Peer-Reviewed Publications
"The Effect of Birth Timing Manipulation around Carnival on Birth Indicators in Brazil" (with N. Menezes Filho) XIII RIDGE FORUM - LACEA’s HEALTH ECONOMICS NETWORK 2021; SBE 2023
Health Economics v. 33, n. 9 (2024)
Available here
Featured at Insper Conhecimento, Agência FAPESP; BBC News; O Estado de S. Paulo; Veja; CNN Brasil; Folha; Revista Galileu; Gaucha ZH Zero Hora - Saúde; Estado de Minas; FAPESP na Mídia; Revista Crescer; Estadão; MSN; O Liberal; Terra; Prematuridade; Intramed; Poder360; EurekAlert!; MedicalXpress; Agencia Iberoamericana para la Difusíon de la Ciencia y la Tecnología; Cultura - Opinião.
Abstract: This paper studies the patterns and consequences of birth timing manipulation around the carnival holiday in Brazil. We document how births are displaced around carnival and estimate the effect of displacement on birth indicators. We show that there is extensive birth timing manipulation in the form of both anticipation and postponement that results in a net increase in gestational length and reductions in neonatal and early neonatal mortality, driven by postponed births that would otherwise happen through scheduled c-sections. We also find a reduction in birthweight for high-risk births at the bottom of the weight distribution, driven by anticipation. Therefore, restrictions on usual delivery procedures due to the carnival holiday can be both beneficial and detrimental, raising a double-sided issue to be addressed by policymakers.
Keywords: birth timing manipulation, carnival holiday, gestational length, neonatal mortality, birthweight
"The Effects of a National Policy to Reduce C-sections in Brazil" (with N. Menezes Filho) LACEA LAMES | ANNUAL MEETING | BOGOTÁ 2021
Health Economics v. 32, n. 2 (2022)
Available here
Featured at Insper Conhecimento
Abstract: In this paper, we assess the effects of a national policy implemented in Brazil to avoid unnecessary cesareans. The policy has a supply-side component that prohibits elective c-sections before the 39th gestational week and a demand-side awareness component. Since the policy is not binding for cases with a strong medical c-section indication, we use births of breech- and transverse-positioned babies as a counterfactual for births of cephalic-positioned babies in a difference-in-differences framework. Our results reveal that the policy decreases the rate of c-sections by 1.6 percentage point, and slightly increases gestational time, birthweight, and first-minute APGAR scores. There is evidence that policy effectiveness is driven by its demand-side component.
Keywords: National Policy, Unnecessary Cesareans, Difference-in-Differences, Event-Study
"Passing through the supply chain: implications for market power" (with R. Moita & S. Sunao) EARIE 2019, SBE 2019
International Journal of Industrial Organization v. 79 (2021)
Available here
Featured at Revista Exame
Abstract: In this paper, we study the connection between pass-through and market power in the Brazilian Liquefied Petroleum Gas (LPG) industry. We use a state tax shock and apply a difference-in-differences strategy to estimate pass-through -- at different levels of the supply chain -- and an instrumented difference-in-differences strategy to estimate demand, and then feed a theoretical model to make inferences about conduct. We find an incomplete pass-through at the distribution and industry levels, and a more-than-complete one at the retail level. Furthermore, we estimate price-elasticity of demand to be greater than one. When we feed a theoretical model of pass-through under imperfect competition with these estimates, we obtain a high conduct at the industry level and an even higher one at the retail level alone. These results show that only considering the total industry pass-through may lead to hasty conclusions about market power. Besides contributing to the empirical literature that connects pass-through with market power, we contribute to on-going national discussions regarding competitiveness in the LPG industry.
Keywords: pass-through, market power, conduct, supply chain, gas industry, difference-in-differences
"Do extended school day programs affect performance in college admission tests?" (with D. Araújo, G. Bayma, L. Sampaio, & M. Mendonça) SBE 2019
Brazilian Review of Econometrics v. 40, n. 2 (2020)
Available here
Featured at Revista Exame
Abstract: We assess the effects of a Brazilian extended high school day program on college admission test scores. The program entails an increase in Math/Science and Language class time, and the introduction of extra-class activity time. We exploit variation in program implementation timing to apply a difference-in-differences strategy and an event-study approach. Results show positive large effects on test scores and suggest that these effects are likely driven by increased class and extra-class activity hours. Moreover, the program affects not only scores in subjects for which it contemplates increased class time, but also in Humanities. Finally, we are able to show that increased time dedicated to academic-related extra-class activities works as a multiplier of program effects. In fact, these additional hours spent in complementary activities make the magnitude of program effects double from 0.101-0.148 to 0.182-0.316 standard deviation.
