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Abstracts of Recent Work

"An Empirical Evaluation Of Devolving Administrative Control To Costa Rican Hospital And Clinic Directors" (with Theodore Lee) (paper)

In the early 2000s Costa Rica implemented comprehensive reforms to its health care system including devolving administrative power from the central government to some providers that remain part of the national system. In this paper, we evaluate how this aspect of the reform affected clinic efficiency and population health by analyzing administrative data on regional providers and mortality rates in local areas. We compare changes in outcomes across time between areas that signed performance contracts with the central government and received limited budgetary control to those that continued to be managed directly by the central government. We believe the reform created opportunities for providers to become more efficient and effective. Our results suggest that the reform significantly decreased costs without adversely affecting quality of care or population health.

"Externalities of Prevention of Mother-to-Child HIV Transmission Programs: A Systematic Review" (with Sarah Nutman and Kaveh Khoshnood) (paper)

There has been considerable debate about the effects of targeted global health assistance in low- and middle-income countries on health systems, specifically HIV/AIDS funding. Recently, a handful of studies have emerged that describe the implementation of PMTCT programs, which have many theoretical links to maternal and child health. Through a systematic review of research published between January 2000 and March 2011, this paper synthesizes evidence evaluating the impact of these programs. We assessed 5855 papers, reviewed 154, and included 21 articles. They offer evidence of beneficial synergies between PMTCT programs and both STI prevention and early childhood immunization. Other data, including information about antenatal and delivery care, family planning, and nutrition supplementation varied considerably across studies demonstrating both positive and negative effects of PMTCT. More research is needed to allow countries and funders to make informed decisions regarding allocation of limited funds to targeted versus broad categories of health care.

"The Longer-term Effects of Human Capital Enrichment Programs on Poverty and Inequality: Oportunidades in Mexico" (with Petra Todd) (paper)

Recent evaluations of the Oportunidades schooling and health subsidy program in Mexico have demonstrated statistically significant positive impacts on schooling and health outcomes. This paper adapts methods developed in Dinardo, Fortin and Lemieux (1996) for use in studying how these schooling and health impacts will affect the future earnings distributions of cohorts recently exposed to the program. Our approach nonparametrically simulates earnings distributions, with and without the program, and quantifies resulting changes in mean earnings, poverty rates, and earnings inequality. It is well recognized that the Oportunidades program has reduced poverty and inequality of the current generation through its targeted cash transfers. This paper finds that by enriching human capital, as measured by schooling and height, the program will also generate increases in future earnings. However, it will achieve only modest reductions in poverty and earnings inequality.

"Health Consequences of Forest Fires in Indonesia" (with Elizabeth Frankenberg and Duncan Thomas) (paper)

We combined data from a population-based longitudinal survey with satellite measures of aerosol levels to assess the impact of smoke from forest fires that blanketed the Indonesian islands of Kalimantan and Sumatra in late 1997 on adult health. To account for unobserved differences between haze and nonhaze areas, we compared changes in the health of individual respondents. Between 1993 and 1997, individuals who were exposed to haze experienced greater increases in difficulty with activities of daily living than did their counterparts in nonhaze areas. The results for respiratory and general health, although more complicated to interpret, suggest that haze had a negative impact on these dimensions of health.

"Is Obesity in the Eye of the Beholder? How standard BMI categories miss the story for socioeconomic outcomes" (with Vida Maralani)

Obesity is associated with poorer socioeconomic outcomes. But the application of medically-based categories of body size to the social world seems both arbitrary and limiting. If body size has a causal effect on life chances this would function through the social construction of "fatness" rather than a predefined set of medically motivated groupings of BMI. The evidence suggests that the effect of body size on social outcomes could not only be nonlinear, but could also differ in important ways for different social groups. In this paper, we use change point models to determine empirically where along the continuum of body weight the substantively important relationships between body size and social status actually fall. This approach allows us to estimate flexible and nonlinear relationships between BMI and a set of socioeconomic outcomes and allow the relevant cutoffs for obesity to differ both by group and by socioeconomic outcome.

"The Evolution of Latent Health over the Life Course" (with Fabian Lange)

In this project, we propose a new method to estimate rich dynamic models of health that exploits longitudinal observations of multiple health measures. Our method adapts and combines two techniques first developed in different contexts. In a first step, we use factor analytic methods to estimate a series of age-specific static measurement models that determine how underlying latent health is related to observed discrete and continuous measures. This step also reveals the unconditional nonparametric distribution of latent health at each age. We then model how latent health evolves stochastically over time. We estimate the parameters of this dynamic model using the method of simulated moments. Specifically, we simulate the dynamic health process and use the previously estimated measurement process to derive an implied set of moments that can be compared with moments observed in the data. We demonstrate the method by estimating health processes for men and women using data from the Health and Retirement Study.

"Do Good Kids Finish First? Characterizing the Bequest Motive in Mexico" (with Beth Soldo) (paper)

This paper tests several leading bequest motive theories using a uniquely appropriate longitudinal data set, the Mexican Health and Aging Study. These data include a population-representative sample of bequests and bequest intentions of parents that is matched with rich measures of child characteristics and behavior. Our results are consistent with the theory of Bernheim et al. that parents use their bequest strategically to induce children to provide services. We also find evidence that contradicts predictions of pure theories of altruism and suggestive evidence that when business assets are at stake, parents favor those children who are most qualified to manage those assets.

"The Impact of Teacher Training and Information Technology on Student Outcomes: Evidence from the Intel Teach for the Future Program in Costa Rica" (with Sarah Mayer)

There is little consensus about the optimal role of technology in education, and unsurprisingly, most classrooms around the world don't look very different from classrooms one hundred years ago. Intel Teach for the Future is a program that trains teachers how to incorporate information and communications technology into their classrooms. Over the last ten years, the program has been implemented in more than 40 countries and in Costa Rica has reached more than 30% of the public elementary and high school teachers. This high level of penetration provides a unique opportunity to evaluate the program's effect on student outcomes. In this project, we match data on program roll out over time across the country to nationally representative household survey data. We use both temporal and spatial variation to estimate causal effects of the program on student retention, college-going, employment, and wages.

"The Intergenerational Transmission of Smoking and Schooling" (with Vida Maralani)

Across birth cohorts of Americans, education and smoking status in families of origin have become more aligned. Over time, men who smoke became more likely to marry women who smoke, especially among couples with less schooling. We examine how much this alignment of smoking and education matters for children's life chances. We use a two-sex demographic projection model, which accounts for the statuses of both men and women, combined with simulations to examine how changes in assortative mating affect the distribution of smoking and education in future generations. The model incorporates assortative mating, differential fertility, and the transmission of status. Preliminary findings show that intergenerational results depend on which cohort's marriage and fertility rules are applied and whether we consider smoking status as a binary status or a quantitative one. But these differences, though descriptively important, are modest. Mobility across generations dominates the effects of assortative mating in the population.