bluuebunny/crossref_metadata_2025 huggingface dataset:
Welfare Politics in Africa
Authors: Seekings Jeremy
Published: July 2019

The emerging literature on the politics of social protection in Africa provides insights into the ways in which the unevenly changing character of representative democracy shapes processes of public policymaking in practice. Reforms are widely on the agenda, in part as a result of their advocacy by diverse international organizations and aid donors. But there are many obstacles between the policy agenda and policymaking (and implementation). In many countries, political elites hold conservative views on cash transfer programs. The institutionalization of regular and nominally contested elections has rarely resulted in significant pressures from below for pro-poor programmatic social policy reforms. In some countries, “democratic” politics continues to revolve around competition for patronage rather than programmatic reform. In others, voters themselves seem to prioritize other programs (especially agricultural subsidies) ahead of social protection. Nonetheless, a growing number of competitively elected governments have introduced reforms, as have some semi-democratic or authoritarian regimes. For both more and less democratic governments, regime legitimation through apparently more inclusive development seems to be a more powerful factor than voter pressure.
Reconsidering African Elections
Authors: van Ham Carolien , Lindberg Staffan
Published: July 2019

The quality of elections in Africa demonstrates considerable progress from the early attempts in the 1950s and 1960s to the increasingly democratic era following the end of the Cold War. In terms of scope, 46 of 49 countries in sub-Saharan Africa now select the most powerful public offices (i.e., the executive and/or legislature) via elections, and reserved power domains have become relatively uncommon. In terms of choice, single-party elections, once so common across Africa, have now all but vanished from the continent. However, the integrity of elections still varies widely, ranging from elections with serious irregularities to elections that are fully free and fair. Even so, considerable progress is apparent over the last three decades. A full 47% of countries in sub-Saharan Africa now hold elections that are free and fair or only involve minor irregularities. Equally important, electoral interruptions in the form of coup d’état, civil war, or annulment of elections have become very rare.

Africa is also a continent where the contemporary trend of elections generating broader democratization is particularly palpable. By providing opportunities for citizens to remove incumbents from office and generating expansion of civil liberties after elections are over, stimulating citizens and other actors to increase pressure for more democratic freedoms, elections seem on average to have been conducive to democratic developments in Africa. Elections also increasingly lead to turnovers, especially elections of high electoral integrity, where on average 34% are associated with alternations in power. Taking a long-term view on developments from 1960 until 2017, African elections have seen an impressive increase in quality over time, and provide a much more significant contribution to democratization in sub-Saharan Africa than is often acknowledged in the literature.
Religious Regulation in Iran
Authors: Tamadonfar Mehran , Lewis Roman B.
Published: July 2019

The history of religious minority politics and rights in Iran dates back to the early periods of the ancient Persian Empire. With the passage of time, expansion of the empire led to increased religious pluralism that necessitated official religious tolerance and accommodation. With the adoption of Shi’a Islam as the official religion of the country at the outset of the 16th century, which was largely motivated by the monarchs’ search for greater political legitimacy, Shi’ism was gradually linked to Persian monarchism and was effectively integrated into the Persian national identity and values. The growing influence of Shi’ism empowered the Shi’a clerical establishment that effectively sought exclusionary and discriminatory policies toward religious and sectarian minorities. With the establishment of the Islamic Republic in the aftermath of the revolution in the late 1970s, religious minority politics in Iran gained a more complex and nuanced dimension that facilitated Shi’a dominance and ushered in increasingly exclusionary and discriminatory governmental policies that have undermined religious and sectarian minority rights. This article surveys the history of religious pluralism and regulation in pre-Islamic Persia as well as pre-revolutionary Iran, and examines the legal and practical underpinnings of religious regulation in the Islamic Republic. While Islam does account for certain exclusive rights for Muslims in an Islamic state, it explicitly rejects discrimination against the Peoples of the Book (ahl-al Kitab). To a large extent, the current discriminatory practices against religious and sectarian minorities in Iran are rooted in the regime’s advocacy for sectarian exclusivity and political self-interests, which have very little to do with the Islamic worldview.
Moral Emotions in Political Decision Making
Authors: Halperin Eran , Schori-Eyal Noa
Published: July 2019

Moral emotions such as guilt, shame, and pride play a central role in motivating and regulating many of people’s thoughts, feelings, and behaviors. When moral emotions are experienced on behalf of one’s group, they can have a deep impact on intergroup relations as well, particularly in situations of intergroup conflict. If society members feel that they, due to their association with the group, are responsible for the disproportional and illegitimate suffering of outgroup members, they may experience moral emotions like guilt and shame. These emotional responses can potentially motivate society members to enact a range of political response tendencies, varying from pure defensiveness, resulting in opposition to any relevant compromise, to sincere willingness to offer an apology or to compensate the outgroup.

