Journal articles

Abstract:

This paper investigates whether an increase in exogenous income through the Child Grants model of the Social Cash Transfer programme in Zambia fosters economic inclusion among rural women. We conceptualize economic inclusion as a transformative process comprised of four pillars: productive capacity, saving capacity, women’s empowerment, and time preferences and expectations. Using experimental data, we find strong evidence of direct impacts of the Child Grant on productive and saving capacity, and time preferences and expectations of rural women. In addition to these direct impacts, we implement a mediation analysis to explore the potential mediating role of time preferences and expectations in affecting the other pillars of economic inclusion. Through this approach, we find indicative evidence of indirect and mutually reinforcing relationships between changes in time preferences and expectations brought about through the Child Grant and improvements in the productive and saving capacity of beneficiaries. These results suggest that cash transfers might be effective in promoting women’s economic inclusion, both through the direct monetary effect and through the mediated effect of time preferences and expectations. 

Abstract

In rural settings, individual risk preferences represent one of the channels driving the shift from low-return/low-risk activities towards high-return/high-risk activities. This study takes advantage of data collected for the impact evaluation of the Child Grants Programme, an unconditional cash transfer program, and the Sustainable Poverty Reduction through Income, Nutrition and Access to Government Services (SPRINGS) project, a community development package, in rural Lesotho. The paper has two major goals. First, we investigate the effects of the programs on risk preferences measured via laboratory experiments in the field and a survey instrument. Second, we perform a mediation analysis to quantify the extent to which the programs affect risky investment decisions in real life through changes in risk preferences. Results show that the combination of programs decreases risk aversion, partially mediating the impact of the programs on risky agricultural investment decisions in real life. 

Dataset: Access to Lesotho CGP+SPRINGS impact evaluation data can be found at the  FAO Microdata catalogue

Abstract

This article develops a conceptual framework on pathways through which noncontributory social protection can support resilient and inclusive agricultural growth in rural Africa. It draws insights from a review of rigorous empirical evidence on the impacts of cash transfers and multifaceted cash plus programs on a range of relevant productive outcomes, including accumulation of productive assets, inputs and farm management practices, off-farm labor and nonfarm enterprises, and farm production and income. This review demonstrates an emerging consensus in the literature: that access to social protection programs contributes positively to increasing the productive asset holdings of rural people, increasing the use of improved inputs and farm practices, and shifting away from casual wage labor arrangements. Moreover, there is limited evidence on heterogeneous effects across different baseline characteristics (income, sex, and labor-constrained households, among others). Finally, the article highlights how social protection programs should be considered an integral part of broader rural and agricultural development strategies in order to achieve a more productive, resilient, and equitable rural transformation in Africa. 

Abstract

We study how participation in various social protection schemes can mitigate the negative relationship between adverse rainfall shocks and agricultural production, thus acting as a tool for climate change adaptation. We use panel data from Ethiopia, analyzing the influence of these programs on the technical efficiency of smallholder farmers and how these effects on agricultural production change in the presence adverse rainfall shocks. We find heterogeneous effects of social protection. Public works are negatively associated with productive efficiency, especially in the presence of negative shocks. Recipients of free food display higher sales and profits while cash transfers are more neutral to production and positively associated with farming profitability. 

Abstract

We present findings from a study of the local-economy impacts of Lesotho’s Child Grants Programme and of a multi-faceted rural development intervention. We designed a micro-data parameterised general equilibrium model and used it to simulate the direct and indirect impacts of the two interventions, considering income and production spillovers. The Child Grants Programme, alone and in combination with the rural development programme, generates total discounted benefits that exceed discounted programme costs. Local-economy spillovers amplify the benefit-cost ratio of both cash transfers and productive interventions. By better integrating with outside markets, it is possible to attain substantial cost-effective income gains for local economies. 

