Foundations of utilitarianism under risk and variable population

Utilitarianism is the most prominent social welfare function in economics. We present three new axiomatic characterizations of utilitarian (that is, additively-separable) social welfare functions in a setting where there is risk over both population size and individuals' welfares. We first show that, given uncontroversial basic axioms, Blackorby et al.'s (1998) Expected Critical-Level Generalized Utilitarianism is equivalent to a new axiom holding that it is better to allocate higher utility-conditional-on-existence to possible people who have a higher probability of existence. The other two characterizations extend and clarify classic axiomatizations of utilitarianism from settings with either social risk or variable-population, considered alone.

The role of children and work-from-home in gender labor market asymmetries: evidence from the COVID-19 pandemic in Latin America

Asymmetry in childcare responsibilities is one of the main reasons behind gender gaps in the labor market. In that context, the ability to work from home may alleviate the hindrances of women with children to participate in the labor market. We study these issues in Latin America, a region with wide gender gaps, in the framework of a major shock that severely affected employment: the COVID-19 pandemic. In particular, we estimate models of job loss exploiting microdata from the World Bank's High-Frequency Phone Surveys conducted immediately after the onset of the pandemic. We find that the mitigating effect of working from home on the severity of job losses was especially relevant for women with children. The results are consistent with a plausible mechanism: due to the traditional distribution of childcare responsibilities within the household, women with children were more likely to stay home during school closures, and therefore the ability to work from home was crucial for them to keep their jobs.

Impact of information and deliberation on the consistency of preferences for prioritization in health care - evidence from discrete choice experiments undertaken alongside citizens' juries

BACKGROUND

Public preferences are an important consideration for priority-setting. Critics suggest preferences of the public who are potentially naïve to the issue under consideration may lead to sub-optimal decisions. We assessed the impact of information and deliberation via a Citizens' Jury (CJ) or preference elicitation methods (Discrete Choice Experiment, DCE) on preferences for prioritizing access to bariatric surgery.

METHODS

Preferences for seven prioritization criteria (e.g. obesity level, obesity-related comorbidities) were elicited from three groups who completed a DCE: (i) participants from two CJs (n = 28); (ii) controls who did not participate in the jury (n = 21); (iii) population sample (n = 1,994). Participants in the jury and control groups completed the DCE pre- and post-jury. DCE data were analyzed using multinomial logit models to derive "priority weights" for criteria for access to surgery. The rank order of criteria was compared across groups, time points and CJ recommendations.

RESULTS

The extent to which the criteria were considered important were broadly consistent across groups and were similar to jury recommendations but with variation in the rank order. Preferences of jurors but not controls were more differentiated (that is, criteria were assigned a greater range of priority weights) after than before the jury. Juror preferences pre-jury were similar to that of the public but appeared to change during the course of the jury with greater priority given to a person with comorbidity. Conversely, controls appeared to give a lower priority to those with comorbidity and higher priority to treating very severe obesity after than before the jury.

CONCLUSION

Being informed and undertaking deliberation had little impact on the criteria that were considered to be relevant for prioritizing access to bariatric surgery but may have a small impact on the relative importance of criteria. CJs may clarify underlying rationale but may not provide substantially different prioritization recommendations compared to a DCE.

Gender Variations and Inequity in Health Care Financing: Evidence from Southeast Nigeria

Health care is central to sustainable development, but it is underfunded in many developing countries such as Nigeria. This study empirically examined gender variations and inequity in health care financing in Southeast Nigeria. To decompose the Gini coefficient and analyze inequity by gender and differences in health care financing among states in the region, Dagum's approach for decomposition of the Gini coefficient is used. Empirical results showed that gender inequity exists in health care financing in Southeast Nigeria. In addition, variations in health care financing inequity among states in the Southeast region were found. Based on the foregoing, the study recommends that when implementing health care financing reforms, different population groups be covered in order to achieve the broader equity and effectiveness goals. Furthermore, governments in various states should step up efforts to assist disadvantaged and oppressed communities, such as poor indigenous people, in terms of health care utilization, which could reduce the health care financing burden.

QALYs and ambulatory status: societal preferences for healthcare decision making

BACKGROUND

This research aimed to review the theoretical and methodological aspects of the quality-adjusted life year (QALY) which give rise to potential for bias against certain patient populations, including those with problems with walking or an inability to walk (ambulatory disabilities), when health technology assessment decisions rely on QALY gain to show cost-effectiveness. Societal preferences for treating ambulatory versus non-ambulatory patients were also investigated.

METHODS

We reviewed published literature to identify information on theoretical underpinnings of the QALY, measurement of utilities for QALY assessment, and empirical evidence of societal preferences for the treatment of ambulatory and non-ambulatory patients.