Of these group-based emotions, guilt has the greatest potential to contribute to the amelioration of intergroup relations in violent, protracted conflicts. Group-based guilt requires the fulfillment of several conditions, including perceived responsibility for the offense; a specific composition or level of identification with the transgressing group; and appraisal of the guilt-inducing action as unjust, immoral or unfair. Group-based guilt is not a prevalent emotion, and various defense mechanisms are frequently employed to curb it. However, when it does arise the experience of guilt in the name of the group can be an important factor in motivating individuals to support policies aimed at compensating victimized groups and their society, either through material reparations or more symbolic gestures such as formal apologies for the harm incurred. Guilt-driven ameliorative actions such as formal apologies or monetary compensation are an important step towards conflict resolution and reconciliation. While up-regulation of group-based guilt is a challenging process, several research directions demonstrate that this emotion can be induced and harnessed to promote conflict resolution and more harmonious intergroup relations.
Bounded Rationality and Cognitive Limits in Political Decision Making
Authors: Shannon Brooke N. , McGee Zachary A. , Jones Bryan D.
Published: July 2019

Bounded rationality conceives of people engaging in politics as goal oriented but endowed with cognitive and emotional architectures that limit their abilities to pursue those goals rationally. Political institutions provide the critical link between micro- and macro-processes in political decision-making. They act to (a) compensate for those bounds on rationality; (b) make possible cooperative arrangements not possible under the assumptions of full or comprehensive rationality; and (c) fall prey to the same cognitive and emotional limits or canals that individual humans do. The cognitive limitations that hamper individuals are not only replicated at the organizational level but are in fact causal.
Prospect Theory and Political Decision Making
Authors: Vieider Ferdinand M. , Vis Barbara
Published: July 2019

Prospect theory—a psychologically founded account of decision making under risk and uncertainty—revolutionized how economists and, later, political scientists thought about decision making under uncertainty. Conceptually, prospect theory is based on two central notions: reference dependence, which is the notion that the utility of outcomes is defined over changes in outcomes from a reference point instead of over absolute outcome levels; and likelihood dependence, which is the notion that people distort probabilities non-linearly when making a decision. Likelihood dependence gives rise to the possibility and certainty effects—changes in probabilities are given much more weight if they fall toward the probability endpoints than if they fall into intermediate probability ranges. Reference dependence gives rise to the reflection effect, predicting mirrored risk attitudes for gains and for losses; and to loss aversion, predicting that people display a disproportionate dislike for losses.

Prospect theory has been extensively applied in the literature on political decision making. Two observations stand out. One, some aspects, such as the reflection effect, have received considerably more attention than others, such as loss aversion or likelihood dependence. Two, there is a twin challenge arising from the combination of this selective modelling and ex post rationalization. A step-wise procedure may help making modelling approaches more principled and systematic. This could furthermore help predicting future decision making behaviour—an aspect that has been neglected in favour of fitting past data.
Scientific Studies of Dreams and Dreaming in the Late 19th and Early 20th Centuries
Authors: Morgese Giorgia
Published: July 2019

In the second half of the 19th century, the study of the phenomenon of the dream was undertaken with “scientific” method, by physicians, physiologists, and psychiatrists before the birth of the “myth” advanced by Freud who claimed for psychoanalysis the birthright of the psychological study of dreams. The article highlights the long and varied process of obtaining scientific knowledge of dreams and the dreaming process, and sheds light on researchers and traditions that have not received as much attention as they should have.
Corporate Social Responsibility: An Overview From an Organizational and Psychological Perspective
Authors: Glavas Ante , Radic Mislav
Published: July 2019