Dataset: Access to Lesotho CGP+SPRINGS impact evaluation data can be found at the  FAO Microdata catalogue

Abstract

Swift response models are vital tools for emergency assistance agencies. The COVID-19 pandemic revealed the lack of economic models for short-run policy relevant research to anticipate local impacts and design effective policy responses. The most direct effects of the pandemic and lockdown tended to be concentrated in urban areas; however, markets quickly transmitted impacts to rural areas as well as among poor and non-poor households. General equilibrium modeling is a tool of choice to capture indirect, spillover effects of exogenous shocks. This article describes an unusual micro general-equilibrium (GE) modeling approach that we developed to quickly simulate impacts of the pandemic and lockdowns on poor and non-poor rural and urban households across sub-Saharan Africa. Monte Carlo bootstrapping was used to construct four stylized regional GE models from 34 existing local economy-wide impact evaluation (LEWIE) models. Simulations revealed that the pandemic and policy responses to curtail its spread were likely to affect rural households at least as severely as urban households. Simulated income losses are greater in poor households in both urban and rural settings. These findings are relatively consistent across models spanning sub-Saharan Africa. Because COVID-19 impacts are so far-reaching, all types of economies experience downturns. Our research underlines the importance of modeling assumptions. We find total annualized impacts of around a 6-percent loss of GDP, smaller than estimates from single-country models that ignore price effects, such as SAM-multiplier models, but in line with The World Bank's baseline forecast of a 5.2% contraction in global GDP in 2020. The largest negative impacts are on poor rural households. 

Abstract

This paper contributes to the literature on the determinants of rural livelihood diversification and its impact on household welfare in the short and medium term using data from a government-run social protection program in Zimbabwe. First, this study investigates whether cash transfers originally intended to ensure minimum food security in the poorest households can also induce the diversification of their livelihood strategies. Second, since diversification may lead to engagement in both low-return and high-return activities, this paper examines whether diversification resulting from the cash transfer increases household welfare. In the short run, the program causes only a small reduction in engagement in survival-led diversification; in the medium run, the program leads to a large shift from survival-led diversification and specialization in on-farm activities towards opportunity-led diversification. Further heterogeneity analysis shows that the program induces a medium-term change in livelihood strategies in both female- and male-headed households. In both time frames, opportunity-led diversification increases food and non-food consumption. 

Abstract

This paper analyses the causal effects of the Zimbabwe Harmonized Social Cash Transfer (HSCT) programme on food security and nutrition after 12 months of implementation. Through mediation analysis, we disentangle the total effect of the programme on its direct effect due to the greater liquidity of beneficiary households, which increases the affordability of food, and its indirect effect mediated by an increase in agricultural activities. We find a total effect of cash transfers on food security and nutrition ranging between a 11 and 16 percent increase with respect to the baseline comparison mean for the household dietary diversity score and number of food items consumed, respectively. Causal mediation analysis shows that most of the effects are driven by the increased liquidity of HSCT beneficiaries. However, approximately between 10 and 21 percent of the total effect is mediated by agricultural activities, suggesting that cash transfer programmes not only play a protective role against food insecurity but also a promoting role towards more diversified nutrition. 

Abstract

We exploit the social cash transfer programme in Ethiopia to study how an increase in unearned income through a government transfer affects children's work time allocation and their school attendance rate. In rural areas, the transfer led to a half an hour reduction in the total number of hours worked, while in urban areas, transfers had the opposite impacts, worsening the child labour situation with no impacts on the share of children attending school. An insufficient transfer amount and lack of messaging on its recommended use may partly explain the mixed results on child labour and the lack of impacts on school attendance. 

Abstract

We estimate the average treatment effect (ATE) of cash transfers on farm profitability by exploiting a randomised control trial for the evaluation Lesotho’s biggest transfer program. We also explore impact heterogeneity by unpacking the ATE into group-specific parameters. We estimate conditional average treatment effects to describe how treatment effects vary with selected covariates and quantile treatment effects to illustrate the variability of effects at different outcome levels. We find that the program had sizable impacts on farm profitability, but these impacts are spread unevenly in the population. The program benefited more those with greater productive potential and had strong distributional impacts. 

