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Benefit‐incidence analysis: are government health expenditures more pro‐rich than we think?

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  • Adam Wagstaff

Abstract

It is generally accepted that government health expenditures should disproportionately benefit the poor. And yet in most developing countries the opposite is the case. This paper examines the implications of a central assumption of benefit incidence analysis, namely that the unit cost of a government-provided service bears no relation to the out-of-pocket payments paid by the patient. It argues that a more plausible assumption is that larger out-of-pocket payments for a given unit of utilization reflect more (or more costly) services being delivered. The paper compares -- theoretically and empirically -- the standard constant-cost assumption with two alternatives, namely that the cost of care in a specific episode of utilization is (a) proportional to or (b) linearly related to the amount of money paid out-of-pocket by the patient. An interesting special case of the linear relationship is where subsidies are focused on a basic unit of care and additional costs are met dollar-for-dollar by additional fees. The paper shows that if fees are more pro-rich than utilization, government spending will be least pro-rich under the constant-cost assumption and most pro-rich under the proportionality assumption. The linear assumption results in a concentration index for subsidies that lies between these two extremes. These results are borne out in an analysis of the incidence of government health spending in Vietnam (a country where fees are more pro-rich than utilization); indeed, under the constant-cost assumption, subsidies are pro-poor while they are pro-rich under the proportionality assumption. The paper also considers the biases created by not allowing for insurance reimbursements.
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Suggested Citation

  • Adam Wagstaff, 2012. "Benefit‐incidence analysis: are government health expenditures more pro‐rich than we think?," Health Economics, John Wiley & Sons, Ltd., vol. 21(4), pages 351-366, April.
  • Handle: RePEc:wly:hlthec:v:21:y:2012:i:4:p:351-366
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    Cited by:

    1. Nora Lustig & Florencia Amábile & Marisa Bucheli & George Gray Molina & Sean Higgins & Miguel Jaramillo & Wilson Jiménez Pozo & Veronica Paz Arauco & Claudiney Pereira & Carola Pessino & Máximo Rossi , 2014. "El impacto del sistema tributario y del gasto social sobre la desigualdad y la pobreza en Argentina, Bolivia, Brasil, México, Perú y Uruguay: Un panorama general," Commitment to Equity (CEQ) Working Paper Series 1313S, Tulane University, Department of Economics.
    2. Anselmi, Laura & Lagarde, Mylène & Hanson, Kara, 2015. "Going beyond horizontal equity: An analysis of health expenditure allocation across geographic areas in Mozambique," Social Science & Medicine, Elsevier, vol. 130(C), pages 216-224.
    3. Nora Lustig & Florencia Amábile & Marisa Bucheli & George Gray Molina & Sean Higgins & Miguel Jaramillo & Wilson Jiménez Pozo & Veronica Paz Arauco & Claudiney Pereira & Carola Pessino & Máximo Rossi , 2014. "El impacto del sistema tributario y del gasto social sobre la desigualdad y la pobreza en Argentina, Bolivia, Brasil, México, Perú y Uruguay: Un panorama general," Commitment to Equity (CEQ) Working Paper Series 13S, Tulane University, Department of Economics.
    4. Christoph Lakner & Maria Ana Lugo & Jorge Puig & Leandro Salinardi & Martha Viveros, 2016. "The Incidence of Subsidies to Residential Public Services in Argentina: The Subsidy System in 2014 and Some Alternatives," CEDLAS, Working Papers 0201, CEDLAS, Universidad Nacional de La Plata.
    5. Nora Lustig & Florencia Amábile & Marisa Bucheli & George Gray Molina & Sean Higgins & Miguel Jaramillo & Wilson Jiménez Pozo & Veronica Paz Arauco & Claudiney Pereira & Carola Pessino & Máximo Rossi , 2014. "El impacto del sistema tributario y del gasto social sobre la desigualdad y la pobreza en Argentina, Bolivia, Brasil, México, Perú y Uruguay: Un panorama general," Commitment to Equity (CEQ) Working Paper Series 1313S, Tulane University, Department of Economics.
    6. Nora Lustig & Florencia Amábile & Marisa Bucheli & George Gray Molina & Sean Higgins & Miguel Jaramillo & Wilson Jiménez Pozo & Veronica Paz Arauco & Claudiney Pereira & Carola Pessino & Máximo Rossi , 2013. "The impact of taxes and social spending on inequality and poverty in Argentina, Bolivia, Brazil, Mexico, Peru and Uruguay: An overview," Working Papers 315, ECINEQ, Society for the Study of Economic Inequality.
    7. Nora Lustig & Carola Pessino & John Scott, 2014. "The Impact of Taxes and Social Spending on Inequality and Poverty in Argentina, Bolivia, Brazil, Mexico, Peru, and Uruguay," Public Finance Review, , vol. 42(3), pages 287-303, May.
    8. Wagstaff, Adam & Bilger, Marcel & Buisman, Leander R. & Bredenkamp, Caryn, 2014. "Who benefits from government health spending and why? a global assessment," Policy Research Working Paper Series 7044, The World Bank.
    9. Nora Lustig & Florencia Amábile & Marisa Bucheli & George Gray Molina & Sean Higgins & Miguel Jaramillo & Wilson Jiménez Pozo & Veronica Paz Arauco & Claudiney Pereira & Carola Pessino & Máximo Rossi , 2013. "The impact of taxes and social spending on inequality and poverty in Argentina, Bolivia, Brazil, Mexico, Peru, and Uruguay," Commitment to Equity (CEQ) Working Paper Series 1313, Tulane University, Department of Economics, revised Aug 2013.
    10. Ahmed Shoukry Rashad & Mesbah Fathy Sharaf, 2015. "Who Benefits from Public Healthcare Subsidies in Egypt?," Social Sciences, MDPI, Open Access Journal, vol. 4(4), pages 1-15, November.

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