Corporate social responsibility (CSR) is an important topic for both academics and practitioners because it potentially influences all aspects of an organization—from relationships with stakeholders to strategy to daily routines and practices. Thus, scholars have explored CSR for close to one hundred years. Prior research has been primarily conducted at the organizational and institutional levels, but has largely overlooked the individual-level of analysis, which is a major gap considering that CSR is enacted by and influences people. Recently, this gap has been addressed by an increased focus on the individual level of analysis—also known as “micro-CSR.” However, CSR is a multilevel construct, so even when focusing on the individual level, all levels need to be taken into consideration at the same time. Moreover, CSR is cross-disciplinary. Prior research has often focused on disciplines such as strategy, but fields such as psychology have much to offer—especially because CSR is conducted through and affects individuals. Moreover, due to the historical focus of CSR on the organizational level of analysis, most studies have aggregated CSR to the firm level. These studies have shown mixed results of the effects of CSR. One reason is that when CSR is aggregated, the variance at the individual level of analysis is lost. Employees might react both positively and negatively to CSR. For example, CSR is often extra-role (e.g., volunteering, being part of committees) and can have a negative effect of role strain and stress. For other employees, they might find tension with the way that CSR is carried out. Future research could dive more deeply into the psychology of CSR and how, when, and why employees might react to CSR differently.
Plastic Changes After Spinal Cord Injury
Authors: Farrell Kaitlin , Detloff Megan R. , Houle John D.
Published: July 2019

Spinal cord injury has instantaneous, destructive effects on bodily functions, as readily demonstrated by muscle paralysis and non-responsiveness to sensory stimulation. This primary response has underlying features at molecular, cellular, tissue and organ levels which will, in a relatively brief time, initiate a secondary cascade of events that exacerbates the extent of the primary focus of damage. Interestingly, the initial extent of motor and sensory loss often is followed by limited, but significant spontaneous functional recovery. Recovery may be due to intrinsic central pattern generators such as for locomotion, the uncovering of dormant anatomical and physiological pathways such as the crossed phrenic for respiration, or to the sprouting of undamaged axons within the spinal cord to establish new connections around or across the injury site. Together the responses to injury and spontaneous efforts for repair represent plastic changes in the central nervous system (CNS) that may result in meaningful functional outcomes, though aberrant sprouting is a possible negative consequence of neuroplasticity that lends caution to the desire for extensive but uncontrolled sprouting.
Molecular Biology and Physiology of Circadian Clocks
Authors: Cao Ruifeng
Published: July 2019

Circadian rhythm is the approximately 24-hour rhythmicity that regulates physiology and behavior in a variety of organisms. The mammalian circadian system is organized in a hierarchical manner. Molecular circadian oscillations driven by genetic feedback loops are found in individual cells, whereas circadian rhythms in different systems of the body are orchestrated by the master clock in the suprachiasmatic nucleus (SCN) of the anterior hypothalamus. SCN receives photic input from retina and synchronizes endogenous rhythms with the external light/dark cycles. SCN regulates circadian rhythms in the peripheral oscillators via neural and humoral signals, which account for daily fluctuations of the physiological processes in these organs. Disruption of circadian rhythms can cause health problems and circadian dysfunction has been linked to many human diseases.
Intercultural Arts
Authors: Burnard Pamela
Published: July 2019

The term “interculturality” acknowledges the complexity of locations, identities, and modes of expression in a global world and the desire to raise awareness, foster intercultural dialogue, and facilitate understanding across and between cultures. Intercultural arts is a critical component of interculturality.

One of many global educational imperatives is to further understanding and engage critically in what constitutes intercultural arts. Intercultural arts practitioners and researchers play a significant role in this undertaking. A close examination of intercultural arts work and encounters unravels complex relationships among arts disciplines and ways to conceptualize and understand intercultural arts travels. Intercultural arts research sheds new insights into shared cultural and intercultural futures that need to be reimagined and co-created with a sense of ethical obligations, exploration, openness, and reflexivity. This leads to embracing a multiperspective worldview that addresses and celebrates the embodied nature of intercultural arts practices across global contexts: a worldview that is continually constructed, dynamic, and fluid, existing both within and between locations, and that connotes a particular type of ethical educational space.