Dataset: Access to Lesotho Child Grants Programme impact evaluation data can be found at the Transfer Project website

Abstract

This paper focuses on the role of unconditional cash transfers in helping smallholders’ commercialization by overcoming barriers to trade from transaction costs. We use data from a controlled experiment for the evaluation of the Child Grant model in Zambia. We employ a Heckman model that allows us to capture the effects of the program on the propensity to engage in trade in both inputs and outputs markets as well as on the value of trade. The cash transfer program contributes significantly to increase farmers’ commercialization. The program produced greater benefits for those households that face more binding transaction costs from transportation and information gathering. 

Abstract

This paper has the double aim to study whether unconditional cash transfers have an impact on farm production and to look into the causal mechanisms through which government transfers produce productive impacts. We use mediation analysis to identify the total effect of transfers on farm production and to isolate the influence of the labour channel from other transmission channels. In particular, we analyze whether changes in farm production are caused by transfer-induced changes in the use of farm labour – either by reallocating family labour between off- and on-farm work or by changes in the demand for hired labour – or if other transmission channels are at work. We find that cash transfers have a sizable impact on farm production but they do not lead to increased use of family or hired labour on the farm, which implies that the productive impacts of cash transfers flow through other channels, different from the labour one.

Dataset: Access to Lesotho Child Grants Programme impact evaluation data can be found at the Transfer Project website

Abstract

We estimate the effects of cash transfers on modern inputs demand, while isolating the role of output risk and risk preferences in channeling these effects. We use data from an RCT collected for the evaluation of Zambia’s Social Cash Transfer. We employ a moments-based method to estimate farmers’ risk attitudes from revealed preferences through production decisions and the impact of cash transfers on modern input demand. We find that the program increases demand for risk-increasing modern inputs but this does not happen as a result of a transfer-induced reduction in farmers’ risk aversion. 

Abstract

Cash transfer programs pursue mainly protective objectives, but can also impact rural livelihoods by inducing investments in productive activities and changing household labor allocation. We adopt a continuous treatment approach to quantify how households’ labor supply responds to transfer size. We find a shift from paid labor to own farm labor and find that the transfer size is well within a level that would have disincentive effects on time spent on own farm activities. The switch from paid to own farm labor occurs at lower levels of transfers for labor-constrained households, and at higher levels for non-labor constrained households. 

Abstract

This paper summarizes evidence on six perceptions associated with cash transfer programming, using eight rigorous evaluations conducted on large-scale government unconditional cash transfers in sub-Saharan Africa under the Transfer Project. Specifically, it investigates if transfers: 1) induce higher spending on alcohol or tobacco; 2) are fully consumed (rather than invested); 3) create dependency (reduce participation in productive activities); 4) increase fertility; 5) lead to negative community-level economic impacts (including price distortion and inflation); and 6) are fiscally unsustainable. The paper presents evidence refuting each claim, leading to the conclusion that these perceptions—insofar as they are utilized in policy debates—undercut potential improvements in well-being and livelihood strengthening among the poor, which these programs can bring about in sub-Saharan Africa, and globally. It concludes by underscoring outstanding research gaps and policy implications for the continued expansion of unconditional cash transfers in the region and beyond. 

Abstract

This paper investigates the interplay between the Social Cash Transfer Programme (SCTP) and the Farm Input Subsidy Programme (FISP) in Malawi. We take advantage of data collected from a 17-month evaluation of a sample of households eligible to receive SCTP, which also provided information about inclusion into FISP. We estimate two types of synergies: i) the complementarity between SCTP and FISP, that is whether the impact of both interventions run together is larger than the sum of the impacts of these interventions when run separately, and ii) the incremental impact of receiving FISP when a household already receives SCTP, as well as the incremental impact of receiving SCTP when a household already receives FISP. The analysis shows that there are synergies between the two policy interventions, mainly in terms of incremental impacts of each programme over the other, in increasing expenditure, agricultural production and livestock. 

