Sisira Sarma

Do physician remuneration schemes matter? The case of Canadian family physicians.

Although it is well known theoretically that physicians respond to financial incentives, the empirical evidence is quite mixed. Using the 2004 Canadian National Physician Survey, we analyze the number of patient visits per week provided by family physicians in alternative forms of remuneration schemes. Overwhelmingly, fee-for-service (FFS) physicians conduct more patient visits relative to four other types of remuneration schemes examined in this paper. We find that family physicians self-select into different remuneration regimes based on their personal preferences and unobserved characteristics; OLS estimates plus the estimates from an IV GMM procedure are used to tease out the magnitude of the selection and incentive effects. We find a positive selection effect and a large negative incentive effect; the magnitude of the incentive effect increases with the degree of deviation from a FFS scheme. Knowledge of the extent to which remuneration schemes affect physician output is an important consideration for health policy.

How important are individual, household and commune characteristics in explaining utilization of maternal health services in Vietnam?

Using Vietnams latest National Household Survey data for 2001-2002 this paper assesses the influence of individual, household and commune-level characteristics on a womans decision to seek prenatal care, on the number of prenatal visits, and on the choice between giving birth at a health facility or at home. The decision to use any care and the number of prenatal visits is modeled using a two-part model. A random intercept logistic model is used to capture the influence of unobserved commune-specific factors found in the data regarding a womans decision to give birth at a health facility rather than at home. The results show that access to prenatal care and delivery assistance is limited by observed barriers such as low income, low education, ethnicity, geographical isolation and a high poverty rate in the community. More specifically, more prenatal visits increase the likelihood of giving birth at a health facility. Having compulsory health insurance increases the odds of giving birth at a health facility for middle and high income women. In contrast, health insurance for the poor increases the likelihood of having more prenatal visits but has little effect on the place of delivery. These results suggest that the existing safe motherhood programs should be linked with the objectives of social development programs such as poverty reduction, and that policy makers need to view both the individual and the commune as appropriate units for policy targeting.

Taking Account of Context: How Important Are Household Characteristics in Explaining Adult Health-Seeking Behaviour? The Case of Vietnam

Understanding the factors affecting the utilization of health services is essential for health planners, especially in low income countries where increasing access to and use of health services is one of the main policy goals of government. While much has been written on adult health-seeking behaviour, there is comparatively little known about the influence of the broader context such as the effects of family and community on individual use of health care services in low income countries. Using Vietnams latest National Household Survey data, this paper empirically assesses the influence of individual- and household-level factors on the use of health care services, while controlling for the unobserved household-level effects. The estimates obtained from a multilevel logistic regression model suggest that the individuals likelihood of seeking treatment is jointly determined by the observed individual- and household-level characteristics as well as unobserved household-level effects. The chance of seeking medical treatment when ill varies strongly with the observed individual- and household-level covariates, including health insurance status, income, the type and severity of illness, the number of other household members with an ailment and the presence of young children in the household. However, the variability implied by the unobservable household-level effects outweighs the variability implied by the observed covariates, indicating a high degree of homogeneity in health-seeking behaviour among the household members. Failure to take account of homogeneity in health-seeking behaviour among the household members leads not only to biased results but also to inefficient policy targeting. Policies aimed at increasing access to and the use of medical services need to be sympathetic to both individuals and households.

The effect of physical activity on adult obesity: Evidence from the Canadian NPHS panel

Although physical activity has been considered as an important modifiable risk factor for obesity, the empirical evidence on the relationship between physical activity and obesity is mixed. Observational studies in the public health literature fail to account for time-invariant unobserved heterogeneity and dynamics of weight, leading to biased estimation of the effect of physical activity on obesity. To overcome this limitation, we propose dynamic fixed-effects models to account for unobserved heterogeneity bias and the dynamics of obesity. We use nationally representative longitudinal data on the cohort of adults aged 18-50 years in 1994/95 from Canadas National Population Health Survey and followed them over 16 years. Obesity is measured by BMI (body mass index). After controlling for a wide range of socio-economic factors, the impact of four alternative measures of leisure-time physical activity (LTPA) and work-related physical activity (WRPA) are analyzed. The results show that each measure of LTPA exerts a negative effect on BMI and the effects are larger for females. Our key results show that participation in LTPA exceeding 1.5 kcal/kg per day (i.e., at least 30 min of walking) reduces BMI by about 0.11-0.14 points in males and 0.20 points in females relative to physically inactive counterparts. Compared to those who are inactive at workplace, being able to stand or walk at work is associated with a reduction in BMI in the range of 0.16-0.19 points in males and 0.24-0.28 points in females. Lifting loads at workplace is associated with a reduction in BMI by 0.2-0.3 points in males and 0.3-0.4 points in females relative to those who are reported sedentary. Policies aimed at promotion of LTPA combined with WRPA like walking or climbing stairs daily would help reduce adult obesity risks.