Keywords: extended high school day program, difference-in-differences, event-study, college admission test scores
"Pandemics and Communication: An Experimental Assessment" (with S. Cabral)
Brazilian Journal of Public Administration v. 54, n. 4 (2020)
Available here
Featured at Revista Exame and UOL Notícias
Communication is a key factor in containing a pandemic. Fragmented information may affect people’s perceptions and behaviors, especially in times of governmental miscommunication, potentially jeopardizing efforts aimed at containing the spread of the disease. To test whether and how people have been sensitive to broken information during the COVID-19 pandemic in Brazil, we performed a randomized survey experiment on a sample of 571 respondents. We found that more pessimistic or more optimistic fragmented messages about the pandemic have no overall significant average effect on perceptions and planned behavior of the respondents. The exploratory analyses showed that particular sociodemographic groups are more sensitive to these fragmented messages. While less educated people react to more pessimistic messages with an increased likelihood to intensify prevention measures, people aged 60 or older – the high-risk group for COVID-19 complications – react to more optimistic messages with a reduced probability to intensify prevention measures. Besides providing insights to the public administration literature on disaster management, the results reinforce the need for governments to consistently centralize communication efforts to guarantee that people are equipped with complete and accurate information to form their perceptions and adequate their behaviors towards a health crisis.
Keywords: COVID-19; communication; survey experiment
Working Papers & Selected Work in Progress
"A call for improved climate adaptation policies: The effects of prolonged droughts on education" (with I. Prenhaca) - to be presented at the XXI RIDGE FORUM – Inequality and Poverty Workshop (May/2025).
New draft coming up soon.
Abstract: We apply the difference-in-differences estimator proposed by d'Haultfoeuille (2024) to evaluate the cumulative effects of a prolonged drought episode on student learning and disentangle the supply-side drivers of these effects. Furthermore, we build on the knowledge of geographers and climate scientists to define and identify municipalities affected by an extreme prolonged drought event in the Brazilian semiarid. Our results show that prolonged (extreme) droughts negatively affect student performance and impacts increase in magnitude as the drought persists over the years. These effects are partly explained by a loss in school quality, evidenced by a decreased total number of teachers -- driven by poor school infrastructure --, decreased teacher-student ratio, and increased number of school closures.
Keywords: drought, economic development, natural experiment, climate change, education
"The economic cost of lung cancer in Brazil: A typical case of high productivity cost due to early mortality" (with V. Boarati, F. Bispo, M. Rocha, G. Rodrigues, & M. Penha)
Invitation to Revise & Resubmit (R&R) at World Medical and Health Policy - Wiley
Abstract: In this study, we use publicly available data from the Brazilian Ministry of Health and the National Agency for Supplementary Health, to perform a descriptive analysis and a population-based cost analysis, considering patients cared for by both the public and the private sectors, and considering not only direct but also indirect costs, related to loss in productivity. For matters of comparison and meaningful interpretation of the results, we also calculate the economic costs of breast and prostate cancer. Our results show that indirect costs of lung cancer, due to premature mortality, are disproportionately high, making evident the problem of late diagnosis and treatment of the disease. This evidence contributes to making the case for the implementation of a system of screening and early detection of lung cancer aimed at reducing premature deaths.
Keywords: economic cost, lung cancer, late diagnosis, screening and eatly detection
"Competing for change: The role of political contests in fostering local development" (with B. Cavani and P. Pichetti) - presented at LACEA LAMES | ANNUAL MEETING | BOGOTÁ 2023
New draft coming up soon.