Abstract

Cash transfer programmes have been shown to have positive effects on a variety of outcomes. While much of the literature focuses on the role of conditionality in achieving desired impact, this paper focuses on the role of ‘soft conditionality’ implemented through both ‘labelling’ and ‘messaging’ in evaluating the impact of the Child Grants Program in Lesotho, an unconditional cash transfer programme targeting poor households with orphans and vulnerable children. Beneficiary households received a clear message that the transfer should be spent on the interest and needs of children. Our findings suggest that ‘soft conditionality’ does play a role in increasing expenditure for children, especially on education, clothing and footwear. Results indicate in fact that transfer income is spent differently from general income as it exerts both an income and a substitution effect. This behavioural change is confirmed by comparing the ex-ante expected behaviours with the ex-post actual response to the programme. We find that for expenditure categories linked to the well-being of children the ex-post response was much higher than the ex-ante expected behaviour. 

Dataset: Access to Lesotho Child Grants Programme impact evaluation data can be found at the Transfer Project website

Abstract

Over the past decade, several African governments have launched Cash Transfer (CT) programmes as part of their social protection systems, with the aim of reducing poverty. Such programmes can also have significant productive impacts. We use data from four major CT programmes implemented in sub-Saharan Africa to estimate their impacts on labour supply and demand and how effects change in relation to transfer size. We find evidence of labour reallocation between farm and off-farm work and limited evidence of monotonicity of the labour supply–transfer size relationship.

Abstract

In July 2013 FAO Lesotho began a pilot initiative called the Linking Food Security to Social Protection Programme (LFSSP). The programme's objective was to improve the food security of poor and vulnerable households by providing vegetable seeds and training on improved homestead gardening. The programme was intentionally provided to households eligible for a large-scale social cash transfer, the Child Grants Programme (CGP). In this paper we present findings from the impact evaluation of the two programmes. Overall we find positive effects of the programmes on homestead gardening and productive agricultural activities. Many of these observed outcomes appear driven by the combination of the two programmes. An additional year of CGP along with one year of the LFSSP achieved a number of outcomes which two years of receiving the CGP alone did not. This pilot has been used as the basis for the design of a national upscale response to El Nino drought in Lesotho including Home Gardening and Nutrition assistance for all CGP beneficiaries who were affected by a sharp increase of food prices.

Dataset: Access to Lesotho Child Grants Programme impact evaluation data can be found at the Transfer Project website

Abstract

Over the past decade, several African governments have launched cash transfer (CT) programmes as part of social protection systems, with the aim of reducing poverty and hunger. Such programmes can also have significant impacts on rural livelihoods by inducing investments in productive activities and changing household labour allocation. In this paper, we look beyond the protective function of CTs and provide evidence on their impacts on labour supply. We use data from the second wave of the impact evaluation of the Zambia Child Grant model of the Social Cash Transfer programme. We focus on the response of households’ labour supply in terms of off-farm paid labour and own-farm labour. We find that CTs cause a shift from agricultural wage labour to own-farm labour and that overall have no work disincentives on-farm households.

Abstract

During 2015 and 2016, Lesotho experienced a large increase in the price of cereals, the main staple food in the country. This has led to an erosion of purchasing power and to a decrease in the consumption of staple foods. For the study, we used a demand system to simulate the effects of an increase in the price of staple foods. We based our analysis on data collected for the evaluation of the Child Grants Programme, which offers unconditional cash transfers to poor households with orphans and vulnerable children. We estimated the necessary increase in total income that is needed to counter the impacts of the current price hike and to maintain households’ utility unchanged. In particular, every percentage increase in the price of cereals would need to be matched by a 0.4% increase in income. As for the possible policy measures, we suggest the country’s social protection system as the source for the extra income. 

Abstract

This paper explores the extent to which government-run cash transfer programs in four sub-Saharan countries affect food security and nutritional outcomes. These programs include Ghana's Livelihood Empowerment Against Poverty, Kenya's Cash Transfer for Orphans and Vulnerable Children, Lesotho's Child Grants Program and Zambia's Child Grant model of the Social Cash Transfer program. Our cross-country analysis highlights the importance of robust program design and implementation to achieve the intended results. We find that a relatively generous and regular and predictable transfer increases the quantity and quality of food and reduces the prevalence of food insecurity. On the other hand, a smaller, lumpy and irregular transfer does not lead to impacts on food expenditures. We complement binary treatment analysis with continuous treatment analysis to understand not only the impact of being in the program but also the variability in impacts by the extent of treatment.

