The non-take up of long-term care benefit in France: A pecuniary motive?

With aging populations, European countries face difficult challenges. In 2002, France implemented a public allowance program (APA) offering financial support to the disabled elderly for their long-term care (LTC) needs. Although currently granted to 1.2 million people, it is suspected that some of those eligible do not claim it--presenting a non-take-up behavior. The granting of APA is a decentralized process, with 94 County Councils (CC) managing it, with wide room for local interpretation. This spatial heterogeneity in the implementation of the program creates the conditions for a "quasi-natural experiment", and provides the opportunity to study the demand for APA in relation to variations in CCs' "generosity" in terms of both eligibility and subsidy rate for LTC. We use a national health survey and administrative data in a multilevel model controlling for geographical, cultural and political differences between counties. The results show that claiming for APA is associated with the "generosity" of CCs: the population tends to apply less for the allowance if the subsidy rate is in average lower. This pecuniary trade-off, revealed by our study, can have strong implications for the well-being of the elderly and their relatives.

To count or not to count deaths: reranking effects in health distribution evaluation.

Populations' structures and sizes can be a result of healthcare policy decisions. We use a two-period theoretical framework and a dynamic microsimulation model to examine the consequences of this assertion on the appraisal of alternative health policy options. Results show that standard welfare-in-health measures are sensitive to changes in populations' sizes, in that taking into account the (virtual) existence of the dead can alter the ranking of policy options. Disregarding differences in the survivals induced by alternative policies can bias programmes' ranking in favour of less live-saving policies. The paper alerts on the risk of policy misranking by the use of ex-post cross-sectional analyses, neglecting deaths occurring in the past as well as counterfactual deaths in alternative policy scenarios.

The macroeconomic consequences of renouncing to universal access to antiretroviral treatment for HIV in Africa: a micro-simulation model.

AIM: Previous economic literature on the cost-effectiveness of antiretroviral treatment (ART) programs has been mainly focused on the microeconomic consequences of alternative use of resources devoted to the fight against the HIV pandemic. We rather aim at forecasting the consequences of alternative scenarios for the macroeconomic performance of countries. METHODS: We used a micro-simulation model based on individuals aged 15-49 selected from nationally representative surveys (DHS for Cameroon, Tanzania and Swaziland) to compare alternative scenarios : 1-freezing of ART programs to current levels of access, 2- universal access (scaling up to 100% coverage by 2015, with two variants defining ART eligibility according to previous or current WHO guidelines). We introduced an "artificial" ageing process by programming methods. Individuals could evolve through different health states: HIV negative, HIV positive (with different stages of the syndrome). Scenarios of ART procurement determine this dynamics. The macroeconomic impact is obtained using sample weights that take into account the resulting age-structure of the population in each scenario and modeling of the consequences on total growth of the economy. RESULTS: Increased levels of ART coverage result in decreasing HIV incidence and related mortality. Universal access to ART has a positive impact on workers' productivity; the evaluations performed for Swaziland and Cameroon show that universal access would imply net cost-savings at the scale of the society, when the full macroeconomic consequences are introduced in the calculations. In Tanzania, ART access programs imply a net cost for the economy, but 70% of costs are covered by GDP gains at the 2034 horizon, even in the extended coverage option promoted by WHO guidelines initiating ART at levels of 350 cc/mm(3) CD4 cell counts. CONCLUSION: Universal Access ART scaling-up strategies, which are more costly in the short term, remain the best economic choice in the long term. Renouncing or significantly delaying the achievement of this goal, due to "legitimate" short term budgetary constraints would be a misguided choice.