Financing Medical Care through Insurance: Policy Lessons from Household‐ and Community‐Level Analysis in Kenya

Medical insurance is an important feature of a health care system in which patients pay user charges to get medical treatment. Without insurance, many people would not afford acceptable care in a fee‐for‐service system. Since health is a merit good, making insurance broadly available in communities is a major policy issue in countries where user fees finance medical treatments. The paper analyses data from facility and household surveys in Kenya and shows that policies which popularize medical insurance can be inefficient because there exist community and household level factors that inhibit its use. The results further reveal substantial variations in the way the variables that influence the use of insurance affect different population sub‐groups. In this regard, it is important to ensure that vulnerable groups in communities are not excluded from insurance schemes in which they invest. The policy value of the paper is to call attention to factors such as place of residence, gender, income, education, community institutions, transaction costs and facility quality – that hinder or facilitate use of medical insurance so that these factors can be considered when institutionalizing insurance in communities. We note that using the community as a unit of analysis in field surveys may strengthen policy conclusions usually obtained from such surveys. L’assurance médicale constitue un élément important de tout système de soins de santé dans lequel les patients paient pour obtenir des soins médicaux. Sans assurance, de nombreuses personnes seraient dans l’incapacié de faire face aux coûts d’un système de paiement à l’acte. La santéétant un bien tutélaire, généraliser l’accès à l’assurance au sein des communautés est une question politique majeure dans les pays où les soins médicaux sont financés par les utilisateurs. S’appuyant sur l’analyse des données d’enquêtes dans les institutions sanitaires et auprès des ménages kenyans, l’article montre que les politiques qui visent à généraliser l’assurance médicale peuventêtre inefficaces parce que certains facteurs aux niveaux des communautés et des ménages en inhibent l’utilisation. Il révèle également de fortes disparités dans la faµon dont les variables qui influencent l’utilisation de l’assurance affectent différentes sous‐sections de la population. A cet égard, il est important de veiller à ce que les groupes vulnérables ne soient pas exclus des plans d’assurance dans lesquels les communautés investissent. S’agissant des politiques à mettre en oeuvre, l’intérêt de cet article est qu’il attire l’attention sur des facteurs tels que le lieu de résidence, le genre, le revenu, l’éducation, les institutions communautaires, les coûts de transaction et la qualité des infrastructures, lesquels entravent ou facilitent l’utilisation de l’assurance médicale, et pourraient être pris en compte lorsque l’on institutionnalise l’assurance dans les communautés. Il est à noter qu’utiliser la communauté comme unité d’analyse des enquêtes de terrain peut renforcer les conclusions qu’engendrent généralement ce type d’enquêtes.     

A world trade model with bilateral trade based on comparative advantage

This paper describes an extension of Duchin's world trade model to include the explicit representation of transportation costs, permitting the endogenous determination of bilateral trade flows and region-specific prices. The original model is a linear program that, based on comparative advantage and the minimization of factor use, determines regional production and trade flows as well as world prices and scarcity rents for m regions, n good, and k factors. The new world trade model with bilateral trade achieves its objectives by introducing transportation services and geographically dependent transportation requirements for each traded good and each pair of potential trade partners. The formulation of this model and its major properties are presented, and results from a preliminary analysis with 11 regions, eight goods, four transportation sectors, and six factors of production are reported and compared with corresponding results from the world trade model. On the basis of this comparison, we conclude that transportation costs have little impact on a region's total imports or exports of a given commodity.     

A MULTI-OBJECTIVE ASSESSMENT OF INPUT–OUTPUT MATRIX UPDATING METHODS

This paper shows that important insights can be lost when assessing the relative performance of balancing methods solely based on individual optima. This is demonstrated through a multi-objective assessment. A trade-off curve between RAS and sign-preserving absolute differences (SPAD) is obtained based on the 60×60 Norwegian 2001 input–output table. The trade-off curve takes on a form that is close to a step function. This demonstrates that the solution surface around the RAS and SPAD optimums are very flat. Solutions can be identified that improve on the other objective or measure with little or marginal cost to the original objective function. Motivation for the assessment is provided, the technique applied is presented and the implications of the findings are discussed in an input–output and industrial ecology context.     