Background and Purpose. An ageing population at greater risk of proximal femoral fracture places an additional clinical and financial burden on hospital and community medical services. We analyse the variation in i) length of stay (LoS) in hospital and ii) costs across the acute care pathway for hip fracture from emergency admission, to hospital stay and follow-up outpatient appointments.

Patients and Methods. We analyse patient-level data from England for 2009/10 for around 60,000 hip fracture cases in 152 hospitals using a random effects generalized linear multi-level model where the dependent variable is given by the patient’s cost or length of stay (LoS). We control for socio-economic characteristics, type of fracture and intervention, co-morbidities, discharge destination of patients, and quality indicators. We also control for provider and social care characteristics.

Results. Older patients and those from more deprived areas have higher costs and LoS, as do those with specific co-morbidities or that develop pressure ulcers, and those transferred between hospitals or readmitted within 28 days. Costs are also higher for those having a computed tomography (CT) scan or cemented arthroscopy. Costs and LoS are lower for those admitted via a 24h emergency department, receiving surgery on the same day of admission, and discharged to their own homes.

Interpretation. Patient and treatment characteristics are more important as determinants of cost and LoS than provider or social care factors. A better understanding of the impact of these characteristics can support providers to develop treatment strategies and pathways to better manage this patient population.

Abstract

In the last decade social cash transfer programmes have become extremely popular in sub-Saharan Africa, and are often portrayed as an instrument that can facilitate graduation out of poverty. The evidence on whether social cash transfers have had actual effects on graduation, however, is limited. This article provides a cross-country reflection of the potential effects of social cash transfers on graduation, drawing from impact evaluation results of cash transfer programmes in Ghana, Kenya, Lesotho and Zambia. We analyse whether social cash transfers have improved the likelihood of graduation, through increased productivity, income generation and resilience to shocks. We identify which factors in terms of programme implementation and household characteristics can increase the likelihood of cash transfer programmes facilitating graduation from poverty

Background

It is important that NHS resources are used to their full extent, but efforts to reduce costs may have an adverse effect on patient outcomes. Our research is designed to provide a better understanding of the inter-relationship between costs and health outcomes among NHS providers (hospitals) for common surgical procedures.

Objectives

In England, patient-reported outcomes measures (PROMs) are collected from patients undergoing one of four elective procedures: unilateral hip replacement, unilateral knee replacement, groin hernia repair and varicose vein surgery. We identify variation in patient-reported outcomes (PROs) across hospitals, assess the relationship between the cost and outcomes among NHS hospitals for these procedures, and determine the extent to which variations in outcomes and costs are due to differences in hospital performance.

Data sources

We link Hospital Episode Statistics (HES) data with reference cost data and PROM data for patients having the four treatments between April 2009 and March 2010.

Methods

The first part of the empirical analysis focuses on variation in different dimensions of self-reported health status. We argue that each of the EuroQol-5D questionnaire (EQ-5D; European Quality of Life-5 Dimensions) dimensions should be assessed separately. Our graphical summary of the differential impact that hospitals have on PROs indicates the probability of reporting a given health outcome and shows how these probabilities vary across EQ–5D dimensions and hospitals. The second part of the empirical analysis focuses on the performance of hospitals and the inter-relationship between PROs and resource use.

Results

We find that poorer post-treatment health status is associated with lower initial health status, higher weighted Charlson score, more diagnoses and lower socioeconomic status. We find significantly unexplained variation among hospitals in outcomes for patients undergoing hip replacement, knee replacement or varicose vein surgery, but not for hernia patients. For all four treatments we find significant unexplained variation in resource use among hospitals, whether measured by cost of treatment or length of stay. This suggests that hospitals can improve their utilisation of resources.