The study of interculturality in today’s society in general, and in actual intercultural arts practice in particular, is indispensable. For educators who want to engage in researching their professional practice in the “field” of intercultural arts, “field” is a useful agricultural metaphor for the various processes and tools used in researching intercultural arts practice. Social researchers talk, for example, about “entering the field” and “gathering” data as if venturing into the world to harvest material for processing (analysis) before its eventual distribution and consumption by a society hungrily seeking new information to build up its body of knowledge and increase its capacity for growth and improvement. However, for education practitioners researching their own professional practice, and their journey into and focus on “intercultural arts,” it will feel much more fluid and uncertain than being on dry land, and it will require them to locate and address the overlap of practice and ethical agendas in educational research.
A/r/tography
Authors: LeBlanc Natalie , Irwin Rita L.
Published: July 2019

Since its conception, a/r/tography has been described as an interdisciplinary, dynamic, and emergent practice, blending visual, narrative, performative, poetic, and other modes of inquiry with qualitative methodologies such as ethnography, auto-ethnography, autobiography, and participatory or educational action research. Although some a/r/tographers utilize traditional modes of data-gathering methods, such as interviews, transcripts, and field notes, not all practices of a/r/tography refer to the recording or collection of ideas as “data,” and if they do, they are used in combination with, or in relation to, art-making, creative writing, or performance. As an arts-based methodology grounded in the physicality of making and creating, a/r/tography is situated outside traditional research structures. It is framed by a continual process of questioning where understandings are not predetermined and where artistic contexts, materials, and processes create transformative events, interactive spaces in which the reader/viewer/audience can co-create in meaning-making. In short, a/r/tography is an arts-based form of inquiry that disrupts standardized criteria of research while evoking and provoking alternate possibilities for understanding.
Simulation as a Strategy in Teacher Education
Authors: Kaufman David , Ireland Alice
Published: July 2019

Simulations provide opportunities to extend and enhance the practice, feedback, and assessment provided during teacher education. A simulation is a simplified but accurate, valid, and dynamic model of reality. A simulation allows users to encounter problem situations, test decisions and actions, experience the results, and modify behavior cost-effectively and without risking harm. Simulations may or may not be implemented using digital technologies but increasingly take advantage of them to provide more realism, flexibility, access, and detailed feedback. Simulations have many advantages for learning and practice, including the ability to repeat scenarios with specific learning objectives, practice for longer periods than are available in real life, use trial and error, experience rare or risky situations, and measure outcomes with validated scoring systems. For skills development, a simulation’s outcome measures, combined with debriefing and reflection, serve as feedback for a formative assessment cycle of repeated performance practice and improvement.

Simulations are becoming more common in preservice teacher education for skills such as lesson planning and implementation, classroom management, ethical practice, and teaching students with varying learning needs. Preservice teachers can move from theory into action, with more practice time and variety than would be available in limited live practicum sessions and without negatively affecting vulnerable students. While simulations are widely accepted in medical and health education, examples in teacher education have often been research prototypes used in experimental settings. These prototypes and newer commercial examples demonstrate the potential of simulations as a tool for both preservice and in-service teacher education. However, cost, simulation limitations, and lack of rigorous evidence as to their effectiveness has slowed their widespread adoption.
Conceptions and Models of Teacher Education
Authors: Robinson Maureen , Mogliacci Rada Jancic
Published: July 2019

Initial teacher education programs across the world bear many resemblances to one another in respect to their overall design features. Students generally follow courses that teach them foundational knowledge pertaining to education, like psychology or sociology, disciplinary knowledge in particular subject areas, and general and specific pedagogical knowledge. In addition, students are exposed to varying degrees of school placements. Despite these similarities in overall structure, the curriculum content and activities of teacher preparation may vary considerably, dependent on the underpinning conceptions of the goals and purposes of the program. Historical and geographical contexts also influence the choice of particular goals for teacher education.

Conceptions of teacher education can be clustered in a number of major approaches, each with its own subcategories. Although different terminologies may be used in the literature, the six major categories are as follows: a social justice approach, a master-apprentice approach, an applied science approach, a teacher identity approach, a competence approach, and a reflective approach. Each approach has certain key features and implications for curriculum design in teacher education, including vision, goals, content, teaching and learning methodologies, and the relationship between schools and colleges/universities. An example here is the difference between an applied science approach, based on the notion of teachers putting theories into practice, and a reflective practice approach, where teachers are encouraged to construct personal theories in and from practice. A second example of the different emphases is the extent to which education is located within its larger social context, with the relationship between school and society being more explicit within a social justice than a competence approach to teacher education. Conceptions may be implicit or explicit; in reality, most programs embody hybrid models with emphasis in particular directions.

