Essays on healthcare access and efficiency

• Ano de defesa: 2024
• Autor(a) principal: Salmen, Maíra Coube
• Orientador(a): Castro, Rudi Rocha de
• Tipo de documento: Tese
• Tipo de acesso: Acesso aberto
• Idioma: eng
• Palavras-chave em Português: Necessidade não atendida; Acesso à saúde; Seguro saúde patrocinado pelo empregador; Serviços de saúde; Utilização; Desigualdades; Terceirização; Contratação externa; Pagamento por desempenho; Eficiência; Qualidade; Brasil
• Palavras-chave em Inglês: Unmet need; Access to healthcare; Employer-sponsored health insurance; Health care services; Utilization; Inequalities; Outsourcing; Contracting-out; Pay-for performance; Efficiency; Quality; Brazil
• Link de acesso: https://hdl.handle.net/10438/35020

The construction of universal health systems represents a remarkable endeavor. In theory, they aim to provide everyone with access to health services of adequate quality and effectiveness, without imposing financial hardship (WHO, 2010). In practice, however, countries face growing and changing health needs of the population, reflecting on increasing domestic financial constraints (Moreno-Serra et al., 2020). This challenge to contain the growth of healthcare costs has led several countries to adopt financing incentives and promote efficient use of health services (Stabile and Thomson, 2014). In the provision of healthcare services, efforts to improve efficiency and health outcomes has been in the direction of changing provider reimbursements incentives (Gruber, 2022; Chalkley et al., 2020) as well as introducing market-oriented mechanisms in the system, such as, the use of various models of public-private collaborations and changing market structure through increased competition (Gaynor et al., 2013). In the financing side, the expansion of private health insurance in universal health systems indicates a larger reliance on the division of the burden of financing across governments, employers, and individuals. This thesis consists of four essays showing how some of these public policies and market dynamics affect broader health system outcomes related to healthcare access, utilization of services and efficiency in the provision. They all focus the analysis on a non-developed country with a publicly-financed universal health care system coexisting alongside a large private sector, offering insights into settings marked by resource constraints and governance challenges. The first essay studies the Brazilian "Organizações Sociais de Saúde" model, which combines transferring the administration of public hospitals to non-profit organizations with performance incentive scheme to augment government’s capacity. Using the synthetic control method, results indicate that this change in provider incentives increases hospital productivity without increasing hospital mortality rates. These impacts point towards the plausible influence of output targets, the potential recalibration of physician incentives, and the inclusion of higher-skilled staff. I also assess the possibility of adverse effects related to potential treatment quality distortion or employee welfare, but find no compelling evidence of such behaviors. While these findings support the idea that incentive-ownership structures can potentially address the traditional quantity-quality trade-off in healthcare, especially within the context of developing countries, assessing the model’s cost-effectiveness is necessary for policy recommendations. The second essay, written joint with Zlatko Nikoloski, Matías Mrejen, and Elias Mossialos, examines the causal relationship between private health insurance and healthcare utilization in a setting where private health insurance plays a supplementary role to publicly financed coverage, totally free at the point of care to everyone. In such contexts, the concern over moral hazard may also be interpreted as "access effect", in which private insurance may provide access to a ‘quality’ of care that is not provided by the public system. In addressing the possible endogeneity of private health insurance coverage in healthcare service demand, the study employs an instrumental variable approach and focus on a specific type of insurance holder. The results reveal a significant impact of private health insurance on physician visits and preventive care tests, but not on other healthcare services, such as, having a hospital admission or a surgery. It also finds that the comprehensiveness of services covered by the insurance plan plays a role in determining differences in utilization. The last two essays, also written joint with Zlatko Nikoloski, Matías Mrejen, and Elias Mossialos, both of them have been published2 , they give a broader overview of the persistent challenges related to access and utilization inequalities in a universal health system. The first paper investigates the evolution of socioeconomic-related inequalities associated with unmet health care needs. Using data from the Brazilian National Health Survey of 2013 and 2019, the study reveals that a significant portion of the population reports unmet needs for both healthcare services and medications, particularly in poorer regions.The second article delves deeper into the pattern of inequalities in the same setting, focusing on the utilization of health care services from 1998 to 2019. The study finds persistent disparities, though diminishing over time, especially in preventive health services. The inequalities are most pronounced in the country’s poorest regions. In both papers, findings suggest that private health insurance coverage and individual socioeconomic status tend to exacerbate these disparities. Collectively, these essays provide empirical evidence of the complex interplay of public and private sectors within a universal health system, offering valuable insights into the pursuit of equitable and efficient health service delivery in similar healthcare settings, as well as illuminating directions for future research.