Limitations

Our analyses are based on the HES. If data are missing from the medical record, or extracted and coded inaccurately, HES will contain errors. Hospitals should minimise these errors. Our study suffers from a large number of missing data, mainly because some hospitals were better than others at administering the baseline survey.

Conclusions

There is no general evidence that hospitals with lower resource use have worse health outcomes. There is a significant positive correlation for varicose veins, but this is sensitive to the choice of resource use and PRO measures. For hip and knee replacement the correlation is either insignificant or negative (depending on the resource use and PRO measures), implying that promoting health outcomes and controlling costs are not contradictory objectives. Indeed, we are able to identify hospitals with better than expected outcomes where resource use is below average. Future research should address how to handle missing data, evaluate hospital performance within the broader health economy, communicate PROMs to prospective patients, evaluate the impact of PROMs on patient choice and provider behaviour and evaluate PROMs for people with chronic conditions.

Abstract

Households’ welfare in developing countries has been hit by dramatic food prices increases which occurred between 2005 and 2008. In this paper, we adopt a partial equilibrium approach to analyze the short-time effects of a staple food price increase on nutritional attainments, as a measure of welfare. The analysis consists of first approximating complete food-demand systems and then performing household level micro-simulations. Instead of focusing on a single country profile, we provide a more complete snapshot by comparing the evidence through a cross-country assessment made possible by the use of nationally representative household surveys. Comparability is assured by the adoption of the same methodological choices in the treatment of the micro data. We find that food price spikes not only reduce the mean consumption of dietary energy, but also worsen the distribution of food calories, further deteriorating the nutritional status of populations. We also discovered that access to agricultural land plays a significant role in ensuring adequate nutritional attainments in rural areas, and surprisingly, even in urban areas. 

Abstract

This article describes sfcross and sfpanel, two new Stata commands for the estimation of cross-sectional and panel-data stochastic frontier models. sfcross extends the capabilities of the frontier command by including additional models (Greene, 2003, Journal of Productivity Analysis 19: 179–190; Wang, 2002, Journal of Productivity Analysis 18: 241–253) and command functionalities, such as the possibility of managing complex survey data characteristics. Similarly, sfpanel allows one to fit a much wider range of time-varying inefficiency models compared with the xtfrontier command, including the model of Cornwell, Schmidt, and Sickles (1990, Journal of Econometrics 46: 185–200); the model of Lee and Schmidt (1993, in The Measurement of Productive Efficiency: Techniques and Applications), a production frontier model with flexible temporal variation in technical efficiency; the flexible model of Kumbhakar (1990, Journal of Econometrics 46: 201–211); the inefficiency effects model of Battese and Coelli (1995 Empirical Economics 20: 325–332); and the “true” fixed- and random-effects models of Greene (2005a, Journal of Econometrics 126: 269–303). A brief overview of the stochastic frontier literature, a description of the two commands and their options, and examples using simulated and real data are provided. 

Abstract

English health policy has moved towards establishing specialist multi-disciplinary teams to care for patients suffering rare or particularly complex conditions. But the healthcare resource groups (HRGs), which form the basis of the prospective payment system for hospitals, do not explicitly account for specialist treatment. There is a risk, then, that hospitals in which specialist teams are based might be financially disadvantaged if patients requiring specialised care are more expensive to treat than others allocated to the same HRG. To assess this we estimate the additional costs associated with receipt of specialised care. We analyse costs for 12,154,599 patients treated in 163 English hospitals in fiscal year 2008/09 according to the type of specialised care received, if any. We account for the distributional features of patient cost data, and estimate ordinary least squares and generalised linear regression models with random effects to isolate what influence the hospital itself has on costs. We find that, for nineteen types of specialised care, patients do not have higher costs than others allocated to the same HRG. However, costs are higher if a patient has cancer, spinal, neurosciences, cystic fibrosis, children's, rheumatology, colorectal or orthopaedic specialised services. Hospitals might be paid a surcharge for providing these forms of specialised care. We also find substantial variation in the average cost of treatment across the hospital sector, due neither to the provision of specialised care nor to other characteristics of each hospital's patients. 