The articulation of the key concepts, principles, and assumptions that underpin the design of teacher education programs contributes to the field in various ways. Promoting an understanding of different traditions of teacher education helps establish a shared vocabulary and knowledge base; this can improve the quality of teacher education through deepening academic debate and enhancing program coherence. In addition, strengthening the conceptual base of teacher education supports the professional autonomy of teacher educators, through advancing debate on the purposes, ethics, and politics of education and providing tools to discuss the curriculum implications of policy reform.
Japanese Territorial Disputes and the Legacy of Empire
Authors: Dudden Alexis
Published: July 2019

Japan has territorial disputes with each of its international neighbors in the form of sovereignty contests over small islands that are shards of its once vast 20th-century empire. Recently emerging global ocean laws have taken root that make it in every nation’s interests to lay claim to exclusively controlled ocean space. As a result, a new kind of ocean imperialism is underway, compelling some nations to take maximalist approaches and others more flexible positions toward defining their countries’ respective claims. Since the 1990s, Japanese leaders have made clear that they are collectively committed to national policies and planning that reorient Japan as a maritime nation, which was not the case in the wake of the nation’s devastating losses in World War II. The question now is whether Japanese leaders will adopt a rigid definition for Japan or a more fluid one that emphasizes borderlines in the sea around it.
Women in Guinea
Authors: Dessertine Anna
Published: July 2019

Women’s involvement in the processes of state formation is marked by a strong ambivalence in Guinea: female political mobilizations appear as an indispensable advantage for state power when they are deployed in support of it, but these mobilizations can likewise disrupt and generate major problems for the state when they are directed against it. The efficacy of female political involvement is closely linked to the historiography of relationships between women and the state in Guinea, a country that helped construct an image of female activism outside of areas considered to be exclusively political, and as a guarantor of social justice.

During the colonial period, as was the case for many other countries under French colonial rule, the influence of women was restricted to the domestic sphere: once households ceased to constitute a political resource for the colonial regimes (in contrast to the precolonial era), the influence that women were able to wield within, for example, matrimonial alliances was considerably reduced. Yet, women played a highly important role in nationalist conflicts and under the regime of Sékou Touré, who served as Guinea’s first president from 1958 to 1984. Presented as the “women’s man,” Touré sought high integration of women into his political party, based on structures inspired by the Soviet socialist model. This was a Guinean political originality. In this context, even though women were given official prominence, their demands nonetheless drew on conservative models that relied on a politicization of the maternal figure. Yet the domestic and apolitical character of female mobilization still lends it a spontaneous efficacy in a context in which laws supporting women are seldom enforced and in which the situation seems to have become increasingly precarious for women due to male emigration and inequalities in property rights.
Women in Nationalist Movements in Africa
Authors: Makana Selina
Published: July 2019

Nationalist movements in Africa may have been led by male luminaries, but the influence and successes of these movements largely depended on women’s grassroots organizing and mobilizing. Women played central roles in local and national organizing efforts, and in some cases, many of them joined their male counterparts on the front lines of war during the armed struggle. From leading protests against taxation policies to distributing anti-colonial propaganda pamphlets, as well as feeding and treating wounded guerrilla soldiers, women’s roles in nationalist movements were diverse. Whether popular mobilization or clandestine networks, women’s anti–colonial efforts were met often with violent resistance from colonial regimes. Many activists were flogged, arrested and imprisoned as a way to repress and immobilize their political participation.

While their personal histories and motivations for joining independence movements differed and varied, many women participated in these movements because they saw their emancipation as women as closely linked with the liberation of their countries. Within various movements, women took their duties as patriotic mothers seriously and for most of them, their gender consciousness was awakened as a result of their political participation and their desire for independence. However, participating in national liberation struggles involved more than just fighting against colonial oppression. Despite their influence and active involvement, women had to contend with their own subordination and marginalization within various nationalist movements due to the patriarchal structures that characterized nationalist politics. A struggle that many female politicians and activists continue to engage within the 21st century.
Supplementary Health Insurance and Regulation of Healthcare Systems
Authors: Dormont Brigitte
Published: July 2019

