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A History of the World Bank's Health Equity and Financial Protection Indicators

This project – a collaboration between the Bank’s research group, data group, and health, nutrition and population global practice – has been a multiyear project, stretching back to 2000. The project’s aim initially was to create country-level data on intra-country inequalities across socioeconomic groups in the receipt of specific types of health service and health outcomes. Subsequently, the project’s scope expanded to include information on household out-of-pocket expenditures on health services in relation to household living standards. Over the years, the project has produced datasets, reports, research papers, a how-to guide, and free software.1-15

The 2000 Dataset

The project’s first dataset, published in 2000, was entitled “Socioeconomic Differences in Health, Nutrition and Population”.1 As shown in Fig 1, the dataset covered 42 countries, with one survey and year per country. All the data were culled from the Demographic and Health Survey (DHS), and the focus was firmly on maternal and child health (MCH) service use, e.g. antenatal care, and outcomes, e.g. stunting and infant mortality. In the absence of a measure of household consumption in the DHS, household living standards were measured a synthetic ‘wealth index’ formed by running principal components analysis on indicators of house characteristics, ownership of durables, water and sanitation, etc.16

evolution

Fig 1: Evolution of the World Bank’s Data on Health Equity and Financial Protection

The datasheets thus showed the gaps in receipt of key MCH interventions and MCH outcomes between different wealth quintiles. Fig 2 shows how immunization varies by quintile – sometimes quite dramatically – within countries: the gap is especially pronounced in Ghana where, in 1993, the immunization rate of the poorest fifth of children was just 16% while the rate among the richest fifth of children (65%) was equal to the immunization rate of the poorest fifth of children in Kenya.

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Fig 2: Inequalities between and within countries: The case of full immunization

The 2007 Dataset

The project’s second dataset, published in 2007 and entitled “Socio-Economic Differences in Health, Nutrition and Population Within Developing Countries”,3 expanded the number of countries to 56 and included more than one survey for some countries. It also included more indicators, expanding the scope of the exercise to include some non-MCH MDG indicators, notably HIV-related indicators.

The 2013 Dataset

The third dataset, published in 2012 and entitled “Health Equity and Financial Protection”, expanded the scope of the exercise in several directions. UNICEF’s Multiple Indicator Cluster Survey (MICS) was analyzed alongside the DHS, along with the World Health Survey (WHS). The number of countries was increased to 109, and included several high-income countries. With the MDG era nearing its end, the set of health indicators was expanded to include several NCD and non-MDG indicators, such as breast cancer screening and the receipt of inpatient care. In addition, indicators of financial protection were included. These analyzed households’ out-of-pocket payments for health services in relation to their living standards, with household spending said to be ‘catastrophic’ if it absorbed more than a fixed percentage (e.g. 10%) of household income or consumption, and ‘impoverishing’ if it was sufficiently large to make the difference between a household being above or below the poverty line.

With so much data, the 2012 dataset allowed us to answer questions about trends in inequalities in use of health services. Fig 3 shows changes in inequality for several key MCH indicators. In the case of immunization, the progress is minimal for the richest 20% of children, while the progress has been appreciable for the poorest 20%. For antenatal care (ANC) and skilled birth attendance (SBA), by contrast, progress has been appreciable for the poorest and richest quintiles.

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Fig 3: Changes in inequalities in selected MNCH coverage indicators from the 1990s to the 2010s

The 2018 Dataset

The fourth dataset, published in 2018 and entitled “Health Equity and Financial Protection Indicators”, expands the scope of the exercise still further, increasing the number of countries from 109 to 183, and the number of surveys from 285 to 1,603. The number of indicators is smaller, but the balance is shifted still further to non-MDG indicators in service coverage, including hypertension and diabetes, and a larger fraction of the dataset is made up of financial protection indicators. The shift of emphasis reflects the growth of interest in Universal Health Coverage (UHC), with the years immediately following the 2013 dataset being devoted to building datasets to analyze progress towards UHC in Latin America and the UNICO countries.14, 15 More recently, the focus has been on expanding coverage of NCD and financial protection indicators. An interim version of the 2018 HEFPI dataset was the source of 80% of the financial protection datapoints in the 2017 Bank-WHO report assessing progress towards UHC.17-19 The 2018 HEFPI dataset includes the Bank-generated datapoints used in the joint report, but also many other datapoints generated by the Bank since the publication of the report. As a result, the 2018 HEFPI dataset includes more datapoints, and covers more countries, than the report.

