, new ways of working, funding, and burden of disease. In this article we conduct a narrative literature review to identify and discuss peer-reviewed articles presenting a theoretical framework or empirical evidence of the factors associated with the adoption of innovation and clinical practice. We find that variation in innovation adoption and medical practice is associated with multiple factors. First, patients’ characteristics, including medical needs and genetic factors, can crucially affect clinical outcomes and the efficacy of treatments. Moreover, differences in patients’ preferences can be an important source of variation. Medical treatments may need to take such patient characteristics into account if they are to deliver optimal outcomes, and consequently, resulting practice variations should be considered warranted and in the best interests of patients. However, socioeconomic or demographic characteristics, such as ethnicity, income, or gender are often not considered legitimate grounds for differential treatment. Second, physician characteristics—such as socioeconomic profile, training, and work-related characteristics—are equally an influential component of practice variation. In particular, so-called “practice style” and physicians’ attitudes toward risk and innovation adoption are considered a major source of practice variation, but have proven difficult to investigate empirically. Lastly, features of healthcare systems—notably, public coverage of healthcare expenditure, cost-based reimbursement of providers, and service-delivery organization, are generally associated with higher utilization rates and adoption of innovation. Research shows some successful strategies aimed at reducing variation in medical decision-making, such as the use of decision aids, data feedback, benchmarking, clinical practice guidelines, blinded report cards, and pay for performance. But despite these advances, there is uneven diffusion of new technologies and procedures, with potentially severe adverse efficiency and equity implications.

Article

What Drives HIV in Africa? Addressing Economic Gender Inequalities to Close the HIV Gender Gap  

Aurélia Lépine, Henry Cust, and Carole Treibich

Ending HIV as a public health threat by 2030 presents challenges significantly different to those of the past 40 years. Initially perceived as a disease affecting gay men, today, HIV disproportionately affects adolescents and young women in Africa. Current strategies to prevent HIV mostly rely on using biomedical interventions to reduce the risk of infection during risky sex and to address that biologically; women are more vulnerable to HIV infection than men. Ongoing policies and strategies to end the AIDS epidemic in Africa are likely to fail if implemented alone, given they fail to address why vulnerable young women engage in risky sexual behaviors. Evidence strongly suggests economic vulnerability, rather than income level, is a primary driver of women's decision to engage in commercial and transactional sex. By viewing HIV through the lens of structural gender inequality, poverty, and use of risky sexual behaviors to cope with economic shocks, a new explanation for the HIV gender gap emerges. New and promising approaches to reduce HIV acquisition and transmission by protecting women from economic shocks and increasing their ability to participate in the economy have proven effective. Such interventions are vital to break the pattern of unequal HIV transmission against women and if HIV is to be beaten.