Dissertation Title: "An Empirical Evaluation of the Kyrgyz Health Reform: Does it Work for the Poor?"
The Kyrgyz Republic is considered a reform pioneer among the countries of the former Soviet Union. To protect households from the financial impact of seeking health care, the Kyrgyz government introduced comprehensive reforms during 2001-04. In the first chapter, I evaluated the 2001-04 reforms on patient financial burden taking advantage of its phased implementation using a difference-in-difference approach. The reforms were successful at containing the out-of-pocket payments for hospitalized patients. The difference-in-difference estimator of the reform effect was 400 soms (US$10), equivalent to 29% of the pre-reform out-of-pocket payments in reform oblasts. The reforms were particularly effective at limiting the financial burden among the poorest 40% of the population. At the same time, I observe spill-over effects for visits and outpatient drug purchases reversing the protective effect the reforms exerted for hospitalization. This trend was stronger for the non-poor than for the poor. Combining the distributional impact of public expenditures with the distributional impact of out-of-pocket payments, the reforms redistributed health care resources to the benefit of the poor.
In the second chapter, I examine the socio-economic distribution of informal payments to health care personnel. Price discrimination has been suggested as the model of pricing behavior for informal payments, but it has not been established empirically. I do not find evidence that the poor are less likely to pay informal payment to medical personnel than the non-poor. Conditional on paying, the poor pay 25% less than the non-poor although their per capita annual consumption is 50% less. Additionally, 32% of patients pay less co-payment than they should leading to a revenue loss equal to 43% of co-payment collections. I do not find evidence that the poor are more likely to receive these discounts than the non-poor. Receiving a co-payment discount is associated with a 27% increase in informal payments. Thus, discounts could reflect strategic revenue maximizing behavior as physicians attempt to re-capture informal payment lost after the introduction of the co-payment policy.
In the third chapter, I evaluate three approaches to the measurement of socioeconomic status in the absence of data on consumption or expenditure. I calculate the concentration index for health care visits and hospitalizations with each ranking variable. The choice of welfare indicator has a significant impact on welfare ranking and on the estimated degree of inequality in health service utilization. Based on the findings of this paper, the scale items I validate can be used in future equity-related research in the Kyrgyz Republic.