RESULTS AND DISCUSSION

Health states which represent mobility impairment and the inability to walk receive low valuation from general public preferences. Non-ambulatory patients, for example those with advanced neuromuscular disease, have lower utilities determined by standardized preference-based measurement (PBM) tools. Any treatment that increases survival but could not restore ambulation would result in lower lifetime QALY gains for non-ambulatory versus ambulatory patients. Treatments could therefore potentially be deemed less cost-effective, or not cost-effective at all for this patient population.Empirical research indicates a societal preference for equal treatment of patients regardless of ambulatory status. The main limitation of our review was the non-systematic approach to evidence search and review, however, given the broad scope of content required to meet the aims of the review, we believe that the targeted approach was appropriate. The evidence presented in this article highlights the need for alternatives to strict QALY-based approaches to prevent avoidable health inequities when determining cost-effectiveness of healthcare interventions for non-ambulatory populations against fixed cost-effectiveness thresholds. An alternative metric, the Equal Value of Life Years Gained (evLYG), has been proposed as a supplementary measure for use alongside the QALY for its potential to alleviate bias against disabled patient populations during the assessment of healthcare treatments.

Cost-effectiveness analysis of sintilimab + chemotherapy versus camrelizumab + chemotherapy for the treatment of first-line locally advanced or metastatic nonsquamous NSCLC in China

BACKGROUND AND OBJECTIVE

Sintilimab is a selective PD-1 inhibitor with efficacy in advanced or metastatic nonsquamous non-small-cell lung cancer (NSCLC) patients. This study evaluated the cost-effectiveness of sintilimab + chemotherapy versus camrelizumab + chemotherapy as the first-line treatment for locally advanced or metastatic nonsquamous NSCLC in Chinese patients. In addition, this study aimed to reveal the impact of the reference treatment choice on the incremental cost-effectiveness ratio (ICER) results.

METHODS

A partitioned survival model (PSM) with three health states was constructed in a 3-week cycle with a lifetime horizon from the Chinese healthcare system perspective. Anchored matching adjusted indirect comparison was used for survival analyses based on individual patient data from Orient-11. Sintilimab + chemotherapy was chosen as the reference treatments in scenarios 1 and 2, while the camrelizumab + chemotherapy was chosen as the reference treatments in scenario 3. The utility values of different health states were derived from the patient-level European Organization for Research and Treatment Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) scores by mapping to the EQ-5D-5L, and QALYs were calculated as the health outcomes. One-way deterministic sensitivity analysis (DSA) and probability sensitivity analysis (PSA) were performed to explore model uncertainty.

RESULTS

Compared to camrelizumab + chemotherapy, sintilimab + chemotherapy was associated with higher effectiveness (incremental QALYs ranged from 0.13-0.62) and lower total costs (incremental costs ranged from $1,099-$5,201), resulting in an ICER ranging from $6,440-$8,454/QALY.

CONCLUSIONS

Sintilimab + chemotherapy is a cost-effective option compared with camrelizumab + chemotherapy as the first-line treatment for locally advanced or metastatic nonsquamous NSCLC in China.

Challenges in developing capability measures for children and young people for use in the economic evaluation of health and care interventions

Methods for measuring outcomes suitable for economic evaluations of health and care interventions have primarily focused on adults. The validity of such methods for children and young people is questionable in areas including the outcome domains measured and how they are measured and valued, with most existing measures narrowly focusing on health. Novel methods for assessing benefits beyond health by focusing on a person's capability have also concentrated on adults to date. This paper aims to set out the rationale for capability measures in children and young people. It argues for the need to expand the evaluative space beyond health functioning towards broader capabilities, with children and young people playing an integral role in capability measure development. Drawing from existing literature, specific challenges related to the identification, measurement, and valuation of capabilities in children and young people are also discussed. Finally, the practical implications for conducting economic evaluation when measuring and valuing capabilities at different stages across the life-course are illustrated. We develop an alternative framework based on conceiving capabilities as evolving across the life-course. This framework may also be helpful in thinking about how to model health outcomes across the life-course.

Quantifying financial market dynamics: Scaling law in rank mobility of Chinese stock prices

Rank mobility, which was designed to measure the average variation of relative rank positions with respect to any absolute variable over a given time period, can be used to explore how the memory of stock price ranking orders fades over time. We investigate the variation in rank order of the closing prices of stocks registered at the Shanghai A-share market over a long period of 16 years. And we find that rank mobility increases as a power law with increasing time scale, and eventually converges to a constant level. This power-law relationship can be observed not only over a long period of 16 years but also for each consecutive year, especially their power law exponents are very close. The empirical evidence indicates a fundamental dynamics of Chinese stock price movements.

Decrease in American birth rates makes it imperative for the United States to implement state mandated fertility coverage

In recent years, the prevalence of infertility has increased due to delayed childbearing and an increase in the rate of male infertility. Given the high cost of fertility treatment, this option is not valid for families with a low income, and those who can afford it usually choose to have multiple embryo transfer, which has led to an increase in multiple birth rates and an increase in the cost of perinatal care. Due to the expected increase in infertility and decrease in the national live birth rate, the US should set a plan to fund infertility treatment and lead a policy for single embryo transfer. This will offset the decrease in the national birth rates and decrease expenditure on perinatal and neonatal complications resulting from multiple births.

