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Measurement and Explanation of Inequality in Health and Health Care in Low-Income Settings

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Author Info
van Doorslaer, Eddy
O'Donnell, Owen

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Abstract

This paper describes approaches to the measurement and explanation of income-related inequality and inequity in health care financing, health care utilization and health and considers the applicability and the feasibility of these methods in low-income countries. Results from a comparative study of 14 Asian countries are used to illustrate the main issues. The structure of health finance in low-income countries, in particular the heavy reliance on out-of-pocket payments, means that the equity issues in finance are quite different from those of concern in high-income countries. Primary concern is not with the distribution of contributions to pre-payment mechanisms but with the deterrent effect of payments on utilization and the distribution of uninsured payment risks. Measurement of inequity in utilization of health care in low-income countries is constrained by the lack of reliable measures of health that can be used to standardize for need. Nonetheless, sufficient is known of the distribution of need in many circumstances in order to make inferences about equity from inequality in health care use. The empirical analyses demonstrate that, in low-income countries, the better-off tend to pay more for health care, both absolutely and in relative terms. But they also consume more health care. Health care is financed is largely according to the benefit principle. Assessing the distributional performance of health systems in low-income settings therefore requires examination of finance and utilization simultaneously.

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Paper provided by World Institute for Development Economic Research (UNU-WIDER) in its series Working Papers with number DP2008/04.

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Length: 34 pages
Date of creation: 2008
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Handle: RePEc:unu:wpaper:dp2008-04

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Keywords: health inequality; equity;