The 2018 HEFPI dataset allows for the analysis of trends in the population incidence of catastrophic health expenditures – see Fig 4. It also allows for the analysis of differences in the incidence of catastrophic spending by income quintile in those countries where household income is routinely available, notably high-income countries – see Fig 4. Inequalities in catastrophic expenditure incidence when expenditure is related to household consumption are not analyzable in the HEFPI dataset, because the numbers are potentially misleading: illness can often result in households borrowing to finance medical expenses, thereby making ‘sick’ households appear richer than ‘healthy’ households, resulting in catastrophic health expenses being concentrated among households that appear to be rich but in reality have simply borrowed to finance their health expenses.18 This potentially misleading result is less likely to occur if out-of-pocket expenses are related to household income because income is less influenced by illness.

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Fig 4: Catastrophic health expenditures – trends and inequalities

References

  1. Gwatkin D, Rutstein S, Johnson K, Pande R, Wagstaff A. Socioeconomic Differences in Health, Nutrition and Population. Washington DC: The World Bank; 2000.
  2. Wagstaff A, van Doorslaer E. Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993-1998. Health Economics 2003; 12(11): 921-34.
  3. Gwatkin D, Rutstein S, Johnson K, Suliman E, Wagstaff A, Amouzou A. Socio-Economic Differences in Health, Nutrition and Population Within Developing Countries: An Overview. Washington, DC: The World Bank; 2007.
  4. O'Donnell O, van Doorslaer E, Wagstaff A, Lindelow M. Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation. Washington DC: World Bank; 2008.
  5. Wagstaff A, Bilger M, Sajaia Z, Lokshin MM. Health Equity and Financial Protection. Washington DC: World Bank; 2011.
  6. Bredenkamp C, Wagstaff A, Buisman L, Prencipe L, Rohr D. Health equity and financial protection datasheet : Sub-Saharan Africa. Washington DC: The World Bank, 2012.
  7. Bredenkamp C, Wagstaff A, Buisman L, Prencipe L, Rohr D. Health equity and financial protection datasheet : Middle East and North Africa. Washington DC: The World Bank, 2012.
  8. Bredenkamp C, Wagstaff A, Buisman L, Prencipe L, Rohr D. Health equity and financial protection datasheet : Europe and Central Asia. Washington DC: The World Bank, 2012.
  9. Bredenkamp C, Wagstaff A, Buisman L, Prencipe L, Rohr D. Health equity and financial protection datasheet : South Asia. Washington DC: The World Bank, 2012.
  10. Bredenkamp C, Wagstaff A, Buisman L, Prencipe L, Rohr D. Health equity and financial protection datasheet : East Asia and the Pacific. Washington DC: The World Bank, 2012.
  11. Bredenkamp C, Wagstaff A, Buisman L, Prencipe L, Rohr D. Health equity and financial protection datasheet : Latin America. Washington DC: The World Bank, 2012.
  12. Bredenkamp C, Buisman LR, Van de Poel E. Persistent inequalities in child undernutrition: evidence from 80 countries, from 1990 to today. International journal of epidemiology 2014; 43(4): 1328-35.
  13. Wagstaff A, Bredenkamp C, Buisman LR. Progress on Global Health Goals: are the Poor Being Left Behind? The World Bank Research Observer 2014; 29(2): 137-62.
  14. Wagstaff A, Dmytraczenko T, Almeida G, Buisman L, Hoang-Vu Eozenou P, Bredenkamp C, Cercone JA, Diaz Y, Maceira D, Molina S, Paraje G, Ruiz F, Sarti F, Scott J, Valdivia M, Werneck H. Assessing Latin America’s Progress Toward Achieving Universal Health Coverage. Health Affairs 2015; 34(10): 1704-12.
  15. Wagstaff A, Cotlear D, Eozenou PH-V, Buisman LR. Measuring progress towards universal health coverage: with an application to 24 developing countries. Oxford Review of Economic Policy 2016; 32(1): 147-89.
  16. Wagstaff A, Bredenkamp C, Buisman L. Progress on global health goals: are the poor being left behind? World Bank Research Observer 2014; 29(2): 137-62.
  17. World Bank, World Health Organization. Tracking Universal Health Coverage : 2017 Global Monitoring Report. Geneva and Washington DC: WHO and World Bank, 2017.
  18. Wagstaff A, Flores G, Hsu J, Smitz MF, Chepynoga K, Buisman LR, van Wilgenburg K, Eozenou P. Progress on catastrophic health spending in 133 countries: a retrospective observational study. The Lancet Global health 2018; 6(2): e169-e79.
  19. Wagstaff A, Flores G, Smitz MF, Hsu J, Chepynoga K, Eozenou P. Progress on impoverishing health spending in 122 countries: a retrospective observational study. The Lancet Global health 2018; 6(2): e180-e92.