Most developed nations provide generous coverage of care services, using either a tax financed healthcare system or social health insurance. Such systems pursue efficiency and equity in care provision. Efficiency means that expenditures are minimized for a given level of care services. Equity means that individuals with equal needs have equal access to the benefit package. In order to limit expenditures, social health insurance systems explicitly limit their benefit package. Moreover, most such systems have introduced cost sharing so that beneficiaries bear some cost when using care services. These limits on coverage create room for private insurance that complements or supplements social health insurance. Everywhere, social health insurance coexists along with voluntarily purchased supplementary private insurance. While the latter generally covers a small portion of health expenditures, it can interfere with the functioning of social health insurance. Supplementary health insurance can be detrimental to efficiency through several mechanisms. It limits competition in managed competition settings. It favors excessive care consumption through coverage of cost sharing and of services that are complementary to those included in social insurance benefits. It can also hinder achievement of the equity goals inherent to social insurance. Supplementary insurance creates inequality in access to services included in the social benefits package. Individuals with high incomes are more likely to buy supplementary insurance, and the additional care consumption resulting from better coverage creates additional costs that are borne by social health insurance. In addition, there are other anti-redistributive mechanisms from high to low risks. Social health insurance should be designed, not as an isolated institution, but with an awareness of the existence—and the possible expansion—of supplementary health insurance.
Economic Incentives, Risk Behaviors, and HIV
Authors: Sosa-Rubí Sandra G. , Galárraga Omar
Published: July 2019

Conditional economic incentives are a theoretically grounded approach for eliciting behavior change. The rationale stems from present-biased preferences, by which individuals attach greater value to benefits in the present and heavily discount long-term health. A growing literature documents the use of economic incentives in the HIV field. Small and frequent conditional economic incentives offered to vulnerable populations can contribute to behavior change. Economic incentives accompanied with other strategies can help overcome obstacles to access health services and in general seem to improve linkage to HIV care, prevention interventions, and adherence to HIV treatment. Future identification of promising combinations of intervention components, modalities, and strategies may yield maximum impact.
Financial Protection Against Medical Expense
Authors: O'Donnell Owen
Published: July 2019

Financial protection is claimed to be an important objective of health policy. Yet there is a lack of clarity about what it is and no consensus on how to measure it. This impedes the design of efficient and equitable health financing. Arguably, the objective of financial protection is to shield nonmedical consumption from the cost of healthcare. The instruments are formal health insurance and public finances, as well as informal and self-insurance mechanisms that do not impair earnings potential. There are four main approaches to the measurement of financial protection: the extent of consumption smoothing over health shocks, the risk premium (willingness to pay in excess of a fair premium) to cover uninsured medical expenses, catastrophic healthcare payments, and impoverishing healthcare payments. The first of these does not restrict attention to medical expenses, which limits its relevance to health financing policy. The second rests on assumptions about risk preferences. No measure treats medical expenses that are financed through informal insurance and self-insurance instruments in an entirely satisfactory way. By ignoring these sources of imperfect insurance, the catastrophic payments measure overstates the impact of out-of-pocket medical expenses on living standards, while the impoverishment measure does not credibly identify poverty caused by them. It is better thought of as a correction to the measurement of poverty.
Considering Health-Systems Constraints in Economic Evaluation in Low- and Middle-Income Settings
Authors: Vassall Anna , Bozzani Fiammetta , Hanson Kara
Published: July 2019

In order to secure effective service access, coverage, and impact, it is increasingly recognized that the introduction of novel health technologies such as diagnostics, drugs, and vaccines may require additional investment to address the constraints under which many health systems operate. Health-system constraints include a shortage of health workers, ineffective supply chains, or inadequate information systems, or organizational constraints such as weak incentives and poor service integration. Decision makers may be faced with the question of whether to invest in a new technology, including the specific health system strengthening needed to ensure effective implementation; or they may be seeking to optimize resource allocation across a range of interventions including investment in broad health system functions or platforms. Investment in measures to address health-system constraints therefore increasingly need to undergo economic evaluation, but this poses several methodological challenges for health economists, particularly in the context of low- and middle-income countries.