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  1. Bidani, Benu & Ravallion, Martin, 1997. "Decomposing social indicators using distributional data," Journal of Econometrics, Elsevier, vol. 77(1), pages 125-139, March. [Downloadable!] (restricted)
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  2. van Doorslaer, Eddy & Wagstaff, Adam, 1992. "Equity in the delivery of health care: some international comparisons," Journal of Health Economics, Elsevier, vol. 11(4), pages 389-411, December. [Downloadable!] (restricted)
  3. Paul Gertler & Jonathan Gruber, 1997. "Insuring Consumption Against Illness," NBER Working Papers 6035, National Bureau of Economic Research, Inc. [Downloadable!] (restricted)
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  4. Chen, Shaohua & Ravallion, Martin, 2004. "How Have the World's Poorest Fared Since the Early 1980s?," Policy Research Working Paper Series 3341, The World Bank. [Downloadable!]
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  5. Adam Wagstaff & Eddy van Doorslaer, 2003. "Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993-1998," Health Economics, John Wiley & Sons, Ltd., vol. 12(11), pages 921-933. [Downloadable!]
  6. Teresa Bago d'Uva & Eddy Van Doorslaer & Maarten Lindeboom & Owen O'Donnell, 2008. "Does reporting heterogeneity bias the measurement of health disparities?," Health Economics, John Wiley & Sons, Ltd., vol. 17(3), pages 351-375. [Downloadable!]
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  7. Eddy van Doorslaer & Xander Koolman, 2004. "Explaining the differences in income-related health inequalities across European countries," Health Economics, John Wiley & Sons, Ltd., vol. 13(7), pages 609-628. [Downloadable!]
  8. Wagstaff, Adam & van Doorslaer, Eddy & Watanabe, Naoko, 2003. "On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam," Journal of Econometrics, Elsevier, vol. 112(1), pages 207-223, January. [Downloadable!] (restricted)
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  9. van Doorslaer, Eddy & Wagstaff, Adam & van der Burg, Hattem & Christiansen, Terkel & Citoni, Guido & Di Biase, Rita & Gerdtham, Ulf-G. & Gerfin, Mike & Gross, Lorna & Hakinnen, Unto, 1999. "The redistributive effect of health care finance in twelve OECD countries," Journal of Health Economics, Elsevier, vol. 18(3), pages 291-313, June. [Downloadable!] (restricted)
  10. Wagstaff, Adam & van Doorslaer, Eddy & van der Burg, Hattem & Calonge, Samuel & Christiansen, Terkel & Citoni, Guido & Gerdtham, Ulf-G & Gerfin, Mike & Gross, Lorna & Hakinnen, Unto, 1999. "Equity in the finance of health care: some further international comparisons1," Journal of Health Economics, Elsevier, vol. 18(3), pages 263-290, June. [Downloadable!] (restricted)
  11. Wagstaff, Adam & van Doorslaer, Eddy, 1992. "Equity in the finance of health care: Some international comparisons," Journal of Health Economics, Elsevier, vol. 11(4), pages 361-387, December. [Downloadable!] (restricted)
  12. van Doorslaer, Eddy & Wagstaff, Adam & van der Burg, Hattem & Christiansen, Terkel & De Graeve, Diana & Duchesne, Inge & Gerdtham, Ulf-G & Gerfin, Michael & Geurts, Jose & Gross, Lorna, 2000. "Equity in the delivery of health care in Europe and the US," Journal of Health Economics, Elsevier, vol. 19(5), pages 553-583, September. [Downloadable!] (restricted)
  13. Lanjouw, Peter & Ravallion, Martin, 1999. "Benefit Incidence, Public Spending Reforms, and the Timing of Program Capture," World Bank Economic Review, Oxford University Press, vol. 13(2), pages 257-73, May.
  14. Gabriela Flores & Jaya Krishnakumar & Owen O'Donnell & Eddy van Doorslaer, 2008. "Coping with health-care costs: implications for the measurement of catastrophic expenditures and poverty," Health Economics, John Wiley & Sons, Ltd., vol. 17(12), pages 1393-1412. [Downloadable!]
  15. O'Donnell, Owen & van Doorslaer, Eddy & Rannan-Eliya, Ravi P. & Somanathan, Aparnaa & Adhikari, Shiva Raj & Akkazieva, Baktygul & Harbianto, Deni & Garg, Charu C. & Hanvoravongchai, Piya & Herrin, Ale, 2008. "Who pays for health care in Asia?," Journal of Health Economics, Elsevier, vol. 27(2), pages 460-475, March. [Downloadable!] (restricted)
  16. Sanjeev Gupta & Marijn Verhoeven & Erwin R. Tiongson, 2003. "Public spending on health care and the poor," Health Economics, John Wiley & Sons, Ltd., vol. 12(8), pages 685-696. [Downloadable!]
  17. Eddy van Doorslaer & Owen O'Donnell & Ravindra P. Rannan-Eliya & Aparnaa Somanathan & Shiva Raj Adhikari & Charu C. Garg & Deni Harbianto & Alejandro N. Herrin & Mohammed Nazmul Huq & Shamsia Ibragimo, 2007. "Catastrophic payments for health care in Asia," Health Economics, John Wiley & Sons, Ltd., vol. 16(11), pages 1159-1184. [Downloadable!]
  18. Deon Filmer & Jeffrey S. Hammer & Lant H. Pritchett, 2002. "Weak Links in the Chain II: A Prescription for Health Policy in Poor Countries," World Bank Research Observer, Oxford University Press, vol. 17(1), pages 47-66.
  19. Lanjouw, Peter & Pradhan, Menno & Saadah, Fadia & Sayed, Haneen & Sparrow, Robert, 2001. "Poverty, education, and health in Indonesia : who benefits from public spending?," Policy Research Working Paper Series 2739, The World Bank. [Downloadable!]
  20. Wan, Guanghua, 2004. "Accounting for income inequality in rural China: a regression-based approach," Journal of Comparative Economics, Elsevier, vol. 32(2), pages 348-363, June. [Downloadable!] (restricted)
  21. Paul Gertler & Jonathan Gruber, 2002. "Insuring Consumption Against Illness," American Economic Review, American Economic Association, vol. 92(1), pages 51-70, March. [Downloadable!]
  22. Besley, Timothy & Coate, Stephen, 1991. "Public Provision of Private Goods and the Redistribution of Income," American Economic Review, American Economic Association, vol. 81(4), pages 979-84, September. [Downloadable!] (restricted)
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  23. van Doorslaer, Eddy & Wagstaff, Adam & Bleichrodt, Han & Calonge, Samuel & Gerdtham, Ulf-G. & Gerfin, Michael & Geurts, Jose & Gross, Lorna & Hakkinen, Unto & Leu, Robert E., 1997. "Income-related inequalities in health: some international comparisons," Journal of Health Economics, Elsevier, vol. 16(1), pages 93-112, February. [Downloadable!] (restricted)
  24. Eddy van Doorslaer & Xander Koolman & Andrew M. Jones, 2004. "Explaining income-related inequalities in doctor utilisation in Europe," Health Economics, John Wiley & Sons, Ltd., vol. 13(7), pages 629-647. [Downloadable!]
  25. Menno Pradhan & Nicholas Prescott, 2002. "Social risk management options for medical care in Indonesia," Health Economics, John Wiley & Sons, Ltd., vol. 11(5), pages 431-446. [Downloadable!]
  26. Adam Wagstaff & Naoko Watanabe, 2003. "What difference does the choice of SES make in health inequality measurement?," Health Economics, John Wiley & Sons, Ltd., vol. 12(10), pages 885-890. [Downloadable!]
  27. Kakwani, Nanok C, 1977. "Measurement of Tax Progressivity: An International Comparison," Economic Journal, Royal Economic Society, vol. 87(345), pages 71-80, March. [Downloadable!] (restricted)
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