Price premiums,payment delays,and default risk: understanding developing country farmers’ decisions to market through a cooperative or a private trader

Smallholder farmers in developing countries face a competitive disadvantage in modern agricultural supply chains. Joint marketing through cooperatives is a potential tool to mitigate these disadvantages; yet cooperatives’ success in these settings is uneven at best. We develop an analytical model to study a farmer's choice of selling to a private trader who pays cash on delivery but may exercise market power or a cooperative that promises a price premium but delays payment and carries a concomitant risk of default. In the presence of impatient and risk‐averse farmers, we show that these factors can severely limit smallholder patronage of a cooperative, despite a promised price premium. We then construct and parameterize a simulation model to fit a profile of heterogeneous farmers within a prototype developing‐country village, and study the optimal decisions of farmers regarding marketing through a cooperative versus a private trader. Results suggest that modest improvements in either timeliness of payment or probability of default can induce a substantial increase in a cooperative's market share and economic viability. Extending the simulation analysis to a dynamic setting shows how implementing reasonable policies to improve a cooperative's payment timeliness and default probability can markedly improve its growth trajectory.     

Why does on-farm storage fail to mitigate price volatility?

We analyze the role of farm stock management on price volatility under liquidity constraints and heterogeneous price expectations. In commodity markets, speculative behaviors by stockholders tend to reduce price volatility, but this is not the case in certain agricultural markets, where speculation by farmers regarding decisions to sell or store grain is subject to liquidity constraints and heterogeneous price expectations. Like stockholders, most farmers sell grain if they expect a price drop in the near future, but unlike stockholders, they are not necessarily able to purchase grain if they expect a price increase in the next period. Heterogeneous price expectations can also lead to suboptimal storage decisions, further increasing price volatility. For these reasons, the storage management behavior of farmers often fails to mitigate price drops in the way that speculation by stockholders does. We merge historical data on maize prices and household storage collected in Burkina Faso in order to build a dynamic panel over the 2005–2012 period. We show that carryover from one season to the next is associated with unexpected price drops during the preceding lean season and that carryover is associated with more frequent unexpected price drops following the subsequent post‐harvest season.     

Local flexibility in wage setting: evidence from the Norwegian local public sector

The public sectors in the Scandinavian countries have been prominent examples of centralized wage-setting systems. In Norway, more room for local flexibility was implemented by a wage frame system introduced in 1990 in which the national wage scale system merely works like a minimum wage system. We analyze the effect of this reform using a unique database where we can track employees and their local government over time and explore the consequences of controlling for fixed individual effects and fixed employer effects. We find that the wage dispersion increased across local governments after 1990, and that wages to some extent became more responsive to local government income, monopsony power and other local government characteristics after the reform. However, the numerical effects of the reform are estimated to be quite small.     

‘Everyone Creates One's Own Borders’: The Dutch–German Borderland as Representation

When examining the internal borders of the European Union in the context of their purportedly official demise following European integration, structural obstacles to cross-border interaction are normally taken into consideration while ignoring borders in people's minds. Approaching this lacuna, the author proposes to understand borders as being constituted by imaginations and representations, and as undergoing a constant reconfiguring through social relations. This article explores the meanings of the Dutch–German border expressed in popular representations that commonly employ national stereotypes. Against the background of ‘popular geopolitics’, and applying semiotics as methodology, the author presents a theatre play on the Dutch–German border as a complex but popular representation. Analysis of the theatre play also focuses on its audiences and the reception of the play by children. This permits to address people's readings of popular representations in order to approach the question of why borders persist in people's lives.     

Competitive advertising within store flyers: A win–win strategy?

This study investigates the effect of competitive advertising within store flyers on both manufacturers and retailers. Prior research implies that competitive advertising may be detrimental for manufacturers and beneficial for retailers. Findings from an intersubject experiment that uses various familiar and unfamiliar competing brands confirm that store flyers’ competitive advertising improves consumers’ perceptions of the variety of the retailer’s assortment, which has a positive impact on intentions to visit the store and buy. However, increasing the number of competing brands does not harm manufacturers; rather, it enhances recognition of brands, especially for well-known brands. This article concludes with a discussion of the theoretical and managerial implications of these findings for the design of store flyers.