Abstract: We use a Regression Discontinuity design to assess the effects of political competition on a set of multidimensional development measures. Results show that, in municipalities eligible to have two-ballot-system mayoral elections -- which previous research has shown to increase political competition --, there is an increase of 7.1 percentage points in the share of the population employed in formal jobs (a 21% change), a decrease in general and juvenile homicide rates by 8.8 and 15.6 occurrences per 1,000 people (a 28% and a 21% change) respectively, and an increase in access to waste disposal services to the poor by 4.4 percentage points (a 5% change). Our results corroborate with previous evidence suggesting that political competition is important for the expansion of key public services, which can significantly contribute to the achievement of a municipality's development goals.
Keywords: Regression Discontinuity, two-ballot system, political competition, multidimensional development measures
Research Projects as Principal Investigator
"Impact evaluation of the remote operation of computed tomography and magnetic resonance equipment in the context of the Public Unified Health System (SUS) in the state of São Paulo" (with Vanessa Boarati, Isabela Furtado, Carla Ramos, Sandro Cabral, Rodrigo Soares, Letícia Nunes, Adriana Bueno, Carlos Roberto Carvalho, Cesar Nomura, Giovanni Cerri, Haliton de Oliveira Jr)
Funded by São Paulo Research Foundation (FAPESP) under process n. 2023/10085-5
Summary: This research project consists of an impact assessment of a public policy in the construction stage. It is proposed to evaluate the impact of a pilot project of remote operation shared between hospitals of computed tomography (CT) and magnetic resonance (MRI) equipment, with the objective of using the evidence produced for the elaboration of a plan to scale-up the technology to hospitals of the Public Unified Health System (SUS) in the State of São Paulo. In a context where there is a shortage of health professionals and the need to reduce costs, remote operation can make it possible to perform CT and MRI exams in a timely manner for SUS users in health regions where access is still limited. Through a randomized experiment at the level of the individual (patient), a pilot project of shared remote operation will be evaluated, between Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) - Partner Institution - and Hospital Alemão Oswaldo Cruz (HAOC) - Associate Institution -, of CT and MR equipment. It will be evaluated impacts on the quality of the operation (standardization of flows and protocols), the existence of unplanned intercurrences and/or interruptions during the exam, the presence of the team originally designated to operate the exam, the time spent in preparing and performing the exam (and the consequent associated cost), the quality of the service provided, and also the quality of the images produced. The estimated effects at the patient level will allow for the calculation of the marginal gains in productivity from the adoption of the remote operation at the level of a health unit and a SUS macro-region, as well as the marginal gain in years of (quality of) life provided by the adoption of the remote operation for a SUS patient and a health region in the State of São Paulo. The analysis of the quantitative results will be complemented with an analysis of qualitative data, in order to have a deeper and more complete understanding of the mechanisms through which the impacts of the remote operation occur in practice. The research results will be communicated both in the form of executive presentations and technical notes to health policymakers - aiming at the elaboration of a scale-up plan for SUS - and in the form of academic presentations at conferences and scientific articles to be submitted to peer-reviewed scientific journals. As a Partner Institution, HCFMUSP is responsible for establishing partnerships, such as those established with the Empresa Brasileira de Serviços Hospitalares (EBSERH), interested in the results of the research to implement the technology in its network of university public hospitals, and with the Health Secretariat of the State of São Paulo, which, in turn, demonstrates interest in considering the results of the work to enable the use of the technology as a solution for access to CT and MR exams in the state public health system. HAOC, as an Associated Institution, makes itself available to facilitate the pilot project of remote operation with sharing between hospitals, being a key player in the pilot project to be evaluated. With regard to the risks involved in the implementation of the impact assessment, the time for approval of the research by the Ethics Committee, the difficulty of reaching the adequate number of participants in the experiment, the difficulty in obtaining data from SUS necessary for estimation of the effects of remote operation at the more aggregated levels and potential limitations of external validity. In the dimension of the effective adoption of remote operation in public hospitals, there is a risk of poor communication of technical research results and resistance from health professionals to face a change in the way of operationalizing CT and MR exams in the field, with the adoption of new routines and protocols.