Designing the appropriate analysis to inform investment decisions concerning new technologies incorporating health systems investment can be broken down into several steps. First, the analysis needs to comprehensively outline the interface between the new intervention and the system through which it is to be delivered, in order to identify the relevant constraints and the measures needed to relax them. Second, the analysis needs to be rooted in a theoretical approach to appropriately characterize constraints and consider joint investment in the health system and technology. Third, the analysis needs to consider how the overarching priority- setting process influences the scope and output of the analysis informing the way in which complex evidence is used to support the decision, including how to represent and manage system wide trade-offs. Finally, there are several ways in which decision analytical models can be structured, and parameterized, in a context of data scarcity around constraints. This article draws together current approaches to health system thinking with the emerging literature on analytical approaches to integrating health-system constraints into economic evaluation to guide economists through these four issues. It aims to contribute to a more health-system-informed approach to both appraising the cost-effectiveness of new technologies and setting priorities across a range of program activities.
The Rationale for Interventions to Foster Child Development
Authors: Berlinski Samuel , Vera-Hernández Marcos
Published: July 2019

Socioeconomic gradients in health, cognitive, and socioemotional skills start at a very early age. Well-designed policy interventions in the early years can have a great impact in closing these gaps. Advancing this line of research requires a thorough understanding of how households make human capital investment decisions on behalf of their children, what their information set is, and how the market, the environment, and government policies affect them. A framework for this research should describe how children’s skills evolve and how parents make choices about the inputs that model child development, as well as the rationale for government interventions, including both efficiency and equity considerations.
Returns to Health Spending in Low- and Middle-Income Countries
Authors: Edoka Ijeoma Peace
Published: July 2019

Low- and middle-income countries (LMICs) bear a disproportionately high burden of diseases in comparison to high-income countries, partly due to inequalities in the distribution of resources for health. Recent increases in health spending in these countries demonstrate a commitment to tackling the high burden of disease. However, evidence on the extent to which increased spending on health translates to better population health outcomes has been inconclusive. Some studies have reported improvements in population health with an increase in health spending whereas others have either found no effect or very limited effect to justify increased financial allocations to health. Differences across studies may be explained by differences in approaches adopted in estimating returns to health spending in LMICs.
Bayesian Statistical Economic Evaluation Methods for Health Technology Assessment
Authors: Gabrio Andrea , Baio Gianluca , Manca Andrea
Published: July 2019

The evidence produced by healthcare economic evaluation studies is a key component of any Health Technology Assessment (HTA) process designed to inform resource allocation decisions in a budget-limited context. To improve the quality (and harmonize the generation process) of such evidence, many HTA agencies have established methodological guidelines describing the normative framework inspiring their decision-making process. The information requirements that economic evaluation analyses for HTA must satisfy typically involve the use of complex quantitative syntheses of multiple available datasets, handling mixtures of aggregate and patient-level information, and the use of sophisticated statistical models for the analysis of non-Normal data (e.g., time-to-event, quality of life and costs). Much of the recent methodological research in economic evaluation for healthcare has developed in response to these needs, in terms of sound statistical decision-theoretic foundations, and is increasingly being formulated within a Bayesian paradigm. The rationale for this preference lies in the fact that by taking a probabilistic approach, based on decision rules and available information, a Bayesian economic evaluation study can explicitly account for relevant sources of uncertainty in the decision process and produce information to identify an “optimal” course of actions. Moreover, the Bayesian approach naturally allows the incorporation of an element of judgment or evidence from different sources (e.g., expert opinion or multiple studies) into the analysis. This is particularly important when, as often occurs in economic evaluation for HTA, the evidence base is sparse and requires some inevitable mathematical modeling to bridge the gaps in the available data. The availability of free and open source software in the last two decades has greatly reduced the computational costs and facilitated the application of Bayesian methods and has the potential to improve the work of modelers and regulators alike, thus advancing the fields of economic evaluation of healthcare interventions. This chapter provides an overview of the areas where Bayesian methods have contributed to the address the methodological needs that stem from the normative framework adopted by a number of HTA agencies.
The Growth of Health Spending in the United States From 1776 to 2026
Authors: Getzen Thomas E.
Published: July 2019

During the 18th and 19th centuries, medical spending in the United States rose slowly, on average about .25% faster than gross domestic product (GDP), and varied widely between rural and urban regions. Accumulating scientific advances caused spending to accelerate by 1910. From 1930 to 1955, rapid per-capita income growth accommodated major medical expansion while keeping the health share of GDP almost constant. During the 1950s and 1960s, prosperity and investment in research, the workforce, and hospitals caused a rapid surge in spending and consolidated a truly national health system. Excess growth rates (above GDP growth) were above +5% per year from 1966 to 1970, which would have doubled the health-sector share in fifteen years had it not moderated, falling under +3% in the 1980s, +2% in 1990s, and +1.5% since 2005. The question of when national health expenditure growth can be brought into line with GDP and made sustainable for the long run is still open. A review of historical data over three centuries forces confrontation with issues regarding what to include and how long events continue to effect national health accounting and policy. Empirical analysis at a national scale over multiple decades fails to support a position that many of the commonly discussed variables (obesity, aging, mortality rates, coinsurance) do cause significant shifts in expenditure trends. What does become clear is that there are long and variable lags before macroeconomic and technological events affect spending: three to six years for business cycles and multiple decades for major recessions, scientific discoveries, and organizational change. Health-financing mechanisms, such as employer-based health insurance, Medicare, and the Affordable Care Act (Obamacare) are seen to be both cause and effect, taking years to develop and affecting spending for decades to come.
Competition and Quality in Healthcare
Authors: Sivey Peter , Chen Yijuan
Published: July 2019