Background. The English Department of Health has introduced routine collection of patient-reported outcome data for selected surgical procedures to facilitate patient choice and increase hospital accountability. However, using aggregate health outcome scores, such as EQ-5D utilities, for performance assessment purposes causes information loss and raises statistical and normative concerns. 

Objectives. For hip replacement surgery, we explore a) the change in patient-reported outcomes between baseline and follow-up on 5 health dimensions (EQ-5D), b) the extent to which treatment impact varies across hospitals, and c) the extent to which hospital performance on EQ-5D dimensions is correlated with performance on the EQ-5D utility index. 

Methods. We combine information on pre- and postoperative EQ-5D outcomes with routine inpatient data for the financial year 2009–2010. The sample consists of 21,000 patients in 153 hospitals. We employ hierarchical ordered probit risk-adjustment models that recognize the multilevel nature of the data and the response distributions. The treatment impact is modeled as a random coefficient that varies at the hospital level. We obtain hospital-specific empirical Bayes (EB) estimates of this coefficient. We estimate separate models for each EQ-5D dimension and the EQ-5D utility index and analyze correlations of EB estimates across these. 

Results. Hospital treatment is associated with improvements in all EQ-5D dimensions. Variability in treatment impact is most pronounced on the mobility and usual activities dimensions. Conversely, only pain/discomfort and anxiety/depression correlate well with performance measures based on utilities. This leads to different assessments of hospital performance across metrics.

Conclusions. Our results indicate which hospitals are better than others in improving health across particular EQ-5D dimensions. We demonstrate the importance of evaluating dimensions of the EQ-5D separately for the purposes of hospital performance assessment. 

Abstract

Observed variation in hospital costs may be attributable to differences in patients' health outcomes. Previous studies have resorted to inherently incomplete outcome measures such as mortality or re-admission rates to assess this claim. This study makes use of a novel dataset of routinely collected patient-reported outcome measures (PROMs) linked to inpatient records to (i) access the degree to which cost variation is associated with variation in patients' health gain and (ii) explore how far judgement about hospital cost performance changes when health outcomes are accounted for. We use multilevel modelling to address the clustering of patients in providers and isolate unexplained cost variation. We find some evidence of a U-shaped relationship between risk-adjusted costs and outcomes for hip replacement surgery. For three other procedures (knee replacement, varicose vein and groin hernia surgery), the estimated relationship is sensitive to the choice of PROM instrument. We do not observe substantial changes in cost performance estimates when outcomes are explicitly accounted for. 

Abstract

This article explores the effects within households of an expanding rural nonfarm (RNF) sector in Ghana. We ask whether the growing RNF sector allows for economies of diversification within farms, how it affects household input demands, and whether it has measurable effects in overall household production efficiency. We explore the intrahousehold linkages between agricultural and RNF activities, first assuming perfectly competitive input and output markets and then with market failures, in particular missing labor and credit markets. We then measure these linkages using a household level input distance function, finding high levels of inefficiency in Ghanaian farms. Also, there are cost-complementarities between the RNF sector and the agricultural sector, particularly with food crops in which the poorest tend to specialize. The expansion of the RNF sector increases demand for most inputs including agricultural land. Finally, we show that smaller farms tend to be more efficient, and that RNF output is helping the farm household to become more efficient, but the latter result is not robust. 

Abstract

We evaluate how the productive structure and level of specialization of a hospital affect technical efficiency by analyzing a six-year panel database (2000/2005) drawn from hospital discharge records and Ministry of Health data. We adopt a distance function approach, while measuring the technical efficiency level with stochastic frontier techniques. After controlling for environmental variables and hospital case-mix, inefficiency is negatively associated with specialization and positively associated with capitalization. Capitalization is typical of private structures which, on average, use resources less efficiently with respect to public and not-for-profit hospitals. Finally, by looking at scale elasticities, we find some evidence of unexploited economies of scale, leaving room for centralization.