Transitions in living arrangements of Canadian seniors: Findings from the NPHS longitudinal data

This paper examines transitions in living arrangement decisions of the seniors using the first six cycles of the Canadian longitudinal National Population Health Survey microdata. Transitions from independent to intergenerational and institutional living arrangements are uniquely analyzed using a discrete-time hazard rate multinomial logit modelling framework and accounted for unobserved individual heterogeneity in the data. Our results show: a) provision of publicly-provided homecare reduces the likelihood of institutionalization, but it has no effect on intergenerational living arrangements; b) access to social support services reduces the probability of both institutional and intergenerational living arrangements; c) higher levels of functional health status, measured by Health Utility Index, reduce the probability of transitions from independent to intergenerational and institutional living arrangements; d) a decline in self-reported health status increases the probability of institutionalization, but its effect on intergenerational living arrangements is statistically insignificant; e) higher levels of household income tend to decrease the probability of institutionalization; and f) the likelihood of transitioning to both intergenerational and institutional living arrangements increases with the duration of survival. Our findings suggest that access to and availability of publicly-provided homecare, social support services and other programs designed to foster better functional health status would contribute positively towards independent or intergenerational living arrangements and reduce the probability of institutionalization.

Demand for outpatient healthcare: empirical findings from rural India.

BACKGROUND Price, income and health status are likely to affect the demand for healthcare in developing countries, and their quantitative effects are unclear in the literature. Some studies report that prices are not important determinants, while others conclude that prices are important determinants of the demand for healthcare. Knowledge of the extent to which price, income and health status affect the demand for healthcare is crucial for the design of effective health policy in developing countries. OBJECTIVES To examine the role of monetary and non-monetary price, income, and a variety of individual- and household-specific characteristics on the demand for healthcare in rural India. METHODS Utilizing micro data from the 52nd round of Indias National Sample Survey, a variable choice set based on geographical location, price, income and the severity of illness was constructed to reflect the underlying true choice-generating process in rural India. Nested multinomial logit models were estimated and simulations with respect to prices and income were conducted to estimate price and income elasticities. RESULTS Contrary to many earlier studies on the demand for healthcare in developing countries, it was found that prices and income were statistically significant determinants of the choice of healthcare provider by individuals in rural India. Demand for healthcare was found to be price and income inelastic, corroborating the findings from other developing countries. Distance to formal healthcare facilities negatively affected the demand for outpatient healthcare, an effect that was mitigated as access to transportation improved. Age, sex, healthy days, educational status of the household members and the number of children and adults living in the household also affected the choice of healthcare provider in rural India. CONCLUSIONS After controlling for a number of sociodemographic factors, it was found that prices, income and distance are statistically significant determinants of the provider chosen by individuals; nevertheless, the demand for healthcare is price and income inelastic in rural India.

Do new cohorts of family physicians work less compared to their older predecessors? The evidence from Canada.

Although demographics, cohort, and contextual factors are expected to influence physician supply at the intensive margin, much of the literature has examined the demographics and very limited cohort analysis is undertaken. This paper employs a cross-classified fixed-effects methodology to examine the importance of age, period and cohort, and contextual factors in explaining the declining work hours of Canadian family physicians. We define cohorts with five-year intervals according to year of graduation from medical school. Contrary to the previous literature, we find no evidence of reduced hours of work provided by the new cohorts of physicians. Compared to the 1995-99 cohort, older male cohorts perform similar total hours of work per week except those who graduated in the 1960s while older female cohorts consistently perform fewer total work hours in the range of 3-10 h per week. Consistent with the literature, it is found that female and older physicians provide fewer hours of work compared to the male and younger counterparts, respectively. Although there has been a decline in total hours of work for all physicians in the range of 2-3 h per week in each period, we find a large decline in direct patient care hours (about 4-6 h) and a marginal increase in indirect patient care (about 2-4 h) over the period. Having children less than 6 years and children aged 6-15 years in the physicians family reduce the work hours of female family physicians by about 7 h and 3 h, respectively. A number of other contextual factors influence work hours of physicians in the expected direction.

Physician's Production of Primary Care in Ontario, Canada

This paper examines the factors affecting the number of patient visits per week reported by family physicians in Ontario. The way that a physician is paid is potentially endogenous to the number of patients seen per week, thus an instrumental variable method of estimation is employed to account for the endogeneity bias. Once account is taken of the endogeneity of remuneration as well as relevant physician and practice characteristics, the estimated elasticity of output with respect to hours worked is 0.74; 0.68 in group practices and 0.82 in solo practices. Physicians paid on a non-fee-for-service (NFFS) conduct 15-31% fewer patient visits per week in comparison to those paid under an FFS scheme. Certain patient populations in practices affect patient visits in important ways, as do a number of physician and practice characteristics.

