Abstract: In this paper we assess the extent to which medical risk and individual preferences determine birth timing manipulation in public and private hospitals, among white and black mothers, using data from approximately 37 million births in Brazil. We find that manipulation is greater in private hospitals and among white women, mainly determined by physicians’ and parents’ convenience. In public hospitals manipulation mainly occurs in response to the risk profile of births, while racial disparities are equalized. The analysis provides a comprehensive and integrated assessment of how treatment decisions respond to different individual incentives, for different population groups, and within distinct institutional settings, thus allowing for comparison of magnitude of estimates across health systems and populations.
Financing needs, spending projection, and the future of health in Brazil (with Rudi Rocha and Isabela Furtado).
Health Economics, v.30(5), May 2021. [link]
Featured at Valor Econômico, Folha de São Paulo, Exame
Abstract: In this paper we adopt a growth accounting projection model to estimate and characterize health-financing needs in Brazil as well as to assess the extent to which financing needs may diverge from spending capacity in the future. We estimate an annual increase of 0.71% in the share of projected financing needs relative to GDP, with excess growth rates being 0.74% and 0.69% for the public and private health sectors, respectively. Institutional reforms and public spending restrictions may leverage public-private segmentation in health financing throughout the next decades, thus potentially leading to losses of equity in the system. Our projections contribute to a scant empirical literature on health financing sustainability in low- and middle-income countries and shed light on the role of spending capacity and institutional constraints over the path towards universal health coverage.
The Effect of Socioeconomic Inequalities and Vulnerabilities on Health System Preparedness and Response to COVID-19 in Brazil: A Comprehensive Analysis (with Rocha, Atun, Massuda, Rache, Nunes, Lago, Castro).
The Lancet Global Health, v.9(6), June 2021. [link]
Featured at Valor Econômico (front page)
Background: COVID-19 spread rapidly in Brazil despite the country's well established health and social protection systems. Understanding the relationships between health-system preparedness, responses to COVID-19, and the pattern of spread of the epidemic is particularly important in a country marked by wide inequalities in socioeconomic characteristics (eg, housing and employment status) and other health risks (age structure and burden of chronic disease).
Methods: From several publicly available sources in Brazil, we obtained data on health risk factors for severe COVID-19 (proportion of the population with chronic disease and proportion aged ≥60 years), socioeconomic vulnerability (proportions of the population with housing vulnerability or without formal work), health-system capacity (numbers of intensive care unit beds and physicians), coverage of health and social assistance, deaths from COVID-19, and state-level responses of government in terms of physical distancing policies. We also obtained data on the proportion of the population staying at home, based on locational data, as a measure of physical distancing adherence. We developed a socioeconomic vulnerability index (SVI) based on household characteristics and the Human Development Index. Data were analysed at the state and municipal levels. Descriptive statistics and correlations between state-level indicators were used to characterise the relationship between the availability of health-care resources and socioeconomic characteristics and the spread of the epidemic and the response of governments and populations in terms of new investments, legislation, and physical distancing. We used linear regressions on a municipality-by-month dataset from February to October, 2020, to characterise the dynamics of COVID-19 deaths and response to the epidemic across municipalities.
Findings: The initial spread of COVID-19 was mostly affected by patterns of socioeconomic vulnerability as measured by the SVI rather than population age structure and prevalence of health risk factors. The states with a high (greater than median) SVI were able to expand hospital capacity, to enact stringent COVID-19-related legislation, and to increase physical distancing adherence in the population, although not sufficiently to prevent higher COVID-19 mortality during the initial phase of the epidemic compared with states with a low SVI. Death rates accelerated until June, 2020, particularly in municipalities with the highest socioeconomic vulnerability. Throughout the following months, however, differences in policy response converged in municipalities with lower and higher SVIs, while physical distancing remained relatively higher and death rates became relatively lower in the municipalities with the highest SVIs compared with those with lower SVIs.
