Inequalities in Health Care Use and Expenditures: Empirical Data from Eight Developing Countries and Countries in Transition

By Makinen, M.; Waters, H. et al. | Bulletin of the World Health Organization, January 2000 | Go to article overview

Inequalities in Health Care Use and Expenditures: Empirical Data from Eight Developing Countries and Countries in Transition


Makinen, M., Waters, H., Rauch, M., Almagambetova, N., Bitran, R., Gilson, L., McIntyre, D., Pannarunothai, S., Prieto, A. L., Ubilla, G., Ram, S., Bulletin of the World Health Organization


Voir page 63 le resume en francais. En la pagina 64 figura un resumen en espanol.

Introduction

This paper summarizes results and draws cross-country conclusions from a set of studies of inequality in the allocation of resources in the health sector. The research was inspired by a study to measure health sector inequities in selected countries of the Organisation for Economic Co-operation and Development (OECD) (1). Its overall purpose is to begin to adapt and apply methods developed in the OECD study, in a simplified manner.

These methods are applied in this paper to developing countries and countries in transition. There is generally little reliable quantitative evaluation of the inequalities that exist in developing countries, in terms of either health status or access to care. Results from the application of tools to measure inequalities can therefore be important inputs into the decision process for resource allocation in the health sector in these countries. Empirical measures of the effects on inequality of resource generation and allocation decisions are major additions to the information base for making and evaluating policy decisions. In addition, the analytical methods employed here could be used to measure ex ante the impact of specific policy changes on inequality.

The following analysis of the socioeconomic distribution of health service use and household health expenditures uses existing national and subnational household survey data and a common methodology across countries. Each country study divides the population into per capita "income" quintiles -- generally using the level of household consumption expenditures as a proxy measure of income. The results of the studies are divided into two broad categories: use of health care and health expenditures. For each of these categories, indicators are compared across the quintiles. The section on health care use includes analysis of the type of providers consulted.

In this research, a simple measurement of inequality is used, as opposed to the more complex and nuanced notion of inequity (1). In the examination of the use of health care, variations from equality of use when ill or injured are considered, by socioeconomic group. The comparisons made on expenditures use the simple measure of variation from equality. Lack of confidence that the available data accurately measure absolute income levels(a) means that reliable comparisons of health expenditures as a share of income are not possible.

Included in the analyses are data from the following eight developing countries and countries in transition: Burkina Faso, Guatemala, Kazakhstan, Kyrgyzstan, Paraguay, South Africa, Thailand, and Zambia.

Background: previous research

In their study for the OECD referred to above, Van Doorslaer, Wagstaff & Rutten (1) define many of the issues related to equity in the health sector and compare equity in health care financing and the distribution of health services in 10 industrialized countries. These workers had access to detailed tax and financing information, in addition to household surveys from each of the countries. In developing countries, reliable data for the financing of health services are often not available, complicating the estimation of equity in the financing of health care.

Studies by LeGrand (2) and Mapelli (3) measured equity using indicators of health status in the United Kingdom and Italy, respectively. O'Donnell & Propper (4) studied the distribution of National Health Service (NHS) resources in Britain, comparing utilization and expenditures among income quintiles. They calculated the average number of physician visits, inpatient stays, and average NHS expenditure, and found evidence of a slightly pro-poor bias in the distribution of NHS resources.

Studies of health sector inequality in developing countries have found that the distribution of public health services is unequal. …

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