The Relationship Between Diet Quality and Adult Obesity: Evidence from Canada

Objective: To assess the relationship between diet quality and body mass index (BMI) in Canadian adults. Methods: We used confidential, individual-level data on 6325 adult men and 7211 nonpregnant adult women from the 2004 Canadian Community Health Survey to construct 2 diet quality indices (the Diet Quality Index [DQI] and and the Healthy Eating Index [HEI]) and BMI. After adjusting for known observable confounders, a latent class modeling analysis was conducted to account for unobservable confounders. Results: We found that there were 2 latent classes (low-BMI and high-BMI components), and that DQI and HEI indices were negatively associated with BMI in the high-BMI component. In the high-BMI component, a one-unit increase in DQI score is associated with a 0.053 kg/m2 decrease in BMI, whereas a one-unit increase in HEI score is associated with a 0.095 kg/m2 decrease in BMI. Subgroup analyses revealed that the association between diet quality and obesity was stronger in women. Conclusions: Diet quality is associated with lower BMI in high-BMI individuals in Canada. Diet quality exhibits a distinct association in each latent class; this association is stronger in women. Latent class analysis offers a superior methodological framework in understanding the modifiable risk factors for obesity.

Association between neighbourhood fast-food and full-service restaurant density and body mass index: A cross-sectional study of Canadian adults

Objective: Frequent fast-food consumption is a well-known risk factor for obesity. This study sought to determine whether the availability of fast-food restaurants has an influence on body mass index (BMI).METHODS: BMI and individual-level confounding variables were obtained from the 2007-08 Canadian Community Health Survey. Neighbourhood socio-demographic variables were acquired from the 2006 Canadian Census. The geographic locations of all restaurants in Canada were assembled from a validated business registry database. The density of fast-food, full-service and non-chain restaurants per 10,000 individuals was calculated for respondents’ forward sortation area. Multivariable regression analyses were conducted to analyze the association between restaurant density and BMI.RESULTS: Fast-food, full-service and non-chain restaurant density variables were statistically significantly associated with BMI. Fast-food density had a positive association whereas full-service and non-chain restaurant density had a negative association with BMI (additional 10 fast-food restaurants per capita corresponded to a weight increase of 1 kilogram; p<0.001). These associations were primarily found in Canada’s major urban jurisdictions.CONCLUSIONS: This research was the first to investigate the influence of fast-food and full-service restaurant density on BMI using individual-level data from a nationally representative Canadian survey. The finding of a positive association between fast-food restaurant density and BMI suggests that interventions aiming to restrict the availability of fast-food restaurants in local neighbourhoods may be a useful obesity prevention strategy.RésuméOBJECTIF: La consommation fréquente d’aliments de restauration rapide est un facteur de risque d’obésité bien connu. Nous avons cherché à déterminer si la présence de restaurants rapides a une influence sur l’indice de masse corporelle (IMC).MÉTHODE: L’IMC et les variables de confusion individuelles ont été puisés dans l’Enquête sur la santé dans les collectivités canadiennes de 2007-2008. Les variables sociodémographiques par quartier ont été obtenues dans le Recensement du Canada de 2006. Nous avons déterminé l’emplacement géographique de tous les restaurants au Canada à partir d’un registre des entreprises validé. Nous avons calculé la densité pout 10 000 habitants des restaurants rapides, plein service et n’appartenant pas à une chaîne, selon la région de tri d’acheminement des répondants. Nous avons effectué des analyses de régression multivariées pour étudier l’association entre la densité des restaurants et l’IMC.RÉSULTATS: Les variables de densité des restaurants rapides, plein service et n’appartenant pas à une chaîne présentaient une corrélation significative avec l’IMC. Pour la densité des restaurants rapides, cette association était positive, tandis que pour les restaurants plein service et n’appartenant pas à une chaîne, la densité était négativement associée à l’IMC (chaque tranche supplémentaire de 10 restaurants rapides par habitant correspondait à une hausse pondérale d’1 kilogramme; p<0,001). Ces associations étaient principalement observées dans les grands centres urbains du Canada.CONCLUSIONS: Notre étude est la première à analyser l’influence de la densité des restaurants rapides et plein service sur l’IMC à l’aide de données individuelles provenant d’une enquête nationale représentative menée au Canada. La découverte d’une association positive entre la densité des restaurants rapides et l’IMC donne à penser que les interventions visant à limiter la présence des restaurants rapides à l’échelle des quartiers pourraient être des stratégies utiles pour prévenir l’obésité.