Interpretation: In Brazil, existing socioeconomic inequalities, rather than age, health status, and other risk factors for COVID-19, have affected the course of the epidemic, with a disproportionate adverse burden on states and municipalities with high socioeconomic vulnerability. Local government responses and population behaviour in the states and municipalities with higher socioeconomic vulnerability have helped to contain the effects of the epidemic. Targeted policies and actions are needed to protect those with the greatest socioeconomic vulnerability. This experience could be relevant in other low-income and middle-income countries where socioeconomic vulnerability varies greatly.
Modelling SARS-COV2 Spread in London: Approaches to Lift the Lockdown (with Goscé, Phillips, Gupta, and Abubakar).
Journal of Infection, v.81(2), August 2020. [link]
Objective: To use mathematical models to predict the epidemiological impact of lifting the lockdown in London, UK, and alternative strategies to help inform policy in the UK.
Methods: A mathematical model for the transmission of SARS-CoV2 in London. The model was parametrised using data on notified cases, deaths, contacts, and mobility to analyse the epidemic in the UK capital. We investigated the impact of multiple non pharmaceutical interventions (NPIs) and combinations of these measures on future incidence of COVID-19.
Results: Immediate action at the early stages of an epidemic in the affected districts would have tackled spread. While an extended lockdown is highly effective, other measures such as shielding older populations, universal testing and facemasks can all potentially contribute to a reduction of infections and deaths. However, based on current evidence it seems unlikely they will be as effective as continued lockdown. In order to achieve elimination and lift lockdown within 5 months, the best strategy seems to be a combination of weekly universal testing, contact tracing and use of facemasks, with concurrent lockdown. This approach could potentially reduce deaths by 48% compared with continued lockdown alone.
Conclusions: A combination of NPIs such as universal testing, contact tracing and mask use while under lockdown would be associated with least deaths and infections. This approach would require high uptake and sustained local effort but it is potentially feasible as may lead to elimination in a relatively short time scale.
Maternal time investment in caregiving activities to promote early childhood development: evidence from rural India (with Batura, Roy, Aziz, Sharma, Kumar, Verma, Correa Ossa, Soremekun, Sikander, Zafar, Divan, Hill, Avan, Rahman, Kirkwood, Skordis)
Frontiers in Pediatrics, v.11, July 2023. [link]
Introduction: Intervention strategies that seek to improve early childhood development outcomes are often targeted at the primary caregivers of children, usually mothers. The interventions require mothers to assimilate new information and then act upon it by allocating sufficient physical resources and time to adopt and perform development promoting behaviours. However, women face many competing demands on their resources and time, returning to familiar habits and behaviours. In this study, we explore mothers' allocation of time for caregiving activities for children under the age of 2, nested within a cluster randomised controlled trial of a nutrition and care for development intervention in rural Haryana, India.
Methods: We collected quantitative maternal time use data at two time points in rural Haryana, India, using a bespoke survey instrument. Data were collected from 704 mothers when their child was 12 months old, and 603 mothers when their child was 18 months old. We tested for significant differences in time spent by mothers on different activities when children are 12 months of age vs. 18 months of age between arms as well as over time, using linear regression. As these data were collected within a randomised controlled trial, we adjusted for clusters using random effects when testing for significant differences between the two time points.
Results: At both time points, no statistically significant difference in maternal time use was found between arms. On average, mothers spent most of their waking time on household chores (over 6 h and 30 min) at both time points. When children were aged 12 months, approximately three and a half hours were spent on childcare activities for children under the age of 2 years. When children were 18 months old, mothers spent more time on income generating activities (30 min) than when the children were 12 years old, and on leisure (approximately 4 h and 30 min). When children were 18 months old, less time was spent on feeding/breastfeeding children (30 min less) and playing with children (15 min). However, mothers spent more time talking or reading to children at 18 months than at 12 months.
Conclusion: We find that within a relatively short period of time in early childhood, maternal (or caregiver) time use can change, with time allocation being diverted away from childcare activities to others. This suggests that changing maternal time allocation in resource poor households may be quite challenging, and not allow the uptake of new and/or optimal behaviours.