Health Disparities and the Socioeconomic Gradient in Elderly Life-Cycle Consumption

We quantify the importance of health disparities in explaining consumption differences at older ages by estimating a panel VAR model of elderly consumption, health, and mortality using data from the Health and Retirement Study. We use the estimated model and initial joint distribution of health and consumption to simulate elderly life-cycle paths and construct a measure of the net present value of expected remaining lifetime consumption at age sixty (NPVC). We first document a steep education gradient in elderly lifetime consumption. We then decompose the gradient in NPVC to quantify the effect of 1) differences in the health distribution at age sixty and 2) differential health and mortality transitions after age sixty. Our decomposition results suggest that roughly 10-12% of the education gradient in NPVC at age sixty could be closed by eliminating elderly health differences.

Inequality of Opportunity in Wages and Consumption in Egypt

Most explanations of the recent political upheavals in Egypt since 2011 include a reference to rising inequality, but the usual indicators of income inequality in Egypt do not support that inequality was on the rise prior to the uprisings. In this paper we provide measures of inequality of opportunity in wages and consumption for Egypt at different points in time from 1988 to 2012 that shed light on the gap between popular perceptions and measured indices of inequality. Our findings indicate that although measures of inequality of wage income have increased over time in Egypt starting in 1998, the share attributable to circumstances declined steadily throughout the whole period. We attribute this decline to the fact that outcomes for individuals from a middle class background have moved closer to the outcomes of those from a poor background. The outcomes for those from privileged backgrounds remain quite apart from the rest.

Heterogeneity, Inequity Aversion, and Group Performance

We investigate the effects of inequality in wealth on the incentives to contribute to a group output when agents are inequity averse and may differ in ability. We show that equality may lead to a reduction of contributions below levels generated by purely selfish agents. But introducing inequality motivates more productive agents to exert higher efforts and help the group to coordinate on equilibria with less free-riding. As a result, less able agents may benefit from initially disadvantageous inequality. Moreover, the more inequity averse the agents, the more inequality should be imposed even by an egalitarian social planner.

Short-term trends in China's income inequality and poverty: evidence from a longitudinal household survey

In the past three decades, income inequality in China has increased rapidly relative to both China's own past and other countries at similar levels of economic development. Using recent longitudinal data from the China Family Panel Studies (CFPS), this article examines changes in income inequality and poverty prevalence between 2010 and 2012. Surprisingly, we find a modest decline in income inequality as measured by the Gini coefficients in the CFPS data. The urban-rural gap narrowed, with rural families enjoying faster income growth than urban families enjoyed. Income growth was greater for middle-income families than for families with either high or low incomes in 2010. By all measures, poverty was greatly reduced between 2010 and 2012. Two-thirds of families that had been poor in 2010 escaped poverty by 2012.

Inequity in the Face of Death

We apply the theory of inequality of opportunity to the measurement of inequity in mortality. Using a rich data set linking records of mortality and health events to survey data on lifestyles for the Netherlands (1998-2007), we test the sensitivity of estimated inequity to different normative choices and conclude that the location of the responsibility cut is of vital importance. Traditional measures of inequity (such as socioeconomic and regional inequalities) only capture part of more comprehensive notions of unfairness. We show that distinguishing between different routes via which variables might be associated to mortality is essential to the application of different normative positions. Using the fairness gap (direct unfairness), measured inequity according to our implementation of the 'control' and 'preference' approaches ranges between 0.0229 and 0.0239 (0.0102-0.0218), while regional and socioeconomic inequalities are smaller than 0.0020 (0.0001). The usual practice of standardizing for age and gender has large effects on measured inequity. Finally, we use our model to measure inequity in simulated counterfactual situations. While it is a big challenge to identify all causal relationships involved in this empirical context, this does not affect our main conclusions regarding the importance of normative choices in the measurement of inequity. Copyright © 2014 John Wiley & Sons, Ltd.

Heterogeneity and Cooperation: The Role of Capability and Valuation on Public Goods Provision

We experimentally investigate the effects of two different sources of heterogeneity - capability and valuation - on the provision public goods when punishment is possible or not. We find that compared to homogeneous groups, asymmetric valuations for the public good have negative effects on cooperation and its enforcement through informal sanctions. Asymmetric capabilities in providing the public good, in contrast, have a positive and stabilizing effect on voluntary contributions. The main reason for these results are the different externalities contributions have on the other group members' payoffs affecting individuals' willingness to cooperate. We thus provide evidence that it is not the asymmetric nature of groups per se that facilitates or impedes collective action, but that it is rather the nature of asymmetry that determines the degree of cooperation and the level of public good provision.

Rising inequalities in income and health in China: who is left behind?

In recent decades, China has experienced double-digit economic growth rates and rising inequality. This paper implements a new decomposition approach using the China Health and Nutrition Survey (1991-2006) to examine the extent to which changes in level and distribution of incomes and in income mobility are related to health disparities between rich and poor. We find that health disparities in China relate to rising income inequality and in particular to the adverse health and income experience of older (wo)men, but not to the growth rate of average incomes over the last decades. These findings suggest that replacement incomes and pensions at older ages may be one of the most important policy levers for reducing health disparities between rich and poor Chinese.