Essays on health care organization and its effect on recipients of conditional cash transfers programs.

This dissertation includes four essays that analyze the organization of health care systems and how they interact with conditional cash transfers programs, a novel and ambitions public policy that is showing to be effective at alleviating poverty in the developing world. The introductory section provides some background on the origins and evolution of health care systems. It also discusses the particularities of the health sector as an area of research. As it is described here, health systems around the world are facing important challenges as governments struggle to finance, regulate and provide health services. Most developed and developing countries are currently reforming their health care systems to deal with an ageing society, a growing number of underserved populations and the increasing costs of medical care. The redefinition of public and private responsibilities in the health care system has been one of the most popular policies to reform health care. The first essay of this dissertation studies the new roles of the public and the private sector in three Latin American countries that chose different approaches to health care privatization. Using some basic national statistics, it is discussed that Chile and Colombia, countries that were more enthusiastic about privatization, actually observed a higher increase in their public financing of health care compared to Mexico, country where health care privatization was marginal. It is argued that even though private organizations have an increasing role in Latin America, it is just part of a more comprehensive reform where governments are actually trying to increase their influence on the regulation and financing of the health care sector. The first essay raises some methodological issues at comparing health care reform across countries. The literature in this area still lacks a widely accepted typology to compare different institutional arrangements in the health sector not only across, but also within countries. As policymakers increasingly rely on health system comparisons to propose new pathways for reform, a new and useful typology seems desirable. The second essay of this dissertation discusses the strengths and weaknesses of different typologies. It later proposed an adaptation of the U-Form and M-Form model that is popular in the Business and Economics literatures to compare health systems. This essay concludes with an application of the U-Form and M-From to define a tradeoff between centralized and decentralized health care providers. The third and fourth essays of this dissertation use data form a conditional cash transfers (CCT) program in Mexico to test the effectiveness of federal and state health care organizations. They compare performance by taking advantage of health care provider duplication in rural Mexico. The analysis benefits from differences in timing and models of health care decentralization, and from a quasi-random distribution of providers. In contrast with the most common predictions in the literature, the centralized provider of health services performs better. Households served by this organization face less regressive out-of-pocket health care expenditures (56% lower), and observe higher utilization of preventive services (5.5% more). Fortunately, state providers improve significantly in those areas targeted by Oportunidades (formerly Progresa), the CCT program of Mexico. This program provides cash transfers to poor families conditional upon school attendance and receiving preventive care. The difference in outcomes between federal and state health care providers narrows in those areas where Oportunidades operates. These findings are robust to...