Submitted for Peer-Review
Effectiveness and health impacts from rationing C-section use: Insights from a successful reform in Brazil (sole author).
Winner of the IDB Young Economist award (3rd prize). [link]
Abstract: This paper evaluates a national reform in Brazil that rationed C-sections’ relative frequency in public sector hospitals by imposing a fixed cap on the proportion of reimbursable births by C-section. In a differences-in-differences approach, I exploit variation in the binding nature of the implemented cap, driven by largely diverse baseline propensities for cesarean procedures. Estimates show a 10% reduction in C-section likelihood and 3.5% decline in infant hospitalization due to respiratory disorders per standard deviation increase in the constructed measure of binding intensity. Event study results demonstrate that reductions in C-section use were immediate and persisted over time. Heterogeneous analysis reveals that effects concentrated among low-risk births. This paper argues that the reform's success in cutting unjustified C-sections while safeguarding medically necessary ones is related to its design and the context of its implementation. These results offer valuable insights for emerging economies dealing with excessive use of unwarranted C-sections.
Community Health Workers As Key Providers of Easy-to-Use Contraceptive Injectables: Experimental Evidence from Rural Burundi (with Victor Orozco, Arndt Reichert, and Michele Andreottola).
World Bank Policy Research Working Paper no. 11074 [link]
Featured at the World Bank's blog
Abstract: This study employs a cluster randomized control trial and administrative health center data to investigate the effects of authorizing community health workers to deliver a new generation of contraceptive injections directly to women during routine home visits following comprehensive training. We observe a significant increase of approximately 70 percent in the administered quantity of these injections, which provide average protection for three months. However, our results suggest that the intervention does not produce a statistically significant change in contraceptive coverage because of significant substitution effects away from long-acting contraceptive implants and intrauterine devices that would have been introduced otherwise.
Pregnancy, food purchases and nutritional quality (with Britta Augsburg, Gabriela Conti, Melanie Luhrmann, and Stephanie von Hinke).
Undertaken during research placement at the Institute for Fiscal Studies (IFS), in London, UK.
Abstract: Pregnancy is a critical period for health investments, bolstered by extensive public health guidance and evidence that healthy prenatal environments foster child development with lifelong benefits. We provide new evidence on the impact of conception on nutritional choices during pregnancy and infancy, using an event study and household scanner data. Households make considerable healthy adjustments in alcohol and fruit purchases. Yet, despite these, the nutritional quality of food choices, measured using the FSA’s nutrient profiling model, declines substantially during pregnancy. The magnitude of the decline amounts to 50% of the mean difference in nutritional quality between a normal weight and an obese individual. It is caused largely by increased purchases of ultra-processed, high-sugar foods currently in the focus of food regulation. The deterioration of nutritional quality varies little by socio-economic status, pregnancy risk factors and food price environments, resulting in a fairly universal in-utero exposure to less healthy food environments.
Relevance and Drivers of Physicians’ Practice Styles: A Survey (sole author).
Cited by Dame Prof. Carol Propper in her keynote presentation at the 2024 EuHEA conference.
Abstract: Physicians often exhibit systematic differences in their treatment decisions for similar patient profiles, even when accounting for common incentives and constraints usually defined at a more aggregate level (e.g., financial considerations, litigation risks, and available infrastructure). This paper summarises studies leveraging largely exogenous variations in care provision to identify physicians' practice styles and their underlying determinants. The accumulated evidence indicates that approximately 50% of the variation in medical practice can be attributed to individual physicians. While variation is justifiable when driven by distinct comparative advantages or a lack of dominant treatment alternatives, evidence points to detrimental variation arising from substantial differences in diagnostic accuracy. Inefficiencies may also stem from beliefs contrary to scientific evidence and the complex task of incorporating uncertainty into the decision-making process. The paper concludes by discussing the role of guidelines and team composition in addressing allocative inefficiency in treatment choices.
Working Papers [titles may change]
Peer Effects in Physicians’ Medical Practice: Evidence from Public Hospitals in Brazil (with Marcos Vera-Hernandez and Aureo De Paula).