Keywords: computed tomography, magnetic ressonance, impact evaluation, remote operation, Public Unified Health System
"Evidence to advance sustainable development: Integration of teaching, research, and extension in graduate studies" (with Sandro Cabral, Sérgio Lazzarini, Ricardo Paes de Barros)
Funded by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes) under process n. 88881.927400/2023-01 of the Programa de Extensão Universitária da Pós-Graduação
Summary: The extension action proposed here aims to generate evidence to inform public policy decisions aimed at solving real public problems in Brazil. This action is based on five fronts: [i] identification of relevant Brazilian public problems related to the themes of activity of the school's research centers involved in the evaluation of public policies (e.g.: Health Policy Unit and Insper Metricis); [ii] mapping available evidence, through systematic literature reviews, and identifying relevant gaps to inform public policies; [iv] communication of these maps of evidence and gaps internally and to the broader community, in order to contribute to the (re)design of activities proposed for students in undergraduate and postgraduate disciplines and encourage academic and technical work that fill such gaps, inside and outside the classroom, involving teachers and students; [v] encourage, support and monitor the use of evidence maps and survey their gaps, checking indicators of their inclusion in subject programs, doctoral theses, master's dissertations and technical and/or academic research carried out by the school research centers.
Keywords: evidence, public problems, public policy, communication
Technical Notes & Policy Work
"O custo econômico do câncer de pulmão e a importância do rastreamento e diagnóstico precoce" (with V. Boarati, F. Bispo, M. Rocha, G. Rodrigues, and M. S. Penha)
Available here
Featured at Folha de S. Paulo & Insper Conhecimento
Other media mentions: Veja Saúde, Medicina S/A, Folha de S. Paulo, Galileu|Saúde, Portal do Holanda, Jornal de Brasilia, Brasil ao Minuto, Vitória News, Info4, MSN.com, Valor Econômico, Fórum DCNTs
Participation in events to communicate research findings: Fleury Seminar, Fórum DCNTs
Resumo:
Neste trabalho, buscamos mostrar que os custos econômicos do câncer de pulmão são relevantes já que a doença apresenta alta taxa de mortalidade em brasileiros em idade produtiva. Isso se deve em partes à falha do sistema de saúde de diagnosticar a doença em estágios iniciais, não permitindo um tratamento efetivo. A solução encontrada para esse problema em outros países se apoia em um sistema de rastreamento da população de risco e diagnóstico precoce, similar ao que já existe no Brasil para o câncer de mama. No entanto, para que se avance em um desenho e uma agenda de implementação de tal solução para o câncer de pulmão, é necessário que se considere aprendizados obtidos internacionalmente sobre as potenciais barreiras a serem enfrentadas e também o conhecimento de especialistas locais, capazes de traduzir essas barreiras para o contexto brasileiro e apontarem outras potenciais dificuldades a serem enfrentadas localmente. Tendo mapeado de forma organizada todo esse conhecimento, este trabalho traz recomendações para a implementação de um sistema de rastreamento e diagnóstico precoce do câncer de pulmão como política de saúde nacional. As recomendações levantadas envolvem dimensões de governança, força de trabalho, financiamento, critérios de elegibilidade, protocolos e monitoramento e avaliação. Um alinhamento entre todas as dimensões é importante para que o processo de implementação seja bem-sucedido.
"Os Determinantes da Realização de Cesáreas no Brasil" (with M. Mesquita de Magalhães, N. Menezes Filho, & B. Komatsu)
Available here
Abstract: This paper aims at understanding the determinants of the high c-section rate in Brazil. We assess the effect of the existence of a hospital with obstetric beds in the municipality of residence of mothers on their rate of c-section and the effect of the percentage of obstetric beds allocated to the public sector in a private hospital on the c-section rate of the hospital. To perform the analysis, we construct a panel of monthly data spanning from 2006 to 2016 at both the hospital level and the municipality level, as well as a panel containing all births given in hospitals that have obstetric beds in 2016. We find that the construction of a new hospital in a municipality reduces the c-section rate practiced by resident mothers and that the percentage of beds allocated to the public sector in private hospitals reduces the c-section rate practiced at the hospital. We also find that c-sections have a higher probability of happening on weekdays, in private hospitals with no beds allocated to the public sector, from white mothers, from married mothers, and from mothers with high levels of schooling, suggesting that non-medical factors affect the probability of a scheduled elective c-section.
Keywords: Health economics, Cesarean section (c-section), Public Policy
"Guide to the Assessment of Socio-Environmental Impact" - Insper Metricis
Available here
"A Lupa na Cidade - Painel de Indicadores de Desenvolvimento de Áreas Urbanas Vulneráveis" - Insper Metricis
Available here
Book Chapters