Quality competition between alternative providers is an increasingly important topic in the health economics literature. This literature includes theoretical and empirical studies that have been developed in parallel to 21st-century policies to increase competition between doctors or hospitals. Theoretical studies have clarified how competitive markets can give healthcare providers the incentive to improve quality. Broadly speaking, if providers have an incentive to attract more patients and patients value quality, providers will raise quality until the costs of raising quality are equal to the additional revenue from patients attracted by the rise in quality. The theoretical literature has also investigated how institutional and policy parameters determine quality levels in equilibrium. Important parameters in models of quality competition include the degree of horizontal differentiation, the level of information about provider quality, the costs of switching between providers, and the time-horizon of quality investment decisions.

Empirical studies have focused on the prerequisites of quality competition (e.g., do patients choose higher quality providers?) and the impact of pro-competition policies on quality levels. The most influential studies have used modern econometric approaches, including difference-in differences and instrumental variables, to identify plausibly causal effects. The evidence suggests that in most contexts, quality is a determinant of patient choice of provider, especially after greater patient choice is made available or information is published about provider quality.

The evidence that increases in competition improve quality in healthcare is less clear cut. Perhaps reflecting the economic theory of quality competition, showing that different parameter combinations or assumptions can produce different outcomes, empirical results are also mixed. While a series of high-quality studies in the United Kingdom appear to show strong improvements in quality in more competitive areas following pro-competition reforms introducing more choice and competition, other studies showed that these quality improvements do not extend to all types of healthcare or alternative measures of quality.

The most promising areas for future research include investigating the “black box” of quality improvement under competition, and behavioral studies investigating financial and nonfinancial motivations for quality improvements in competitive markets.
Strategies to Counteract Risk Selection in Social Health Insurance Markets
Authors: Kleef Richard C. van , McGuire Thomas G. , Schut Frederik T. , Ven Wynand P. M. M. van de
Published: July 2019

Many countries rely on social health insurance supplied by competing insurers to enhance fairness and efficiency in healthcare financing. Premiums in these settings are typically community rated per health plan. Though community rating can help achieve fairness objectives, it also leads to a variety of problems due to risk selection, that is, actions by consumers and insurers to exploit “unpriced risk” heterogeneity. From the viewpoint of a consumer, unpriced risk refers to the gap between her expected spending under a health plan and the net premium for that plan. Heterogeneity in unpriced risk can lead to selection by consumers in and out of insurance and between high- and low-value plans. These forms of risk selection can result in upward premium spirals, inefficient take-up of basic coverage, and inefficient sorting of consumers between high- and low-value plans.

From the viewpoint of an insurer, unpriced risk refers to the gap between his expected costs under a certain contract and the revenues he receives for that contract. Heterogeneity in unpriced risk incentivizes insurers to alter their plan offerings in order to attract profitable people, resulting in inefficient plan design and possibly in the unavailability of high-quality care. Moreover, insurers have incentives to target profitable people via marketing tools and customer service, which—from a societal perspective—can be considered a waste of resources.

Common tools to counteract selection problems are risk equalization, risk sharing, and risk rating of premiums. All three strategies reduce unpriced risk heterogeneity faced by insurers and thus diminish selection actions by insurers such as the altering of plan offerings. Risk rating of premiums also reduces unpriced risk heterogeneity faced by consumers and thus mitigates selection in and out of insurance and between high- and low-value plans. All three strategies, however, come with trade-offs. A smart blend takes advantage of the strengths, while reducing the weaknesses of each strategy. The optimal payment system configuration will depend on how a regulator weighs fairness and efficiency and on how the healthcare system is organized.